Social Discrimination As A Barrier For The Treatment Of Chronic Diseases In Venezuelan Migrants Of Peru

Objective: To determine the association between discrimination and treatment of chronic diseases in Venezuelan emigrants. Methodology: Cross-sectional study, secondary analysis of the database of the "Survey directed at the Venezuelan population residing in the country" (ENPOVE), carried out in Peru in 2018. To evaluate the main association, we used a regression model of poisson, by adjusting the effect of the multistage sample using the svy command, and obtaining prevalence ratios (RP) with their respective condence intervals (95% CI). Results: A population of 865 Venezuelans (58.2% women, mean age: 36.6 ± 0.7 years) were evaluated, in which 54.8% reported having felt discriminated against for being Venezuelan and 89.2% reported not receiving treatment for their chronic disease. A statistically signicant association was found between having been discriminated for being Venezuelan and having received treatment for chronic diseases, in the bivariate model (RPc: 0.38; 95% CI: 0.20–0.73) and the adjusted model (RPa: 0.49; 95% CI: 0.25–0.97). Conclusion: Our study found that having felt discriminated against decreases the prevalence of receiving treatment for chronic diseases by approximately 50% compared to those who did not report having been discriminated against. Future studies are necessary to evaluate the consistency of the results, with a larger population of Venezuelans residing in Peru.


Introduction
Venezuela is a country that is going through a marked economic and political crisis since 2013 (1), which has led the country to continued high economic in ation (2), forcing to emigrate to Latin American neighboring countries, being Peru the second with most Venezuelan migrants to date (3).
Until 2019, Peru was home to more than 860,000 Venezuelans, being only below Colombia in number of immigrants from Venezuela. (3).
This immigrations of Venezuelans has mainly led to a slowdown in the increasing trend of the average salary and a decrease in the labor supply in the Peruvian market, affecting above all the most vulnerable sectors (4), and so generating discomfort in the Peruvian population which probably triggers multiple attitudes of discrimination and disgust against Venezuelans.
Discrimination is de ned as unequal and differential treatment towards a person or a group of people in the different areas of social life; this being an act that hinders and limits access to the right of all those affected (5).
Studies have shown that social discrimination is a frequent act during these migratory phenomena, reporting discrimination frequencies in migrants of 33.2% (6).
Social discrimination can affect the mental health of the immigrant, it can create a feeling of insecurity in the destination country and also a feeling of exclusion (7). Social discrimination could create an additional barrier in the access to national institutes, mainly the health ones (8), due to the fear of suffering discrimination acts that could be translated into medical malpractice.
We carry out the present study with the objective of determining the association between discrimination and access to treatment of chronical diseases in Venezuelan migrants. This study could contribute for the implementation of national agencies responsible for protecting this vulnerable group, regulation of sanctioning rules for acts of discrimination, and generation of policies that promote the rights of migrants within Peru.

Study design
Transversal analytic study. Secondary analysis of the database in "Encuesta dirigida a la población venezolana que reside en el país -ENPOVE", realized in 2018 by the Peruvian National Institute of Statistics and Informatics (9), which methodology has been previously reported (10). Study population, samples and selection criteria Study population by ENPOVE was made up of venezuelan immigrants living in the urban areas of the capitals of the departments of Tumbes, La Libertad, Arequipa, Cusco, Lima, and the constitutional province of Callao, because they were the cities that concentrated 85% of the Venezuelan population residing in Peru.
A multi-stage sampling was carried out, using a block at rst instance as a sampling unit, and at second instance the households. Obtaining a sample of 3611 blocks, with 3697 houses and 9847 people interviewed.
Only immigrants who report having had any type of chronic disease and who were older than 18 years were included in the present study, evaluating a total of 865 Venezuelans.

Procedure
The ENPOVE 2018 was executed on November -December 2018, with the objective of providing data on the situation of the Venezuelan population residing in Peru; for the formulation, evaluation and monitoring of policies, plans, programs or projects directed at this population.
This survey was structured in eight topics: dwelling and home characteristics, house resident characteristics, migratory situation, health, education, job and earnings, discrimination, and gender and victimization. Although for the present secondary analysis topics related to characteristics of the residents, migratory situation, health, job, and discrimination were used.

Outcome: Treatment of chronic disease
The variable treatment of chronic disease was evaluated by the self-report of the interviewed with the following question: Do you receive treatment in Peru for the chronic illness or discomfort that you present? Which had three response options: 1) yes, with the necessary frequency, 2) yes, but without the necessary frequency, 3) do not receive treatment. For the present study the variable was categorized (do receive and do not receive treatment), considering just the ones who reported to receive treatment with the necessary frequency like "do receive treatment".

Exposition: Discrimination
The variable discrimination was evaluated with the question "have you ever felt discriminated for being a Venezuelan since you came to Peru?", and categorized in non-discriminated and discriminated.

Others variables
Including other variables as gender (male and female), age (categorized in thirds), marital state (single and married/widower), education levels (no studies or primary, secondary, and high studies), current job (unemployed and employed),totally economic income (soles), residency department (Arequipa, Lima y Callao, Cusco, La Libertad and Tumbes), presence of disability (without disability and with a disability), type of chronic disease (high blood pressure, bronchial asthma, diabetes mellitus, and others), migratory situation (legal and illegal or in the process of legalization), and health insurance (Without health insurance and with health insurance).

Statistical analysis
Data analysis was performed using the Stata v.15 statistical package. An adjustment was made for the effect of multi-stage sampling using the "svy" command, taking the block as the sampling unit and the city of residence as the stratum. Subsequently, a descriptive analysis of the data was performed using absolute and relative frequencies, and the comparison of the proportions and means using the chi-square and student's t tests.
For the evaluation of the association of interest between discrimination and the treatment of chronic disease, a poisson regression model was used. In this way, crude prevalence ratios (RPc) and adjusted under potential confounders (RPa), with their respective 95% con dence intervals (95% CI) were obtained. P < 0.005 was taken into account as signi cant.

Results
From a total population of 9,852 Venezuelan migrants, 1,956 interviewees were excluded for being under the age of 18, and 7,031 for not having reported having a chronic disease.
A population of 865 Venezuelans (58.2% women, mean age: 36.6 ± 0.7 years) was evaluated, of which 55.1% were married / widowed, 58.5% had a higher educational level, 76.2% currently had a job, 92.7% did not have health insurance, and 54.8% reported having felt discriminated against for being Venezuelan within Peru. (Table 1)

Discussion
Descriptive results Of the total population surveyed by ENPOVE (N = 9852) only 865 participants reported having a chronic disease, representing less than 10% of the population. This low proportion of patients with chronic diseases is probably because, during the migration phenomenon, migrants tend to be in good health since this allows them to achieve their goals in the destination country (11), so it would be expected that the population with some previously diagnosed pathology would refrain from migrating. However, the collapse of medical care in Venezuela can also lead to the search of health systems abroad, that would allow them to control their health needs, such as reproductive health, contagious diseases, chronic diseases, mental disorders, among others (12).
The most frequent chronic diseases reported by Venezuelans are high blood pressure and diabetes mellitus. This agrees with the WHO/PAHO reports where high blood pressure and diabetes mellitus are the most prevalent chronic diseases in the world, including Latin America and the Caribbean (13,14).
Approximately 97% of the migrant population was concentrated in Lima and Callao, probably due to the globalization and urbanization characteristic of the capital (15), since it has better business and investment opportunities for migrants compared to other cities in the country.

Treatment of chronic disease
In our study, 11% of Venezuelan migrants received treatment for their chronic disease. Similar gures have been reported in a study in Chile (16), where 13% of migrants received some treatment for their medical condition.
This interruption of treatment may be originated during the displacement or migration phenomena (17), requiring health care and access to permanent treatment for their control and management of complications at their nal destination (18). However, in the absence of this treatment, the chronic disease of migrants progresses and worsens (19), leading to a decrease in the quality of life of the migrant and an increase in the health care expenditure in the local health sector (20).
In many cases this lack of treatment is due to irregular documentation, which limits the migrant free access to the health service, paying for their health needs with their own money (16). This added to a greater probability of being in a bad economic situation (11,21), motivates them to prioritize spending on other basic needs, leaving aside their medical care. However, in our study almost 56% of migrants had valid immigration documents, so there are probably other possible factors that cause this lack of treatment. Some studies mention that behavioral and idiosyncratic factors (22)(23)(24), such as discrimination, lack of support, ignorance of the destination country's health system and others, make migrants to not demand health services (25).

Social discrimination
More than 50% of the surveyed migrants claimed to have been victims of discriminatory acts. These gures are similar to those reported in previous studies carried out on a population of migrants in Korea (26) and the Netherlands (27), where 50% and 55% of migrants, respectively, reported being victims of discrimination.
It has been reported that it is common to detect discriminatory attitudes during a migratory phenomenon, both by the personnel of the health facility and the general population, as a result of indifference to the circumstances and conditions for which migration occurred (28). This event is probably due to the fact that there is a change in the behavior of the migrant themselve, being more permissive since they are in a country different from their own, which contributes to an imbalance in their biopsychosocial well-being, making them a vulnerable population for discrimination (29). Likewise, these discriminatory acts become more frequent because they are allowed by the migrants themselves for fear of the authorities, employers and society in general (30), which may lead to this discriminatory act being normalized and even underestimated in the country.
This behavior of rejection or discrimination against migrants is the product of a society fearful of the negative burden on the country's economy, the risk of substitution of jobs for citizens and, above all, the reduction of their wages. (11). However, in Peru, according to statistics from the National Institute of Statistics and Informatics (INEI), the economically active migrant population is less than 1% of the total Peruvian labor market. This means that migrants could not have any negative effect on the local economy, and even a study maintains that the migratory phenomenon has a positive long-term effect on the economy of the destination country (4).
Discrimination is a stressful factor for the migrant, which could generate negative feelings, affect health, promoting unhealthy behavior such as abandonment of pharmacological treatment, and it can also lead to physiological changes (neuroendocrine, autonomic and immune) (31). Being able to modify the course of chronic diseases, even producing acute episodes of it (32).
Even if, in Peru, the law N° 28867 (33) of the penal code establishes the sanctions against discriminatory acts, many of these acts are not reported, denounced or are simply underestimated by the affected population (29). For this reason, it is necessary that in a migratory phenomenon the national authorities of the receptor country consider the development of preventive strategies for discrimination, such as establishing a communicative campaign to inform the bene ts of a systematic migration process and the corrective strategies against xenophobia. Likewise, they could implement organizations responsible for looking after this vulnerable population, being able to collaborate with national and international organizations to provide aid to migrants.
Other associated factors 7.3% of the migrant population has health insurance, and the prevalence of receiving treatment for chronic diseases in them increases to 94% compared to uninsured migrants.
Possible causes that lead migrants to not process their health insurance include lack of knowledge about the policies that bene t them, discrimination, immigration irregularity, because migrants with illegal status fear that health service providers will report them to the authorities (11); the different disease patterns, different access behaviors to the health system, economic and social variability, and the provision of health insurance coverage (16).
However, the "International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families" is an international instrument, which objective is to protect the migrant rights. It details that documented or undocumented migrants have the right to access only emergency medical care (11 On the other hand, the prevalence of access to long-term drug treatment among migrants aged 35-93 increased substantially (224%) compared to migrants aged 18-26. This result may be due to higher prevalence of chronic conditions at that age, which requires greater disease control and adherence to drug treatments (35). In contrast to the young age group from 18 to 26 years old, who prioritize work, exposing themselves to occupational diseases and unhealthy environments, or risking their own safety (36), and so neglecting their health care.

Limitations And Strengths
This study may have limitations that must be considered. First, a low percentage of participants with chronic diseases was observed, compared to other populations, probably because the evaluation of chronic diseases of Venezuelan migrants was done through selfreport, and there may be an underestimation of the data in case the participant has a chronic disease, but has not gone to a health center where they are diagnosed. Second, social discrimination is a variable that is self-perceived by the participants, there are probably immigrants who consider an act that does not fall within the de nition of social discrimination as discrimination, and may overestimate the results.
Despite this, there is little evidence about migratory phenomena and their consequences on migrants health, being this study one of the few that has taken a population of Venezuelans living in more than one department of Peru. Likewise, the present study evidences a common social problem that needs to be addressed not only because of its consequences on the mental health of the migrant but also due to its interference in health access.

Conclusion
In the study population, the prevalence of receiving treatment for chronic diseases in discriminated Venezuelan migrants decreased compared to the non-discriminated, being it statistically signi cant. New studies with a larger population of Venezuelan migrants residing in Peru are necessary to evaluate the consistency of the results. Likewise, it is necessary to establish preventive strategies and protective institutions for this vulnerable population that are the migrants.

Declarations
Ethics approval and consent to participate The present study is secondary analysis of ENPOVE. ENPOVE participants were previously informed of the objectives and implications of the survey. Likewise, a codi cation of both the surveyed individual and the dwelling, block, and home was performed.

Consent for publication
Does not apply to this study

Competing interests
The authors have no con ict of interest to declare.

Availability of data and materials
The data of this study are available to the web site of "National Institute of Statistics and Informatics of Peru" (http://iinei.inei.gob.pe/microdatos/) Funding The present study has been self-nanced by the authors.
Authors' contribution OSC and WNG conception or design of the work. CDF and analysis and interpretation of data for the work. All of the authors drafting the work or revising it critically for important intellectual content, and nal approval of the version to be published. The authors agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.