The influence of lack of legal status, age and gender was analyzed using a generalized linear model with robust estimators. The qualitative data was analyzed following the grounded theory approach [ 42 ], using Atlas.
The interview transcripts and field notes were coded parallel to fieldwork, and analytical categories and conclusions were developed inductively over the course of the research project. Two forms of coding were employed: in-vivo coding, which generated analytical categories based on the actual words used by research participants, and open coding, were codes were generated by the researcher based on a close reading of the textual data. Codes were complemented by memos , i. Interview data, conversational notes and field notes were triangulated.
Emerging categories and analytical insights were discussed with research participants to further ensure data validity. Of the 51 migrants not included in the study 17 were excluded for language barriers, 16 did not want to participate, nine had no time to participate, seven needed immediate medical treatment not allowing study participation and two refused to participate because of fear.
Sociodemographic characteristics of the sample of undocumented migrants for the quantitative study and the different comparison groups. Mean scores in all eight dimensions of HRQOL in the sample of undocumented migrants were significantly lower than the U. American norm scores. Mean scores more than a standard deviation below the U. American norm.
Summary scores could be computed for 79 undocumented migrants. Mental and physical summary scores health showed significant lower scores in undocumented migrants when compared to representative U.
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American and German samples of people, who suffered from illnesses as well. Undocumented migrants seeking health care at the Medibuero scored a mean of Americans with at least one health condition Generalized linear model with robust estimates indicates a significant negative effect of living without legal status on mental and physical health. Mental health summary scores of undocumented migrants were reduced by A total of 35 migrants from various Latin American countries took part in the qualitative ethnographic study.
The research participants were either undocumented at study entry, or shared their experiences of having lived in Germany illegally in the past. All of the research participants had completed secondary education, and many had received vocational training or studied at a university. The analysis of interview transcripts and field notes showed that prevalent stressors are precarious socioeconomic conditions and a constant fear of denunciation, detention and deportation.
All research participants had come to Germany to either work or study in order to provide a better life for themselves and, in most cases, also for dependent family members. Many of the participants experienced phases of homelessness, unemployment or poverty, usually at the beginning of their stay in Germany. Over the course of time these conditions usually stabilized: the majority of the research participants found paid work, usually as cleaners and child-minders or in the service industry, and lived in their own apartment.
However the absence of employment contracts or rental agreements, and the constant threat of losing work and housing resulted for most study participants in perceived instability of daily routine. This precarious situation is exacerbated by the fact that many undocumented migrants have debts due to the costs of migration, and their income in Germany often lies significantly below what they had hoped for and counted on.
Getting sick or not being able to work due to childcare responsibilities, or even worse, being arrested and subsequently deported would have significant negative economic consequences for migrants and for their families, in addition to the emotional trauma caused by imprisonment and an involuntary return to the country of origin. The majority of participants reported that the perceived threat of deportation was impacting on daily life as much as on accessing health care as consulting a hospital or a physician was considered a potential way of being identified and subsequently transferred to the country of origin.
All study participants experienced problems in accessing health care and many reported deterioration of health status due to the lack of access. The following case studies exemplify precarious socioeconomic conditions experienced by undocumented migrants and the effect of criminalization on physical and emotional well-being of undocumented migrants. Dominga came from La Paz, Bolivia to Berlin in The woman in her early twenties was invited over on a tourist visa by a Bolivian family who employed her illegally as a care-taker for their children. They had paid for her travel costs, and expected her to pay off her debt by what came down to working for less than one Euro per hour.
Half a year after she arrived, when her visa had already expired, Dominga realized that she was pregnant. After she had digested the shock of the unplanned pregnancy, Dominga decided to keep the child, and to make a life for herself and her son in Berlin. The following years were shaped by hardship: as an undocumented migrant and single mother, Dominga relied heavily on friends and non-governmental organizations to get by.
She received perinatal and postnatal care through the Berlin-based Medibuero, one of the non-governmental organizations introduced above. The rent for the apartment she lived in was paid for by a network of women supporting undocumented Latin American migrants. A few months after her son Christian was born, Dominga started working as a cleaner in private households.
She could only work for a few hours at a time, as she had no one to take care of her son while she was working. Dominga was worried that she would denunciate her to the police. She explained in an interview:. My ears, I got an infection, blood came out of my ears. From all the stress, from the shock that I got when I needed to move out of the apartment. Look, I got sick because of that. It was the fear of the police, that the police would come find me.
It was difficult, you know. Dominga was ill for almost one year. In the end, she decided to return to Bolivia:. What happens to my son if I get sick again? Who takes care of him? It is too much stress, too much fear. Jaime, a young man from Chile, had come to Europe — first to Italy and then to Germany — with the aim to study. His student visa application failed, however, and he ended up as an undocumented migrant in Berlin.
The four-hour interview was not recorded, as he was concerned about confidentiality, so the following narrative is based on extensive notes. He suffered a great deal from what he perceived to be a failure to achieve his aims.
He said:. It was tearing me apart. To see your dream shattered means to see yourself shattered. Linking his physical and emotional health to his living circumstances, he commented:. Bad alimentation, too much work, too much stress, sleeping badly. All of this directly affects the heart. Tabea came to Germany in , together with her German boyfriend whom she met in Bolivia. She wanted to study German in order to improve her education and subsequently, her job opportunities. Like Jaime, she was denied a student visa, and once her tourist visa ended, she was illegalized. In an interview, she described how her illegal status affected her life:.
Sometimes I stumble into a depression. So far, I never ran into a control. Thank God! So, that [sighs]… that affects my health, because I am always nervous, I always live with this fear that something could happen to me. Tell me, how do you live?? I always have this fear, I always cry, I am not doing well. We utilized a mixed method approach to investigate subjective health of undocumented migrants and influencing factors.
We demonstrated that HRQOL of undocumented migrants is significantly lower than in comparison groups, in particular mental health is rated lower and pain intensity is rated higher. The results of the qualitative research illustrate how negative social determinants, stress and fear, and exclusion from the health care system contribute to a deterioration of the health of undocumented migrants. Undocumented migrants rated their health significantly worse than the general population in all eight dimensions of HRQOL measured by the SFv2.
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Scores were particularly low in the dimensions assessing pain, mental health, role limitations due to mental problems and social functioning. Subjective physical and mental health was worse for undocumented migrants than for German and U. American comparison groups.
Given the mean age in the U. American comparison group in accordance with what has been described in the literature [ 15 , 16 ]. However, these differences can as well represent differences in pain intensity tolerated until medical care is sought. Even though all but one undocumented migrant declared to have come to the Medibuero for a physical health problem, their mental health summary scores differed significantly from the comparison groups.
The differences are possibly a result of mental health problems of undocumented that are expressed as non-specific physical health complaints, which is described in the literature as a common consultation pattern of undocumented migrants [ 8 , 15 ].
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The ethnographic study supports these findings, sheds light on the prevalent stressors and explains how and why the health status of undocumented migrants is often significantly worse than the health status of legal residents, as discussed below. SFv2 physical and mental health summary scores as well as the eight subscales correlate with social determinants of health such as socioeconomic background, education attainment, income and employment [ 38 ]. They are as such possible indicators for negative effects of socioeconomic conditions associated with life without legal status which could not be controlled for in the present study.
Significantly lower scores compared to Germans for physical and mental health are likely to reflect differences in socioeconomic status and ability to participate in society.