Introduction

The continuous political and economic instability in many Latin American countries and the United States’ tightening of migration conditions and controls have positioned the European Union (EU) as an alternative destination for Latin American migrants (LAM). Spain in particular experienced massive migration from Latin America (LA) between 2000 and 2006, although other countries like Italy and Portugal also saw a considerable increase in their populations of Latin American origin. This relatively new migrant group is composed mainly of Ecuadorians, Colombians, Peruvians, Bolivians and Brazilians who often work in low-paid sectors where irregular employment is common, such as services, construction, domestic work and personal care.

The recent economic recession and high unemployment rates in South-European countries have caused secondary migration flows back to the countries of origin, the Unites States and other European countries [1]. Nonetheless, with an estimated 1.6 million resident Latin Americans, Spain continues to be the most important reception country for this population within the EU. LAM benefit from positive selection legislation that facilitates the acquisition of Spanish nationality after two years of continued residence. Still irregular foreign residents from Latin America were estimated at 478,000 in 2008 [2].

Undocumented migrants in Spain can be detained and retained for up to 60 days. Violations of human rights at custody centres [3] and race-based police raids aimed at identifying irregular migrants in public spaces such as metro stations and Internet cafés have been denounced by a number of organizations [4]. In 2013, a total of 23,889 irregular migrants were repatriated [5].

As part of the austerity measures that accompanied the economic recession in Spain, a Royal decree-law came into force in 2012, which excluded undocumented migrants from full healthcare entitlements [6, 7]. The congestion of emergency services caused by this policy recently led authorities to announce partial reinstitutions of their health care rights [8].

Although migrants tend to be, at least initially, relatively healthy compared with the non-migrant population in the host country, they are often more vulnerable to communicable diseases, occupational health hazards, injuries, and maternal and child health problems [9]. Many are exposed to social, occupational and economic conditions that may have detrimental effects on their health [10]. Research on the health of LAM in Europe has focused mostly on communicable infections, a range of psycho-pathologies and maternal and child health, with a predominance of studies focused on Chagas disease, a potentially life-threatening vector-borne disease that is particularly prevalent amongst migrants originating from parts of Bolivia [11]. LAM have a tendency to be overweight and are prone to allergies and asthma. Specific sub-populations carry a disproportionate burden of communicable infections such as HIV and tuberculosis (TB). Inconsistent results cast doubts on some widespread assumptions, including popular perceptions that LAM are more prone to psychological disorders and resort to health care services more frequently than the indigenous population. The role played by perceived discrimination has also been insufficiently explored, with studies finding both strong and no association with mental health indicators [1].

Providing an adequate response to the health needs of migrant populations is imperative on both human rights and public heath grounds but it is impeded by major cultural, legal, administrative, political and financial challenges. While the importance of participation by intended beneficiaries in the planning of health services is recognised as key to responding to some of these challenges [12–14], there have been few attempts to engage migrant populations in the definition of priorities [15]. Discussions often take place among experts over the heads of migrant populations and priorities are generally driven by the interests of academics, policy makers and clinicians [12].

This study is part of a broader project which aimed at developing a multi-disciplinary research agenda on the priority health issues that affect LAM (Coordinating Resources to Assess and Improve the Health of Latin American Migrants in Europe- COHEMI). Based on the assumption that the health priorities of migrant populations are not necessarily aligned with those of scientists and that lay opinions constitute a valid source of knowledge, this qualitative study challenged traditional hierarchies of control over knowledge production by engaging LAM in the development of the research agenda, and giving them a voice in the identification of priorities right from the onset of the process.

Methods

We conducted 30 group activities with 84 persons from 14 Latin American countries in the two cities hosting the largest numbers of LAM in the EU (Barcelona and Madrid). In cooperation with community-based organisations we recruited participants purposively to maximize diversity of ages, nationalities, duration of stay, family circumstances, sexual orientation, and economic, occupational and educational background. We worked with already existing natural groups that gather regularly to play sports, practice folkloric dances or pray, as well as vulnerable and/or harder-to-reach persons such as participants in a voluntary return program, women without any formal education, young mothers, sex workers, and sexual minorities, including men who have sex with men (MSM) and transgender women. We considered as Latin American migrants all persons currently residing in Spain that were born in any Spanish or Portuguese speaking country located in Central-South America and the Caribbean. We pragmatically included their descendants in our definition in order to account for potential generational divergences. The majority of study participants had lived in Spain for more than seven years, 85% originated from urban areas, and most had secondary or university education. Further details on the characteristics of study participants are provided in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0136315.t001

We gathered a total of 11 different groups and conducted repeated discussion sessions with each of them at their usual gathering venues or in rooms facilitated by community-based organisations. We aimed at organising three rounds of activities with each group in order to engage participants in the identification of priority health concerns (Round 1) and possible solutions (Round 2) using task-focused activities specifically tailored to encourage groups to work together in the identification, ranking and analysis of their most prominent health concerns. During these activities, participants were asked by the facilitators (one anthropologist and one cultural mediator trained in qualitative methods) to identify main health problems using symbolic bricks that were ranked by participants into a wall of challenges that the researchers used to probe further and gather additional insights. The use of open-ended questions gave participants the opportunity to respond in their own words as opposed to forcing them to choose from fixed responses [16]. During Round 2, the researchers catalysed a deliberative process aimed at co-creating a tree of solutions where symbolic fruits represented potential ways to overcome the challenges identified during the previous round. The initial data collection guideline used during these activities is provided as supporting file 1 (S1 File). We encouraged participants to contribute to the interpretation of our findings by organising a third round of discussions where we shared our study results and engaged them in the refinement and revision of our interpretations (Round 3).

A generous time allocation of approximately three hours per activity allowed us to progressively build trust and gain depth of insight and analysis so we could explore emerging topics, share our findings with participants and validate our interpretations in a two-way communication flow between social scientists and study participants. We brought together 65% of participants from eight of the groups for three consecutive rounds and a total of nine new persons joined us for Round 2 or Round 3. For three of the groups it was not possible to organise a final session due to difficulties in convening the group within the time frame of our study. Overall, 42% of study participants took part in the three rounds (Table 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Number of participants by group and data collection round

https://doi.org/10.1371/journal.pone.0136315.t002

Data collection, processing and analysis took place simultaneously allowing for timely adaptation of data collection guidelines as soon as salient new topics were identified [17]. During the fieldwork period (November 2012—March 2013) we organised weekly debriefing meetings to adapt the tools based on the contributions of a multidisciplinary team composed of a sociologist, two anthropologists and a cultural mediator. New questions and probes were added to the initial data collection guidelines as a result of this ongoing process.

All discussions were tape-recorded and transcribed (BN, FB). We also took notes and pictures of visual outputs. The quality of transcriptions was checked and the process fully revised when deemed necessary. The first author (MR) conducted the analysis of data in its original language (Spanish) with inputs from FB and BN. Recurrent topics were assigned codes and were sorted into categories and subcategories within an initial coding frame that accounted for the diverse layers of health determinants underscored by the socio-ecological theoretical framework developed by Dahlgren and Whitehead including the broader structural context, living and working conditions, social networks and individual factors [18]. Codes continued to be created, merged and modified as data collection and analysis progressed, employing a combination of inductive and deductive approaches. A definitive coding framework was agreed on through research team consensus and then the first author coded all the data with the aid of NVIVO-10 software [19, 20]. We matched our findings against the key areas of research identified in a recent systematic literature review focused on LAMs’ health [1] in order to identity most prominent gaps between the current scientific focus and participants’ views on what the priorities should be. We paid particular attention to disconfirming evidence in order to provide a nuanced account of our findings and refine emerging interpretations [17]. During the third round of activities we presented our preliminary results and collected participants’ views on our preliminary findings. One of the facilitators (BN) ensured that the doubts raised and gaps in knowledge identified were clarified for participants. She distributed informative leaflets and telephone contacts where participants could obtain further information including medical, social and legal advice.

Ethical approval was obtained from the Hospital Clinic-University of Barcelona ethical committee board (CEIC). Informed consent procedures were administered throughout fieldwork. At the recruitment stage all prospective participants were informed in detail about the overall aim of the project, the approach used and their expected role. We highlighted the voluntary nature of participation and asked participants for consent to be anonymously quoted in study reports so they could take a decision about whether or not to attend the activity. In addition, prior to each group discussion, an information sheet was read-out and sufficient time allocated for questions. Special emphasis was placed on avoiding false expectations and clarifying the boundaries of the potential support to be offered by the project. All necessary information was provided in a language that suited the participants' level of understanding and the group facilitator stressed that each participant was free to leave the group at any time or to refuse to participate in any of the activities. As this study carried a minimal risk, attendance and participation in the activities was considered sufficient proof of consent by the ethical committee board. No remuneration or compensation was provided to participants, except for a small lunch shared with the researchers during the breaks in the activities.

Results

The main health concerns identified by study participants were consistent across groups and related to stressful working and living conditions associated with their condition as migrants and further exacerbated by the accelerated rhythm of life in the host society. Participants consistently delineated a body-mind continuum where emotional and health problems were intrinsically linked and manifested in a constellation of ill-health symptoms rather than as specific diseases.

The health system: “ibuprofen and paracetamol”

Consistent with perceived priority health needs, health care was commonly sought for unspecific symptoms as opposed to concrete diagnosable diseases.

A range of barriers prevented some persons from accessing health services. These mainly related to recent legislative changes restricting health care entitlements for irregular migrants. Not having a health card and fears of being arrested were key obstacles in a context where irregular work was common and confusion over the actual implications of new regulations prevailed. Restrictions of health care entitlements could lead to deployment of a range of strategies to access health care, including borrowing medical cards and resorting to emergency care for non-urgent conditions. Bureaucratic procedures, lack of information, incompatibility of work duties with hospital schedules, and concerns over being diagnosed with a serious disease also hindered service use. In a population unanimously self-defined as stressed, time was a highly valued asset that was carefully administered to fit in competing priorities. Earning hourly-paid wages ranked high in the hierarchy of life priorities and was often prioritised over attending a doctor or getting the necessary rest to recover from illness (“You have to choose between your work and your disease”).

Factors influencing health seeking that transcended access barriers included the cost of medicines, not being physically examined and having to go through general practitioners in order to access specialised care. Many participants reported that they were always prescribed the same medicines (ibuprofen, paracetamol and omeprazole), which discouraged them from seeking care and triggered self-medication. The need to endure pain to be able to work fostered routine use of pain-killers/anti-inflammatory drugs that reached levels categorised as addiction by a few participants. The widespread routine medicalisation described by study participants was often attributed to the local culture, characterised by marked preference for medicines over natural remedies. (Table 3)

F2: I’ve heard people say: “Why should I go to see a doctor if all what I’ll get is paracetamol? I can just buy it myself in a pharmacy”. Many people have stopped going to the doctor because they just give you paracetamol and that is it!

Group 5, round 2- various countries

A few participants ascribed it to clinicians’ tendency to attribute their pains to stress or categorise them as psychosomatic and hence not deserving additional medical examination.

F4: They always end up prescribing omeprazole. [Pretended doctor’s response]: “Ah, you [Hispano-Americans] complain about minor things”.

M7 [Pretended doctor’s response]: “It is stress”. That’s all what they tell you

M4 [Pretended doctor’s response]: “Ibuprofen”

Several voices [Pretended doctor’s responses]: “Paracetamol”, “omeprazole”.

Group 1, round 1- Bolivia

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Medicated lives: “I carry ibuprofen in my bag”.

https://doi.org/10.1371/journal.pone.0136315.t003

Views on the quality of health-care varied and were mostly influenced by the attitude of professionals. In spite of sharing the Spanish language some participants reported communication problems with providers. These included use of medical jargon and a tone of voice described as rough. Some felt discriminated in the attention received but others attributed it to Spanish culture and sympathised with the deteriorating working conditions of health professionals. The functioning of the health system compared favourably with services received in the home countries, the free services were appreciated, and the system was seen as particularly efficient in dealing with severe diseases such as cancer and HIV.

When we asked participants to identify interventions that would benefit their health, most proposals targeted health institutions and providers. These included training HPs on interpersonal relations, the establishment of monitoring mechanisms to identify discriminatory practice, the diversification of clinicians’ ethnic profiles, expanded presence of cultural mediators at health facilities, and provision of services beyond usual working hours. Participants also mentioned that they would benefit from psychological support services, provision of clear information about their entitlements and occupational safety courses specifically adapted to their needs (E.g. ergonomic advice for cleaners and carers). They mentioned that they should take care of themselves (“eat well, sleep well”) and that veteran migrants could be involved as mentors providing health support and advice to new comers.

Discussion

This qualitative study found that stress, and to a lesser extent depression, were the major health concerns of a population that conceptualised their health status as a constellation of symptoms, often manifested as pain, rather than as specific diseases. Participants described a generalised situation of stress that could trigger the adoption of unhealthy habits, which they attributed to the cumulative toll of challenges they had to face on a daily basis, with a particular predominance of work-related factors. The accelerated rhythm of life prevailing in the reception society was felt to be contagious and to contribute to the high levels of stress reported by study participants. Other sources of chronic strain related to the legislative framework regulating citizenship entitlements and feeling ethnically discriminated. Colds and other ailments attributed to environmental conditions were also frequently mentioned, with episodes of asthma and allergies commonly reported. With the exception of STIs, participants rarely mentioned specific diseases as a concern. Health seeking could be hindered by lack of access to services, short-term prioritization of work over health, and the perception that they were always prescribed the same drugs: ibuprofen, paracetamol and omeprazole (Table 3). During a final round of group activities designed to engage study participants in the interpretation of results, stress was ratified as the leading overarching perceived cause of ill-health, but the conceptualization of depression as a disease was sometimes questioned.

The body-mind continuum consistently described by participants and the relevance attributed to relatively common ailments such as anxiety, migraines, colds, digestive problems, and backache, is in sharp contrast to the vertical, disease-centred approach that prevails in the scientific literature addressing LAM’s health in Europe [1]. In our study, participants of both sexes acknowledged having adopted more liberal sexual behaviours after migration, and only the youngest reported adoption of safer-sex practices, which they attributed to increased availability of information. Most were unaware of risks related to diseases known to be particularly prevalent amongst specific Latin American populations including TB and Chagas disease [1, 11]. Our findings thus emphasise the importance of paying increased research and policy attention to communicable diseases that disproportionately affect LAM. In addition, it should be acknowledged that communicable diseases contribute only partially to the burden of ill-health in a population that is more commonly affected by gynaecological and obstetric conditions, traumatic accidents, migraine, headaches, lower back pain, anaemia, emotional downturns and gastrointestinal disorders [1]. Our results are in line with studies conducted in other populations, which also suggest that migrants are commonly affected by the same diseases as locals [12, 21–23]. The few conditions for which migrants have specific health needs must be addressed but the focus on differences rather than similarities should not divert attention from the most common causes of morbidity in this, and other migrant populations.

For our study participants, job insecurity, unemployment, long working hours, communication problems with employers and low status employment were important sources of stress and major underlying reasons for most of the symptoms described. Within a perceived vicious circle, body defences deteriorated and unhealthy mechanisms to cope with stress were deployed, including anxiety-induced unhealthy eating, smoking and alcohol abuse.

The aetiology of disease described by our study participants resembles the accounts provided by social epidemiologists on the multiple pathways through which the psycho-social environment influences health outcomes, both directly through deterioration of the immune system and indirectly via adoption of unhealthy behaviours [24]. The brain is able to influence immune function [25] and a growing body of research has examined the pathways though which subjective experience and emotions translate into chronic stress to affect health outcomes [25, 26]. As described by our study participants, these involve the immune system, but also metabolic and neuro-endocrine reactions [25].

Psychobiological studies suggest that while the stress response is an essential element in the total adaptive system of the body, a period of recovery is necessary to manage new demands [27]. Our study participants vividly described feeling overwhelmed by a cumulative succession of daily challenges, suggesting that a period of recovery was often unavailable to them. This allostatic load associated to repeated or chronic challenges [28] can potentially lead to sustained psychobiological activation and loss of dynamic capacity to respond to new challenges, and has been related to higher risk of illness among people with lower socio-economic status [27]. Additional research is needed to assess how the potential accumulation of psychosocial disadvantage may exacerbate these processes in this population and the potential effects on health of the coping/resistance strategies mobilised [29].

The participants’ view that they were working themselves to death is consistent with epidemiological research pointing to occupational strain as a major cause of ill-health [30, 31]. High job strains and effort-reward imbalances [32, 33], limited decision-making autonomy [34, 35], shift-work [36], job insecurity [37], unemployment [38] and lack of opportunities to use skills [30] have been reported as detrimental to health in the general population. These factors may be exacerbated in migrant populations that are less likely to have job security, more likely to work at a very high speed, and to work shifts or at least have variable working hours [39, 40]. Our study participants reported common effort-reward unbalances including employment in low status jobs, occupational insecurity, and poor promotional prospects. Qualitative research should build on sociological theories commonly used in epidemiological research—such as the effort-reward imbalance model [33]—to examine its applicability to diverse migrant populations. The degree to which strains and/or buffers rooted in other spheres of life (emotional, relational, financial) synergistically operate to negatively and/or positively influence migrants’ health status and behaviours also deserves further attention. Greater policy attention should be paid to the invisibility of domestic and personal care work frequently performed by LAM [41]. A careful evaluation of the achievements and pitfalls of policies designed to regularise domestic work, such as the voucher system in Belgium [42], could shed light into what should be done to address this issue.

Unhealthy behaviours such as smoking, excessive eating and alcohol/substance use were generally seen as mechanisms for coping with stress. This highlights the importance of addressing the underlying determinants of behaviours [43], moving beyond bio-behavioural reductionist health promotion interventions that subtly blame the affected ones out of their ignorance and/or unwillingness to change. To transcend the current narrow focus on culturally friendly information materials we need to further understand the linkages between contextual factors and the adoption of specific health behaviours without neglecting individuals’ personal agency. Inductive theory-generating qualitative inquiries could provide a better account of how self-efficacy, coping mechanisms and resistance/resilience strategies are deployed by populations constrained by major structural barriers, contributing to advance our understanding of the interplay between culture and social structures, and migrants’ possibilities to influence their lives [44].

The health problems prioritised by the participants in this study were strikingly consistent across heterogeneous groups, and participants often referred to certain characteristics of the host society as sources of ill-health. These were shared with the local populations and included an accelerated rhythm of life, greater exposure to chemical products, more liberal sexual norms, social acceptability of some unhealthy habits and widespread medicalisation. The health problems associated with stress were not necessarily seen as specific to migrants or LAM but rather as a particularity of the receiving country where stress was part of normal life and could be “caught”. Still, many study participants reported that they were also affected by sources of stress that were specific to their status as migrants, and which derived from discrimination, irregular residence status, occupational disadvantages, financial concerns and poor social support.

Participants were generally satisfied with the health services but a common complaint was that they were always prescribed the same drugs: paracetamol, ibuprofen and omeprazole. This could hinder health-seeking and foster self-medication as a routine strategy to palliate a range of pains (dolores), especially when these interfered with their capability to work. While the use of these drugs is widespread in many parts of the world and some participants viewed them as harmless, they are not exempt from pharmacological debate [45–47]. A recent systematic review and a placebo-controlled trial, for example, have questioned the innocuousness of paracetamol [48] and its efficacy for back pain [49].

In contrast with the traditional view of migrants’ culture as a source of dysfunction, our results support calls for a more comprehensive approach where cultures of all kinds, including professional and political cultures, are tackled as major barriers to better health [50]. The conditions of daily life affect individuals’ health and these are in turn influenced by structural factors including laws and policy frameworks [43] as well as by super-structural determinants related to the hegemony of western values, unequal distribution of power and resources, and macro-social, economic and political arrangements (Fig 1). Beyond the micro-level focus on health behaviours and social networks due attention must be paid to broader structural factors [44, 51], including the underlying reasons of the accelerated rhythm of life prevailing in the host society, the medicalisation of common conditions [52] and the socially un-sanctioned practice of employing LAM as domestic workers in irregular conditions. As illustrated by the reports of participants rushing out of the metro “like Colombian cattle”, holding “embarrassing” cigarettes, or having “two, three shags”, behaviours may change faster than values. The emotional unrest derived from this and its implication for health and wellbeing requires additional research.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Priority health concerns and determinants identified by study participants.

https://doi.org/10.1371/journal.pone.0136315.g001

Quantitative reports point to wide disparities in mental health status across different LAM populations [53] supporting the idea that perceptions of psychological wellbeing differ markedly both across and within societies [50]. Studies examining the mental health of LAM in Europe show inconclusive results [1] and a meta-analysis found that the overall prevalence of depression in migrants is similar to figures for the general population [54]. Still, LAM are frequently portrayed in the popular media and in medical/academic circles as a population that has a low tolerance of pain [55], is prone to depression [56] and somatisation [57], and at high risk of developing psychiatric problems [58]. It could be hypothesised that the culture of viewing LAM in this light might have contributed to the over-attribution of their symptoms to a depressed mood. Our data does not allow us to confirm this hypothesis, although concerns about the pathologisation of migration have been previously raised. In the UK for example, the higher prevalence of diagnosed mental illness in Afro-Caribbeans is generally attributed to the stressful conditions of migration, but it has been argued that this could also be due to the practitioners’ shared view that this group is particularly prone to mental disorders [50].

Migrants’ cultures (like the host cultures) are hybrid, heterogeneous, many-layered and constantly changing [12, 51, 59]. They draw on many cultural sources through social interactions including encounters with health providers from whom they pick up new schemas through which to think about and conceptualise illness. Health providers participate in a process of mutual interaction that shapes migrants’ culture, influencing their mindset [60]. We can’t rule out that these interactions might have influenced our study participants’ perceptions of their own health, leading to frequent prioritisation of depression as a health concern. If, as suggested by medical anthropologists, the differences in the cultural meaning of depression alter individuals’ experience of depressed mood [61], the categorization as disease of what could also be considered as a normal pattern of distress in response to stressful life events [50, 62] could negatively influence individuals’ self-perception of wellbeing [60]. Tagging a group with a diagnostic label is problematic as once integrated into a set of cultural beliefs, labels are difficult to remove and may be internalised by individuals (and groups) who accept the label they have been assigned, potentially reinforcing the expectations created by that label. It should also be considered that cultural variations in the way distress is experienced and expressed may lead to under-diagnosis of mental health problems because diagnostic tools based on western expression of emotional wellbeing may be less sensitive in specific migrant groups who also may experience poorer access to medication and care [63]. It is important to consider the potential harm resulting from unnecessary labelling [64] attached to shifting medically-defined boundaries between the normal and the pathological [52]. At the same time, it should be acknowledged that the construction of a diagnostic term may help some persons to make sense of their suffering, legitimate access to services and establish entitlement to rights reserved for the sick. The existence of mild categories of mental health problems could foster health-seeking for otherwise highly stigmatised psychiatric conditions likely to remain undiagnosed.

The dramatic discrepancy between the priority health problems addressed in the scientific literature (mostly focused on communicable infections) and the views of LAM themselves (mainly centred around constellations of ill-health symptoms) highlights the need for greater interaction between different forms of expertise. As pointed out in the Review of Social Determinants of Health “effective mechanisms are needed to enable individuals and groups who are the target of policy to be heard and meaningfully involved in decisions that affect their lives” [43]. In this process, the biomedical culture and its reliance on pharmacological solutions should not remain unquestioned [60]. In our study, participants’ beliefs coincided with what has so far been reported in epidemiological research, while health providers often prescribed painkillers of questionable effectiveness in treating common ailments. Our findings cast doubt on the popular assumption that health providers’ knowledge is the only valid one, and that concessions must be made to accommodate migrants’ cultural beliefs [50]. The adoption of culturally humble approaches that question the adequacy of dominant cultural frameworks and foster self-reflection [60] is a potential promising avenue for a “better recognition among those who care for the sick of their own cultural assumptions and biases” [50]. Along the same line of argument, the explicit recognition of the harms of over-diagnosis and overtreatment in some medical circles [64–66] and severe criticism of proliferating diagnostic categories “dressed up by modern psychiatry as diseases” [62] calls for revisiting the assumption that the biomedical culture is homogeneous and fixed.

In our study, participants from populations severely affected by Chagas disease—a potentially deadly condition- did not identify it as a major health priority, illustrating the importance of balancing patient involvement with professional medical opinion. While most health problems were attributed to the overarching social determinants of health, the solutions proposed focused on the health sector and disregarded broader level interventions as unrealistic. Important health issues must be addressed even if they are not socially constructed in a community as warranting research and action [67].

This study has several limitations. We did not reach data saturation. The iterative process of collecting and analysing data and feeding results back to participants could have continued to add more depth to our analysis and generate additional insights. The views of persons more severely depressed, isolated or overwhelmingly stressed are likely to have been under-documented as they are probably less likely take part in time-consuming and demanding research. We achieved modest success in sustaining participant involvement throughout the project and acknowledge the enormous challenges laying ahead for our study results to be translated into a policy effectively addressing the broader, macro-structural external layers of the social-ecology. Additional time and resources would have been required to engage relevant parties such as health providers and policy makers to increase the chances of translation of results into interventions. While our findings make a convincing case for the importance of integrating health policies into other sectors, placing health-related goals on the agendas of policy-makers who have other aims and priorities is beyond the scope of this study. In spite of these limitations, we expect that our findings will contribute to stretch the limits of migrant health policies beyond their current focus on infectious diseases and individual lifestyle and will nurture critical thinking about the use of participatory approaches in health research. As the importance of accounting for diverse forms of knowledge is increasingly recognized in scientific circles [68] and the community engagement paradigm is growingly embraced in health research beyond its traditional focus on HIV [69–70], it its crucial to account for the lessons learnt and acknowledge the challenges posed, resources needed, and limitations of this increasingly popular approach [71, 72].

Conclusion

It is important to tackle both the diseases that disproportionately affect LAM and the health conditions that affect them more frequently. Health systems face limitations in addressing health problems whose roots are embedded in broader contextual factors. Occupational and migration policies should be tackled as major structural determinants of health. The consideration of migrants’ strengths, vulnerabilities, commonalities, heterogeneities and continually re-constructed hybrid cultures adds layers of intricacy to a field of undeniable empirical complexity.

The mismatch between researchers’ emphasis on communicable infections and the health concerns of Latin American migrants highlights the need for greater interaction between different forms of knowledge. In this process, the biomedical culture of reliance on pharmacological solutions should not remain unquestioned. The limitations and costs of participatory approaches must be acknowledged.

Supporting Information

Acknowledgments

We wholeheartedly thank all the individuals who generously dedicated their time to this study as well as the organisations that helped us during the recruitment process. We would also like to acknowledge the constructive feedback and useful insights provided by two anonymous reviewers. We thank Lara Alonso for her contributions to data collection and the COHEMI working group, which includes: Maurizio Bonati, Francesca Severino, Valeria Confalonieri, Chiara Pandolfini, Zeno Bisoffi, Dora Buonfrate, Andrea Angheben, Marco Albonico, Alessandro Bartoloni, Marianne Strohmeyer, Lorenzo Zammarchi, Robert Pool, Maria Roura, Barbara Navaza, Federico Bisoffi, Ana Requena Mendez, Jose Muñoz, Joaquim Gascón, Mª Jesús Pinazo, Mª Elizabeth Posada, Laia Ventura, Anita Hardon, Christopher Pell, Peter L. Chiodini, Juan Moreira, Roberto Sempértegui, Mariella Anselmi, Eduardo Gotuzzo, Maria Alejandra Mena, Hector H. Garcia, Javier Bustos, Saul Santiva, Faustino Torrico, Daniel Lozano, Guido Chumiray Rojas, Teresa Hinojosa Cabrera, Javier Ochoa Morón, Ignacio Abapori, Cuellar, Jaime Amorós Suarez, Gianni Tognoni, Alessandra Nicoletti, Elisa Bruno.