In line with traditional countries of immigration, such as Australia, Canada and the United States, the issue of migrant health receives increasing attention in Europe , and particularly in Luxembourg. Accurate data on the health of Portuguese migrants are an essential pre-condition for providing appropriate and accessible health services to this population group.
In contrast to the widespread opinion among the general practitioners, this analysis of a large national sample documented, for the first time, an absence of heterogeneity between Luxembourgers and Portuguese immigrants to Luxembourg, concerning the most important preventable and potentially modifiable cardiovascular risk factors, except the higher overweight/obesity among the Portuguese. As in most European countries, the organization of Luxembourg’s health care services ensures equal access and utilization to different immigrant groups. In addition, a number of measures were already implemented by policy-makers to improve access of immigrants to health services. These include overcoming language barriers and poor communication by providing interpretation and regular Portuguese translation of official documents. The translated documents help publicizing health education messages to immigrants. Therefore, our findings may reflect a national parity in health and equal opportunities to care access.
Prior studies have suggested mixed evidence concerning the relationship between acculturation, lifestyle behaviors, and cardiovascular risk factors among immigrants [7, 8]. Several studies suggest that acculturation is associated with some positive healthy behaviors, such as leisure-time physical activity , whereas others suggest that the positive health behaviors decline with acculturation [32, 33]. It is noteworthy that similar prior studies were largely carried out in US, few studies carried out in Europe, and even none in Luxemburg.
Luxembourg’s immigration rate rose sharply in the course of the last century, with a noticeably important influx of Portuguese immigrants during the last 40 years. In contrast to the tendency of other minorities, a large majority of Portuguese immigrants seem to keep their original culture. The geographical proximity to their country of origin allows for frequent contact and travel. Many resident Portuguese continue to speak Portuguese and are closely tied to their cultural roots; however, many do learn the official languages of Luxembourg (French and German, beside Luxembourgish), integrate the new culture, and thus become bicultural and multilingual to different extents. The distinct cultural particularity of Portuguese immigrants to Luxembourg provided the opportunity to examine the overweight/obesity-acculturation relationship among Portuguese of first and second generation. For this objective, we considered three proxy indicators including proportion of life spent in Luxembourg, language proficiency or preference, and immigrant generation status. Although none of the acculturation markers, both individually and taken together as a score of acculturation, were statistically significant after controlling for age and gender, we observe a tendency of lower risk with higher acculturation. The absence of statistically sensible effect may be related to low sample size of Portuguese of second generation. In fact, the selected ORISCAV-LUX sample was representative of the source population with respect to nationality, however, the participation rate was lower in Portuguese residents (13.62%, n 195) as compared to Luxembourgers (62.08%, n 889) . Positively, the breadths of confidence intervals were not excessively wide-ranging, particularly for the acculturation score, which gives a more accurate representation of acculturation than each indicator alone. These confidence intervals provide an ‘estimate interval’, which gives us a measure of ‘precision’ or ‘confidence’ around our point estimate; wide confidence intervals indicate lack of precision . Therefore, we globally concluded that the most acculturated Portuguese immigrants seemed to be protected and less susceptible to be overweighed/obese than the least acculturated. The absence of levelheaded association is probably because the effect size (culture) is too small to get a statistically significant result, i.e., although may exist, it couldn’t be detected by the actual sample size.
Another potential explanation of our finding may be related to the “healthy migrant effect phenomenon” . Although immigrants face particular health challenges and are vulnerable to a number of threats to their physical and mental health, they are often healthy and enjoy a good health to work, notably in case of successive labor Portuguese migration.
In addition, the prevalence of main cardiovascular risk factors, in particular overweight/obesity are highly elevated both in Portugal  and in Luxembourg . This homogeneity between the two populations may limit the ability to detect a discriminative effect of acculturation.
Overweight/obesity is a national public health problem. According to previous ORISCAV-LUX survey findings, more than 50% of adults’ residents in Luxembourg were affected, the prevalence increased with age, and varied by country of birth . In this study, we documented a higher prevalence of overweight/obesity among Portuguese immigrants compared to Luxembourgish participants. About two-fold odds associated with migration status (Luxembourgers versus Portuguese immigrants) remained after adjustment for age, gender, and socioeconomic status. Further adjustment for physical activity did not significantly change this association, but adjustment for dietary factors attenuated the relationship between migration status and overweight/obesity. This finding suggests that diet may be an important contributor to the risk of overweight/obesity in Portuguese immigrants and dietary practice may explain the high likelihood of overweight/obesity among Portuguese subjects.
Owing to the total lack of knowledge concerning the health status of Portuguese immigrants to Luxembourg, the current study constitutes the first exploratory study to address the prevalence of cardiovascular risk factors between Luxembourgers and Portuguese immigrants and thus fill in the gap knowledge as regards cardiovascular health and immigration status in Luxembourg. It confers a valuable baseline evidence for health professionals, hospital managers and public health decision-makers to obtain more knowledge on Portuguese migrants’ health.
Despite the unique and innovative findings which are based on recent data (2007–2008), the study has however several limitations. It is possible that only healthier Portuguese have participated and hence little variability was detected between Portuguese and Luxembourgers, as regards the cardiovascular risk factors. Despite the observed protective tendency of acculturation, the small sample size of second generation might limit the statistical power to detect a sensible meaningful association between acculturation and overweight/obesity. However, low response rates and small sample sizes are typical limitations in most immigrant data collected from the population-based surveys, which may partly explain the important heterogeneity in the literature regarding the association between acculturation, health behaviors and chronic disease prevalence .
The ORISCAV-LUX survey was primarily not designed to examine migration and acculturation effect among minorities. However, it provided information on four proxy measures of acculturation : language proficiency or preference, length of residency/age (proportion of life lived in Luxembourg), immigrant’s generation and country of birth. The majority of studies on health and acculturation use different measures of acculturation, and this variation may account for different results across the studies. Although the proxy measures have been widely used in similar studies [23, 24, 27], these variables do not fully capture the complex process of acculturation and its health effects . Acculturation is an indication of the cultural change of minority individuals to the majority culture. Across literature, the relationship between acculturation and health status in immigrant population vary widely according to the construct used, immigrant population, and outcomes of interest. It has been demonstrated that when thoroughful assessments of acculturation are unfeasible or unavailable, shorter proxy measures can be useful and constitute suitable substitutes to assess acculturation, with several advantages: simplicity of assessment, feasibility of collection in large health surveys, and limited respondent burden .
Given the high prevalence of cardiovascular risk factors among our growing multicultural society in Luxembourg, a future larger scale cross-cultural study is warranted.