Immigration and social exclusion: examining health inequalities of immigrants through acculturation lenses

Over the last three decades, the number of people migrating from developing to developed countries has been increasing in stepwise fashion as a result of insecurity, war and poverty. Such mass population movement has resulted in dramatic demographic transformations of most developed countries (Organisation for Economic Co-operation and Development 2007). The latest demographic data indicate that about 4 million new immigrants entered OECD countries on a permanent basis in 2005, an increase of 10 per cent from 2004 (Organisation for Economic Co-operation and Development 2007). In Australia, the 2006 census data indicate that more than one in five Australians (22.2 per cent) were born overseas, a pattern that has remained constant since 1996. The overseas-born population increased in number between 1996 and 2006 by 13 per cent, from around 3.9 million to 4.4 million (Australian Bureau of Statistics 2007d). Although a considerable proportion of Australian residents born overseas (including refugees and humanitarian entrants) come from countries recently affected by war and political unrest (Australian Bureau of Statistics 2007d), at a global level, migration for family reunion is the dominant reason for the inflows, and labour immigration is expanding, while humanitarian migration (including refugees and asylum seekers) has been declining (Organisation for Economic Co-operation and Development 2007). Regardless of their migration status, cultural differences and differentexpectations characterise new settlers in Australia and other OECD countries. New entrants experience varying inequalities ranging from difficulties establishing social networks, finding accommodation or employment, learning English, and looking after their general health. However, the level of inequality differs according to the degree of cultural transition. Consequently, acculturation has become a dominant framework used to explain disparities among minority groups. As such, we focus on reviewing the evidence on the relationship between acculturation and social exclusion at structural, group and individual levels. For this chapter, Atkinson’s (1998) notion of social exclusion is used, which emphasises social relations and ruptures in the social contract rather than resource poverty, and identifies three key features ofsocial exclusion: first, relativity (measuring exclusion by spatially comparing the circumstances of some individuals or communities relative to others at a given time), second, agency (examining the role of some agents and institutions to explain exclusion); and third, dynamics (looking at long-term effects or characteristics of exclusion). Given the complexity of the web to be untangled, we begin by defining the concept of acculturation and examining its historical background. We then move on to examine social exclusion through acculturation lenses focusing on the impact of acculturation on the access to and utilisation of social and health services, and acculturation-related differentials in health outcomes. We finish by examining the implications for public health. Early research on acculturation emphasised that the acculturation processhappens at a group level, with the whole group experiencing structural, cultural, biological, psychological, economic and political changes (for more details see Flannery and colleagues 2001). In addition, it was implied that mutual changes occur in both groups: the dominant group (host society) and the acculturating groups (migrants or refugees). However, due to influences from the host society, most changes occur in the acculturating group (Graves 1967). Nowadays, anthropologists have demonstrated that acculturation occurs at the individual level (Berry 1990a). At this level, acculturation has been termed psychological acculturation, that is, changes in both overt behaviours and covert traits of an individual from a cultural group going through the collective acculturation process (Graves 1967). However, regardless of the structural level at which the acculturation pro-cess occurs, two theoretical models have dominated the literature on acculturation: the unidirectional model (UDM) and the bi-dimensional model (BDM). The UDM assumes that it is not possible to be a fully integrated member of two cultures with two differing sets of cultural values. According to Flannery and colleagues, ‘the UDM describes acculturation as the shedding off of an old culture and the taking on of a new culture … and describes only one outcome of acculturation – assimilation’ (Flannery et al. 2001: 1035). In this respect, the UDM considers acculturation as a linear process where an individual moves from being traditional to assimilating. The problem with this assumption is that the model fails to identify those who are bicultural. Unfortunately, the UDM has predominated research on acculturation and has become the standard view of acculturation (Park and Miller 1921). In contrast, the BDM measures two cultural orientations – the home andhost cultures (Figure 2.3), and assumes that the identifications with traditional and host cultures are independent. This model identifies migrants on four cultural orientations: (1) Traditional, also known as separation (keeps loyalty to traditional culture and does not recognise the host/dominant culture) (Berry and Kim 1988; MacLachlan 1997), (2) Assimilation, also known as ‘cultural shift’ (Berry 1990b) or the ‘melting pot’ theory of acculturation (MacLachlan 1997) (rejects traditional culture and fully embraces the host/dominant culture), (3) Integration, also known as bicultural orientation or cultural incorporation (retains cultural identity at the same time moving to join the dominant society) (MacLachlan 1997) and (4) Marginalisation (rejects traditional culture and fails to connect with the host/dominant culture by exclusion or withdrawal (MacLachlan 1997).