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Logo of jepicomhInstructions for authorsCurrent TOCJournal of Epidemiology and Community Health
J Epidemiol Community Health. Aug 2006; 60(8): 694–698.
PMCID: PMC2588083

Health related quality of life in immigrants and native school aged adolescents in Spain



To compare health related quality of life (HRQL) between native and immigrant adolescents aged 12 to 18 years, and to analyse psychosocial factors associated with HRQL.


A cross sectional study of adolescents (12–18 years old) who answered a self administered questionnaire.


All the secondary schools from Lloret de Mar (Girona, Spain).


1246 participants (88.9% of the eligible students).

Main outcome measures

Main outcome was the Spanish version of the Vecu et Sante Percue de l'Adolescent (VSP‐A), a HRQL measure addressed to adolescents. Mean scores of the VSP‐A index of natives and immigrants were compared, as well as their sociodemographic and health related factors. Multiple regression examined the relation between HRQL and psychosocial factors, controlling for the effect of socioeconomic variables.


Half of the sample were boys, in the middle socioeconomic status, and 18.2% were immigrants (n = 226). HRQL score was higher in native Spanish adolescents than immigrants (p<0.01). Multiple regression model explaining 48.1% of the VSP‐A variance showed that migration in itself has no statistically significant impact on HRQL, and age, socioeconomic status, social support, discrimination, and psychological distress do play a part.


Migrants have worse HRQL than natives but it seems to be mediated by their disadvantage in socioeconomic status, social support, and psychological distress.

Keywords: children, health related quality of life, immigration, self perceived health

Inequalities in health in function of social class, sex, and/or ethnicity have been widely shown. The global pattern of better health among classes with higher socioeconomic status (SES) has been reported in different historical moments, using different health indicators as well as various socioeconomic measures. Numerous studies have analysed the relation between immigration and/or ethnic minority status and health.1,2,3,4,5,6,7 The main intention of these studies was to discover if ethnicity is independently associated with health, or there are other factors that mediate this relation, such as the SES. Factors that determine differences in health among ethnic groups or immigrants have been constructed around three hypotheses. Some authors attribute an essential role to socioeconomic inequalities as an explicative factor of ethnic inequalities in health, others authors insist on the importance of genetic, biological, and cultural factors distinctive to every ethnic background, and most authors think that other elements, such as racism and migratory experience, play an important part influencing health.8,9,10,11

Most authors agree that race is a social construction and not a biological category.

It has been shown that there is more genetic variation among people of the same race than among different races.9,12

The reaction to the different kinds of discrimination can vary in function of the cultural extraction and of the social support webs that each person has. Nazroo suggests that an adequate understanding of racism and of the discriminatory element is fundamental to understanding ethnic inequalities in health.10 Racism plays a part both in structuring social and economic disadvantage in the population and in institutional and individual discrimination against ethnic minority groups. Racism affects individual health from both a psychological perspective and in terms of limiting access to those material resources. Dominant and subordinate social relationships also have effects on health: corporeal manifestations become the biological reflex of these.13

It has been widely shown that social support has positive effects on different aspects of physical and mental health, and that the lack of a social relationships web or the perception of one's relational environment as inadequate can influence mental and physical health.14

The migratory experience has been traditionally related to a mourning process caused by the loss of social relations and by the impact of cultural differences from the place of origin. Adolescence represents a period of change, not only in a biological aspect and in terms of the body image, but also in the psychological, emotional, and social context of the person. In several studies in adolescents, it is not clear if behavioural patterns in health among adolescents are a precocious phase of the individual trajectory towards adult health patterns, or if behavioural models in adolescence are a specific phase influenced by precise determinants.15

The ways in which ethnicity affects adolescent health have been little studied, although it is true that studies relating to psychological wellbeing and ethnicity have been done. These studies show that the immigration experience can influence the mental health of adolescents,16 and that the factors beyond SES, such as culture of origin, beliefs, religion, group cohesion, and a numerous presence act as protection against mental health disturbances.17 Another study analysed individual health perception in adolescents from the standpoint of physical, personal, social, environmental, and behavioural factors.18

The aims of this study are to compare health related quality of life (HRQL) between native and immigrant adolescents aged 12 to 18 years, and to analyse psychosocial factors associated with HRQL. The main hypothesis of the study is that there are differences in HRQL between immigrants and native school aged adolescents in Lloret de Mar. We intend to analyse whether these differences are attributable to other factors closely related to migratory experience, such as lack of social support, poor economic conditions, cultural differences, or discrimination perception.


Sample selection

A cross sectional study of the entire school population, 12–18 year olds, in Lloret de Mar (Girona‐Spain) was conducted. All secondary school student of the academic year 2004–05 (n = 1402) were invited to participate. Those students who refused to participate and those who did not have enough knowledge of Spanish language to answer the questionnaire were excluded from the study.

In agreement with the school councils a consent letter was sent to the parents that had to be signed and returned on the day of the questionnaire administration. The questionnaire was given attempting to minimise inconveniences to the classes. It was given to the three secondary schools of Lloret de Mar, (two state and one private) comprising 55 classrooms.

Taking into account the enrolled adolescents in the previous year, it was expected that at least a 20% of the students would be foreign. It was calculated that to detect a minimal important difference of 2.07 points in HRQL scale (and a standard deviation of 10) between natives and immigrants with an α error smaller than 0.05 and a power of 0.80, at least 225 cases were needed in each group.

Variables of the study

The Veçu et Sante Perçue de l'Adolescent (VSP‐A) questionnaire was used as the main outcome measure. The VSP‐A is a generic, self administered instrument of HRQL, designed for 11–17 years old adolescents, which was developed in Marseille University Hospital.19 The questionnaire contains 39 items, distributed in 11 dimensions: energy; physical wellbeing; psychological wellbeing; self esteem; relationships with friends; relationships with parents; relationships with teachers; school life; leisure; relationships with health workers, and satisfaction with romantic and sexual life. Items are scored in a Likert scale ranging from 1 to 5. The mean score for every dimension is created from the mean of the items. A global score of HRQL (VSP‐A index) was obtained on a 0–100 scale, where a higher score corresponds to a higher HRQL. The Spanish version has shown good validity and reliability.20,21

The sociodemographic variables included in the study were: age, (12–14 or 15–18 years old), sex, and SES, measured by the family affluence scale (FAS), which includes family car ownership, having their own unshared room, the number of computers at home, and how many times they spent on holidays in the past 12 months. The FAS was categorised into three groups: low, middle, and high.22 Native or immigrant status was based on the country where the child was born. Immigrants were those adolescents born outside of Spain. Immigrants' nationality was recoded and the time of residence in Spain (in months) was also collected. In addition, analysis of the variable self perception of nationality was used as a complement for the definition of migratory status.

Psychological distress was measured with the 12 items of Goldberg's general health questionnaire (GHQ‐12).23 A higher score corresponds to higher likelihood of psychological distress. The Spanish version was adapted by Muñoz.24 Social discrimination was defined in the study as self perception of the person of discrimination or inferiority because of country of origin, skin colour, culture, or religion. It was measured using five items (whether they have perceived to be discriminated at school, at their neighbourhood, in the city, in leisure time places, or at their medical centre) and was adapted from a study by Krieger et al.25,26 Score range is 5 to 25, where high score means more discrimination. Social support was measured by the Oslo scale. This scale collects the number of people who can provide a sense of security to the adolescent, and instrumental and emotional support received from those people, which has shown to be valid and reliable to one social relationship that can promote health. The total score calculated by summarising those three items ranged from 0 to 11 with values less than 6 recognised in the literature as “poor social support”.27,28 Self perception of acceptance or rejection from peers at school and to feelings of anxiety with peers was measured through three items of the KIDSCREEN questionnaire (whether they have been afraid of other girls and boys, if other girls or boys made fun, or bullied them) that determine the social acceptance dimension “(bullying)”. The Spanish version has shown good reliability.29


A descriptive and bivariate analysis were carried out in the whole sample and stratified for both groups, natives and immigrants. Collinearity among continuous variables was analysed.

A multiple regression equation was adjusted to examine the influence of migration status and psychosocial factors (psychological distress, discrimination, social acceptance, and social support) on HRQL, controlling for the effect of socioeconomic variables. Variables were introduced in the model step by step based on statistical significance in the bivariate analysis and relevance for the study. The model was then applied to each subgroup of immigrants. Interactions between migration status, and socioeconomic factors were also checked.


Response rate was 88.9% (n = 1246) (five refused to answer the questionnaire, four did not have enough knowledge of Spanish, and the rest were absent from school). Eleven adolescents older than 18 years old were excluded from the analysis. The sample was uniformly distributed between boys and girls who represent respectively a 51.1% and a 48.9% respectively of the sample (table 11).). There were a higher percentage of children 12–14 years old (54.8%). Eighteen per cent (n = 226) were immigrants, of those 40.3% were Latinos and 32.3% were Eastern Europeans. The mean time of residence in Spain for immigrants was 46 months.

Table thumbnail
Table 1 Sociodemographic description of the sample (n = 1235)

The overall mean VSP‐A index was 64.18. The VSP‐A index was higher in natives than in immigrants (65.04 v 60.80; p<0.01) a difference higher than the minimal important difference (2.07). Native adolescents scored also better in the GHQ‐12 (mean score 2.16 v 2.60; p<0.001), in perceived discrimination (5.90 v 6.51; p = 0.02), social acceptance (49.20 v 47.42; p<0.001), and perceived higher social support (p = 0.02) (table 22).

Table thumbnail
Table 2 Mean score (or percentage) and standard deviation (SD) of VSP‐A HRQL index and other variables included in the study, by migration status

HRQL was slightly higher in boys than in girls and higher in 12–14 year old adolescents than in 15–18 year olds (table 33).). HRQL was also higher in high SES groups, with significant differences between the highest and the lowest SES groups (p<0.001). Similar results were found stratifying the analysis by migration status although differences by sex and age did not reach statistical significance among immigrants (table 33).). The probability of experiencing psychological distress (correlation coefficient, r = −0.60; p<0.001), discrimination (r = −0.22; p<0.001), and bullying (r = 0.21; p<0.001) has a significant correlation with HRQL (data not shown).

Table thumbnail
Table 3 Mean score of the VSP‐A index stratified by migration status and sex, age, SES, and social support

Table 44 shows that sociodemographic variables (age, FAS), social discrimination, bullying, social support, and psychological distress were associated to VSP‐A index (the model explained 48.1% of its variance). The influences of being an immigrant or being a boy disappear when taking into account the rest of variables. The time of residence in Spain does not have an influence on HRQL. When the model was stratified for migratory status, the factors analysed behave similarly. Nevertheless, being an immigrant has significance (0.04) in the case of Eastern European immigrants. When self perceived nationality was compared with the country of birth 20 Latinos and 15 Eastern Europeans declared feeling a native. No differences were found when replicating the analysis using data by self perceived nationality (data not shown). No significant interactions were found between migration status and socioeconomic and psychosocial factors.

Table thumbnail
Table 4 Multiple regression model of VSP‐A index of HRQL

Policy implications

Preventive care programmes in native and immigrant adolescents should be mainly addressed to diminish social inequalities in health and to promote psychological wellbeing in the school environment


This is to our knowledge the first study conducted on adolescents that compares HRQL among natives and immigrants, and collects information on SES, psychological distress, discrimination, and social support. As a multidimensional measure, HRQL attempts to identify the most relevant aspects of health, which in adolescence are both physical and emotional wellbeing and self esteem, and social functioning perception with peers, parents, and teachers. Results suggest that there are differences between natives and immigrants in HRQL, even if most of these differences can be attributed to psychological distress, to discrimination perception, and to a lack of social support.

What is already known on this subject?

  • The migratory experience during childhood and adolescence, and its effects on health have been little studied
  • Most of the studies analyse specific aspects of health in adolescence, such as behaviour disorders and mental health, psychological wellbeing, or self esteem
  • Immigration can influence mental health of adolescents. Some factors beyond SES, such as culture of origin, beliefs, religion, and group cohesion and numerousness could act as protection against mental health disturbances.

Some studies have shown that there is a clear relation between the migratory experience in adolescents and its consequences on health, and between ethnicity and health. Most of these studies analyse specific aspects of health in adolescence, such as behaviour disorders and mental health, psychological wellbeing, or self esteem, but none of them studies HRQL as a dependent variable that gathers all these aspects as a unique measure.8,17,30,31,32,33,34 Sam's study, which analysed satisfaction with life as a dependent variable,35 showed similar results as our study; however, in our study discrimination perception was a determinant factor of HRQL.

What does this study add?

  • This is to our knowledge the first study conducted on adolescents that compares HRQL among natives and immigrants taking into account simultaneously SES, discrimination, social support, and psychological distress.
  • Immigrants have worse HRQL than natives but it seems to be mediated by their disadvantage in SES, social support, and psychological distress. Hence, migratory experience does not seem to have an independent role in determining differences in HRQL.
  • Determinant factors of HRQL seem to be the same for natives and for immigrants.

In some other studies, the information was collected from the parents or a proxy respondent that could lead to a “proxy bias”.30 Moreover, few cases compared the results of native and immigrants adolescents. In our study, besides psychological distress and social and individual factors we took into account the family SES as a determinant of health differences among the analysed subgroups of adolescents.

Although migratory experience does not seem to have an independent role in determining differences in HRQL, we also found differences between Eastern European adolescents and natives. Even though these differences were at the limit of significance (p = 0.04), they reflect the need to examine more profoundly in future studies specific cultural aspects of this group.

The influence of immigration on health seems to be less accentuated in adolescents than in the adult population. This phenomenon could also be attributable to the fact that in adult populations, work and legal situation play a more important part36,37 than in the case of adolescents who are attending school.

The study also includes a few limitations that are worth comment. The study was developed from a migratory status definition based on the birth country, but this definition can limit the generalisation of the results.

We have to consider that the analysed group of immigrants declared a residence mean of 46 months in Spain. This factor together with other factors that have not been analysed, such as integration or perception of belonging to a specific group, could have influenced the results in the null hypothesis direction. The results were similar even when comparing HRQL in those who have been living in Spain for less than one year and the rest of the immigrants.

Immigrant condition alone is not the only differential factor in perceived health. Differences between ethnic groups can determine the manner in which one faces the migratory experience. Elements such as group cohesion, social support webs, religion, and family structure can all differ in each culture and can change significantly the migration experience and its consequences on health.38,39

Finally, not all the immigrant groups in Spain are represented in the analysed population; therefore the generalisation of results is limited to the analysed groups. In some cases, the adolescents could emigrate without family, a feasible possibility beginning at a certain age. It is also probable that these adolescents are not attending school, and therefore have not been selected in this study. This circumstance could be possible in case of adolescents that come from Maghrib, a group that has not been analysed for lack of a sufficient sample.

Immigrant condition by itself does not determine HRQL, but social, psychological, relational, and economic factors do contribute to determine HRQL and are affected by migratory experience.

Adolescence is a moment of individual change, fragility, and vulnerability. There is the need to continue investigating to understand how the migratory experience influences their physical, psychological, and social health. These “immigrant” people will stop being immigrants and will become citizens and the next generation of parents and workers.40


The authors thank Anna Schiaffino for her help in the statistical analysis, Maite Solans for her logistical support, Sabrina Pane, Antònia Domingo, and Pascal Auquier for their comments, and Emily Ahonen for her linguistic help.


SES - socioeconomic status

HRQL - health related quality of life

VSP‐A - Vecu et Sante Percue de l'Adolescent

FAS - family affluence scale


Funding: partially financed by the Fondo de Investigación Sanitaria, Spanish Ministry of Health (contract no PI0212206) and the Network of excellence on Health outcomes and Health Services Research IRYSS (contract no G03/202).

Competing interests: none declared.

A preliminary version of this work was presented at the 12th annual ISOQOL conference, in San Francisco, and represented the Minor Thesis of Karin Pantzer to achieve Master in Public Health qualification.


1. Keil J E, Sutherland S E, Knapp R G. et al Does equal socioeconomic status in black and white men mean equal risk of mortality? Am J Public Health 1992. 821133–1136.1136 [PMC free article] [PubMed]
2. King G, Williams D R. Race and health: a multidimensional approach to African‐American health. In: Amick BC, Levine S, Tarlov AR, et al, eds. Society and health. New York: Oxford University Press, 1995. 93–130.130
3. Krieger N, Sidney S. Racial discrimination and blood pressure: the CARDIA study of young black and white women and men. Am J Public Health 1996. 861370–1378.1378 [PMC free article] [PubMed]
4. Lillie‐Blanton M, LaVeist T. Race/ethnicity, the social environment, and health. Soc Sci Med 1996. 4383–92.92 [PubMed]
5. Ostrove J M, Feldman P, Adler N E. Relations among socioeconomic status indicators and health for African: Americans and whites. J Health Psychol 1999. 4451–463.463 [PubMed]
6. Williams D R, Lavizzo‐Mourey R, Warren R. The concept of race and health status in America. Public Health Rep 1994. 10926–41.41 [PMC free article] [PubMed]
7. Williams D R, Collins C. US socioeconomic and racial differences in health: patterns and explanations. Annu Rev Sociol 1995. 21349–386.386
8. Reijneveld S A. Reported health, lifestyles, and use of health care of first generation immigrants in Netherlands: do socioeconomic factors explain their adverse position? J Epidemiol Community Health 1998. 52298–304.304 [PMC free article] [PubMed]
9. Williams D R. Race/ethnicity and socioeconomic status: measurement and methodological issues. Int J Health Serv 1996. 26483–505.505 [PubMed]
10. Nazroo J Y. The structuring of ethnic inequalities in health: economic position, racial discrimination and racism. Am J Public Health 2003. 93277–284.284 [PMC free article] [PubMed]
11. Krieger N, Williams D R, Moss N E. Measuring social class in US public health research: concept, methodologies and guidelines. Annu Rev Public Health 1997. 18347–348.348 [PubMed]
12. Marks J. Genes, bodies and species. In: Peregrine PN, Ember CR, Ember M, eds. Physical anthropology original readings in method and practice. New Jersey: Prentice Hall, 2002. 14–28.28
13. Krieger N. Discrimination and health. In: Kawachi I, Berkman L, eds. Social epidemiology. New York: Oxford University Press, 2000. 36–75.75
14. Stanfeld S A. Social support and social cohesion. In: Marmot M, Wilkinson RG, eds. Social determinants of health. Oxford: Oxford University Press, 1999. 155–178.178
15. Goodman E, Amick B C, Rezendes M O. et al Influences of gender and social class on adolescents perception of health. Arch Pediatr Adolesc Med 1997. 151899–904.904 [PubMed]
16. Fazel M, Stein A. Mental health of refugee children: comparative study. BMJ 2003. 327134 [PMC free article] [PubMed]
17. Stansfeld S A, Haines M M, Head J A. et al Ethnicity, social deprivation and psychological distress in adolescents. Br J Psychiatry 2004. 185233–238.238 [PubMed]
18. Vingilis E R, Wade T J, Seeley J S. Predictors of adolescent self‐rated health. Can J Public Health 2002. 93193–197.197 [PubMed]
19. Siméoni M C, Auquier P, Antoniotte S. et al Validation of a French health‐related quality of life instrument for adolescents: the VSP‐A. Qual Life Res 2000. 9393–403.403 [PubMed]
20. Serra‐Sutton V, Herdman M, Rajmil L. et al Adaptación al español del cuestionario Veçu et sante perçue de l'adolescent (VSP‐A): una medida genérica de calidad de vida para adolescentes. Rev Esp Salud Publica 2002. 76701–712.712 [PubMed]
21. Serra‐Sutton V, Rajmil L, Berra S. et al Fiabilidad y validez del cuestionario de salud y calidad de vida para adolescentes Vecú et Santé Perçue de l'Adolescent (VSP‐A). Aten Primaria 2006. 37203–208.208 [PubMed]
22. Currie C E, Elton R A, Todd J. et al Indicators of socioeconomic status for adolescents: the WHO health behaviour in school‐aged children survey. Health Educ Res 1997. 12385–397.397 [PubMed]
23. Goldberg D P, Williams P. A user's guide to the general health questionnaire. Windsor: NFER‐Nelson, 1988
24. Muñoz P E. Estudio de la distribución de los trastornos psiquiátricos y de los niveles de salud mental en una población rural: aplicación de un método estándar al conocimiento de la morbilidad psiquiátrica [Thesis]. Madrid: Universidad Autónoma, 1987
25. Krieger N, Sydney S. Racial Discrimination and blood pressure: in CARDZA. Study in young black and white adults. Am J Public Health 1996. 861370–1378.1378 [PMC free article] [PubMed]
26. Krieger N. Racial and gender discrimination: risk factors for high blood pressure? Soc Sci Med 1990. 301273–1281.1281 [PubMed]
27. Murad S D, Joung I M, Verlhulst F C. et al Determinants of self reported emotional and behavioural problems in Turkish inmigrant adolescents aged 11–18. Soc Psychiatry Psychiatr Epidemiol 2004. 39196–207.207 [PubMed]
28. Sam D L. Psychological adaptation of adolescents with inmigrant backgrounds. J Soc Psychol 2000. 1405–25.25 [PubMed]
29. Aymerich M, Berra S, Guillamón I. et al Desarrollo de la versión en español del KIDSCREEN, un cuestionario de calidad de vida para la población infantil y adolescente. Gac Sanit 2005. 1993–102.102 [PubMed]
30. Murad S D, Joung I M, Verlhulst F C. et al Determinants of self reported emotional and behavioural problems in Turkish inmigrant adolescents aged 11–18. Soc Psychiatry Psychiatr Epidemiol 2004. 39196–207.207 [PubMed]
31. Virta E, Sam D L, Westin C. Adolescents with Turkish background in Norway and Sweden: a comparative study of their psychological adaptation. Scand J Psychol 2004. 4515–25.25 [PubMed]
32. Oppedal B, Roysamb E. Mental Health, life stress and social support among young Norwegian adolescents with inmigrant and host national background. Scand J Psychol 2004. 45131–144.144 [PubMed]
33. Sam D L. The psychological adjustment of young immigrants in Norway. Scand J Psicol 1994. 35240–253.253 [PubMed]
34. Georgiades K, Boyle M H, Duku E. et al Tobacco use among immigrant and nonimmigrant adolescents: individual and family influences. J Adolesc Health 2006. 38e1–17.17 [PubMed]
35. Sam D L. Predicting life satisfaction among adolescents from immigrant families in Norway. Ethn Health 1998. 35–18.18 [PubMed]
36. Corvalan C F, Driscoll T R, Harrison J E. Role of migrant factors in work‐related fatalities in Australia. Scand J Work Environ Health 1994. 20364–370.370 [PubMed]
37. Sundquist J. Ethnicity, social class and health. A population‐based study on the influence of social factors on self‐reported illness in 223 Latin American refugees, 333 Finnish and 126 south European labour migrants and 841 Swedish controls. Soc Sci Med 1995. 40777–787.787 [PubMed]
38. Flores G, Bauchner H, Feinstein A R. et al The impact of ethnicity, family income, and parental education on children's health and use of health services. Am J Public Health 1999. 891066–1071.1071 [PMC free article] [PubMed]
39. Williams D R, Spencer M S, Jackson Race J S. Stress and physical health: the role of group identity. In: Contrada RJ, Ashmore RD, eds. Self and identity: fundamental issues. New York: Oxford University Press, 1999. 71–100.100
40. Wadsworth M. Early life. In: Marmot M, Wilkinson RG, eds. Social determinants of health. Oxford: Oxford University Press, 1999. 44–63.63

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