Abstract

The objective was to analyze the mortality of Bolivian immigrants compared to the Brazilian population, living in the city of São Paulo, with an emphasis on the analysis of avoidable deaths. Descriptive study of deaths in the city of São Paulo, between 2007 and 2018, registered in the Mortality Information System. Deaths of people aged 5 to 74 years were analyzed, according to “Brazilian List of Causes of Preventable Deaths”, according to groups and sex; Pearson’s chi-square test was used to compare nationalities. The temporal trend of avoidable deaths was evaluated by Prais-Winsten regression. There were 1.123 Bolivians deaths and 883.116 among Brazilians, with a predominance of male deaths and the Bolivians died on average 13.6 years younger. The proportion of deaths from preventable causes was similar between Bolivians (71.0%) and Brazilians (72.8%) and the trend did not show significant proportional annual variation for both nationalities. There is a higher frequency, among Bolivians, of external causes (27.6%) and of causes reducible by actions to health promotion, prevention, control, and care for infectious diseases (20.8%) than to Brazilians. Conclusion: Bolivians died younger and showed no reduction in the proportion of potentially avoidable causes, which may indicate unequal access to health services.

Key words:
Immigrants; Cause of death; Mortality premature

Introduction

The Lancet Commission on Migration and Health report¹1 Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C, THE UCL - Lancet Commission on Migration and Health. THE UCL - Lancet Commission on Migration and Health: the health of a world on the move. Lancet 2018; 392(10164):2606:2654. concluded that migration should be treated as a central feature of 21st century health and development. It also states that commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs).

The process of migration in search of better living conditions involves a series of events that can be traumatizing and place migrants at risk. The process involves uprooting, beginning with separation from family and traditional values, and being placed in new social and cultural situations where job and legal security may be minimal. Unemployment is one of the factors causing poor quality of life in migrant populations²2 Carballo M, Nerukar A. Migration, refugees, and health risks. Emerg Infect Dis 2001;7(3l):556-560.^,33 Oliveira EM, Matias MMM, Felix TA, Cavalcanti MMB, Lopes RE, Neto F. Mulheres brasileiras vivendo em Portugal: trabalho e qualidade de vida. Saude Soc 2019; 28(1):182-192.. Factors such as lifestyle, social and community influences, living and working conditions, and general socioeconomic, cultural and environmental conditions are determinants that influence a person’s health. These social determinants of health are also the main factors responsible for health inequalities and inequities within and between countries, also affecting immigrants⁴4 International Organization for Migration (IOM). Social Determinants of Migrant Health. [acessado 2019 ago 31]. Disponível em: https://www.iom.int/social-determinants-migrant-health
https://www.iom.int/social-determinants-... .

Over the last three decades, Brazil has witnessed new trends in international migration, becoming a hosting country for immigrants from Korea, China, Bolivia, Paraguay, Chile, Peru and various African countries⁵5 Patarra NL. Brasil: país de imigração? e-metropolis 2012; 3(9):6-18.. In 1980, the profile of immigrants shifted from European to predominantly Latin American nationalities, above all Bolivians, who initially migrated to areas close to the border and later to São Paulo⁶6 Silva S. Costurando sonhos - trajetória de um grupo de imigrantes bolivianos em São Paulo. São Paulo: Paulinas; 1997..

According to the country’s national immigrant register, Bolivians account for the largest share of immigrants in São Paulo (20.8%)⁷7 Prefeitura de São Paulo, Organização Internacional para as Migrações. A cidade de São Paulo - perfil 2019 indicadores da governança migratória local. Genebra: Organização Internacional para as Migrações; 2019.. The results of the 2010 census show that Bolivian immigrants living in São Paulo are predominantly young (20-34 years) and male and have a lower level of education that the overall population⁸8 Yazaki LM, Ortiz LP, Almeida MF, Aranha V, Silva ZP. Indicadores de saúde reprodutiva e mortalidade dos bolivianos residentes na cidade de São Paulo. Trabalho apresentado no XIX Encontro Nacional de Estudos Populacionais; 2014 nov 24 a 28; São Pedro-SP..

Mortality indicators indirectly show the health status of a community and may reflect the effects of health interventions and socioeconomic disparities. Many causes of death are preventable and the analysis of these causes can provide important inputs for the formulation of prevention and health promotion programs and measures to reduce inequalities in access to good quality health services⁹9 Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais NOL, Moura L, Ferraz W, Souza MFM. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saude 2007; 16(4):233-244.^,1010 Malta DC, Saltarelli RMF, Prado RR, Monteiro RA, Almeida MF. Mortes evitáveis no Sistema Único de Saúde na população brasileira, entre 5 e 69 anos, 2000-2013. Rev Bras Epidemiol 2018; 21:e180008..

A study undertaken in Belgium with immigrants aged 50 years and over showed that, depending on country of origin, age, sex, and socioeconomic status, immigrants have a higher risk of dying than nonmigrants¹¹11 Reus-Pons M, Vandenheede H, Janssen F, Kibele EUB. Differences in mortality between groups of older migrants and older non-migrants in Belgium, 2001-2009. Eur J Public Health 2016; 26(6):992-1000.. On the other hand, a systematic literature review reported that international migrants in high-income countries had a mortality advantage compared with the general population and that this advantage persisted across the majority of the disease categories analyzed by the study¹²12 Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P, Burns R, Hargreaves S, Miranda JJ, Tollman S, Friedland JS, Abubakar I. Global patterns of mortality in international migrants: a systematic review and meta-analysis. Lancet 2018; 392(10164):2553-2566..

To provide quality, accessible health care, it is necessary to undertake ongoing monitoring of patterns of mortality in different population groups. The comparison of mortality between immigrant and nonimmigrant populations can help understand possible differences and ultimately indicate the need for actions to reduce health inequalities¹¹11 Reus-Pons M, Vandenheede H, Janssen F, Kibele EUB. Differences in mortality between groups of older migrants and older non-migrants in Belgium, 2001-2009. Eur J Public Health 2016; 26(6):992-1000.. Given the scarcity of studies on mortality among immigrants in Brazil¹³13 Silveira RC. A mortalidade de imigrantes internacionais no município de São Paulo de 2006 a 2015 [dissertação]. São Paulo: Universidade de São Paulo; 2019., the aim of this study was to compare mortality among Bolivian immigrants and nonimmigrants in São Paulo, focusing on avoidable causes of death during the period 2007-2018.

Materials and methods

We undertook a population-based study of mortality among Bolivian immigrants living in São Paulo, a city with a population of 12,176,866 (2018) and Human Development Index of 0.805¹⁴14 Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades@. [acessado 2019 ago 24]. Disponível em: http://cod.ibge.gov.br/QHF
http://cod.ibge.gov.br/QHF... .

We used microdata on deaths among the population living in São Paulo occurring between 01/01/2007 and 31/12/2018 taken from the national mortality information system, (SIM). The files were made available by the São Paulo City Council Department of Health (SMS/CEInfo/PRO-AIM).

Nationality was taken from the death certificate. The number of ignored cases was minimal, accounting for only two deaths in 2007¹³13 Silveira RC. A mortalidade de imigrantes internacionais no município de São Paulo de 2006 a 2015 [dissertação]. São Paulo: Universidade de São Paulo; 2019..

The distribution of sex and age group was represented using a population pyramid of total deaths during the study period for each population, and the mean age at death was also calculated.

We analyzed the underlying cause of death based on the codes of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (CID-10). Since deaths among Bolivian children under five were infrequent (35 deaths or 3.1% of the total), we opted to study causes of death among individuals aged 5-74 years grouped according to the List of Avoidable Causes of Deaths through Interventions under Brazil’s Unified Health System¹⁵15 Malta DC, França E, Abreu DX, Oliveira H, Monteiro RA, Sardinha LMV, Duarte EC, Silva GA. Atualização da lista de causas de mortes evitáveis (5 a 74 anos de idade) por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saude 2011; 20(3):409-412.: 1) Causes of avoidable deaths and subgroups, 2) Ill-defined causes of death, and 3) Other causes of death - not clearly avoidable. We calculated the proportions and respective 95% confidence intervals (CI) for groups and subgroups, sex, and nationality.

Descriptive statistics were used to analyze the data. Pearson’s chi-squared test was used to test the null hypothesis (no relationship between population group and death due to preventable causes), adopting a 5% significance level. Two male deaths with inconsistent cause of death and six deaths with unknown data for sex variable were excluded.

The analysis of temporal trends in the proportion of preventable deaths in the period 2007-2018 among the population aged between 5 and 74 years was performed using Prais-Winsten regression. The data were processed using Microsoft Office Excel 2016 and R version 3.4.4. The software packages foreign, prais, readxl, stats and tidyverse were also used.

The study protocol was approved by the University of São Paulo’s School of Public Health’s (FSP/USP) research ethics committee (reference number 2.728.230/2018).

Results

There were 1,123 deaths among Bolivian immigrants and 883,116 among nonimmigrants during the period 2007-2018. Most of the deaths were among men (58.0% among Bolivian immigrants and 53.0% in nonimmigrants).

The distribution of deaths among nonimmigrants took the form of an inverted pyramid, with the number of deaths rising with increasing age, while deaths among Bolivian immigrants were concentrated in the 15-64 year age group (57.79%) (Graph 1). The difference in mean age at death between Bolivian immigrants (50.2 years) and nonimmigrants (63.8 years) was 13.6 years.

The analysis of the mortality curves using Prais-Winsten regression showed that neither population showed statistically significant proportional variability (Graph 2).

No differences were found in the proportion of overall deaths due to avoidable causes (p = 0.266) between Bolivian immigrants (71.0%, 95%CI [67.9;74.1]) and nonimmigrants (72.8%, 95%CI [72.7;72.9]) in both men (p = 0.210) and women (p = 0.811). However, differences were found when deaths due to specific causes were compared (Table 1).

The proportion of causes of deaths that could be avoided through adequate health promotion, prevention and control actions and non-communicable disease care was much lower among Bolivian immigrants than in nonimmigrants (45.9%, 95%CI [41.9; 49.9] versus 67.7%, 95%CI [67.5; 67.8]). For all other groups of avoidable causes of death, the proportion of deaths was higher among Bolivian immigrants (Table 1). With regard to specific causes within these groups, the proportion of deaths was higher among nonimmigrants for the causes in the ICD chapter Diseases of the Circulatory System. These differences were more pronounced for acute myocardial infarction and ischaemic heart disease (16.8% [95%CI: 16.6; 16.9] versus 11.4% [95%CI: 7.6; 15.1] and 6.7% [95%CI: 6.7; 6.8] versus 1.5% [95%CI: 0.0; 2.9] respectively (Table 2).

Causes of deaths that could be avoided through intersectoral, health promotion and prevention actions and adequate external cause care (accidents and violence) accounted for 27.6% (95%CI: 24.0; 31.2) and 16.8% (95%CI: 16.7;16.9) of deaths among Bolivian immigrants and nonimmigrants, respectively. The frequency of these causes was higher among men. Within this group, transport accidents accounted for approximately one-quarter of deaths in both populations (Table 2).

Causes of deaths that could be avoided through health promotion actions and adequate infectious disease prevention, control and care represented 20.8% (95%CI: 17.6; 24.1) and 15.1% (95%CI: 15.0; 15.2) of deaths among Bolivian immigrants and nonimmigrants, respectively (Table 1), with deaths due to tuberculosis accounting for 25.8% (95%CI: 18.1; 33.5) and 5.4% (95%CI: 5.2; 5.6) of deaths in the two groups, respectively (Table 2).

Deaths that could be avoided through adequate prevention, control, and care of causes of maternal death were more frequent among Bolivian immigrants (3.7%, 95%CI [2.2; 5.7]) than in nonimmigrants (0.3%, 95%CI [0.3; 0.3]) (Table 1).

Ill-defined causes were also more frequent among Bolivian immigrants than in nonimmigrants in the overall population (2.6%, 95%CI [1.5; 3.7] versus 1.4%, 95%CI [1.4; 1.5]) and in men (3.7%, 95%CI [1.9; 5.2] versus 1.7%, 95%CI [1.7; 1.7]).

The proportion of avoidable causes was higher among men than in women in both groups (72.1% versus 69.4% in Bolivian immigrants and 74.6% versus 69.9% in nonimmigrants); however, this difference was statistically significant only in nonimmigrants (p < 0.001).

Discussion

Deaths among Bolivian immigrants were concentrated in the economically active population, while in nonimmigrants the population aged 65 and over accounted for the largest share of deaths. The proportion of deaths from avoidable causes remained relatively stable during the study period among both Bolivian immigrants and nonimmigrants. Overall, there was no significant difference in the proportion of avoidable deaths between Bolivian immigrants and nonimmigrants; however, there were differences in proportions of deaths due to specific causes within the different groups of avoidable causes of death and between sexes.

Our findings show a -13.6 year difference in mean age at death between Bolivian immigrants and nonimmigrants. This difference partially reflects the profile of Bolivian immigrants, who are predominantly young people of working age⁸8 Yazaki LM, Ortiz LP, Almeida MF, Aranha V, Silva ZP. Indicadores de saúde reprodutiva e mortalidade dos bolivianos residentes na cidade de São Paulo. Trabalho apresentado no XIX Encontro Nacional de Estudos Populacionais; 2014 nov 24 a 28; São Pedro-SP.^,1616 Aguiar ME, Mota A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface (Botucatu) 2014; 18(50): 493-506.. A study in Canada also showed that age at death was lower in immigrants, although the difference was smaller (six years)¹⁷17 Khan AM, Urquia M, Kornas K, Henry D, Cheng SY, Bornbaum C, Rosella LC. Socioeconomic gradients in all-cause, premature and avoidable mortality among immigrants and long-term residents using linked death records in Ontario, Canada. J Epidemiol Community Health 2017; 71(7):625-632..

Avoidable causes of deaths may be defined as causes that can be wholly or partly prevented by effective health care services that are accessible at a particular place and time, and must be updated in light of advancing knowledge and technologies⁹9 Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais NOL, Moura L, Ferraz W, Souza MFM. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saude 2007; 16(4):233-244.. In contrast to the present study, an investigation comparing deaths among the population aged 5-69 years in Brazil¹⁰10 Malta DC, Saltarelli RMF, Prado RR, Monteiro RA, Almeida MF. Mortes evitáveis no Sistema Único de Saúde na população brasileira, entre 5 e 69 anos, 2000-2013. Rev Bras Epidemiol 2018; 21:e180008. and the Southeast between 2000-2013 using the Brazilian list of causes of avoidable deaths reported a fall in the proportion of deaths from avoidable causes over the study period. This may indicate that the living conditions and health status of the population in São Paulo may be less conducive to a reduction in avoidable mortality during the study period.

The findings show a high percentage of deaths from avoidable causes among Bolivian immigrants. Although the legislation in Brazil ensures access to health services for immigrants, a number of barriers to access remains¹⁶16 Aguiar ME, Mota A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface (Botucatu) 2014; 18(50): 493-506.^,1919 Aith FMA, Forsyth C, Shikanai-Yasuda MA. Chagas Disease and Healthcare Rights in the Bolivian Immigrant Community of São Paulo, Brazil. Trop Med Infect Dis 2020; 5(2):62.. Bolivian immigrants have specific characteristics, including language barriers and high level of mobility¹⁶16 Aguiar ME, Mota A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface (Botucatu) 2014; 18(50): 493-506.. In addition, illegal entry into the country and lack of documentation can also hamper access to primary health care¹⁹19 Aith FMA, Forsyth C, Shikanai-Yasuda MA. Chagas Disease and Healthcare Rights in the Bolivian Immigrant Community of São Paulo, Brazil. Trop Med Infect Dis 2020; 5(2):62..

In both population groups deaths that could be avoided through adequate health promotion, prevention and control actions and non-communicable disease care accounted for the largest share of avoidable deaths; however, the proportion was lower in Bolivian immigrants, which may be explained by the younger demographic profile of the two populations^{8, 16}. Non-communicable diseases are one of the biggest public health problems because they result in a large number of premature deaths, loss of quality of life, and severe limitations in activities of daily living¹⁰10 Malta DC, Saltarelli RMF, Prado RR, Monteiro RA, Almeida MF. Mortes evitáveis no Sistema Único de Saúde na população brasileira, entre 5 e 69 anos, 2000-2013. Rev Bras Epidemiol 2018; 21:e180008..

According to Yazaky et al.⁸8 Yazaki LM, Ortiz LP, Almeida MF, Aranha V, Silva ZP. Indicadores de saúde reprodutiva e mortalidade dos bolivianos residentes na cidade de São Paulo. Trabalho apresentado no XIX Encontro Nacional de Estudos Populacionais; 2014 nov 24 a 28; São Pedro-SP., São Paulo has a large concentration of working-age Bolivian men. Bolivian immigrants come to Brazil primarily in search of better employment, with over 70% of the population employed in low-paid jobs in the clothing industry with poor working terms and conditions. With regard to causes of deaths that could be avoided through health promotion actions and adequate infectious disease prevention, the proportion of deaths due to tuberculosis was higher among Bolivian immigrants. This concurs with the findings of a study by Martinez et al.²⁰20 Martinez VN, Komatsu NK, Figueredo SM, Waldman EA. Equity in health: tuberculosis in the Bolivian immigrant community of São Paulo, Brazil. Trop Med Inter Health 2012; 17(11):1417-1424., which reported an increase in the number of cases of tuberculosis among Bolivian immigrants in São Paulo between 1998 and 2008, and other studies showing that the prevalence of the disease is higher in this population²¹21 Silva ECC. Rompendo barreiras: os bolivianos e o acesso aos serviços de saúde na cidade de São Paulo. Travessia 2009; 63:26-31.^-2222 Melo R, Campinas LLSL. Multiculturalidade e morbidade referida por imigrantes bolivianos na Estratégia Saúde da Família. O Mundo da Saúde 2010; 34(1):25-35.. Other studies have shown that Bolivian immigrants living in São Paulo experience poor living and working conditions and often live and work in the same space¹⁶16 Aguiar ME, Mota A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface (Botucatu) 2014; 18(50): 493-506.^,2323 Rizek CS, Georges I, Silva CF. Trabalho e imigração: uma comparação Brasil-Argentina. Lua Nova 2010; 79:111-142.

24 Junior NC, Oliveira RLS, Jesus CH, Luppi CG. Migração, exclusão social e serviços de saúde: o caso da população boliviana no centro da cidade de São Paulo. SUS Mosaico de Inclusões 2011; 13(2):177-181.^-2525 Silveira C, Carneiro Junior N, Ribeiro MCSA, Barata RCB. Living conditions and access to health services by Bolivian immigrants in the city of São Paulo, Brazil. Cad Saude Publica 2013; 29(10):2017-2027.. A similar situation was observed with Bolivian immigrants living in the Buenos Aires metropolitan area²⁶26 Goldberg A. Contextos de vulnerabilidad social y situaciones de riesgo para la salud: tuberculosis en inmigrantes bolivianos que trabajan y viven en talleres textiles clandestinos de Buenos Aires. Cuadernos de Antropología Social 2014; 39:91-114. and other studies have shown poor living and working conditions can lead to a higher frequency of respiratory diseases²⁷27 San Pedro A, Oliveira RM. Tuberculose e indicadores socioeconômicos: revisão sistemática da literatura. Rev Panam Salud Publica 2013; 33(4):294-301..

Various studies²⁶26 Goldberg A. Contextos de vulnerabilidad social y situaciones de riesgo para la salud: tuberculosis en inmigrantes bolivianos que trabajan y viven en talleres textiles clandestinos de Buenos Aires. Cuadernos de Antropología Social 2014; 39:91-114.^,2828 Souza LG, Siviero PCL. Diferencias por sexo na mortalidade evitável e ganhos potenciais de esperança de vida em São Paulo, SP: um estudo tranversal entre 2014 e 2016. Epidemiol Serv Saude 2020; 29(3):e2018451. show that women have better health status than men. Our findings show that the proportion of deaths from avoidable causes was higher among men in both nationalities. Similar findings were reported by a study in São Paulo²⁸28 Souza LG, Siviero PCL. Diferencias por sexo na mortalidade evitável e ganhos potenciais de esperança de vida em São Paulo, SP: um estudo tranversal entre 2014 e 2016. Epidemiol Serv Saude 2020; 29(3):e2018451. that investigated avoidable deaths due to cancer, hypertension, and external causes, which showed that men were more affected by external causes than women.

External causes disproportionately affect men²⁹29 Organização Pan-Americana da Saúde (OPAS). Saúde nas Américas, 2012. Volume regional. OPAS; 2012.^,3030 Moura EC, Gomes R, Falcão MTC, Schwarz E, Neves ACM, Santos W. Desigualdade de gênero na mortalidade por causas externas no Brasil, 2010. Cien Saude Colet 2015; 20(3):779-788.. This is confirmed by the high proportion of these deaths in this group among both nonimmigrants and immigrants in the present study, with the latter showing a higher percentage than the former. These findings are corroborated by a report on immigrant health produced by the São Paulo City Council Department of Health showing that Bolivian immigrants registered the highest proportion of deaths due to external causes³¹31 Secretaria Municipal da Saúde de São Paulo (SMS-SP). Coordenação de Epidemiologia e Informação (CEInfo). Alguns aspectos da saúde de imigrantes e refugiados recentes no município de São Paulo. Boletim CEInfo Análise 2015; 10(13):1-48.. This situation is explained partly by the demographic profile of this population, which is predominantly young and male⁸8 Yazaki LM, Ortiz LP, Almeida MF, Aranha V, Silva ZP. Indicadores de saúde reprodutiva e mortalidade dos bolivianos residentes na cidade de São Paulo. Trabalho apresentado no XIX Encontro Nacional de Estudos Populacionais; 2014 nov 24 a 28; São Pedro-SP.. In this regard, a systematic literature review of studies from 92 countries found that mortality rates due to external causes were higher among migrants than in the general population¹²12 Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P, Burns R, Hargreaves S, Miranda JJ, Tollman S, Friedland JS, Abubakar I. Global patterns of mortality in international migrants: a systematic review and meta-analysis. Lancet 2018; 392(10164):2553-2566.. This may be due to several interrelated factors, such as socioeconomic status, cultural adaptation, prejudice²2 Carballo M, Nerukar A. Migration, refugees, and health risks. Emerg Infect Dis 2001;7(3l):556-560.^,2424 Junior NC, Oliveira RLS, Jesus CH, Luppi CG. Migração, exclusão social e serviços de saúde: o caso da população boliviana no centro da cidade de São Paulo. SUS Mosaico de Inclusões 2011; 13(2):177-181.. In addition, young men are more likely to be exposed to occupational risk, drink, and engage in aggressive behavior and dangerous driving¹⁸18 Saltarelli RMF, Prado RR, Monteiro RA, Machado IE, Teixeira BSM, Malta DC. Mortes evitáveis por ações do Sistema Único de Saúde na população da região Sudeste do Brasil. Cien Saude Colet 2019; 24(3):887-898..

The proportion of deaths due to that could be avoided through adequate prevention, control, and care of causes of maternal death was also higher among Bolivian immigrants. A study undertaken in Spain showed excess risk of maternal death among immigrant women and that women from South America had the highest adjusted risk of maternal death³²32 Atanasova VB, Arevalo-Serrano J, Alvarado EA, Larroca SGT. Maternal mortality in Spain and its association with country of origin: cross-sectional study during the period 1999-2015. BMC Public Health 2018; 18(1):1171.. Various factors may explain these disparities, including preexisting conditions and other risk factors such as differences in access and adherence to antenatal care. Differences in access to health services have also been reported, with a study by Ferreira et al.³³33 Ferreira EK, Almeida MF, Alencar GP, Silva ZP. Live births of immigrant mothers in Brazil: a population-based study. J Migration Health 2022;5:100108. showing that, despite the provision of free health care by Brazil’s public health system, Bolivian immigrants go to less antenatal care appointments and begin care later than Brazilian mothers³³33 Ferreira EK, Almeida MF, Alencar GP, Silva ZP. Live births of immigrant mothers in Brazil: a population-based study. J Migration Health 2022;5:100108..

São Paulo has excellent information coverage and high-quality death certification. An important factor influencing the quality of death certification in São Paulo is the Mortality Information Enhancement Program (PRO-AIM), which seeks to provide timely and quality data and decentralize information³⁴34 Drumond M. Homicídios e desigualdades sociais na cidade de São Paulo: uma visão epidemiológica. Saude Soci 1999; 8(1):63-81.^-3535 Secretaria Municipal da Saúde de São Paulo (SMS-SP). Coordenação de Epidemiologia e Informação (CEInfo). PRO-AIM Programa de Aprimoramento das Informações de Mortalidade. [acessado 2021 nov 1]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/saude/epidemiologia_e_informacao/mortalidade/index.php?p=29586
https://www.prefeitura.sp.gov.br/cidade/... . As a result, we identified a low proportion of ill-defined causes among both study populations in comparison to the average rate for the overall population in Brazil in 2010 (7%)³⁶36 França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Neto OLM, Szwarcwald CL. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saude Publica 2014; 48(4):671-681..

There is no consensus about the “healthy migrant effect”, which suggests that migrants often have a better health status than the population of the host country. Although some studies have shown the presence of this effect¹²12 Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P, Burns R, Hargreaves S, Miranda JJ, Tollman S, Friedland JS, Abubakar I. Global patterns of mortality in international migrants: a systematic review and meta-analysis. Lancet 2018; 392(10164):2553-2566., others, including the present study, suggest that it is not observed in some regions³⁷37 Kennedy S, McDonald JT, Biddle N. The healthy immigrant effect and immigrant selection: evidence from four countries. Social and Economic Dimensions of an Aging Population Research Papers; McMaster University; 2006.

38 Moullan Y, Jusot F. Why is the 'healthy immigrant effect' different between European countries? Eu J Public Health 2014; 24(1):80-86.^-3939 Lu C, Ng E. Healthy immigrant effect by immigrant category in Canada. Health Rep 2019; 30(4):3-11.. The lack of research in this area means it is not possible to determine whether migration improves or worsens health by altering a range of individual and population health risk factors¹1 Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C, THE UCL - Lancet Commission on Migration and Health. THE UCL - Lancet Commission on Migration and Health: the health of a world on the move. Lancet 2018; 392(10164):2606:2654.. The health risks faced by migrants are determined by their pre-migration health status and are part of a complex combination of biological and socioeconomic factors that accumulate throughout the lifecycle¹1 Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C, THE UCL - Lancet Commission on Migration and Health. THE UCL - Lancet Commission on Migration and Health: the health of a world on the move. Lancet 2018; 392(10164):2606:2654.. Further research on this topic is warranted in São Paulo, a region with a high level of inter-regional population mobility, which has regained importance recently due to the rise in international migration⁸8 Yazaki LM, Ortiz LP, Almeida MF, Aranha V, Silva ZP. Indicadores de saúde reprodutiva e mortalidade dos bolivianos residentes na cidade de São Paulo. Trabalho apresentado no XIX Encontro Nacional de Estudos Populacionais; 2014 nov 24 a 28; São Pedro-SP..

One of the limitations of this study is that data on how long the immigrants have resided in the country and the region and different immigrant subgroups (vulnerable groups such as refugees for example) was not available. Second, we did not use mortality rates, which provide a better measure of risk of death, due to the lack of a denominator for Bolivian immigrants. It is important to consider that the list of avoidable causes may vary according to advances in knowledge and the use of new technologies and should therefore be constantly updated.

In conclusion, Bolivian immigrants died younger than nonimmigrants and the profile of causes of death in this group is different to that of the general population, there was no reduction in the proportion of potentially preventable causes, showing greater difference for the group of infectious causes and accidents and violence. Differences in avoidable mortality are an indicator of disparities in access to and the utilization of health services and living conditions. A better understanding of the mortality profile of this population can provide important inputs to inform the formulation of disease prevention and health promotion programs and policies and help avoided premature deaths in this group.

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