The influence of country of birth on mortality from all causes and cardiovascular disease in Sweden 1979-1993

The problematic nature of existing explanations for differential immigrant mortality: Insights from a comparative cross-national systematic review and meta-analysis

Empirical studies in multiple disciplines have frequently observed an immigrant mortality advantage. Yet, questions remain regarding the possible mechanisms underlying this phenomenon. We obtained data from 61 studies of relative immigrant mortality from single origin-destination country pairings, providing information on immigrants from 77 origin countries. We systematically review the arguments made in these studies about origin-country factors that might influence immigrant mortality and then use meta-analyses to examine the veracity of these arguments. We find that most existing origin-country explanations for immigrant mortality patterns (e.g., health behaviors, genetic characteristics, environmental conditions, and socioeconomic conditions) are problematic or insufficient when accounting for differential mortality by origin country. We identify non-comparative analyses and geographic aggregation as the two major obstacles to understanding the mechanisms underlying the immigrant mortality advantage. We conclude by advocating for a risk-factor-based, cross-national approach.

The Effects of Ethno-cultural Origin-Destination Interactions on Immigrants' Longevity

A large body of research has documented an immigrant mortality advantage. However, we still do not know enough about how interactions between the characteristics of origin and destinations countries shape variabilities in immigrants' experiences and health. In this paper, we examine the effects of ethno-cultural similarities and differences between the country of origin and the country of destination on immigrants' longevity. We use meta-regression methods to examine data on 78 origin and 16 destination countries (1092 risk estimates from 69 studies). In contrast to expectations from approaches that focus on immigration/acculturation stress, we found that a shared official linguistic family, moving to a country where one is not likely to be considered a visible minority, and more integrative immigration policies actually reduce or even eliminate the immigrant mortality advantage. We discuss potential explanations for these findings and argue that selection mechanisms provide a better account.

A Global Meta-analysis of the Immigrant Mortality Advantage

A large body of research on the “Healthy Immigrant Effect” (or “Paradox”) has reported an immigrant mortality advantage. However, other studies do not find such significant effects, and some even present contradictory evidence. This article is the first systematic meta-analysis that investigates the immigration-mortality relationship from a global perspective, examining 1,933 all-cause and cardiovascular mortality risk estimates from 103 publications. Our comprehensive analysis allows us to assess interactions between origin and destination regions and to reexamine, on a global scale, some of the most notable explanations for the immigrant mortality advantage, including suggestions that this paradox may be primarily the result of selection effects. We find evidence for the existence of a mild immigrant mortality advantage for working-age individuals. However, the relationship holds only for immigrants who moved between certain world regions, particularly those who immigrated from Northern Africa, Asia, and Southern Europe to richer countries. The results highlight the need in the broader migration literature for an increased focus on selection effects and on outcomes for people who chose not to migrate or who were denied entry into their planned destination country.

Big Data-Driven Approach for Health Inequalities in Foreign Patients with Injuries Visiting Emergency Rooms

Objectives

Foreign patients are more likely to receive inappropriate health service in the emergency room. This study aimed to investigate whether there is health inequality between foreigners and natives who visited emergency rooms with injuries and to examine its causes.

Methods

We analyzed clinical data from the National Emergency Department Information System database associated with patients of all age groups visiting the emergency room from 2013 to 2015. We analyzed data regarding mortality, intensive care unit admission, emergency operation, severity, area, and transfer ratio.

Results

A total of 4,464,603 cases of injured patients were included, of whom 67,683 were foreign. Injury cases per 100,000 population per year were 2,960.5 for native patients and 1,659.8 for foreign patients. Foreigners were more likely to have no insurance (3.1% vs. 32.0%, p < 0.001). Serious outcomes (intensive care unit admission, emergency operation, or death) were more frequent among foreigners. In rural areas, the difference between serious outcomes for foreigners compared to natives was greater (3.7% for natives vs. 5.0% for foreigners, p < 0.001). The adjusted odds ratio for serious outcomes for foreign nationals was 1.412 (95% confidence interval [CI], 1.336–1.492), and that for lack of insurance was 1.354 (95% CI, 1.314–1.394).

Conclusions

Injured foreigners might more frequently suffer serious outcomes, and health inequality was greater in rural areas than in urban areas. Foreign nationality itself and lack of insurance could adversely affect medical outcomes.

Distinctive role of income in the all-cause mortality among working age migrants and the settled population in Finland: A follow-up study from 2001 to 2014

BACKGROUND

Although income level may play a significant part in mortality among migrants, previous research has not focused on the relationship between income, migration and mortality risk. The aim of this register study was to compare all-cause mortality by income level between different migrant groups and the majority settled population of Finland.

METHODS

A random sample was drawn of 1,058,391 working age people (age range 18-64 years; 50.4% men) living in Finland in 2000 and linked to mortality data from 2001 to 2014. The data were obtained from Statistics Finland. Cox proportional hazards models were used to investigate the association between region of origin and all-cause mortality in low- and high-income groups.

RESULTS

The risk for all-cause mortality was significantly lower among migrants than among the settled majority population (hazards ratio (HR) 0.57; 95% confidence interval (CI) 0.53-0.62). After adjustment for age, sex, marital status, employment status and personal income, the risk of mortality was significantly reduced for low-income migrants compared with the settled majority population with a low income level (HR 0.46; 95% CI 0.42-0.50) and for high-income migrants compared with the high-income settled majority (HR 0.81; 95% CI 0.69-0.95). Results comparing individual high-income migrant groups and the settled population were not significant. Low-income migrants from Africa, the Middle East and Asia had the lowest mortality risk of any migrant group studied (HR 0.32; 95% CI 0.27-0.39).

CONCLUSIONS

Particularly low-income migrants seem to display a survival advantage compared with the corresponding income group in the settled majority population. Downward social mobility, differences in health-related lifestyles and the healthy migrant effect may explain this phenomenon.

Trends and Disparities in Mortality Among Spanish-Born and Foreign-Born Populations Residing in Spain, 1999-2008

Spain's immigrant population has increased 380% in the last decade, accounting for 13.1% of the total population. This fact has led her to become during 2009 the eighth recipient country of international immigrants in the world. The aim of this article is to describe the evolution of mortality and the main causes of death among the Spanish-born and foreign-born populations residing in Spain between 1999 and 2008. Age-standardised mortality rates (ASRs), average age and comparative mortality ratios among foreign-born and Spanish-born populations residing in Spain were computed for every year and sub-period by sex, cause of death and place of birth as well as by the ASR percentage change. During 1999-2008 the ASR showed a progressive decrease in the risk of death in the Spanish-born population (-17.8% for men and -16.6% for women) as well as in the foreign-born one (-45.9% for men and -35.7% for women). ASR also showed a progressive decrease for practically all the causes of death, in both populations. It has been observed that the risk of death due to neoplasms and respiratory diseases among immigrants is lower than that of their Spanish-born counterparts, but risk due to external causes is higher. Places of birth with the greater decreases are Northern Europe, Eastern Europe, Western Europe, Southern Europe, and Latin America and the Caribbean. The research shows the differences in the reduction of death risk between Spanish-born and immigrant inhabitants between 1999 and 2008. These results could contribute to the ability of central and local governments to create effective health policy. Further research is necessary to examine changes in mortality trends among immigrant populations as a consequence of the economic crisis and the reforms in the Spanish health system. Spanish data sources should incorporate into their records information that enables them to find out the immigrant duration of permanence and the possible impact of this on mortality indicators.

[Mortality risks of migrants: Analysis of the healthy-migrant-effect after the 2011 German Census]

In Germany there are 16 million people with a migration background, one in five of the total population. There are relatively few migrant mortality studies in Germany, which is primarily due to the restricted quantity and quality of existing data. The official migrant death statistics for Germany suffer from incomplete migrant population stock data due to non-registered remigration events. After the German census in 2011 especially the migrant stock data was adjusted downwards, and therefore realistic estimates of the migrant mortality risk and the healthy-migrant-effect are possible. Between 2010 and 2013 mortality risks of foreigners rose strongly due to the census corrections of the migrant population. However, the risks for adults and pensioners still lie below the risks for Germans in the same age groups. The lower risks indicate a healthy-migrant-effect, whicht was primarily effective shortly after the immigration event. Analysis based on data from the Statutory Pension Insurance (GRV) shows higher migrant mortality risks in the age group from 65 to 84. In that age group there are supposedly a lot of people, who immigrated to Germany in the context of the guest worker recruitment in the 1950s to 1970s and who had hard working conditions in their lifetimes. Their mortality risk, therefore, increased in the long-term perspective. In the future the lack of data in the migrant population will again rise due to unregistered remigration. Alternative databases need to be used for migrant mortality analyses.

Applications and limitations of the concept of 'avoidable mortality' among immigrant groups in Europe: a scoping review

OBJECTIVES

Avoidable mortality is often used as a key indicator of broader health inequalities. Health inequalities refer to unfair differences in the quality of health and wellbeing, and health care across different populations. This includes differences in the presence of disease, health outcomes, or access to health care. Migrants represent a disadvantaged and growing demographic with special health risks. This study analyses the usages of the concept of avoidable mortality as applied in studies on migrants in Europe. In doing so, the study aims to identify the strengths and limitations of the concept of avoidable mortality for comparative work.

STUDY DESIGN

A scoping review was conducted for the period of 1990-2011.

METHODS

Publications were identified by a systematic search of PUBMED and WEB OF SCIENCE. An additional five publications were found through the search via references. A total number of 37 publications from 10 European countries were included in the analysis.

RESULTS

The authors divided studies according to direct versus indirect usage of the concept. Studies with direct usage of the concept established a correlation between patterns of avoidable mortality and health care system performance. Additionally, they searched studies which indirectly used avoidable mortality to examine further evidence for the strengths and weaknesses of the concept. These studies used indicators of amenable mortality (at times alongside other mortality indicators) without making direct reference to the concept. Findings using both approaches identified a similar trend in principal causes of premature death. The difference between the two types of studies concerned the more detailed analysis of the causes of death in studies with direct usage categorising into treatable versus preventable causes of death, or health policy versus medical intervention.

CONCLUSIONS

The results of this article highlight the role of health care systems in contributing to migrant health outcomes: whereas mixed outcomes across a number of indicators of avoidable mortality used indirectly do arise, the large number of studies - especially those using the concept directly - evidence a higher share of premature mortality for migrants compared to host populations. These findings can provide policy makers with important insights into targeted ways of improving the access and quality of health services for marginalised populations. However, the strength and depth of such insights stand to improve, as current research on avoidable mortality is often indirect (rather than overt and systematic), thereby limiting the potential for cross-national comparison, as well as a clearer understanding of the links between health outcomes and health care system performance for a disadvantaged group.

Causes of death among undocumented migrants in Sweden, 1997-2010

BACKGROUND

Undocumented migrants are one of the most vulnerable groups in Swedish society, where they generally suffer from poor health and limited health care access. Due to their irregular status, such migrants are an under-researched group and are not included in the country's Cause of Death Register (CDR).

OBJECTIVE

To determine the causes of death among undocumented migrants in Sweden and to ascertain whether there are patterns in causes of death that differ between residents and undocumented migrants.

DESIGN

This is a cross-sectional study of death certificates issued from 1997 to 2010 but never included in the CDR from which we established our study sample of undocumented migrants. As age adjustments could not be performed due to lack of data, comparisons between residents and undocumented migrants were made at specific age intervals, based on the study sample's mean age at death±a half standard deviation.

RESULTS

Out of 7,925 individuals surveyed, 860 were classified as likely to have been undocumented migrants. External causes (49.8%) were the most frequent cause of death, followed by circulatory system diseases, and then neoplasms. Undocumented migrants had a statistically significant increased risk of dying from external causes (odds ratio [OR] 3.57, 95% confidence interval [CI]: 2.83-4.52) and circulatory system diseases (OR 2.20, 95% CI: 1.73-2.82) compared to residents, and a lower risk of dying from neoplasms (OR 0.07, 95% CI: 0.04-0.14).

CONCLUSIONS

We believe our study is the first to determine national figures on causes of death of undocumented migrants. We found inequity in health as substantial differences in causes of death between undocumented migrants and residents were seen. Legal ambiguities regarding health care provision must be addressed if equity in health is to be achieved in a country otherwise known for its universal health coverage.

Mortality differentials by immigrant groups in Sweden: the contribution of socioeconomic position

OBJECTIVES

We studied mortality differentials between specific groups of foreign-born immigrants in Sweden and whether socioeconomic position (SEP) could account for such differences.

METHODS

We conducted a follow-up study of 1 997 666 men and 1 964 965 women ages 30 to 65 years based on data from national Swedish total population registers. We examined mortality risks in the 12 largest immigrant groups in Sweden between 1998 and 2006 using Cox regression. We also investigated deaths from all causes, circulatory disease, neoplasms, and external causes.

RESULTS

We found higher all-cause mortality among many immigrant categories, although some groups had lower mortality. When studying cause-specific mortality, we found the largest differentials in deaths from circulatory disease, whereas disparities in mortality from neoplasms were smaller. SEP, especially income and occupational class, accounted for most of the mortality differentials by country of birth.

CONCLUSIONS

Our findings stressed that different aspects of SEP were not interchangeable in relation to immigrant health. Although policies aimed at improving immigrants' socioeconomic conditions might be beneficial for health and longevity, our findings indicated that such policies might have varying effects depending on the specific country of origin and cause of death.

Immigrants' mortality patterns in the short- and long-term point toward origin-related diversities: the Israeli experience

Immigrant mortality studies reveal conflicting results that were attributed to diversity in immigrant definition, different classifications, and lack of appropriate comparisons. This work studied mortality patterns of the immigrations absorbed in Israel. Short-term mortality was evaluated by comparing the Standardized Mortality Rate (SMR) of the first year after immigration to the SMR of the second to fifth years. Long-term mortality was evaluated by comparing recent immigrant cohorts to cohorts of immigrants who have been residents 5 and 10 years. Stratification was made by source country classification and gender. Data were derived from the Israel National Population Registry and were analyzed anonymously. Immigrants from developed and developing countries had the highest SMR in the first year, which considerably decreased in both short and long term. Immigrants from mid-developed countries had stable SMR in the short term followed by only a modest decrease in the long term. Ethiopian immigrants exhibited exceptionally low SMR in the first year, following which it increased but remained relatively low. Mortality patterns of different immigrant groups differ even under similar definitions, conditions, and period. Only immigrants of developed and developing countries presented the expected pattern of excessive short-term mortality, which consistently decreased with time. Unique mortality patterns were discovered among two groups: Immigrants from mid-developed countries presented stable mortality attributable to isolation and delayed adaptation, and Ethiopian low mortality attributable to pre-migration natural selection.

Work and health among immigrants and native Swedes 1990-2008: a register-based study on hospitalization for common potentially work-related disorders, disability pension and mortality

Background

There are many immigrants in the Swedish workforce, but knowledge of their general and work-related health is limited. The aim of this register-based study was to explore whether documented migrant residents in Sweden have a different health status regarding receipt of a disability pension, mortality and hospitalization for lung, heart, psychiatric, and musculoskeletal disorders compared with the native population, and if there were variations in relation to sex, geographical origin, position on the labor market, and time since first immigration.

Methods

This study included migrants to Sweden since 1960 who were 28–47 years old in 1990, and included 243 860 individuals. The comparison group comprised a random sample of 859 653 native Swedes. These cohorts were followed from 1991 to 2008 in national registers. The immigrants were divided into four groups based on geographic origin. Hazard ratios for men and women from different geographic origins and with different employment status were analyzed separately for the six outcomes, with adjustment for age, education level, and income. The influence of length of residence in Sweden was analyzed separately.

Results

Nordic immigrants had increased risks for all investigated outcomes while most other groups had equal or lower risks for those outcomes than the Swedes. The lowest HRs were found in the EU 15+ group (from western Europe, North America, Australia and New Zealand). All groups, except Nordic immigrants, had lower risk of mortality, but all had higher risk of disability pension receipt compared with native Swedes. Unemployed non-Nordic men displayed equal or lower HRs for most outcomes, except disability pension receipt, compared with unemployed Swedish men. A longer time since first immigration improved the health status of men, while women showed opposite results.

Conclusions

Employment status and length of residence are important factors for health. The contradictory results of low mortality and high disability pension risks need more attention. There is great potential to increase the knowledge in this field in Sweden, because of the high quality registers.

Excess mortality in women of reproductive age from low-income countries: a Swedish national register study

Background: Cause-of-death statistics is widely used to monitor the health of a population. African immigrants have, in several European studies, shown to be at an increased risk of maternal death, but few studies have investigated cause-specific mortality rates in female immigrants. Methods: In this national study, based on the Swedish Cause of Death Register, we studied 27 957 women of reproductive age (aged 15–49 years) who died between 1988 and 2007. Age-standardized mortality rates per 100 000 person years and relative risks for death and underlying causes of death, grouped according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, were calculated and compared between women born in Sweden and in low-, middle- and high-income countries. Results: The total age-standardized mortality rate per 100 000 person years was significantly higher for women born in low-income (84.4) and high-income countries (83.7), but lower for women born in middle-income countries (57.5), as compared with Swedish-born women (68.1). The relative risk of dying from infectious disease was 15.0 (95% confidence interval 10.8–20.7) and diseases related to pregnancy was 6.6 (95% confidence interval 2.6–16.5) for women born in low-income countries, as compared to Swedish-born women. Conclusions: Women born in low-income countries are at the highest risk of dying during reproductive age in Sweden, with the largest discrepancy in mortality rates seen for infectious diseases and diseases related to pregnancy, a cause of death pattern similar to the one in their countries of birth. The World Bank classification of economies may be a useful tool in migration research.

Migration and health: a study of effects of early life experiences and current socio-economic situation on mortality of immigrants in Sweden

OBJECTIVES

Previous research has demonstrated mortality differences between immigrants and natives living in Sweden. The aim of this study is to investigate the effects of early life conditions in the country of birth and current socio-economic conditions in adult life in Sweden on cardiovascular, cancer, all other cause and total mortality among immigrants and natives in Sweden.

DESIGN

The cohort data concerning individual demographic characteristics and socio-economic conditions stems from the Swedish Longitudinal Immigrant Database (SLI), a register-based representative database, and consists of individuals from 11 countries of birth, born between 1921 and 1939, who were residents in Sweden between 1980 and 2001. The associations between current socio-economic conditions as well as infant mortality rates (IMR) and Gross Domestic Product (GDP) per capita in the year and country of birth, and total, cardiovascular, cancer and 'all other' mortality in 1980-2001 were calculated by survival analysis using Cox proportional hazards regression to calculate hazard rate ratios.

RESULTS

The effects of current adult life socio-economic conditions in Sweden on mortality are both stronger and more straightforward than the effects of early life conditions in the sense that higher socio-economic status is significantly associated with lower mortality in all groups of diagnoses; however, we find associations between infant mortality rates (IMR) in the year and country of birth, and cancer mortality among men and women in the final model.

CONCLUSIONS

Socioeconomic conditions in Sweden are more strongly associated with mortality than early life indicators IMR and GDP per capita in the year of birth in the country of origin. This finding has health policy and other policy implications.

Participation of Danish and immigrant cleaners in a 1-year worksite intervention preventing physical deterioration

Worksite health promotion is seldom offered to workers who are low-educated and multi-ethnic, possibly due to an assumption that they are more reluctant to participate. Furthermore, little has been done to promote health at female-dominated workplaces. The main aim of this study was to investigate differences in participation among immigrant and Danish cleaners throughout a 1-year randomised controlled study tailored to cleaners and carried out in predominantly female workplaces. No significant differences in ethnicity were found in consent and participation throughout the 1-year intervention. Dropout was equally distributed among Danish and immigrant cleaners. This study indicates that a worksite health promotion intervention among a female-dominated, high-risk occupation such as cleaning can be equally appealing for Danes and immigrants.

PRACTITIONER SUMMARY

This study provides insight about participation of Danish and immigrant cleaners in a worksite health promotion intervention in a predominantly female occupation. For attaining high participation and low dropout in future worksite health promotion interventions among cleaners, the intervention ought to not only target the ethnic background of the workers, but also to be specifically tailored to the job group.

Self-rated health, ethnicity and social position in a deprived neighbourhood in Denmark

Background

In recent years the close connection between SES and differences in health between ethnic groups have been subject to growing interest among researchers, and some studies have found an association between ethnicity and long term illness and poor health. However, there is limited research-based knowledge about health and illness in ethnic groups in Denmark and about ethnic Danes living in deprived neighbourhoods. The purpose of this study is to investigate associations between self-rated health and ethnicity and social position in a deprived neighbourhood in Denmark in which a relatively largely proportion of the residents are immigrants.

Methods

This study investigates the association between self-rated health used as dependent variable and ethnicity and social position (defined as index for life resources) as the independent variables. The analyses are based on data collected in a survey in a geographically bounded and social deprived neighbourhood, Korskaerparken, located in the municipality of Fredericia in Denmark. The sample consisted of 31% of the residents in Korskaerparken and of these 29% have an ethnic background other than Danish.

The analyses were conducted using logistic regression adjusting for confounding variables.

Results

This study indicates no significant association between ethnicity and having poor/very poor self-rated health.

On the other hand the study confirms that a strong and significant association between the number of residents' life resources and their self-rated health does indeed exist. The results clearly suggest that the more life resources an individual has, the lower is the risk of that individual reporting poor health.

Conclusion

The results show a strong association between the residents' number of life resources and their self-rated health. In this study, we were not able to identify any association between ethnicity and self-rated health, i.e. our results suggest that ethnicity does not constitute an explanation to differences in self- rated health.

Health disparities between immigrant and Danish cleaners

PURPOSE

It is unknown whether immigrants working in the cleaning industry have a poorer health and work ability than cleaners from the native population. The main aim was to investigate differences in objective and self-reported health measures between immigrant and Danish cleaners.

METHODS

Three hundred and fifty-one cleaners, consisting of 166 Danes (88% women) and 179 immigrants (74% women) (6 with unknown ethnicity), from 9 workplaces in Denmark participated in the study. Health and work ability were obtained by objective (e.g., BMI and blood pressure) and self-reported measures (e.g., work ability, self-rated health, and musculoskeletal symptoms). In order to investigate differences between Danish and immigrant cleaners, logistic regression analyses and General Linear Models were performed.

RESULTS

When controlling for age, sex, workplace, job seniority, and smoking, more Danish compared with immigrant cleaners were current smokers (42% vs. 28%, p < 0.001 (not controlled for smoking)), had hypertension (46% vs. 26%, p < 0.05) and drank more alcohol (3.0 vs. 0.8 units per day, respectively, p < 0.001). Contrary, more immigrants compared with Danish cleaners were measured to be overweight (47% vs. 30%, p < 0.05), reported less than good work ability (57% vs. 42%, p < 0.01), considered it unthinkable/unsure to be able to perform work 2 years ahead (37% vs. 23%, p < 0.01), reported reduced self-rated health (46% vs. 38%, p < 0.01) and everyday pain in the neck/shoulder (28% vs. 11%, p < 0.01), wrist (18% vs. 7%, p < 0.01), and lower back (21% vs. 10%, p < 0.01). There were no differences in self-reported chronic diseases.

CONCLUSIONS

Although the health of the cleaners was alarmingly poor, the immigrant cleaners generally had a poorer self-reported health and work ability than the Danish cleaners. These findings highlight the need for occupational health actions among cleaners, particularly tailored to the immigrant subpopulation.

Country of birth and risk of hospitalization due to heart failure: a Swedish population-based cohort study

To explore the relation between country of birth and risk of hospitalization due to heart failure (HF). All 40-89 year-old inhabitants in the city of Malmö, Sweden (n = 114,917, of whom 15.2% were born outside Sweden) were followed from November 1st, 1990 until December 31st, 2007. During a mean follow-up of 13.5 ± 5.3 years, a total of 7,640 individuals (47.4% men) were discharged from hospital with first-ever HF as primary diagnosis. Of them, 1,243 individuals had myocardial infarction (MI) before or concurrent with the HF hospitalization. The risk of HF was compared between immigrants from selected countries and Swedish natives. The overall analysis showed substantial differences among immigrant groups (P < 0.001). Compared to Swedish natives, significantly increased HF risk was found among immigrants from Finland (HR (hazard ratio): 1.40; 95% CI, 1.10-1.81), Former Yugoslavia (1.45: 1.23-1.72) and Hungary (1.48: 1.16-1.89), taking age, sex, marital status, annual income and housing condition into account. Analysis results were similar when cases with MI before or concurrent with the HF hospitalization were included in the analysis. In general, the risk of HF was significantly higher among immigrants from high-income and middle-income countries. Marital status, annual income and housing condition were also significant independent risk factors for HF in this population. There are substantial differences in risk of hospitalization due to HF among immigrants from different countries that can not be explained by socioeconomic factors. To what extent these differences could be explained by biological risk factors remains to be explored.

Cardiovascular risk factors in Assyrians/Syrians and native Swedes with type 2 diabetes: a population-based epidemiological study

BACKGROUND

A large number of people throughout the world have diabetes and the prevalence is increasing. Persons with diabetes have a twice higher risk of cardiovascular disease than those without diabetes. There is a lack of studies focusing on cardiovascular risk factors in Assyrians/Syrians with type 2 diabetes. The aim of this study is to estimate the prevalence of some cardiovascular risk factors among Assyrians/Syrians and native Swedes with type 2 diabetes and to study whether the association between ethnicity and cardio-vascular risk factors remains after adjustment for age, gender, employment status and housing tenure.

METHODS

In the Swedish town of Södertälje 173 Assyrians/Syrians and 181 ethnic Swedes with type 2 diabetes participated in a study evaluating cardiovascular risk factors such as increased haemoglobin A1c (HbA1c), high blood lipids (total serum cholesterol and triglycerides), hypertension and high urinary albumin. The associations between the outcome variables and sociodemographic characteristics were estimated using unconditional logistic regression.

RESULTS

The prevalence of increased triglycerides in Swedish-born subjects and Assyrian-Syrians was 61.5% and 39.7% respectively. Swedes had a prevalence of hypertension 76.8% compared to 57.8% in Assyrians/Syrians. In the final logistic models adjusted for gender, age, housing and employment the odds ratio (OR) for Swedish-born subjects for increased triglycerides was 2.80 (95% CI1.61-4.87) and for hypertension 2.32 (95% CI 1.35-4.00) compared to Assyrians-Syrians.

CONCLUSION

Ethnic Swedes had higher prevalence of increased triglycerides and hypertension than Assyrians/Syrians. Total cholesterol, HbA1c and urinary albumin did not differ between the two ethnic groups.

Mortality in first generation white immigrants in California, 1989-1999

OBJECTIVE

To identify mortality differentials in the first generation non-Hispanic White (NHW) immigrants in California for 1989 through 1999.

METHODS

First generation NHW immigrants (107,432) were identified in California Death Certificate files by place of birth outside the US and were grouped into Anglo-Saxon dominant, Northern, Western, Eastern, and Southern Europe, former USSR, Arabs and non-Arab Middle Eastern areas. US-born NHW (1,480,347) were used as standard to determine proportional mortality ratios (PMR) for major causes of death including: cancers, coronary heart disease, cerebrovascular accidents, chronic obstructive pulmonary disease (COPD), HIV/AIDS, accidents, diabetes, pneumonia, suicide, and homicide.

RESULTS

All immigrants had significantly higher PMR for suicide and with few exceptions for cardiovascular diseases. Lower PMR was recorded for COPD and homicide. No difference was noticed for pneumonia and accidents. Cancer deaths were generally higher in European immigrants.

CONCLUSIONS

Mortality patterns of NHW immigrants reflect the mixed impacts of acculturation, ethnic-specific characteristics, and psychological well being.

Migration and coronary heart disease: A study of Finnish twins living in Sweden and their co-twins residing in Finland

BACKGROUND

Finland and Sweden are neighbouring countries with a substantially higher incidence and mortality from coronary heart disease (CHD) in Finland. Migration from Finland to Sweden has resulted in a population of about 187,000 Finnish immigrants, with a higher risk of CHD than Swedes. The aim of the present study was to analyse the prevalence of CHD in migrants to Sweden compared with co-twins remaining in Finland.

METHODS

The study population consisted of twin pairs of the Finnish Twin Cohort Study where at least one twin had lived one year or more in Sweden, including 1,534 subjects and 251 complete twin pairs discordant regarding residency in Sweden. Emigrant twins were compared with nonmigrant co-twins regarding prevalence of CHD in 1998. CHD prevalence was assessed by self-reported questionnaires validated using information from a clinical examination.

RESULTS

Self-reported CHD showed a good correspondence with clinical diagnosis. Differences in social and behavioural risk factors for CHD among men were small but emigrants were more physically active than non-migrants. Female emigrants had less overweight and better education, but were more often working class than non-migrants. Intra-pair comparisons restricted to migration discordant pairs showed a tendency towards a reduced prevalence of CHD in the migrant co-twins (0.6; 0.3-1.4). In analyses of all subjects disregarding pair status, emigrants showed a reduced prevalence of CHD compared with subjects always living in Finland (0.6; 0.4-0.9).

CONCLUSION

Emigration from Finland to Sweden may be associated with a reduced prevalence of CHD. The causes are most likely multifactorial and may involve changes in dietary habits, physical activity, psychosocial factors, and inflammation.

Migration and differences in dietary habits-a cross sectional study of Finnish twins in Sweden

OBJECTIVE

To compare dietary habits between Finnish twin migrants to Sweden and their co-twins always living in Finland, and to analyse how migration influenced food consumption patterns in the migrants.

SUBJECTS/METHODS

Same-sexed twin pairs born in Finland below 75 years of age, with at least one twin migrating to Sweden (n=1083 pairs). Dietary habits were assessed by a food frequency questionnaire included in a comprehensive mailed questionnaire (response rate 71%). For 76 male twin pairs, information was also collected by a dietary history interview inquiring the habitual diet during the previous year.

RESULTS

Migrant twins in Sweden had a lower intake of typical Finnish foods like dark bread and berries, and an increased consumption of fresh fruit compared with co-twins living in Finland. The migrants consumed less potatoes and more rice and pasta. Sweet pastries were consumed less often by the migrants and they also tended to more often cut out visible fat of meat and on the other hand add salt to dishes. Among men the migrants had a lower alcohol intake than their co-twins living in Finland.

CONCLUSIONS

Migration from Finland to Sweden is associated with differences in the food pattern that reflect population differences in eating habits between the two countries. The differences include a reduced consumption of typical Finnish foods like dark bread and berries and are of bidirectional nature from the point of view of cardiovascular health.

Social capital, anticipated ethnic discrimination and self-reported psychological health: a population-based study

This study investigates the association between anticipated ethnic discrimination and self-reported psychological health, taking generalized trust in other people into consideration. The 2004 Public Health Survey in Skåne, Sweden, is a cross-sectional postal questionnaire study including a total of 27,757 respondents aged 18-80 with a 59% response rate. Multivariate analyses of anticipated discrimination and self-reported psychological health were performed using logistic regressions in order to investigate the importance of possible confounders (age, country of origin, education and horizontal trust). Poor psychological health was reported by 13.0% of men and 18.9% of women, and 44.8% and 44.7%, respectively, reported that 50% or more of employers would discriminate according to race, colour of skin, religion, or cultural background. Respondents in younger age groups, born abroad, with high education, low trust and high levels of self-reported anticipated discrimination, had significantly higher levels of poor self-reported psychological health. There was a significant association between anticipated discrimination and low horizontal trust. After multiple adjustments for age, country of origin and education, the addition of trust in the model reduced the odds ratio of poor self-reported psychological health in the "most employers" category from 1.8 (1.4-2.1) to 1.5 (1.3-1.9) among men and from 2.2 (1.8-2.6) to 1.8 (1.5-2.2) among women. Generalized trust in other people may be a confounder of the association between anticipated discrimination and poor psychological health. Anticipated discrimination may have effects on the mental health of not only the affected minorities, but also on the mental health of the general population.

Mortality from all causes and circulatory disease by country of birth in England and Wales 2001-2003

BACKGROUND

Differences in mortality by country of birth in England and Wales in people under 70 years of age have been demonstrated previously. Changes in age distribution of migrants and in migration patterns have occurred subsequently.

METHODS

All-cause and circulatory disease mortality for people aged 20 years and over in England and Wales by country of birth were examined using population data from the 2001 Census and mortality data for 2001-2003. Indirect standardization was used to estimate sex-specific standardized mortality ratios (SMRs) and 95% confidence intervals (CI) in comparison to mortality for England and Wales as a whole.

RESULTS

SMRs for all-cause mortality were statistically significantly higher than the national average for people born in Ireland, Scotland, East Africa and West Africa and lower for people born in China and Hong Kong. SMRs for circulatory disease were highest among people born in Bangladesh and lowest among people born in China and Hong Kong. Patterns of ischaemic heart disease and cerebrovascular disease mortality differed by country of birth.

CONCLUSIONS

Mortality, particularly due to ischaemic heart disease and stroke, differs markedly by country of birth in all age groups including the > or =70-year-old group.

Hip Fractures Among the Elderly: Personal and Contextual Social Factors That Matter

BACKGROUND

There is evidence of independent neighborhood effects on the risk of hip fracture among the elderly. This study builds on earlier investigations and measures the crude and adjusted effects of individual personal- and area-based social attributes on hip fracture.

METHODS

The study is cross-sectional and register-based, and covers all people aged 65 or older living in the Stockholm metropolitan area during 1993 to 1995. It combines individual data from hospital inpatient registers, population data from census records, and area-based (parish) data from the Stockholm County's registers. Marital status (married or not), country of birth (three categories), and two area-based compositional indexes (social status and economic deprivation, each split into three levels) were considered. Both age adjusted odds ratios and odds adjusted for all other variables were compiled.

RESULTS

The age adjusted effects of individual marital status, country of birth, and area-based social status are considerable and not much affected by the other exposures, to the detriment of married men and women, Swedish-born men and women, and those men and women living in parishes characterized by average and high social status. By contrast, after adjustment, the odds of men and women living in average and high socioeconomic deprivation lose significance.

CONCLUSIONS

The attributes of both people and places may contribute to a better understanding of the occurrence of hip fractures among the elderly. The effects of individual marital status, country of birth, and social status of the living area are noticeably robust.

Are there differences in all-cause and coronary heart disease mortality between immigrants in Sweden and in their country of birth? A follow-up study of total populations

Background

Mortality from cardiovascular diseases is higher among immigrants than native Swedes. It is not clear whether the high mortality persists from the country of birth or is a result of migration. The purpose of the present study was to analyse whether all-cause and coronary heart disease mortality differ between immigrants in Sweden and in the country of birth.

Methods

Two cohorts including the total population from Swedish national registers and WHO were defined. All-cause and CHD mortality are presented as age-adjusted incidence rates and incidence density ratios (IDR) in eight immigrant groups in Sweden and in their country of birth. The data were analysed using Poisson regression.

Results

The all-cause mortality risk was lower among seven of eight male immigrant groups (IDR 0.39–0.97) and among six of eight female immigrant groups (IDR 0.42–0.81) than in their country of birth. The CHD mortality risk was significantly lower in male immigrants from Norway (IDR = 0.84), Finland (IDR = 0.91), Germany (IDR = 0.84) and Hungary (IDR = 0.59) and among female immigrants from Germany (IDR = 0.66) and Hungary (IDR = 0.54) than in their country of birth. In contrast, there was a significantly higher CHD mortality risk in male immigrants from Southern Europe (IDR = 1.23) than in their country of birth.

Conclusion

The all-cause mortality risk was lower in the majority of immigrant groups in Sweden than in their country of birth. The differences in CHD mortality risks were more complex. For countries with high CHD mortality, such as Finland and Hungary, the risk was lower among immigrants in Sweden than in their country of birth. For low-risk countries in South Europe, the risk was higher in immigrants in Sweden than in South Europe.

Coronary heart disease risks in first- and second-generation immigrants in Sweden: a follow-up study

OBJECTIVES

To analyse whether there is an association between country of birth in first-generation immigrants and first hospitalization for or death from coronary heart disease (CHD) and to analyse whether this association remains in second-generation immigrants.

DESIGN

In this follow-up study, the MigMed database at the Karolinska Institute, Stockholm, was used to identify all hospital diagnoses of and deaths from incident CHD in first- and second-generation immigrants in Sweden between 1 January 1987 and 31 December 2001. Incidence ratios standardized by age, geographical region and socio-economic status were estimated by sex in first- and second-generation immigrants; the reference group was Swedish-born people whose parents were both born in Sweden.

SUBJECTS

The total Swedish population aged 25-69 years.

RESULTS

First-generation immigrants from Finland, central European countries, other eastern European countries and Turkey had higher rates of CHD than men or women in the reference group. First-generation immigrant women born in southern Europe, other western European countries and Baltic countries had lower CHD risks than the reference group. Sons of both male and female first-generation immigrants showed CHD risks similar to or slightly higher than those of their parents. Amongst second-generation women, only subjects with Finnish fathers or mothers had higher risks of developing CHD than the reference.

CONCLUSIONS

Increased risks of CHD found in some first-generation immigrant groups often persist in second-generation immigrant men. Healthcare professionals and policy makers should take this into account when designing and undertaking measures to prevent CHD.

Higher Mortality and Different Pattern of Causes of Death Among Foreign-Born Compared to Native Swedes 1970–1999

In a previous Swedish longitudinal study of mortality among 723,948 foreign born and native-born Swedes, 1970-1999, increased mortality was found among foreign-born persons. This study describes and analyses the differences in mortality between 361,974 foreign-born persons and 361,974 native Swedes during the period 1970-1999, based on data from Statistics Sweden and the National Board of Health and Welfare. The mortality pattern showed dissimilarities; with a significantly higher number of deaths among foreign-born persons in six diagnose groups and a significantly lower mean age at time of death. A high number of deaths were found for migrants from Denmark in Neoplasm, for migrants from Finland and Poland in Diseases of the circulatory system and for migrants from Yugoslavia in Symptoms, signs and ill-defined conditions. There is a tendency to a more similar pattern between foreign- and Swedish-born persons over time. Migration may be a risk factor for health, and therefore seems to be an important factor to consider when studying morbidity and health and when planning preventive work.

Mortality among 723 948 foreign- and native-born Swedes 1970–1999

BACKGROUND

Mortality in a population is regarded as an accurate and valid measure of the population's health. There are a few international studies, predominantly cross-sectional, of mortality among all foreign-born compared with an indigenous population, and the results have varied. No Swedish longitudinal study describing and analysing mortality data was found in a literature review.

METHODS

This study describes and analyses the differences in mortality between foreign-born persons and native Swedes during the period 1970-1999, based on data from Statistics Sweden and the National Board of Health and Welfare. The database consisted of 723,948 persons, 361 974 foreign-born living in Sweden in 1970, aged > or = 16 years, and 361 974 Swedish controls matched for age, sex, occupation and type of employment, living in the same county in 1970.

RESULTS

The results showed increased mortality for foreign-born persons compared with the Swedish controls [odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.08]. Persons who had migrated 'late' (1941-1970) to Sweden were 2.5 years younger at time of death than controls. In relation to country of birth, the highest risk odds were for men born in Finland (OR 1.21), Denmark (OR 1.11) and Norway/Iceland (OR 1.074). Age cohorts of foreign-born persons born between 1901 and 1920 had higher mortality at age 55-69 years than cohorts born between 1921 and 1944.

CONCLUSIONS

Migrants had higher mortality than the native population, and migration may be a risk factor for health; therefore, this seems to be an important factor to consider when studying mortality and health.

Determinants of complaint symptoms in a Swedish health care practice--results of a questionnaire survey

OBJECTIVE

The aim of this study was to identify predictors of complaint symptoms in an adult general practice population.

METHOD

The study was performed in 1055 out of 1442 consecutive adult patients visiting a Swedish health care centre. The relationship between complaint symptoms and sociodemographic characteristics, perceived health, and chronic disease was assessed using multiple regression analysis.

RESULTS

Gender and perceived health were related to all symptom categories independently of each other, and when the effects of various symptom categories were taken into account in the regression analysis, the depression and tension symptom categories could predict about 50% of the explanation.

CONCLUSION

The results of this study suggest that psychiatric symptoms, particularly depression and tension symptoms, interact and have an impact on somatic symptom reporting in addition to sociodemographic characteristics, perceived health, and chronic disease, which have impact on only some symptom categories.

Country of birth, socioeconomic position, and healthcare expenditure: a multilevel analysis of Malmö, Sweden

STUDY OBJECTIVE

The principle of equity aims to guarantee allocation of healthcare resources on the basis of need. Therefore, people with a low income and persons living alone are expected to have higher healthcare expenditures. Besides these individual characteristics healthcare expenditure may be influenced by country of birth. This study therefore aimed to investigate the role of country of birth in explaining individual healthcare expenditure.

DESIGN

Multilevel regression model based on individuals (first level) and their country of birth (second level).

SETTING

The city of Malmö, Sweden.

PARTICIPANTS

All the 52 419 men aged 40-80 years from 130 different countries of birth, who were living in Malmö, Sweden, during 1999.

MAIN RESULTS

At the individual level, persons with a low income and persons living alone showed a higher healthcare expenditure, with regression coefficients (and 95% confidence intervals) being 0.358 (0.325 to 0.392) and 0.197 (0.165 to 0.230), respectively. Country of birth explained a considerable part (18% and 13%) of the individual differences in the probability of having a low income and living alone, respectively. However, this figure was only 3% for having some health expenditure, and barely 0.7% with regard to costs in the 74% of the population with some health expenditure.

CONCLUSIONS

Malmö is a socioeconomically segregated city, in which the country of birth seems to play only a minor part in explaining individual differences in total healthcare expenditure. These differences seem instead to be determined by individual low income and living alone.

Decreasing gender differences in "avoidable" mortality in Sweden

AIMS

"Avoidable" mortality, that is mortality from conditions amenable to healthcare intervention, is commonly studied as an indicator of the outcome of healthcare. The objective of this study was to analyse gender equity in avoidable mortality trends in Sweden from 1971 to 1996.

METHODS

The underlying cause of death was analysed for all deaths in the Swedish population in the age group 0-69 years during the period 1971-96. On the basis of those used in international studies, 18 indicators of avoidable mortality were identified. The conditions were divided into two groups: those mainly indicating an outcome of medical care and those mainly reflecting the effect of health policy. Age-standardized death rates were calculated for each indicator of avoidable mortality and for total mortality broken down by sex. Gender differences in death rates were studied. The annual trends in death rates were analysed using regression models.

RESULTS

For total mortality the death rates were 80% higher for males than for females. The largest gender differences were found among those conditions mainly reflecting the effects of health policy. For most medical care indicators the gender differences were fairly small. For several avoidable causes of death the gender differences decreased considerably and for some causes of death the differences were eliminated.

CONCLUSIONS

The avoidable mortality method seems to be useful in continuous epidemiological surveillance of the equity in healthcare. The comparatively low gender differences for avoidable death indicators as well as the decrease in these differences indicate decreasing gender inequity in health.

Morbidity in cardiovascular diseases in immigrants in Sweden

INTRODUCTION

Although immigration to Sweden has increased in the last few decades, the incidence rates of cardiovascular disease and coronary heart disease in immigrants are unknown. The aim of the present study is to estimate whether place of birth affects the incidence rates of cardiovascular disease and coronary heart disease.

MATERIAL AND METHODS

The study was designed as a follow-up study on morbidity in cardiovascular disease and coronary heart disease between 1 January 1997 and 31 December 1998, including three and a half million persons with age range 35-64 years, of whom 550 000 were born abroad, from the database MigMed consisting of the whole Swedish population. Incidence rates and relative risks were estimated by indirect standardization and a proportional hazard model.

RESULTS

The age-adjusted risk of coronary heart disease was higher in most foreign-born groups than in Swedes. For example, in nine of 12 male groups, the relative risks varied between 1.1 and 2.2, and in seven of 12 female groups, the relative risks varied between 1.4 and 2.5. When also adjusting for level of education and employment status, the risks were still high, but on a lower level.

CONCLUSIONS

Foreign-born people possess an over-risk of cardiovascular or coronary heart disease(CVD/CHD) compared with Swedish-born persons, also when level of education and employment status are taken into account.

Life expectancy and mortality differences between migrant groups living in Amsterdam, The Netherlands

There is an apparent contradiction between the high level of morbidity and the low level of mortality observed in certain groups of migrants living in Europe. This observation should have some consequences for health policy development and the targeting of resources in a city like Amsterdam. In this paper a number of hypotheses to explain the low mortality in migrant groups are discussed. An analysis is made of mortality in Amsterdam using data from the civil registry as to mortality according to age, sex and nationality group of the deceased. Standard demographic techniques such as the standardised mortality ratio (SMR) and life table analysis were employed. Life table analysis shows that life expectancy in Amsterdam is lowest among residents of Dutch descent (73.3 yr for males and 79.1 yr for females) and highest among those of Mediterranean origin (77.6 yr for males and 86.1 yr for females). This appears to contradict previous research based on the SMR, which showed high mortality in migrant groups. To find the cause of this contradiction, the SMR and risk ratios by age are studied. The conclusion of this paper is that on the basis of life table analysis it appears that some immigrant groups living in Amsterdam have a remarkably high life expectancy. Since the SMR is sensitive to demographic differences between groups compared, questions can be raised about previous studies using the SMR. It has been suggested that the high life expectancy in migrant groups is not really caused by good health but by 'spurious' phenomena, such as problems in mortality registration. However, in view of the available data it seems likely that some migrant groups do in fact have high life expectancy, although the morbidity in these groups can be quite high. These findings should inform health-related policy.

Migration and mortality: a 20 year follow up of Finnish twin pairs with migrant co-twins in Sweden

STUDY OBJECTIVE

Finland has a higher mortality overall and for major causes of death than Sweden, primarily in men. The objective of this study was to analyse mortality in migrants from Finland to Sweden.

DESIGN

A longitudinal study based on the Finnish Twin Cohort Study. Information about migration from Finland to Sweden, duration of stay in Sweden for the migrants, and deaths 1976-1995 was obtained from national registers. Observed numbers of deaths in migrants were compared with expected numbers based on the age standardised mortality experience of the Finnish Twin Cohort. First deaths in migrants and non-migrants of migrant discordant pairs were compared controlling for genetic and early childhood factors.

PARTICIPANTS

Twin pairs of the Finnish Twin Cohort Study where at least one twin had migrated to Sweden (1542 twin pairs).

MAIN RESULTS

Among men, migrants from Finland to Sweden showed an overall similar mortality compared with all subjects of the Finnish Twin Cohort (SMR 1.1; 95% CI 0.9 to 1.4). Mortality from non-violent causes was increased for migrants with at most 20 years in Sweden (SMR 1.9; 95% CI 1.2 to 2.6) and decreased in those with a longer stay (SMR 0.7; 95% CI 0.4 to 0.9). Similar results were obtained concerning first deaths in twin pairs discordant for migration. Among women, migrants had an increased mortality overall (SMR 1.4; 95% CI 1.0 to 1.8), from cardiovascular disease (SMR 1.7; 95% CI 1.0 to 2.7), and from violent causes (SMR 2.5; 95% CI 1.2 to 4.6) compared with all women of the Finnish Twin Cohort. In analyses of migrant discordant pairs only first deaths from cardiovascular disease tended to be more common in the migrants than in non-migrant co-twins.

CONCLUSIONS

Migrants from Finland to Sweden seem to have an overall mortality comparable to that prevailing in Finland suggesting no strong influence on mortality by the migration. Duration of stay seems to be associated with mortality in the migrants, at least in men, with a lower mortality after several years in Sweden.

Immigration and leisure-time physical inactivity: a population-based study

OBJECTIVE

To investigate the relationship between migration status and sedentary leisure-time physical activity status in the city of Malmö, Sweden.

METHODS

The public health survey in 1994 is a cross-sectional study. A total of 5,600 individuals aged 20-80 completed a postal questionnaire. The response rate was 71%. The population was categorized according to country of birth. Multivariate analysis was performed using a logistic regression model to investigate the importance of possible confounders for the differences in sedentary leisure-time physical activity status.

RESULTS

The prevalence of a sedentary leisure-time physical activity status was 18.1% among men and 26.7% among women. The odds ratio of a sedentary leisure-time physical activity status was significantly higher among men born in Arabic-speaking countries, in All other countries, and among women born in Yugoslavia, Poland, Arabic-speaking countries, and the category all other countries', compared to the reference group born in Sweden. The multivariate analysis including age, sex, and education did not alter these results.

CONCLUSION

There were significant ethnic differences in leisure-time physical activity status. This is a CVD risk factor that could be affected by intervention programs aimed at specific ethnic subgroups of the population.

Major risk factors for cardiovascular disease in elderly migrants in Sweden

OBJECTIVE

The knowledge of elderly migrants' health, particularly those who are retired or in transition to retirement is limited. The purpose of this study was to analyse the association between migration, socio-economic status (SES), and risk factors for cardiovascular disease (CVD).

DESIGN

A simple random sample of 253 foreign-born persons and 2847 Swedish-born persons aged 55-74 were drawn from the Swedish Population Registry. They were interviewed by Statistics Sweden in 1988-89. Outcome variables were leisure-time physical inactivity, smoker/non-smoker status, body mass index (BMI), hypertension, and diabetes mellitus. Explanatory variables were sex, age, marital status, migration status (country of birth), and SES (income). Logistic and linear regression were used.

RESULTS

Elderly foreign-born people ran an increased risk of engaging in no physical activity (men only), being a current smoker, and having an increased BMI after adjustment for background factors. In addition, a low income (first tertile) was an independent risk factor for physical inactivity (men only), as was being a current smoker (men only), BMI, hypertension, and diabetes mellitus. Thus, the burden of being an elderly migrant increases the risk of a disadvantaged lifestyle between 50 and 80% compared with Swedes.

CONCLUSIONS

This study shows that migrants who are retired or in transition to retirement have a disadvantaged risk profile for cardiovascular disease. It might be possible to improve this situation by intervention, as for example by increasing a person's interest in walking.

Does immigration contribute to decreasing CHD incidence? Coronary risk factors among immigrants in Göteborg, Sweden

OBJECTIVES

To investigate if an increasing proportion of immigrants may have contributed to the decreasing trend in coronary heart disease (CHD) in Sweden during the last few decades and to analyse the cardiovascular risk factor pattern in immigrants compared to Swedish-born subjects.

POPULATION AND METHODS

CVD risk factors were investigated within the framework of the WHO MONICA project. A random sample of 1618 men and women aged 25-64 years responded to the invitation to a screening procedure including questionnaires and physical and laboratory examination. Data on myocardial infarctions (MI) were collected from the Göteborg Myocardial Infarction Register. Data from the City Council secretariat were used to estimate the number of immigrants in the total population.

RESULTS

In 1995, immigrants constituted 22.4% of the population between 25 and 64 years of age in Göteborg. The incidence of MI in immigrants, 21.7%, was similar to that in Swedish-born subjects. Non-Finnish immigrants reported more unemployment, low physical activity during leisure time and psychological stress than Swedish subjects. Immigrant men also smoked more. BMI and WHR were significantly higher in immigrant women and Finnish immigrants had higher blood pressure than Swedes. Total- and LDL-cholesterol were higher in Finnish men. HDL-cholesterol was significantly lower and s-triglycerides significantly higher in non-Finnish immigrants of both genders.

CONCLUSION

The decreasing trend in CHD in Sweden during the last few decades is not due to an increasing number of immigrants from 'low-risk countries'. On the contrary, the immigrants in the present study seem to have a worse CVD risk factor profile than Swedes.

Ten-year trends in all-cause mortality and coronary heart disease mortality in socio-economically diverse neighbourhoods

OBJECTIVE

Although all-cause mortality and coronary heart disease (CHD) mortality is declining in Sweden, as in most other countries in the industrialised world, we have limited information about the distribution and trends of mortality in deprived and affluent neighbourhoods.

DESIGN

This study analyses the extent to which the decline in all-cause mortality and CHD mortality (over the age range 25-74 y) differs between affluent and deprived neighbourhoods during the decade 1984-1993. Incidence density ratios (IDR), estimated by Poisson regression, were calculated for small areas, grouped into population deciles, by both the care need index (CNI) and the Townsend deprivation score. On average, there were about 14 500 residents and 560 deaths in each decile over the period.

SETTING

A large Swedish city.

MAIN OUTCOME MEASURES

All-cause mortality and mortality from CHD.

RESULTS

The most deprived neighbourhoods had the highest IDR for all-cause mortality and CHD mortality. Over the period from 1984-1988 to 1989-1993 there was an overall decrease in all-cause mortality and CHD mortality, which was significantly higher in the most affluent areas. The mortality ratios for the most deprived neighbourhoods were almost three times higher than those of the most affluent areas.

CONCLUSIONS

People liviing in more affluent neighbourhoods have had the benefit of most of the last decade's decline in CHD mortality.

Cardiovascular risk factors in Mexican American adults: a transcultural analysis of NHANES III, 1988-1994

OBJECTIVES

This study examined the extent to which cardiovascular disease risk factors differ among subgroups of Mexican Americans living in the United States.

METHODS

Using data from a national sample (1988-1994) of 1387 Mexican American women and 1404 Mexican American men, aged 25 to 64 years, we examined an estimate of coronary heart disease mortality risk and 5 primary cardiovascular disease risk factors: systolic blood pressure, body mass index, cigarette smoking, non-high-density lipoprotein cholesterol, and type 2 diabetes mellitus. Differences in risk were evaluated by country of birth and primary language spoken.

RESULTS

Estimated 10-year coronary heart disease mortality risk per 1000 persons, adjusted for age and education, was highest for US-born Spanish-speaking men and women (27.5 and 11.4, respectively), intermediate for US-born English-speaking men and women (22.5 and 7.0), and lowest for Mexican-born men and women (20.0 and 6.6). A similar pattern of higher risk among US-born Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors.

CONCLUSIONS

These findings illustrate the heterogeneity of the Mexican American population and identify a new group at substantial risk for cardiovascular disease and in need of effective heart disease prevention programs.

Gender, marital status and ethnicity. A Swedish retrospective study of criminality, morbidity and mortality among victims of non-fatal firearm injuries

OBJECTIVE

To study gender and ethnic aspects in a population consisting of patients treated for non-fatal firearm injuries at public hospitals in Stockholm, Sweden, during a period of 21 years.

DESIGN

Retrospective study. Ethnicity was defined as being a foreign-born individual or a native Swede. The morbidity and criminality data were analysed with unconditional logistic regression and the mortality data were analysed by a proportional hazard model.

RESULTS

Females and foreign-born persons were more often victims of attempted murder than males or native Swedes. Attempted suicide was more common among native Swedes. Male patients, single persons and Finnish immigrants treated for a firearm injury all showed an increased risk of being registered for criminality or committing a violent crime. There was no difference between native Swedes and foreign-born persons concerning the number of hospitalisations during the follow-up period. Living alone and being of male gender were associated with an increased risk of hospitalisation. Firearm victims, independently of ethnicity, had an increased mortality rate compared to a Swedish population; the standardised mortality ratio (SMR) for males was almost 3 and for females almost 8 compared to the SMR of 1 for the whole Swedish population.

CONCLUSION

Firearm victims constitute a population at risk from social, psychological as well as from medical points of view. The present study shows an association between gender, ethnicity, criminality, and morbidity among firearm victims underlining the importance of ethnic- and gender-specific violence prevention strategies.