Social inequalities in mental health and mortality among refugees and other immigrants to Sweden – epidemiological studies of register data

Abstract

The aim of this PhD project was to increase knowledge, using population-based registers, of how pre- and post-migration factors and social determinants of health are associated with inequalities in poor mental health and mortality among refugees and other immigrants to Sweden. Study I and II had cross-sectional designs and used logistic regression analysis to study differences in poor mental health (measured with prescribed psychotropic drugs purchased) between refugee and non-refugee immigrants. In Study I, there was a significant difference in poor mental health between female refugees and non-refugees (OR=1.27; CI=1.15–1.40) when adjusted for socio-economic factors. In Study II, refugees of most origins had a higher likelihood of poor mental health than non-refugees of the same origin. Study III and IV had cohort designs and used Cox regression analysis. Study III analysed mortality rates among non-labour immigrants. Male refugees had higher relative risks of mortality from cardiovascular disease (HR=1.53; CI=1.04–2.24) and external causes (HR=1.59; CI=1.01–2.50) than male non-refugees did, adjusted for socio-economic factors. Study IV included the population with a strong connection to the labour market in 1999 to analyse the relative risk of hospitalisation due to depressive disorder following unemployment. The lowest relative risk was found among employed Swedish-born men and the highest among foreign-born females who lost employment during follow-up (HR=3.47; CI=3.02–3.98). Immigrants, and particularly refugees, have poorer mental health than native Swedes. Refugee men have a higher relative mortality risk for cardiovascular disease and external causes of death than do non-refugees. The relative risk of hospitalisation due to depressive disorder following unemployment was highest among immigrant women. To promote mental health and reduce mortality among immigrants, it is important to consider pre- and post-migration factors and the general social determinants of health.

Differences in all-cause mortality

“…On the other hand, health self-selection might be negative, i.e., people with illness migrate hoping for better treatment in the destination country (Davies et al 2011;McDonald and Kennedy 2004;Ronellenfitsch et al 2006). This is also the case for involuntary migration (refugees), as their health may have been adversely affected prior to and/or after migration (DesMeules et al 2005;Hollander 2013;Hollander et al 2012;Norredam et al 2012). Another theory suggests that as migrants age or fall ill they migrate back to their country of origin to die, and this phenomenon is commonly referred to as the 'salmon bias hypothesis' (Lu and Qin 2014).…”

Reporting of Cultural Factors in Autism Research Publications in Sweden: Application of the GAP-REACH Checklist

“…This finding could be partly explained by the design of the study-not based on national population registers-where a good command of Swedish was a requirement to test lexical and semantical ability in young children. Hollander (2013) maintains that it is difficult to define ethnicity as a variable in an epidemiological empirical study. Therefore, it could be argued that different definitions, conceptualizations and operationalization of the ethnicity variable as demonstrated in the present review could be indicative of the contemporary view of culture as multidimensional and dynamic, where ethnicity is just one of the several dimensions (Kagawa Singer et al 2014.…”

“…In this study the majority of the articles that defined and conceptualized ethnicity were population-based register studies. As Hollander (2013) states, BSwedish registers do not record race, culture, or ethnicity for ethical reasons. However, they do register the immigrants' country of origin… [that]… can sometimes be used as a proxy for ethnicity^(p.19).…”

Improving Early Detection of Refugee-Related Stress Symptoms: Evaluation of an Inter-Professional and Inter-Cultural Skills Training Course in Sweden

“…Furthermore, according to the same authors, there is a limitation in the case of a project, which is time-limited for collaboration, but which needs continuity. Both international and national data show that refugees are a group, which is more at risk of severe mental illness, compared with other groups of immigrants and the majority of the population [5,7,16]. There is a risk that newly arrived refugees are unable to meet the demands of the reception to be able to work, but they do not have access to active rehabilitation, which is connected to the social insurance scheme, because they have not worked in Sweden previously.…”

“…The relative risk of a depressive disorder following unemployment is highest among immigrant women. Refugee men have a higher mortality risk for cardiovascular disease and external causes of death than do non-refugees [7].…”