The European Journal of Public Health Advance Access originally published online on July 21, 2005
The European Journal of Public Health 2005 15(5):511-517; doi:10.1093/eurpub/cki026
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Health Inequalities |
Mortality among 723 948 foreign- and native-born Swedes 1970–1999
Björn Albin1, Katarina Hjelm2, Jan Ekberg3 and Sölve Elmståhl4
1 School of Health Sciences and Social Work, Växjö University, Växjö, Sweden
2 Department of Community Medicine, University of Lund and School of Health Sciences and Social Work, Växjö University, Växjö, Sweden
3 School of Management and Economics, Växjö University, Växjö, Sweden
4 Department of Community Medicine, Division of Geriatric Medicine, University of Lund, Lund, Sweden
Correspondence: Björn Albin, School of Health Sciences and Social Work, Växjö University, S-351 95 Växjö, Sweden, tel: +46 470 708304 or +46 708 673794, fax: +46 470 36310, e-mail: bjorn.albin{at}ivosa.vxu.se
Received February 10, 2004, accepted June 15, 2004
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Abstract |
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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
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.
Keywords: epidemiology, longitudinal study, mortality, public health, Sweden, transients and migrants
Mortality in a population is regarded as an accurate and valid measure of the population's health.1 Previous studies, predominantly cross-sectional, of mortality among foreign and native-born have reported contradictory results.2–6 In Australia, persons born overseas were found to generally have a lower mortality rate than native-born Australians.2 A study in the USA showed a 13–18% lower mortality rate for migrants than native US-born,3 and low mortality for groups of Hispanic origin.4 Variations in and causes of mortality between different migrant groups have been described in a study from the UK.5
Turkish residents in Germany have shown lower overall mortality than native Germans.6 One explanation of a lower mortality rate among foreign-born could be a ‘healthy migrant effect’: only people with good health migrate.1
A limited number of studies, none of them longitudinal, on mortality among foreign-born persons in Sweden was been found in our search.7,8 One study showed the same mortality between foreign-born from countries outside the Nordic region and native Swedes, but increased mortality among migrants from the Nordic countries.7 Another investigation found increased mortality risk among the Finnish born.8 Some studies have found low mortality rates among foreign-born persons from countries outside the Nordic area,9,10 and there is a discussion as to whether this is a consequence of shortcomings in the Swedish population register, such as when persons leave the country without this being reported to the authorities.7,10
Swedish society has changed during the last century due to international migration. In 1950, 2.8% of the total population in Sweden was foreign-born and today the percentage has increased to 11.5%.11,12 The migrant population in Sweden is a mixture of different nationalities, but is dominated by European labour migrants. The major groups are people from the Nordic countries (especially Finland) and European countries like the former Yugoslavia, Germany and Poland.12,13
The effect of migration on people's health is difficult to determine, as both positive and negative influences may be in operation. The degree of adaptation also has a strong influence on the health of the migrant population.14
The aim of this study was to describe and analyse differences in mortality among foreign-born persons living in Sweden between 1970 and 1999, and to compare their mortality with mortality among native Swedes. Mortality will be discussed in relation to year of migration to Sweden, year of birth and country of birth.
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Materials and methods |
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Data from Statistics Sweden (SCB) and the National Board of Health and Welfare Centre for Epidemiology covering the period 1970–1999 were analysed. The database included all foreign-born aged
16 years who were registered as living in Sweden in 1970, together with a matched Swedish ‘control’ for each person. For 20 518 foreign-born persons it was impossible to find a matched Swedish control. The Swedish controls were matched and were similar in age (±3 years), sex, occupation and type of employment, and lived in the same county in 1970. Type of employment was described in three groups (government, public or other employer). Occupation was coded according to the Nordic Occupation Classification System (NYK) and county was represented by all 25 different geographical areas in Sweden. These data were taken from the National Census of 1970, a total census relating to the situation on 1 November 1970. A cross-check was performed with the National Population Register (RTB), which included data up to 31 December 1999, and each person was assigned a code if they were deceased, still living in Sweden, had emigrated or if no information was available. Information from the National Board of Health and Welfare Centre for Epidemiology on date of death was added to the database. In total, 906 564 people were included, 50% of whom were foreign-born.
A total of 163 896 persons were excluded from the database, because they had emigrated, migrated back (‘re-migrated’) or because no information was available. Persons were then also excluded if the information from the control subject was missing due to migration.
The database used for analysis finally consisted of 723 948 persons, 361 974 foreign-born and 361 974 Swedish controls.
The analysis involved first a comparison of the total group of foreign-born with the total group of Swedish controls, and secondly a comparison of groups of foreign-born from specific countries or regions with their controls. Natives from the following countries have been studied in particular: Denmark, Finland, Norway/Iceland, Yugoslavia, Poland, Germany, other European countries, non-European countries and stateless/unknown (table 1).
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In order to compare different conditions, in the youth and teenage periods, during the depression years two age cohorts were analysed, one with persons born between 1901 and 1920 and one with persons born between 1921 and 1944. The age interval for time of death was chosen with respect to the largest differences in percentage of deceased between foreign-born persons and native Swedes (table 2).
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The mortality pattern among foreign-born persons from Finland who have migrated back to their country from Sweden was compared with the pattern among migrants who remained in Sweden during the study period. It was possible to obtain information from the Population Register Centre in Finland regarding 37 904 of the 44 067 individuals (86%) that had re-migrated from Sweden. The re-migrant Finns showed the same mortality risk as the Finnish-born who have stayed in Sweden, for men with an odds ratio (OR) of 1.21 [95% confidence interval (CI) 1.19–1.24] and for women with an OR of 1.09 (95% CI 1.05–1.13).
Differences in mortality between native Swedes and foreign-born persons who emigrated from Sweden during 1970–1999 and who were not included in the study were analysed using the Kaplan–Meier method. The differences were significantly higher in foreign-born persons in general, but also found for specific countries or regions (P < 0.001), except for those persons recorded as stateless/unknown country of birth.
Comparisons were also made with official statistics on mortality from Denmark and Finland.
Statistical analysis and ethics
Values are given as numbers, means (range) and percentages. Mortality risks were calculated as ORs with 95% CI. Comparisons were made by tests of significance with Pearson's 
2-test (two-sided), Mann–Whitney U-test and the Kaplan–Meier method. A P-value of <0.05 was considered statistically significant.15 All analyses were performed using SPSS, version 11.5. The Ethics Committee of the University of Lund approved the study after all other Swedish University Ethics Committees had reviewed it.
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Results |
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Characteristics of the study population
The majority of the foreign-born population come from the Nordic and other European countries (table 1). Finland was the most common country of origin, with 143 503 individuals, followed by Norway/Iceland (35 649), Germany (33 966), Denmark (29 422), Yugoslavia (19 960) and Poland (9178). Other European countries each had small numbers, but comprised 62 739 individuals in total. There were also migrants from countries outside Europe (27 116) and a small group (441) registered as stateless or of unknown country of birth (table 1). More than half of the total study population was women (53.4%), and the mean age differed between groups of migrants. The lowest mean age was found in the Yugoslavian group (men 32 years, women 31 years) and the highest mean age (men 50 years, women 56 years) in the group of individuals who were stateless or had unknown country of birth (table 1).
Mortality
During the study period 1970–1999, a total of 116 063 deaths among foreign-born persons and 104 865 among native Swedes were registered (table 3). The numbers of deaths for foreign-born persons were higher for both men (58 820) and women (57 243) than for the Swedish controls (men 51 391, women 53 474; P < 0.001). The mortality risk was higher for the total group of foreign-born persons (OR 1.08; 95% CI 1.07–1.08). Foreign-born persons, especially from Nordic countries and all Europeans except females from Germany and Yugoslavia, had higher mortality than the controls (table 4). The percentage of deceased was higher for men than for women in all groups of foreign-born persons, except for the non-European group (table 1).
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Mortality risks were higher for all groups of foreign-born people than for their Swedish controls, and were especially high for foreign-born men (table 4). The highest risk odds were for men born in Finland (OR 1.21; 95% CI 1.20–1.22), Denmark (OR 1.11; 95% CI 1.08–1.13) and Norway/Iceland (OR 1.07; 95% CI 1.05–1.10). Foreign-born women had a lower mortality risk odds than foreign-born men, with the exception of women born in Poland (OR 1.10; 95% CI 1.06–1.14).
Higher percentages were found for death among foreign-born persons of younger age than native Swedes, and as a consequence a higher percentage for death among native Swedes was noted between the ages of 75 and 94 years. The highest differences in proportions were noted (5.6 versus 7.4% and 7.9 versus 9.5%; P < 0.001) in the age range 55–64 years. Similar mortality was noted among the oldest (tables 3 and 4).
Differences in mortality between foreign-born persons and native Swedes were also confirmed by the Kaplan–Meier method for persons who emigrated from Sweden during the study period 1970–1999.
A higher percentage of foreign-born individuals died at a lower age when age at death was divided by decades and during three time intervals (1970–1979, 1980–1989, 1990–1999; table 5). During these three time intervals, diminishing differences were noted and the percentage of deaths at age 45–54 years, especially among foreign-born, has been reduced. Thus the difference for this age group is still significant in 1990–1999 (P < 0.001).
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In addition, the mean age at time of death related to year of birth was different among foreign-born compared with Swedish controls (table 6). With the exception of the oldest individuals in the database, all other foreign-born had a lower mean age at death. The difference in mean age is
2 years for individuals born later than 1906.
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The possible effect of age cohort on mortality at the age of 55–69 years was studied by grouping foreign-born persons into those born 1901–1920 and 1921–1944 (table 6). The highest mortality among foreign-born persons, both men (OR 1.44; 95% CI 1.41–1.47) and women (OR 1.34; 95% CI 1.32–1.36), was noticed in the age cohorts 1901–1920 (table 7).
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Mortality was also investigated in relation to latest year of migration. For those who migrated to Sweden between 1941 and 1980, there were significantly more persons who had died than among Swedish-born for each decade of migration year (P < 0.001) and the mean age at time at death for subjects with immigration years 1941–1950, 1951–1960 and 1961–1970 were 72.5, 66.3 and 60.5 years. Corresponding ages for Swedish-born persons were 75.0, 69.1 and 63.2 years. There was thus a significantly lower age at death, between 2.5 and 2.8 years, for foreign-born persons than for Swedes (P < 0.001). Interestingly, the time spent in Sweden was 40.8, 33.0 and 22 years, respectively, for these groups. No differences were noted for individuals with latest immigration year 1872–1940.
Three age groups, with individuals born in Sweden, Finland and Denmark, have been analysed and compared with the official statistics16 (table 8). The studied countries were chosen because they constituted the largest groups of migrants in the study. The percentage of deceased in those age groups was lower (0.0–1.2%) than the official statistics state.
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Discussion |
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This is the first Swedish longitudinal study based on a large sample that describes and analyses mortality among foreign- and Swedish-born persons during the period 1970–1999.
The main finding in this study was higher mortality among foreign-born persons living in Sweden compared with native Swedes during the period 1970–1999. The differences in mortality decreased during this period, but differences remained even though the migrants had lived in Sweden for a long time.
The study population represents foreign-born persons mainly with a labour migrant background, but refugees are also included. A ‘healthy migrant effect’ has been used as an explanation in some studies that find low mortality among foreign-born persons.1–3,7 The population studied included people with different reasons for migration. Labour migrants came to Sweden during the period when Swedish companies recruited healthy workers.13,17 Thus, a large group was from the Nordic countries, where a free labour market has existed since 1954.18
Several studies have shown more health problems and lower self-rated health among foreign-born than native Swedes,8,19–21 and there is a well-established association between self-rated health and mortality.22,23 This might also be an explanation for the results presented in this study.
Increased mortality can be the result of several different factors. Migration can influence people's health in both a positive and a negative way,14 depending on the ability to adapt to a new situation. Also, the length of residence, the reasons for migration and socioeconomic factors are important for health and mortality.19,21,24,25 A study of economic progress among foreign-born and native Swedes from 1970 to 1990 showed small differences in career and income changes. However, some groups of foreign-born persons had slow economic progress: men from Yugoslavia and to some extent migrants from Finland.17 This study controlled for occupation in 1970, but different occupational careers for foreign-born persons are supported by economic publications.17,26,27
The increased mortality for male migrants compared with Swedish controls was higher than the corresponding mortality found for females. This may indicate a gender-specific vulnerability. The only exception to this was for women born in Poland. One explanation for this may be the number of women that arrived directly after the Second World War, and their background. Out of 1846 persons with latest immigration year 1945, 1186 were women and 660 men. The majority of Polish migrants that arrived in 1945 were in very poor health and came directly from Nazi concentration camps like Ravensbrück, Neuengamme and Bergen-Belsen.28
The overall increased migrant mortality found in this study was higher than that of native Swedes in younger age groups. This has not been found in any previous study and can have implications for health care and health promotion. It may be important to focus health education and health promotion on different age groups among foreign-born compared with native Swedes. The differences might be explained by differences in social network and social support between foreign-born and native Swedes. Poor social network and low social support are more common among foreign-born persons,29 and have been shown to influence and increase mortality.30 These factors can increase stress, and are added to the stress of migration.31 Stress could change the endocrine balance and thus increase the susceptibility to diseases.32–34 It could also be socioeconomic conditions that influence the higher mortality among foreign-born. The high percentage difference in mortality in the age range 55–64 years may be explained as a long-term effect of long annual working hours and more shift work.17 Migrants have also had higher unemployment rates since the late 1970s,35 a more segregated labour market with more low-status and low-paid jobs, segregated housing and poor housing standards.29,36,37 Differences in food habits may be a factor to consider, as this can influence health.38,39
The age group differences in mortality have a tendency to decrease, and foreign-born and native Swedes tend to have a more similar pattern in 1990–1999 than in 1970–1979. Migration can be seen as a process with different stages, adaptation being the final stage.31 Adjustment to new places and society takes time, and is a process, with integration as the last stage.14 A good social network and a social role are parts of integration, and their absence may lead to negative stress.29 The decrease in mortality can also be an effect of the most vulnerable persons having died during the first years.
Higher mortality differences at age 55–59 years between foreign-born and Swedish-born in the age cohort born 1901–1920 than in cohort born 1921–1944 might be influenced by negative socioeconomic factors in childhood and adolescence. The worldwide depression during the 1920–1930s was deeper in most countries outside Sweden,40 and may have had more negative health effects on the age cohorts born 1901–1920 in these countries than on later age cohorts. The decreasing differences in mortality during the three time intervals (1970–1979, 1980–1989, 1990–1999) may be due to adjustment of migrants or to the fact that the most vulnerable persons died during the first years.
Mortality among persons with a ‘late’ year of migration (1941–1980) showed differences in age of death compared with the Swedish controls, the mean age at death being significantly lower. This can be explained and related to country of birth. The largest group of migrants with ‘early’ migration year had USA as country of birth; many of them may be supposed to be children of Swedish migrants, who ‘re-migrate’ back to Sweden.13 Migrants with a late last migration year represent more of a mixture of different countries. It is important to notice that persons immigrating after 1940 have a long time of residence in Sweden (28–68 years), but still have a higher mortality rate, with being 2.5 years younger at time at death.
The comparison with official statistics from three countries showed a lower death rate among persons in the database used. The differences in death rate were significant in the age groups 70–74 years and 75–79 years, except for Danes aged 75–79 years. The sample used for the study was a selection of people (migrants and controls) and not based on the whole population, as the official statistics are. This explains some of the difference, because the whole population also includes 10% migrants. The difference for Finns and Danes indicates that the migrants are healthier than the population they leave, a selection of ‘healthy migrants’.
This study showed that migrants had higher mortality than the native population in Sweden, and that migration can be a risk factor for health. Migration seems to be an important factor to consider when studying mortality and health in a population. The increasing international migration we see today will influence health care and its organization in the future. Health care for the migrant population needs to be related to their country of birth, year of migration and year of birth.
Strengths and limitations
The study was based on data from Statistics Sweden and from the National Board of Health and Welfare Centre for Epidemiology. The data from Statistics Sweden consisted of 473 800 foreign-born persons and 453 282 Swedish controls. It was not possible to find matched Swedish controls for 20 518 of the foreign-born persons. The number of matching criteria has thus been a limiting factor but the matching has also given strength to the comparisons made between foreign-born persons and native Swedes. The study was based on a large sample, 723 948 persons, of whom 361 974 were foreign-born and 361 974 were matched Swedish-born controls.
Data used to establish the database originated from the Population and Housing Census of 1970, which is considered to be a total census.41 The dropout has only been estimated for some of the variables such as occupation, and Statistics Sweden estimates the dropout on this variable to be 3.5–4.5%. It can only be speculated whether participation in the census is related to health problems and whether there were a number of migrants that did not take part. If so, the differences in mortality between Swedes and foreign-born in this study could be underestimated due to this, but not overestimated. Other reasons for migrants not participating in the census could be language problems.
A higher number of elderly persons aged 100 years than expected was noted in the Swedish-born and the foreign-born groups. This might be explained by a less accurate registration of mortality in the Swedish Register during 1850 to 1890. However, no differences were noted between the two study groups of interest, and therefore this should not influence the differences in mortality.
A validation of the mortality rate has been performed in relation to the group born in Finland, which is the group with the highest mortality compared with the Swedish controls. Their mortality rate was compared with Finns that have re-migrated back to Finland, and no differences were found. There was no evidence that the re-migrants consisted of people who were more or less healthy than the migrants that remained in Sweden. No support could be found for a ‘re-migration unhealthy effect’ or ‘Salmon bias’, as reported or discussed in some studies.6,42 There are no reasons to believe that re-migrants with other countries of birth differ from the Finnish group.
Key points
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Acknowledgments |
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This work was supported by grants from the research-profile AMER (labour market and ethnical relations) Växjö University, Sweden and the KP PENSION & FÖRSÄKRING (The Pension Insurance Institute of the Co-operative Societies), Sweden.
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