The European Journal of Public Health Advance Access originally published online on February 14, 2006
The European Journal of Public Health 2006 16(4):376-382; doi:10.1093/eurpub/ckl013
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Migration and health |
Mortality from external causes among ethnic German immigrants from former Soviet Union countries, in Germany
Catherine Kyobutungi1, Ulrich Ronellenfitsch1, Oliver Razum1,2 and Heiko Becher1
1 Department of Tropical Hygiene and Public Health, University of Heidelberg, Germany
2 Department of Epidemiology and International Public Health, School of Public Health, University of Bielefeld, Germany
Correspondence: Heiko Becher, Department of Tropical Hygiene and Public Health, University of Heidelberg, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany, tel: +49 6221 565031; fax: +49 6221 565948; e-mail: heiko.becher{at}urz.uni-heidelberg.de
Received March 15, 2005, accepted December 7, 2005
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Abstract |
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Background: Diaspora migration flows from the former Soviet Union to Western Europe and Israel have increased since the late 1980s. Risk factors responsible for the East-West mortality gap and post-migration factors may lead to higher mortality from external causes of death like suicide amongst such Diaspora immigrants. We investigated whether ethnic German immigrants from the former Soviet Union had increased mortality from external causes compared to native Germans. Methods: We conducted a retrospective cohort study of 34 393 adults, so-called Aussiedler who arrived in Germany's largest federal state between 1990 and 2001. We ascertained vital status and causes of death from registry data. Standardized mortality ratios (SMRs) were calculated using the native German population as comparison. Multivariate effects were assessed using Poisson regression. Results: 1 657 members (4.8%) died, 88 from external causes. Overall SMR was 1.29 (95% confidence intervals 1.05–1.61). Males had a 39% higher mortality from all external causes and accidents, and a 30% higher mortality from suicide than German males. Females had slightly higher mortality from accidents but comparable mortality from all external causes. Aussiedler aged <65 years had rate ratios above one for external causes and accidents in multivariate models. SMRs for suicide and all external causes decreased with length of stay. Conclusion: While ethnic German immigrants have a mortality disadvantage compared to the NRW population, it is on a much lower scale than expected if they were representative of their source populations in former Soviet Union countries.
Keywords: cause of death, immigration, mortality, Soviet Union, suicide
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Introduction |
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Aussiedler or ‘settlers’ are descendants of Germans who emigrated to the Russian empire in the 17th and 18th centuries. They suffered intermittent periods of persecution and discrimination in Russia especially in the aftermath of the two world wars.1 Since the lifting of the iron curtain, two million have resettled in Germany.2 This phenomenon of Diaspora migration is not limited to Aussiedler; other groups have immigrated to Israel, Finland and Ukraine3 based on ethnicity and religion in the case of Jews. It is expected that ‘healthy migrant effects’4 are attenuated in such groups of immigrants if the majority migrate. Such attenuation could have resulted from opposing forces5 like the pro-return-migration German government policy, and discrimination and socioeconomic hardships in the former Soviet Union (FSU), and could have been enhanced by the almost complete immigration of Aussiedler.6 Therefore, mortality in this population is unlikely to be appreciably modified by selection effects. Since 1993, this group is technically known as Spätaussiedler but for purposes of this study the term Aussiedler is used. Aussiedler do not include Jewish immigrants from the FSU to Germany during the same period.
In the FSU, mortality from external causes, especially suicide, contributes 
23% to the East–West mortality gap.7–9 Binge drinking and socioeconomic hardships have been identified as contributing factors.10 Suicide mortality among immigrants in Australia was observed to correlate with rates in sending countries,11,12 probably because socio-cultural characteristics are carried over. Consequently, since suicide mortality in the FSU is high, it should be high among Aussiedler in Germany. In addition, being an immigrant is a risk factor for suicide13 because of post-migration stress, loss of control, and psychological distress.14,15 Other factors, which may affect Aussiedler mortality from external causes, include their socioeconomic disadvantage,16 integration and acculturation difficulties, high unemployment, poor German language skills, and lower incomes than the German average.17 Such factors may increase the risk of committing suicide.11,18
The migration of Aussiedler to Germany is an exceptional case but little is known about associated health consequences. We assessed whether they experience a higher mortality from external causes (especially suicide) than native Germans.
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Methods |
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Study population and design
Our study population comprised Aussiedler who arrived from countries of the FSU aged 15 years or older, and settled in North Rhine Westphalia (NRW), Germany's most populous federal state, between 1990 and 2001. Selection procedures and other methodological details have been described elsewhere.19 Briefly, we obtained a list of 281 356 eligible Aussiedler containing names, sex, dates of birth and arrival in Germany, first city of residence, a family code, and country of origin from the NRW Aussiedler reception centre. From these, we selected 34 393 for whom automated record-linkage was possible at local population registries in the first cities of residence. Since allocation to federal states at national level and to first residence in federal states is done on a quasi-random basis,20 it can be assumed that our study population is representative of all Aussiedler from the FSU in Germany.
We performed a retrospective cohort study in which we ascertained vital status through local population registries of the first cities of residence and of subsequent cities for moved participants. Deceased participants were censored at their date of death, moved ones at the last known date of moving, and all other participants on 31 December 2002. For deceased participants, we established causes of death from the NRW statistical office through a record-linkage system.21 International Classification of Disease version 9 (ICD9) codes for deaths before 1998, and version 10 (ICD10) codes for deaths thereafter were obtained this way in 96% of cases. For the remaining 4%, death certificates were obtained from regional health offices and coded professionally at the Saarland Cancer registry. For 29 participants (1.8% of deaths), cause of death could not be determined. Twenty died abroad and death certificates were unavailable in nine cases.
Statistical analysis
Person years were calculated for each sex, 5-year age groups, and calendar year and distributed to sub-categories of length-of-stay periods, family size, and size of first city of residence. For comparison purposes, we used official cause-of-death statistics for the German population of NRW.22
We calculated standardized mortality ratios (SMR) for three dependent variables: all external causes of death (ICD9; E47–E56 or ICD10 V01–Y89), suicide and self-inflicted harm (ICD9; E54 or ICD10; X60–X84), and accidents and adverse effects (ICD9; E47-E53 or ICD10; V01-X59, Y40-Y86, Y88). We calculated sex-specific SMR and mortality ratios (MRs) for 10-year age groups. We calculated 95% confidence intervals (95% CIs) using the exact method.23 To investigate effects of covariates on SMR, we performed multivariate analyses using Poisson regression with the logarithm of expected number of deaths as offset. We included all covariates in regression models, categorized as follows: Family size on arrival (Single, 2–4members, 5+ members), size of first city of residence (<100 000 and 
100 000 inhabitants), age (10-year age groups), length of stay (<3 years, 3 to <6 years, 6 to <9 years and 9+ years) and calendar period (1990–1993, 1994–1997, 1998+). In the multivariate model for suicide, we omitted sex because there were very few observed deaths amongst females. Person-year calculations, SMR and regression analyses were performed using SAS 9.1.24
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Results |
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The cohort's characteristics are shown in table 1. It comprised
49% males and 51% females. Vital status was ascertained in 90.5% of participants.
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Overall mortality was significantly lower than expected. There were 1 657 observed deaths with 1 960 expected, yielding an SMR of 0.85 (95% CI: 0.81–0.89). Observed and expected deaths for the three outcomes, distributed across covariates, are shown in table 2.
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Standardized mortality ratios and age-specific mortality ratios
Age-specific MR of the three outcomes are shown in table 3.
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All external causes of death
Males have significantly increased mortality with an SMR of 1.39 (95% CI: 1.09–1.77). The MR for the age groups 15–24 years and 45–54 years are about two while the MR in most other age groups are >1 though non-significant. In females, SMR is only slightly increased at 1.06 (95% CI: 0.66–1.62). However there are variations in age-specific MR with estimates for the 65+ year age groups being <1 while those in the youngest age group are almost 2-fold though non-significant.
Suicide and self-inflicted harm
There were only three observed deaths from this category among females; so only results for males are presented. Male Aussiedler have slightly increased mortality with an SMR of 1.30 (95% CI: 0.87–1.99). The MR is 2.66 (95% CI: 1.28–4.89) in the 45–54 year age group while in most other age groups, MR are close to 1 and their confidence intervals contain 1.
Accidents and adverse effects
Male Aussiedler have higher mortality from accidents and adverse effects with an SMR of 1.39 (95% CI: 0.97–1.93). There are also age-specific variations in the MR which are >1 in all age groups except the oldest two, though all confidence intervals contain 1. Among females, mortality from accidents and adverse effects is only slightly increased with an SMR of 1.31 (95% CI: 0.72–2.21). There are large differences in age-specific MR with a high and significant MR of 5.13 (95% CI: 1.66–11.96) amongst females in the 55–64 age group and a low but non-significant MR of 0.26 amongst the 75+ age group. Due to the small number of observed deaths, confidence intervals are very wide.
Multivariate analysis
Results from Poisson regression models are presented as rate ratios (RRs) for the three outcomes in table 4. For all external causes, age has a non-linear effect on SMR. The patterns seen in the univariate analysis are generally attenuated after adjusting for all covariates. None of the RR for age is significant but RR are still high in age groups with high MR in the univariate analyses. Sex and family size have no effect on SMR and calendar period shows no clear trend. RR seem to decrease linearly with length of stay although confidence intervals of all RR include 1.
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For suicide and self-inflicted harm, the effect of age is also non-linear. The high MR of the 45–54 year age group seen in the univariate analysis is slightly attenuated and looses significance. Sex has a significant effect despite the small numbers in females. The RR of females compared to males is 0.28 (95% CI: 0.08–0.93) in a model where sex was included. There is a significant downward trend of RR with length of stay and a significant upward trend with calendar period. Family size has no effect on SMR.
For accidents and adverse effects there are large differences in RR by age. The 55–64 years age group still has the highest RR which is almost 10 times that for the 75+ year age group, when the age group 35–44 is taken as reference, though all confidence intervals contain 1. Sex has no significant effect on SMR and length of stay shows no clear trend. RR is higher in small-sized families but differences are not significant.
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Discussion |
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Our study shows that Aussiedler have slightly increased mortality from suicide and self-inflicted harm among males and higher mortality from all external causes, and accidents and adverse effects than native Germans in NRW. There are differences in the degree of this excess mortality between sexes for the latter two causes, and between age groups for all three causes, with males <65 years of age showing the largest excess.
Though the study was conducted in one federal state, we believe the results are a fair representation of the Aussiedler population from the FSU in Germany since first residency was quasi-randomly allocated.20 The cohort was selected based on practical field considerations that we assumed did not have an effect on external cause mortality and we found no differences between the cohort and the total Aussiedler population in terms of sex, age, and year-of-arrival compositions. We could accurately determine the denominator for our mortality estimates, a problem in immigrant studies.25 Besides, ‘unhealthy re-migration’—the phenomenon where socially successful migrants with lower mortality risk stay in the host country while less successful ones return home,26 did not occur to an appreciable extent in our cohort where 0.3% of members returned to the FSU.
We used NRW mortality rates instead of the rates for Germany since external causes of death like suicide and accidents show geographical variation.22,27 Over the study period, the NRW German population had 30% lower mortality from suicide and 30–50% lower mortality from accidental deaths compared to the German population22 in the whole country. This implies that compared to the whole German population, male Aussiedler have only slightly increased or comparable mortality from all external causes while females have lower mortality. However, given the spatial variation of external causes of death, using rates for a smaller geographical area is more appropriate.
As in most studies of this kind, individual cohort members were not contacted. Therefore we could only use mortality as an indicator of health status and we could not assess the prevalence of risk factors for external causes of death like psychiatric illness, substance abuse, socioeconomic, or employment status in the cohort. We also could not assess changes over time in variables like family size. For organizational reasons, we did not follow up individuals beyond the second move to another city. Thus follow-up was incomplete for 8.5% of such cohort members. This is unlikely to cause bias although individuals who move frequently may have experienced less integration and subsequently higher mortality than those who remained in the first city of residence. A further evaluation is ongoing.
The small number of observed deaths made further breakdown of cause-of-death categories impossible and resulted in large confidence intervals for many estimates. The small number of deaths from suicide, especially among females, may have been due to misclassification of suicides as ill-defined causes of death (ICD9; 460–469 or ICD10; R98–R99). Such misclassification is dependent on nationality.28,29 Though Aussiedler are recorded as Germans on death certificates, cultural differences between them and natives may lead to misclassification. A high probability of misclassification is demonstrated by ratios >1 of ill-defined deaths/suicide deaths based on absolute number of cases in different age and sex categories as described by Razum and Zeeb,29 in their study on suicide amongst Turkish immigrants. We found high ratios among the 55+ year age groups, especially females contrary to what was observed among Germans in the Razum and Zeeb study. There were significant differences in mean age (SD) at death for suicide and ill-defined causes: 47.53 (15.09) and 59.65 (20.07), respectively, (two-sided P < 0.0005). This implies that misclassification may also be age-dependent. Such misclassification would lead to underestimation of overall SMR and age-specific MR for all external causes and for suicides among older age groups and females. It could also explain the absence of an age gradient in the observed MR.
Lower all-cause mortality is driven by unexpectedly lower mortality from cardiovascular diseases. The overall SMR in this case is 0.79 (95% CI 0.73–0.85) and MR are significantly lower in older (65+) participants.30 Healthy selection is an unlikely explanation as discussed in the introduction section. For Aussiedler, moving to Germany in the 1990s meant better prospects, a more certain future and considerably better standards of living. They moved from countries at the height of socioeconomic upheavals to a prosperous one in which they were no longer a minority. The hope and aspirations engendered by such a move, may explain such mortality advantage,31 post-migration difficulties notwithstanding.
Higher mortality from all external causes is driven by the underlying causes of death. The observed SMR of 1.30 (95% CI: 0.87–1.99) for suicide and self-inflicted harm among males is of similar magnitude and direction to the age-adjusted RR of 1.6 observed among male Russian Jews immigrating to Israel in the early 1990s.32 Socioeconomic deprivation, higher unemployment, poor integration, psychological distress, loss of control, and hate speech are known risk factors for suicide amongst immigrants.11,13,18,33 Empirical evidence suggests that Aussiedler have experienced these factors3,17,34,35 in Germany and this may explain our findings. In addition some Aussiedler could have carried over suicide risk.
Compared to mortality in the FSU, Aussiedler have much lower risk. From 1990 to 2000, mortality among males aged <65years from all external causes was four to nine times as high in FSU countries compared to Germany while mortality from suicide and self-inflicted harm, was 2–4 times as high.36 When we calculated the SMR for all external causes and suicide for Aussiedler using rates for the population of the Russian Federation as comparison, the risk amongst Aussiedler was indeed lower. The SMR was 0.17 (95% CI: 0.13–0.21) and 0.34 (95% CI: 0.23–0.48) for all external causes and suicide, respectively. A study done in Moscow showed that Jews have mortality advantage over the general Russian population, not explainable by differences in educational status.37 This suggests that the mortality burden in FSU countries is not uniformly distributed amongst Russians and other minorities although such comparison is absent for Aussiedler. In addition, Aussiedler have formed very strong social networks in Germany38,39 and some studies have found an inverse relationship between strong social ties and mortality from suicide and accidents.40,41 Individual information on such factors could not be assessed with the available data.
The observed higher mortality in the 45–54 year age group may reflect greater difficulty in integration. They are more likely to have higher expectations than the older ones and yet poorer prospects for employment than the younger ones, or downward social mobility when employed.17,42 This could lead to greater frustration among this pre-retirement age group.
Concerning accidents and adverse effects, the observed SMR is also of similar magnitude and direction to findings amongst Jewish immigrants from Russia where the age-adjusted RR were 1.5 and 1.3 for males and females, respectively.32 Differences in lifestyle like alcohol consumption may explain the overall disadvantage and the excess mortality in the 15–24 year age group who are known to have higher rates of alcohol and drug abuse than native Germans.43 Differences in spatial distribution of risk factors for traffic accidents may also explain the overall higher mortality from accidents since Aussiedler settlements tend to be clustered and segregated from native Germans.39,44
Length of stay in Germany is inversely associated with SMR for all external causes and for suicide and self-inflicted harm. Our findings are similar to those from studies among recent Jewish immigrants from the FSU to Israel. One found high levels of suicide ideation among immigrants who had stayed for 2–3 years45 while another found that levels of psychological distress peaked at 27 months after arrival and then decreased.46 Both suicide ideation and psychological distress are risk factors for completed suicide albeit in psychiatric patients.47,48
The absence of calendar year effects on SMR for accidental deaths implies that rates for accidents among Aussiedler have decreased with calendar period possibly due to the same factors responsible for reductions in the German rates like improvements in car and road safety and in emergency care. In contrast Aussiedler seem not to have benefited from factors responsible for reductions in suicide rates among Germans possibly due to carried over risk. The upward trend is similar to that in the Russian Federation although this was largely influenced by the socioeconomic upheavals of the 1990s.
In conclusion, our study shows that Aussiedler are disadvantaged in terms of mortality from external causes on a scale consistent with previous studies in another group of Diaspora immigrants. Factors responsible for this difference are diverse and were not fully investigated in this study. Minorities in FSU countries may have a mortality advantage over the general population in those countries. Such pre-migration advantage may explain the observed degree of excess mortality. Further studies should investigate this and what influence such advantage (if it exists) had on the mortality crisis in FSU given the scale of Diaspora emigration in the 1990s.
Key points
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Acknowledgments |
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The study was supported by the German Research Foundation (Deutsche Forschungsgemeinschaft) under the Graduiertenkolleg 793—epidemiology of communicable and non communicable diseases and their interrelationships. Preliminary results from this study were presented at the IEA-EEF, European Congress of Epidemiology conference, Porto Portugal, 8–11 September 2004.
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