Psychological distress by age at migration and duration of residence in Sweden

Migrants suffer from worse psychological health than natives in many countries, yet the extent to which this varies by age at migration and duration of residence in the receiving context remains unexplored in Sweden. Drawing on a life course approach, we investigate differences in psychological distress by age at migration and duration of residence in working-age migrants to Sweden, and examine the role of various social determinants of health in explaining these differences relative to Swedish-born. Using pooled cross-sectional data from the 2011/2015 Health on Equal Terms survey in Västra Götaland Region, Sweden (n = 58,428), we applied logistic regression analysis to calculate predicted probabilities and average marginal effects (AME) of migrant status, by age at migration and duration of residence, on psychological distress. Analyses were stratified by sex and region of origin and controlled for indicators of socioeconomic status (SES), social cohesion, and discrimination to assess their potential contribution to differences in migrants' and natives' psychological distress. All migrants except men from OECD-predominant regions had a greater probability of psychological distress than Swedish-born (ranging from AME 0.031 [95% Confidence Interval or CI 0.000–0.062] for OECD women to AME 0.115 [95% CI 0.074–0.156] for non-OECD men). Marginal effects of migration status on psychological distress probabilities generally increased with age at migration and duration of residence. Differences between migrants and natives were largely attenuated after controlling for social determinants, the greatest contribution coming from inequalities in social cohesion, followed by inequalities in discrimination and SES. Our results suggest a relative health advantage of early-life compared to later-life migration, albeit with worse outcomes with longer residence in Sweden. The predominance of integration opportunities in childhood strengthens calls for supportive policies to assist older migrants' integration directly upon arrival, which may ultimately improve their psychological wellbeing

Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis

Background: Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health. Methods: We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104. Findings: We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13–0·75; I2=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor self-rated health (OR 1·67, 95% CI 1·35–1·98; I2=82·0%) and mortality (1·38, 1·10–1·65; I2=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85–0·98; I2=0·0%), but did not reduce public health insurance coverage (0·89, 0·71–1·07; I2=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90–1·21; I2=54·9%). Interpretation: Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective

Explaining COVID-19 mortality among immigrants in Sweden from a social determinants of health perspective (COVIS): protocol for a national register-based observational study

Introduction: Adopting a social determinants of health perspective, this project aims to study how disproportionate COVID-19 mortality among immigrants in Sweden is associated with social factors operating through differential exposure to the virus (eg, by being more likely to work in high-exposure occupations) and differential effects of infection arising from socially patterned, pre-existing health conditions, differential healthcare seeking and inequitable healthcare provision. Methods and analysis: This observational study will use health (eg, hospitalisations, deaths) and sociodemographic information (eg, occupation, income, social benefits) from Swedish national registers linked using unique identity numbers. The study population includes all adults registered in Sweden in the year before the start of the pandemic (2019), as well as individuals who immigrated to Sweden or turned 18 years of age after the start of the pandemic (2020). Our analyses will primarily cover the period from 31 January 2020 to 31 December 2022, with updates depending on the progression of the pandemic. We will evaluate COVID-19 mortality differences between foreign-born and Swedish-born individuals by examining each mechanism (differential exposure and effects) separately, while considering potential effect modification by country of birth and socioeconomic factors. Planned statistical modelling techniques include mediation analyses, multilevel models, Poisson regression and event history analyses. Ethics and dissemination: This project has been granted all necessary ethical permissions from the Swedish Ethical Review Authority (Dnr 2022-0048-01) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access peer-reviewed international journals, as well as press releases and policy briefs

[C-11]carfentanil PET imaging for studying the peripheral opioid system in vivo : effect of photoperiod on mu-opioid receptor availability in brown adipose tissue

Purpose Photoperiod determines the metabolic activity of brown adipose tissue (BAT) and affects the food intake and body mass of mammals. Sympathetic innervation of the BAT controls thermogenesis and facilitates physiological adaption to seasonal changes, but the exact mechanism remains elusive. Previous studies have shown that central opioid signaling regulates BAT thermogenesis, and that the expression of the brain mu-opioid receptor (MOR) varies seasonally. Therefore, it is important to know whether MOR expression in BAT shows seasonal variation. Methods We determined the effect of photoperiod on BAT MOR availability using [C-11] carfentanil positron emission tomography (PET). Adult rats (n = 9) were repeatedly imaged under various photoperiods in order to simulate seasonal changes. Results Long photoperiod was associated with low MOR expression in BAT (beta = -0.04, 95% confidence interval: - 0.07, - 0.01), but not in muscles. We confirmed the expression of MOR in BAT and muscle using immunofluorescence staining. Conclusion Photoperiod affects MOR availability in BAT. Sympathetic innervation of BAT may influence thermogenesis via the peripheral MOR system. The present study supports the utility of [C-11]carfentanil PET to study the peripheral MOR system.Peer reviewe

[11C]carfentanil PET imaging for studying the peripheral opioid system in vivo: effect of photoperiod on mu-opioid receptor availability in brown adipose tissue

Purpose Photoperiod determines the metabolic activity of brown adipose tissue (BAT) and affects the food intake and body mass of mammals. Sympathetic innervation of the BAT controls thermogenesis and facilitates physiological adaption to seasonal changes, but the exact mechanism remains elusive. Previous studies have shown that central opioid signaling regulates BAT thermogenesis, and that the expression of the brain mu-opioid receptor (MOR) varies seasonally. Therefore, it is important to know whether MOR expression in BAT shows seasonal variation.Methods We determined the effect of photoperiod on BAT MOR availability using [C-11] carfentanil positron emission tomography (PET). Adult rats (n = 9) were repeatedly imaged under various photoperiods in order to simulate seasonal changes.Results Long photoperiod was associated with low MOR expression in BAT (beta = -0.04, 95% confidence interval: - 0.07, - 0.01), but not in muscles. We confirmed the expression of MOR in BAT and muscle using immunofluorescence staining.Conclusion Photoperiod affects MOR availability in BAT. Sympathetic innervation of BAT may influence thermogenesis via the peripheral MOR system. The present study supports the utility of [C-11]carfentanil PET to study the peripheral MOR system.</p

Mental health after migration to Sweden : The role of the social determinants of health

Migrants often experience worse mental health after migration than natives in Sweden. Using survey, register and peer-reviewed published data, the five studies of this thesis explored the mental health variation of different migrant groups settled in Sweden, including by the timing of migration, level of integration and region of origin. In parallel, the studies considered the role of downstream (individual) and upstream (structural) social determinants of health as drivers of mental health inequalities. Study I assessed migrants’ risk of self-reported psychological distress by their age at migration and duration of residence in Sweden, relative to Swedish-born natives. Migrants generally had higher risks of psychological distress than natives, increasing with older age at migration and longer duration of residence, especially among migrants from regions not affiliated with the Organization for Economic Cooperation and Development (OECD). Health differences were largely explained by inequalities in socioeconomic position, social connection and discrimination.  Study II explored how prescription rates of psychotropic medications varied by native-migrant marital composition as a proxy for integration in Sweden. Intramarried migrants had the highest prescription hazards, whereas migrants intermarried with natives had lower hazards, albeit higher than for intramarried natives. Migrant women, but not men, had attenuated hazards after adjusting for socioeconomic and other marriage-related social factors. Study III reviewed the international literature for previous evidence of the effects of non-health-related policies for migrant health. Restrictive entry and integration policies, including social welfare policies, were found to be associated with poorer self-rated general and mental health. Studies examining generous integration-related policies revealed largely positive mental health effects for migrants. Study IV investigated the mental health effects of the 1995 Father’s quota, a Swedish parental leave reform that incentivized fathers’ leave use. Whereas both native and migrant fathers increased their parental leave use following the reform, only migrant fathers, especially those from non-OECD regions and with migrant partners, experienced concurrent decreases in psychiatric hospitalizations. Study V examined the mental health effects of another Swedish parental leave policy, the 2012 Double Days reform, which introduced a month of simultaneous parental leave for mothers and fathers. Although both native and migrant fathers had increased levels of parental leave use, only native fathers and their partners exhibited decreased psychotropic medication prescription rates and greater outpatient care uptake related to mental health.  The findings of this thesis highlight the dynamic nature of mental health after migration, and the relevance of the social determinants of health within the receiving country context. The studies provide empirical support for how migrants’ mental health can vary by the timing of migration and level of integration, through downstream determinants, including socioeconomic position and social connection, and upstream determinants, such as welfare programs and migration policies. Taken together, the thesis emphasizes the need to consider migrant mental health inequalities as socially-patterned phenomena amenable to change after migration.Migranter har ofta sämre psykisk hälsa efter invandring jämfört med inrikes födda i Sverige. Genom att använda enkätdata, registerinformation och tidigare publicerade studier undersöker denna avhandling skillnader i psykisk hälsa mellan olika migrantgrupper och inrikes födda och hur vistelsetid i landet, integration och specifikt födelseland påverkar dessa skillnader. I de fem ingående delstudierna studeras också betydelsen av olika närliggande (individuella) och avlägsna (strukturella) bestämningsfaktorer för migranters psykiska hälsa.   I Studie I undersöktes självskattad psykiska hälsobesvär bland migranter efter ålder vid invandringen och vistelsetid i landet. Högre ålder vid invandringen och längre vistelsetid i landet innebar i genomsnitt ökad risk för psykisk ohälsa särskilt bland migranter från länder utanför Organisationen för ekonomiskt samarbete och utveckling (OECD) regioner. Skillnader i psykisk hälsa förklarades till stor del av låg socioekonomisk position, bristfälligasociala kontakter och utsatthet för diskriminering. I Studie II studerades variationer i utskrivning av psykofarmaka i blandäktenskap som en proxy för integrationsnivå. Störst risk för utskrivning av psykofarmaka återfanns i äktenskap bestående av utrikesfödda makar medan risken var lägre i blandäktenskap dvs. bland migranter gifta med en inrikes född partner. Bland utrikesfödda kvinnor försvann sambanden efter justering för socioekonomiska- och sociala förhållanden inom äktenskapet vilket inte var fallet för utrikesfödda män. I Studie III undersöktes den internationella litteraturen kring effekter av icke hälsorelaterade policys på migranters hälsa genom en systematisk översikt. Översikten visade att restriktiv migrations- och integrationspolitik ökade risken för självskattade hälsobesvär och psykisk ohälsa bland migranter. En generös integrationspolitik visade sig däremot ha en positiv inverkan på migranters psykiska hälsa.   I Studie IV studerades införandet av en svensk föräldraledighetsreform under 1995 som syftar till att uppmuntra ett utökat uttag av föräldraledighet bland fäder (pappadagar), och dess konsekvenser för migranters psykiska hälsa. Både utrikesfödda och inrikes födda fäder ökade sitt uttag av föräldradagar till följd av reformen. Utrikesfödda fäder, och särskilt de födda utanför OECD regionerna eller med en utrikesfödd partner, uppvisade en minskning av psykiatrisk slutenvård till följd av reformen. I Studie V undersöktes effekterna av en annan svensk föräldraledighetsreform under 2012, som innebär en månads samtidig föräldraledighet för båda föräldrarna (dubbeldagar) och dess konsekvenser för deras psykiska hälsa. Både inrikes födda och utrikesfödda fäder utökade sitt uttag av föräldradagar till följd av reformen. Inrikes födda fäder och deras partners uppvisade minskad användning av psykofarmaka och utökat psykiatrisk öppenvårdutnyttjande till följd av reformen.    Resultaten från denna avhandling visar att den psykiska hälsan hos migranter i Sverige har en dynamisk karaktär och att flera olika sociala bestämningsfaktorer i mottagarlandet är av betydelse för deras psykiska hälsotillstånd. De olika delstudierna ger empiriskt stöd för att ålder vid invandringen, vistelsetid i landet och integrationsnivån är faktorer av stor betydelse för den psykiska hälsan bland utrikesfödda. Såväl närliggande sociala bestämningsfaktorer, som socioekonomisk position och sociala kontakter, och avlägsna bestämningsfaktorer, som välfärdsprogram och migrations politik, har betydelse för migranters psykiska hälsa. Sammantaget visar denna avhandling att skillnader i psykisk hälsa efter födelseland påverkas av sociala faktorer i mottagarlandet vilket därmed också innebär att det är möjligt att påverka föreliggande ojämlikheter

Mental health after migration to Sweden : The role of the social determinants of health

Migrants often experience worse mental health after migration than natives in Sweden. Using survey, register and peer-reviewed published data, the five studies of this thesis explored the mental health variation of different migrant groups settled in Sweden, including by the timing of migration, level of integration and region of origin. In parallel, the studies considered the role of downstream (individual) and upstream (structural) social determinants of health as drivers of mental health inequalities. Study I assessed migrants’ risk of self-reported psychological distress by their age at migration and duration of residence in Sweden, relative to Swedish-born natives. Migrants generally had higher risks of psychological distress than natives, increasing with older age at migration and longer duration of residence, especially among migrants from regions not affiliated with the Organization for Economic Cooperation and Development (OECD). Health differences were largely explained by inequalities in socioeconomic position, social connection and discrimination.  Study II explored how prescription rates of psychotropic medications varied by native-migrant marital composition as a proxy for integration in Sweden. Intramarried migrants had the highest prescription hazards, whereas migrants intermarried with natives had lower hazards, albeit higher than for intramarried natives. Migrant women, but not men, had attenuated hazards after adjusting for socioeconomic and other marriage-related social factors. Study III reviewed the international literature for previous evidence of the effects of non-health-related policies for migrant health. Restrictive entry and integration policies, including social welfare policies, were found to be associated with poorer self-rated general and mental health. Studies examining generous integration-related policies revealed largely positive mental health effects for migrants. Study IV investigated the mental health effects of the 1995 Father’s quota, a Swedish parental leave reform that incentivized fathers’ leave use. Whereas both native and migrant fathers increased their parental leave use following the reform, only migrant fathers, especially those from non-OECD regions and with migrant partners, experienced concurrent decreases in psychiatric hospitalizations. Study V examined the mental health effects of another Swedish parental leave policy, the 2012 Double Days reform, which introduced a month of simultaneous parental leave for mothers and fathers. Although both native and migrant fathers had increased levels of parental leave use, only native fathers and their partners exhibited decreased psychotropic medication prescription rates and greater outpatient care uptake related to mental health.  The findings of this thesis highlight the dynamic nature of mental health after migration, and the relevance of the social determinants of health within the receiving country context. The studies provide empirical support for how migrants’ mental health can vary by the timing of migration and level of integration, through downstream determinants, including socioeconomic position and social connection, and upstream determinants, such as welfare programs and migration policies. Taken together, the thesis emphasizes the need to consider migrant mental health inequalities as socially-patterned phenomena amenable to change after migration.Migranter har ofta sämre psykisk hälsa efter invandring jämfört med inrikes födda i Sverige. Genom att använda enkätdata, registerinformation och tidigare publicerade studier undersöker denna avhandling skillnader i psykisk hälsa mellan olika migrantgrupper och inrikes födda och hur vistelsetid i landet, integration och specifikt födelseland påverkar dessa skillnader. I de fem ingående delstudierna studeras också betydelsen av olika närliggande (individuella) och avlägsna (strukturella) bestämningsfaktorer för migranters psykiska hälsa.   I Studie I undersöktes självskattad psykiska hälsobesvär bland migranter efter ålder vid invandringen och vistelsetid i landet. Högre ålder vid invandringen och längre vistelsetid i landet innebar i genomsnitt ökad risk för psykisk ohälsa särskilt bland migranter från länder utanför Organisationen för ekonomiskt samarbete och utveckling (OECD) regioner. Skillnader i psykisk hälsa förklarades till stor del av låg socioekonomisk position, bristfälligasociala kontakter och utsatthet för diskriminering. I Studie II studerades variationer i utskrivning av psykofarmaka i blandäktenskap som en proxy för integrationsnivå. Störst risk för utskrivning av psykofarmaka återfanns i äktenskap bestående av utrikesfödda makar medan risken var lägre i blandäktenskap dvs. bland migranter gifta med en inrikes född partner. Bland utrikesfödda kvinnor försvann sambanden efter justering för socioekonomiska- och sociala förhållanden inom äktenskapet vilket inte var fallet för utrikesfödda män. I Studie III undersöktes den internationella litteraturen kring effekter av icke hälsorelaterade policys på migranters hälsa genom en systematisk översikt. Översikten visade att restriktiv migrations- och integrationspolitik ökade risken för självskattade hälsobesvär och psykisk ohälsa bland migranter. En generös integrationspolitik visade sig däremot ha en positiv inverkan på migranters psykiska hälsa.   I Studie IV studerades införandet av en svensk föräldraledighetsreform under 1995 som syftar till att uppmuntra ett utökat uttag av föräldraledighet bland fäder (pappadagar), och dess konsekvenser för migranters psykiska hälsa. Både utrikesfödda och inrikes födda fäder ökade sitt uttag av föräldradagar till följd av reformen. Utrikesfödda fäder, och särskilt de födda utanför OECD regionerna eller med en utrikesfödd partner, uppvisade en minskning av psykiatrisk slutenvård till följd av reformen. I Studie V undersöktes effekterna av en annan svensk föräldraledighetsreform under 2012, som innebär en månads samtidig föräldraledighet för båda föräldrarna (dubbeldagar) och dess konsekvenser för deras psykiska hälsa. Både inrikes födda och utrikesfödda fäder utökade sitt uttag av föräldradagar till följd av reformen. Inrikes födda fäder och deras partners uppvisade minskad användning av psykofarmaka och utökat psykiatrisk öppenvårdutnyttjande till följd av reformen.    Resultaten från denna avhandling visar att den psykiska hälsan hos migranter i Sverige har en dynamisk karaktär och att flera olika sociala bestämningsfaktorer i mottagarlandet är av betydelse för deras psykiska hälsotillstånd. De olika delstudierna ger empiriskt stöd för att ålder vid invandringen, vistelsetid i landet och integrationsnivån är faktorer av stor betydelse för den psykiska hälsan bland utrikesfödda. Såväl närliggande sociala bestämningsfaktorer, som socioekonomisk position och sociala kontakter, och avlägsna bestämningsfaktorer, som välfärdsprogram och migrations politik, har betydelse för migranters psykiska hälsa. Sammantaget visar denna avhandling att skillnader i psykisk hälsa efter födelseland påverkas av sociala faktorer i mottagarlandet vilket därmed också innebär att det är möjligt att påverka föreliggande ojämlikheter

Mortality by country of birth in the Nordic countries – a systematic review of the literature

Abstract Background Immigration to the Nordic countries has increased in the last decades and foreign-born inhabitants now constitute a considerable part of the region’s population. Several studies suggest poorer self-reported health among foreign-born compared to natives, while results on mortality and life expectancy are inconclusive. To date, few studies have summarized knowledge on mortality differentials by country of birth. This article aims to systematically review previous results on all-cause and cause-specific mortality by country of birth in the Nordic countries. Methods The methodology was conducted and documented systematically and transparently using a narrative approach. We identified 43 relevant studies out of 6059 potentially relevant studies in August 2016, 35 of which used Swedish data, 8 Danish and 1 Norwegian. Results Our findings from fully-adjusted models on Swedish data support claims of excess mortality risks in specific categories of foreign-born. Most notably, immigrants from other Nordic countries, especially Finland, experience increased risk of mortality from all causes, and specifically by suicide, breast and gynaecological cancers, and circulatory diseases. Increased risks in people from Central and Eastern Europe can also be found. On the contrary, decreased risks for people with Southern European and Middle Eastern origins are found for all-cause, suicide, and breast and gynaecological cancer mortality. The few Danish studies are more difficult to compare, with conflicting results arising in the analysis. Finally, results from the one Norwegian study suggest significantly decreased mortality risks among foreign-born, to be explored in further research. Conclusions With new studies being published on mortality differentials between native and foreign-born populations in the Nordic countries, specific risk patterns have begun to arise. Regardless, data from most Nordic countries remains limited, as does the information on specific causes of death. The literature should be expanded in upcoming years to capture associations between country of birth and mortality more clearly

Psychiatric consequences of a father’s leave policy by nativity : a quasi-experimental study in Sweden

Background Parental leave use has been found to promote maternal and child health, with limited evidence of mental health impacts on fathers. How these effects vary for minority populations with poorer mental health and lower leave uptake, such as migrants, remains under-investigated. This study assessed the effects of a Swedish policy to encourage fathers’ leave, the 1995 Father’s quota, on Swedish-born and migrant fathers’ psychiatric hospitalisations. Methods We conducted an interrupted time series analysis using Swedish total population register data for first-time fathers of children born before (1992–1994) and after (1995–1997) the reform (n=198 589). Swedish-born and migrant fathers’ 3-year psychiatric hospitalisation rates were modelled using segmented negative binomial regression, adjusting for seasonality and autocorrelation, with stratified analyses by region of origin, duration of residence, and partners’ nativity. Results From immediately pre-reform to post-reform, the proportion of fathers using parental leave increased from 63.6% to 86.4% of native-born and 37.1% to 51.2% of migrants. Swedish-born fathers exhibited no changes in psychiatric hospitalisation rates post-reform, whereas migrants showed 36% decreased rates (incidence rate ratio (IRR) 0.64, 95% CI 0.47 to 0.86). Migrants from regions not predominantly consisting of Organisation for Economic Cooperation and Development countries (IRR 0.50, 95% CI 0.19 to 1.33), and those with migrant partners (IRR 0.23, 95% CI 0.14 to 0.38), experienced the greatest decreases in psychiatric hospitalisation rates. Conclusion The findings of this study suggest that policies oriented towards promoting father’s use of parental leave may help to reduce native–migrant health inequalities, with broader benefits for family well-being and child development.Data availability statemen