Country of birth and survival after a first myocardial infarction in Stockholm, Sweden

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 mortality risk after myocardial infraction in migrants compared with natives: a systematic review and meta-analysis

Background and Objective

The evidence on the risk of mortality after myocardial infarction (MI) among migrants compared with natives is mixed and limited. The aim of this study is to assess the mortality risk after MI in migrants compared to natives.

Methods

This study protocol is registered with PROSPERO, number CRD42022350876. We searched the Medline and Embase databases, without time and language constraints, for cohort studies that reported the risk of mortality after MI in migrants compared to natives. The migration status is confirmed by country of birth, both migrants and natives are general terms and are not restricted to a particular country or area of destination or origin. Two reviewers separately screened searched studies according to selection criteria, extracted data, and assessed data quality using the Newcastle-Ottawa Scale (NOS) and risk of bias of included studies. Pooled estimates of adjusted and unadjusted mortality after MI were calculated separately using a random-effects model, and subgroup analysis was performed by region of origin and follow-up time.

Result

A total of 6 studies were enrolled, including 34,835 migrants and 284,629 natives. The pooled adjusted all-cause mortality of migrants after MI was higher than that of natives (OR, 1.24; 95% CI, 1.10-1.39; I2 = 83.1%), while the the pooled unadjusted mortality of migrants after MI was not significantly different from that of natives (OR, 1.11; 95% CI, 0.69-1.79; I2 = 99.3%). In subgroup analyses, adjusted 5-10 years mortality (3 studies) was higher in the migrant population (OR, 1.27; 95% CI, 1.12-1.45; I2 = 86.8%), while adjusted 30 days (4 studies) and 1-3 years (3 studies) mortality were not significantly different between the two groups. Migrants from Europe (4 studies) (OR, 1.34; 95% CI, 1.16-1.55; I2 = 39%), Africa (3 studies) (OR, 1.50; 95% CI, 01.31-1.72; I2 = 0%), and Latin America (2 studies) (OR, 1.44; 95% CI, 1.30-1.60; I2 = 0%) had significantly higher rates of post-MI mortality than natives, with the exception of migrants of Asian origin (4 studies) (OR, 1.20; 95% CI, 0.99-1.46; I2 = 72.7%).

Conclusions

Migrants tend to have lower socioeconomic status, greater psychological stress, less social support, limited access to health care resources, etc., therefore, face a higher risk of mortality after MI in the long term compared to natives. Further research is needed to confirm our conclusions, and more attention should be paid to the cardiovascular health of migrants.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: r CRD42022350876.

K. H, Osler M, Larsen ML, Gustafsson I, Zwisler AD, Sibilitz KL. Socioeconomic and ethnical disparity in coronary heart disease outcomes in Denmark and the effect of cardiac rehabilitation—A nationwide registry study

Aims

Cardiovascular patients with low socioeconomic status and non-western ethnic background have worse prognostic outcomes. The aim of this nationwide study was first to address whether short-term effects of hospital-based outpatient cardiac rehabilitation (CR) are similar across educational level and ethnic background, and secondly to study whether known disparity in long-term prognosis in patients with cardiovascular disese is diminished by CR participation.

Methods

All patients with myocardial infarction and/or coronary revascularization from August 2015 until March 2018 in the Danish national patient registry or the Danish cardiac rehabilitation database (DHRD) were included. We used descriptive statistics to address disparity in achievement of quality indicators in CR, and Cox proportional hazard regression to examine the association between the disparity measures and MACE (cardiovascular hospitalization and all-cause mortality) with adjustment for age, gender, index-diagnose and co-morbidity.

Results

We identified 34,511 patients of whom 19,383 had participated in CR and 9,882 provided information on CR outcomes from the DHRD. We demonstrated a socioeconomic gradient in improvements in VO_2peak, and non-western patients were less often screened for depression or receive dietary consulting. We found a strong socioeconomic gradient in MACE irrespective of CR participation, medication, and risk factor control (adjusted HR 0.65 (95% CI 0.56–0.77) for high versus low education). Non-western origin was associated with higher risk of MACE (adjusted HR 1.2 (1.1–1.4)).

Conclusion

We found only minor socioeconomic and ethnic differences in achievement of CR quality indicators but strong differences in CHD prognosis indication that conventional risk factor control and medical treatment following CR do not diminish the socioeconomic and ethnical disparity in CHD prognosis.

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.

Undoing the unspeakable: researching racism in Swedish healthcare using a participatory process to build dialogue

Background

Racism is difficult to discuss in the context of Swedish healthcare for various cultural and administrative reasons. Herein, we interpret the fragmentary nature of the evidence of racialising processes and the difficulty of reporting racist discrimination in terms of structural violence.

Methods

In response to the unspeakable nature of racism in Swedish healthcare, we propose a phased participatory process to build a common vocabulary and grammar through a consultative framework involving healthcare providers and service users as well as policy-makers. These stakeholders will be involved in an educational intervention to facilitate discussion around and avoidance of racism in service provision.

Discussion

Both the participatory process and outcomes of the process, e.g. educational interventions, will contribute to the social and political conversation about racism in healthcare settings. Creating new ways of discussing sensitive topics allows ameliorative actions to be taken, benefitting healthcare providers and users. The urgency of the project is underlined.

Short and long-term prognosis following acute myocardial infarction according to the country of origin. Soroka acute myocardial infarction II (SAMI II) project

BACKGROUND

Reports from many countries have shown birthplace-associated disparities in the incidence and mortality following acute myocardial infarction (AMI). The aims of the study were to identify and compare short- and long-term post-AMI mortality according to birthplace.

METHODS

A retrospective analysis of Israeli AMI patients from a tertiary medical center in Southern Israel throughout 2002-2012.

DATA SOURCE

the hospital's computerized systems. Patients were classified according to the country of birth (Israel, Southern Europe/Balkans, Northern Africa, Eastern/Central Europe, India/Pakistan, Middle-East, Yemen, and Ethiopia).

STUDY OUTCOMES

in-hospital and up to 10-years post-discharge all-cause mortality.

RESULTS

The study included 11,143 patients, age 67.4 ± 13.9 and 67.5% men. Israeli-born patients were significantly younger, with lower rate of diabetes mellitus and hypertension but significantly higher rate of obesity, smoking, history of coronary artery disease and male sex compared with immigrants. The rate of STEMI and administration of percutaneous coronary revascularization was higher, yet extent of coronary findings and severe left ventricular dysfunction was lower in Israeli-born patients. In-hospital as well as post-discharge 1-and 10-year mortality rates were approximately 65% lower in Israeli-born patients compared with immigrants. Following adjustment for potential confounders the inequalities in post-discharge mortality attenuated (Yemen OR = 2.3 [95%CI: 1.4-3.6], Southern Europe/Balkans 1.75 [1.2-2.5], Northern Africa 1.5 [1.3-1.8], Eastern/Central Europe 1.4 [1.2-1.7] and India/Pakistan 1.4 [1.1-1.9], for 10-years mortality, p < 0.05 for each) and those for in-hospital mortality disappeared.

CONCLUSIONS

Immigrants are at increased risk for post-discharge, yet not in-hospital mortality following AMI. Appropriate targeted preventive programs are required for these groups of patients.

Cardiovascular disease incidence and survival: Are migrants always worse off?

Studies on cardiovascular disease (CVD) incidence and survival show varying results between different ethnic groups. Our aim was to add a new dimension by exploring the role of migrant status in combination with ethnic background on incidence of-and survival from-CVD and more specifically acute myocardial infarction (AMI) and stroke. We conducted a historically prospective cohort study comprising all newly-arrived migrants to Denmark between 1.1.1993 and 31.12.2010 (n = 114,331), matched 1:6 to Danish-born by age and sex. CVD incidence was retrieved from the National Patient Registry and differences in incidence were assessed by Poisson regression and stratified by sex. Survival differences were assessed by Cox regression using all-cause and cause-specific mortality as outcome. Male refugees had significantly lower incidence of CVD (RR = 0.89; 95 % CI 0.85-0.93) and stroke (IRR = 0.62; 95 % CI 0.56-0.69) compared to Danish-born, but significantly higher incidence of AMI (IRR = 1.12; 95 % CI 1.02-1.24). Female refugees had similar rates of CVD and AMI, but significantly lower incidence of stroke (RR = 0.76; 95 % CI 0.67-0.85). Both male and female family-reunified immigrants had significantly lower incidence of CVD, AMI and stroke. All-cause and cause-specific survival after CVD, AMI and stroke was similar or significantly better for migrants compared to Danish-born, regardless of type of migrant (refugee vs. family-reunified) or country of origin. Refugees are disadvantaged in terms of some types of cardiovascular disease compared to Danish-born. Family-reunified migrants on the other hand had lower rates of CVD. All migrants had better survival than Danish-born indicating that migrants may not always be disadvantaged in health.

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.

The Shanghai Changfeng Study: a community-based prospective cohort study of chronic diseases among middle-aged and elderly: objectives and design

The Shanghai Changfeng Study is a community-based prospective cohort study of chronic diseases ongoing since February 2009 in Shanghai, China. The study focuses on multiple chronic diseases, including obesity and metabolic syndrome, diabetes, osteoporosis, liver diseases, cardiovascular diseases and neurologic diseases. 15,000 subjects of 40 years or over are planned to be recruited. The rationale, objectives and design of this study are described in this paper.

The Generation R Study: design and cohort update 2010

The Generation R Study is a population-based prospective cohort study from fetal life until young adulthood. The study is designed to identify early environmental and genetic causes of normal and abnormal growth, development and health during fetal life, childhood and adulthood. The study focuses on four primary areas of research: (1) growth and physical development; (2) behavioural and cognitive development; (3) diseases in childhood; and (4) health and healthcare for pregnant women and children. In total, 9,778 mothers with a delivery date from April 2002 until January 2006 were enrolled in the study. General follow-up rates until the age of 4 years exceed 75%. Data collection in mothers, fathers and preschool children included questionnaires, detailed physical and ultrasound examinations, behavioural observations, and biological samples. A genome wide association screen is available in the participating children. Regular detailed hands on assessment are performed from the age of 5 years onwards. Eventually, results forthcoming from the Generation R Study have to contribute to the development of strategies for optimizing health and healthcare for pregnant women and children.

Early influences on cardiovascular and renal development

The hypothesis that a developmental component plays a role in subsequent disease initially arose from epidemiological studies relating birth size to both risk factors for cardiovascular disease and actual cardiovascular disease prevalence in later life. The findings that small size at birth is associated with an increased risk of cardiovascular disease have led to concerns about the effect size and the causality of the associations. However, recent studies have overcome most methodological flaws and suggested small effect sizes for these associations for the individual, but an potential important effect size on a population level. Various mechanisms underlying these associations have been hypothesized, including fetal undernutrition, genetic susceptibility and postnatal accelerated growth. The specific adverse exposures in fetal and early postnatal life leading to cardiovascular disease in adult life are not yet fully understood. Current studies suggest that both environmental and genetic factors in various periods of life may underlie the complex associations of fetal growth retardation and low birth weight with cardiovascular disease in later life. To estimate the population effect size and to identify the underlying mechanisms, well-designed epidemiological studies are needed. This review is focused on specific adverse fetal exposures, cardiovascular adaptations and perspectives for new studies.

Large-scale epidemiological data on cardiovascular diseases and diabetes in migrant and ethnic minority groups in Europe

BACKGROUND

Data on differences by ethnicity in cardiovascular diseases (CVDs) and diabetes, reflecting the influence of diverse cultural, social and religious factors, are important to providing clues to disease aetiology and directing public health interventions and health care resources.

METHODS

Through a network of European public health researchers and searches of bibliographic databases and internet sites, we determined the availability and characteristics of ethnically relevant data on mortality and morbidity from coronary heart disease (CHD), stroke and diabetes, in current European Union countries; data from the four countries comprising the UK were assessed separately.

RESULTS

In total, 25 countries had one or more relevant data sets (72 in total); however, two-thirds (n = 47) of the data sources came from only eight Nordic and Western European countries. For several countries, no data could be identified. Ethnically relevant, national death registers were available in 24 countries. Country of birth was the most common indicator of ethnicity. Data on CHD, stroke and diabetes morbidity among migrant and ethnic minority populations are currently scarce; both between and within countries, there are important differences in how ethnicity as well as disease outcomes are defined and measured which limits data comparability.

CONCLUSION

Reliable routine data are key to evidence-based public health policies at both national and EU level. EU countries have a relatively weak base for assessing needs and planning health care interventions for its migrant and ethnic minority populations. The lack of ethnically relevant data on CVD and diabetes across the EU needs to be addressed urgently.

The Rotterdam Study: 2010 objectives and design update

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in close to a 1,000 research articles and reports (see www.epib.nl/rotterdamstudy). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.