Are there differences in injury mortality among refugees and immigrants compared with native-born?

Home injuries in British Columbia: patterns across the deprivation spectrum

The significant burden of home injuries has become a growing concern that affect thousands of people every year across Canada. This study examined the relationship between neighbourhood deprivation and unintentional injuries occurring at home leading to hospitalizations in British Columbia (BC) between 2015 and 2019. This study used de-identified hospitalization data on unintentional home-related injuries from the Discharge Abstract Database (DAD) and population data for each dissemination area from Statistics Canada's 2016 Census Profiles. Hospitalization rates were computed for unintentional home-related injuries across four dimensions specified in the Canadian Index of Multiple Deprivation (CIMD) for BC. For three CIMD dimensions (situational vulnerability, economic dependency, and residential instability), unintentional home injury rates were higher in areas with higher deprivation, while the inverse was observed for ethno-cultural diversity. Understanding socio-economic disparities within neighbourhoods enables injury prevention partners to identify vulnerable populations and prioritize the development and implementation of evidence-based injury prevention interventions.

Suicide among migrants: a comprehensive narrative review of literature

Suicidality among migrants represents a multifaceted and complex issue with significant implications and challenges for public mental health and policies. This narrative review aims to explore the factors contributing to suicidality within the migrant groups, consequently highlighting the need for tailored interventions and supporting strategies. Firstly, we reviewed the evidences on the prevalence of suicidal ideation, attempted suicides, and deaths by suicide among migrants. The results were extremely heterogeneous, mostly depending on the different migrant group considered. Significant differences in suicide risk have been found depending on the legal status of migrants and their country of origin/migration. The second section explored the protective and risk factors for suicidal ideation and behaviours in different migrant groups. The analysis concluded that a set of factors may interact in various ways, contributing to a heterogeneous and complex framework underpinning the phenomenon of suicide. Migration itself may be a challenging and traumatizing experience, characterized by social isolation, cultural dislocation and adjustment, as well as economic and financial distress, all of which may exacerbate pre-existing mental health vulnerabilities or trigger new mental disorders. Acculturative stress, discrimination, and language barriers further compound these challenges, often hindering access to mental health services.

Suicidality Among Syrian Refugee Children in Jordan

History of adverse events in childhood is one of the strongest predictors of developing negative mental health outcomes with suicidality being the most devastating consequence. Syrian refugee children are at very high risk of developing mental illness, however, the prevalence and significance of suicidal thoughts among this population remains undocumented. A total of 339 Syrian refugee children and adolescents aged 10 to 17 years and their parents living in Jordan were surveyed to assess resilience, depression and suicidality. Demographics and parental depression were correlated with child suicidality. Multivariate logistic regression analyses were used to determine the predictors of suicidality within this population. A total of 94 (27.7%) children reported suicidal statements. In the multivariate analyses we found that younger children were more likely to state suicidal ideation than older children. Of the children who stated suicidal ideation, 49 were in primary school, 19 in pre-secondary and 26 in upper-secondary school. In the multivariate analyses, mild (OR 2.633 (95% CI 1.283, 5.709)) and high (OR 6.987 (95% CI 3.532, 14.614)) depression levels among the surveyed children were predictive of suicidality. Experiencing bullying was also predictive of suicidality (OR 2.181 (95% CI 1.179, 4.035)) when compared to those who did not report any bullying. We report high rates of suicidal ideation among Syrian refugee children, especially in children with exposure to pre-existing depression or bullying. Prevention through raising awareness, education and early detection of depression are needed to address suicidality in this and other vulnerable populations of children.

Physical injuries and burns among refugees in Lebanon: implications for programs and policies

BACKGROUND

Refugees are prone to higher risks of injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and to examine injury characteristics, risk factors, and outcomes.

METHODS

We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the 'Surgeons Overseas Assessment of Surgical Need (SOSAS)' tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.

RESULTS

750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value = 0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs. 13.3%, p value = 0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.

CONCLUSIONS

Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching about heating and cooking safety practices.

Differences in all-cause and cause-specific mortality due to external causes and suicide between young adult refugees, non-refugee immigrants and Swedish-born young adults: The role of education and migration-related factors

BACKGROUND

International migration has increased during the past years and little is known about the mortality of young adult immigrants and refugees that came to Sweden as children. This study aimed to investigate 1) the risk of all-cause and cause-specific mortality in young accompanied and unaccompanied refugees and non-refugee immigrants compared to Swedish born individuals; and 2) to determine the role of educational level and migrations-related factors in these associations.

METHODS

This register linkage study is based on 682,358 individuals (633,167 Swedish-born, 2,163 unaccompanied and 25,658 accompanied refugees and 21,370 non-refugee immigrants) 19-25 years old, who resided in Sweden 31.12.2004. Outcomes were all-cause mortality and mortality due to suicide and external causes. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models with a maximum follow-up to 2016.

RESULTS

After adjusting for covariates, all-cause mortality was significantly lower in non-refugee immigrants (aHR 0.70, 95% CI 0.59-0.84) and refugees (aHR 0.76, 95% CI 0.65-0.88) compared to Swedish-born individuals. The same direction of association was observed for mortality due to suicide and external causes. No differences between accompanied and unaccompanied refugees were found. Risk estimates for all migrant groups varied with educational level, duration of residency, age at arrival and country of birth. Further, the mortality risk of migrants arriving in Sweden before the age of 6 years did not significantly differ from the risk of their Swedish-born peers. Low education was a considerable risk factor.

CONCLUSION

In general, young adult refugees and non-refugee immigrants have a lower risk of all-cause and cause-specific mortality than Swedish-born individuals. The identified migrant groups with higher mortality risk need specific attention.

Suicide rates amongst individuals from ethnic minority backgrounds: A systematic review and meta-analysis

BACKGROUND

Existing evidence suggests that some individuals from ethnic minority backgrounds are at increased risk of suicide compared to their majority ethnic counterparts, whereas others are at decreased risk. We aimed to estimate the absolute and relative risk of suicide in individuals from ethnic minority backgrounds globally.

METHODS

Databases (Medline, Embase, and PsycInfo) were searched for epidemiological studies between 01/01/2000 and 3/07/2020, which provided data on absolute and relative rates of suicide amongst ethnic minority groups. Studies reporting on clinical or specific populations were excluded. Pairs of reviewers independently screened titles, abstracts, and full texts. We used random effects meta-analysis to estimate overall, sex, location, migrant status, and ancestral origin, stratified pooled estimates for absolute and rate ratios. PROSPERO registration: CRD42020197940.

FINDINGS

A total of 128 studies were included with 6,026,103 suicide deaths in individuals from an ethnic minority background across 31 countries. Using data from 42 moderate-high quality studies, we estimated a pooled suicide rate of 12·1 per 100,000 (95% CIs 8·4-17·6) in people from ethnic minority backgrounds with a broad range of estimates (1·2-139·7 per 100,000). There was weak statistical evidence from 51 moderate-high quality studies that individuals from ethnic minority groups were more likely to die by suicide (RR 1·3 95% CIs 0·9-1·7) with again a broad range amongst studies (RR 0·2-18·5). In our sub-group analysis we only found evidence of elevated risk for indigenous populations (RR: 2·8 95% CIs 1·9-4·0; pooled rate: 23·2 per 100,000 95% CIs 14·7-36·6). There was very substantial heterogeneity (I²  > 98%) between studies for all pooled estimates.

INTERPRETATION

The homogeneous grouping of individuals from ethnic minority backgrounds is inappropriate. To support suicide prevention in marginalised groups, further exploration of important contextual differences in risk is required. It is possible that some ethnic minority groups (for example those from indigenous backgrounds) have higher rates of suicide than majority populations.

FUNDING

No specific funding was provided to conduct this research. DK is funded by Wellcome Trust and Elizabeth Blackwell Institute Bristol. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Rebecca Musgrove is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC-2016-003).

Suicide rates and suicidal behaviour in displaced people: A systematic review

Background

Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging.

Methods and findings

A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations.

Conclusion

While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area.

Registration

PROSPERO CRD42019137242.

Prevalence of Suicide in Immigrants/Refugees: A Systematic Review and Meta-Analysis

OBJECTIVE

In recent years, there has been an increase in immigrant populations worldwide. This study aims to present the global prevalence of suicide between immigrants and refugees as well as to report the prevalence of suicide ideation, suicide mortality, suicide attempts, and plan of suicide.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA's) rules were used as a guide in the current research path. PubMed and EMBASE were targeted for the study until December 2019. After collecting the data, the number of events and sample size extracted for each study and also pooled odds ratio and confidence interval (CI) were used to investigate the suicide ratio among immigrants and refugees compared to the native population.

RESULTS

Fifty-one studies were included in the meta-analysis to investigate suicide prevalence or suicide odds ratio. The prevalence of suicidal ideation was 16% (CI: 0.12-0.20, I² = 99.4%), for attempted suicide was 6% (CI: 0.05-0.08, I² = 98.0%), and for suicide plan prevalence was 4% (CI: 0.00-0.08, I² = 96.8%). The prevalence of suicidal ideation was 10% (CI: 0.04-0.17, I² = 0.0%) in men and 17% (CI: 0.10-0.24, I² = 96.8%) in women. The prevalence of attempted suicide was 1% (CI: 0.01-0.02, I² = 0.0%) in men and 7% (CI: 0.03-0.10, I² = 94.4%) in women. The odds ratio of suicide mortality among immigrants was 0.91 (CI: 0.90-0.93, p < 0.001; I² = 97.6%) and for attempted suicide was 1.15 (CI: 1.10-1.20, p < 0.001; I² = 92.0%). Begg's test (p = 0.933) (Egger test; p = 0.936) rejected publication bias.

CONCLUSION

Given the high prevalence of suicide, especially suicide ideation and suicide attempts in immigrants, increased attention needs to be paid to the mental health of this population.

Trends in suicide mortality in Spain, 2000-2019: Moderation by foreign-born status

BACKGROUND

Suicide rates in Spain remained stable during the early 21st century. Suicide rates among specific socially vulnerable groups, however, remain unknown, and there are no data on suicide mortality rates and trends among migrants living in Spain.

METHODS

We analyzed Spain's 2000-2019 suicide mortality data by migration status (native- vs. foreign-born), examining crude and age-standardized rates and trends overall and by sex, age-group, suicide method, Spanish citizenship status, and country of origin, using joinpoint regression models.

RESULTS

Annual crude suicide mortality rates were higher among native- than foreign-born individuals (9.2 versus 6.2 por 100.000 inhabitants, respectively). While suicide rates decreased among native-born men and remained roughly stable among native-born women - with slight decreases among older native-born women, they increased after 2010 among foreign-born men aged 15-44 and ≥65 years and foreign-born women aged ≥65 years. Increases in suicide trends among foreign-born residents in Spain were largely driven by increases specific to individuals without Spanish citizenship.

LIMITATIONS

Suicide mortality data are subject to potential errors due to underreporting of suicide in death certificates CONCLUSIONS: Between 2010-2019, suicide in Spain increased only among foreign-born residents. These findings should enhance our understanding of the dynamics and potential actionable causes of suicide among migrants living in Spain.

Suicide attempt and suicide in refugees in Sweden - a nationwide population-based cohort study

BACKGROUND

Despite a reported high rate of mental disorders in refugees, scientific knowledge on their risk of suicide attempt and suicide is scarce. We aimed to investigate (1) the risk of suicide attempt and suicide in refugees in Sweden, according to their country of birth, compared with Swedish-born individuals and (2) to what extent time period effects, socio-demographics, labour market marginalisation (LMM) and morbidity explain these associations.

METHODS

Three cohorts comprising the entire population of Sweden, 16-64 years at 31 December 1999, 2004 and 2009 (around 5 million each, of which 3.3-5.0% refugees), were followed for 4 years each through register linkage. Additionally, the 2004 cohort was followed for 9 years, to allow analyses by refugees' country of birth. Crude and multivariate hazard ratios (HRs) with 95% confidence intervals (CIs) were computed. The multivariate models were adjusted for socio-demographic, LMM and morbidity factors.

RESULTS

In multivariate analyses, HRs regarding suicide attempt and suicide in refugees, compared with Swedish-born, ranged from 0.38-1.25 and 0.16-1.20 according to country of birth, respectively. Results were either non-significant or showed lower risks for refugees. Exceptions were refugees from Iran (HR 1.25; 95% CI 1.14-1.41) for suicide attempt. The risk for suicide attempt in refugees compared with the Swedish-born diminished slightly across time periods.

CONCLUSIONS

Refugees seem to be protected from suicide attempt and suicide relative to Swedish-born, which calls for more studies to disentangle underlying risk and protective factors.

Risk of suicide attempt and suicide in young adult refugees compared to their Swedish-born peers: a register-based cohort study

PURPOSE

Refugees, especially minors, who often have experienced traumatic events, are a vulnerable group regarding poor mental health. Little is known, however, of their risk of suicidal behaviour as young adults. We aimed to investigate the risk of suicidal behaviour for young adult refugees who migrated as minors. The moderating role of education and history of mental disorders in this association was also investigated.

METHODS

In this register linkage study, all 19-30-year-old Swedish-born (n = 1,149,855) and refugees (n = 51,098) residing in Sweden on December 31st, 2009 were included. The follow-up period covered 2010-2016. Cox models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). The multivariate models were adjusted for socio-demographic, labour market marginalisation and health-related factors.

RESULTS

Compared to Swedish-born, the risk of suicide attempt was lower for all refugees (HR 0.78, 95% CI 0.70-0.87), and accompanied refugee minors (HR 0.77, 95% CI 0.69-0.87), but estimates did not differ for unaccompanied refugee minors (HR 0.83, 95% CI 0.62-1.10). Low education and previous mental disorders increased the risk of suicide attempt in both refugees and Swedish-born, with lower excess risks in refugees. Findings for suicide were similar to those of suicide attempt.

CONCLUSION

Young adult refugees have a lower risk of suicidal behaviour than their Swedish-born peers, even if they have low educational level or have mental disorders. Young refugees who entered Sweden unaccompanied do not seem to be equally protected and need specific attention.

Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population

BACKGROUND

It has been hypothesised that refugees have an increased risk of suicide.

AIMS

To investigate whether risk of suicide is higher among refugees compared with non-refugee migrants from the same areas of origin and with the Swedish-born population, and to examine whether suicide rates among migrants converge to the Swedish-born population over time.

METHOD

A population-based cohort design using linked national registers to follow 1 457 898 people born between 1 January 1970 and 31 December 1984, classified by migrant status as refugees, non-refugee migrants or Swedish-born. Participants were followed from their 16th birthday or date of arrival in Sweden until death, emigration or 31 December 2015, whichever came first. Cox regression models estimated adjusted hazard ratios for suicide by migrant status, controlling for age, gender, region of origin and income.

RESULTS

There were no significant differences in suicide risk between refugee and non-refugee migrants (hazard ratio 1.28, 95% CI 0.93-1.76) and both groups had a lower risk of suicide than Swedish born. During their first 5 years in Sweden no migrants died by suicide; however, after 21-31 years their suicide risk was equivalent to the Swedish-born population (hazard ratio 0.94, 95% CI 0.79-1.22). After adjustment for income this risk was significantly lower for migrants than the Swedish-born population.

CONCLUSIONS

Being a refugee was not an additional risk factor for suicide. Our findings regarding temporal changes in suicide risk suggest that acculturation and socioeconomic deprivation may account for a convergence of suicide risk between migrants and the host population over time.

DECLARATION OF INTEREST

None.

Mental disorders, suicide attempt and suicide: differences in the association in refugees compared with Swedish-born individuals

BACKGROUND

Mental disorders are associated with an elevated risk for suicide attempt and suicide. Whether the strength of the associations also holds for refugees is unclear.

AIMS

To examine the relationship between specific mental disorders and suicide attempt and suicide in refugees and Swedish-born individuals.

METHOD

This longitudinal cohort study included 5 083 447 individuals aged 16-64 years, residing in Sweden in 2004, where 196 757 were refugees. Mental disorders were defined as having a diagnosis in psychiatric care during 2000-2004. Estimates of risk of suicide attempt and suicide were calculated as hazard ratios with 95% confidence intervals. Adjustments were made for important confounding factors, including history of attempt. The reference group comprised Swedish-born individuals without mental disorders.

RESULTS

Rates for suicide attempt in individuals with a mental disorder were lower in refugees compared with Swedish-born individuals (480 v. 850 per 100 000 person-years, respectively). This pattern was true for most specific disorders: compared with the reference group, among refugees, multivariable-adjusted hazard ratios for suicide attempt ranged from 3.0 (anxiety) to 7.4 (substance misuse), and among Swedish-born individuals, from 4.9 (stress-related disorder) to 9.3 (substance misuse). For schizophrenia, bipolar disorder and personality disorder, estimates for suicide attempt were comparable between refugees and Swedish-born individuals. Similar patterns were seen for suicide.

CONCLUSIONS

For most mental disorders, refugees were less likely to be admitted to hospital for suicide attempt or die by suicide compared with Swedish-born individuals. Further research on risk and protective factors for suicide attempt and suicide among refugees with mental disorders is warranted.

DECLARATION OF INTEREST

None.

Mortality Rate and Causes of Death Among Refugees Resettled in Washington State, 2006-2016

Cause of death among refugees resettled in the United States is not well documented. This evaluation determined cause of death among refugees who resettled to and died in Washington State. Records of refugees who arrived in Washington State from 2006 to 2016 were linked to state death records for the same period. Rates and proportions of death were calculated and compared to those for all Washingtonians. From 2006 to 2016, 171 of 30,243 refugees (0.6%) resettled to and died in Washington. The age-adjusted all-cause mortality rate was 3.93 (95% CI 3.12-4.75) per 1000 refugees, compared to 6.98 (95% CI 6.96-7.00) per 1000 Washingtonians. Malignant neoplasms and heart disease were the leading causes of death for both refugees and Washingtonians. Determining cause of death among refugee populations can identify emerging trends in mortality. This information can be used to help inform disease and injury prevention interventions for refugee communities.

Health care utilisation for treatment of injuries among immigrants in Norway: a nationwide register linkage study

Background

Previous research has generally found lower rates of injury incidence in immigrant populations than in native-born populations. Most of this literature relies on mortality statistics or hospital data, and we know less about injuries treated in primary health care. The aim of the present study was to assess use of primary and secondary care for treatment of injuries among immigrants in Norway according to geographic origin and type of injury.

Methods

We conducted a nationwide register-based cohort study of all individuals aged 25–64 years who resided in Norway as of January 1st 2008. This cohort was followed through 2014 by linking sociodemographic information and injury data from primary and secondary care. We grouped immigrants into six world regions of origin and identified immigrants from the ten most frequently represented countries of origin. Six categories of injury were defined: fractures, superficial injuries, open wounds, dislocations/sprains/strains, burns and poisoning. Poisson regression models were fitted to estimate incidence rate ratios separately for injuries treated in primary and secondary care according to immigrant status, geographic origin and type of injury, with adjustment for sex, age, county of residence, marital status and socioeconomic status.

Results

Immigrants had a 16% lower incidence of injury in primary care than non-immigrants (adjusted IRR = 0.84, 95% CI 0.83–0.84), and a 10% lower incidence of injury in secondary care (adjusted IRR = 0.90, 95% CI 0.90–0.91). Immigrants from Asia, Africa and European countries outside EU/EEA had lower rates than non-immigrants for injuries treated in both primary and secondary care. Rates were lower in immigrants for most injury types, and in particular for fractures and poisoning. For a subset of injuries treated in secondary care, we found that immigrants had lower rates than non-immigrants for treatment of self-harm, falls, sports injuries and home injuries, but higher rates for treatment of assault, traffic injuries and occupational injuries.

Conclusions

Health care utilisation for treatment of injuries in primary and secondary care in Norway was lower for immigrants compared to non-immigrants. Incidence rates were especially low for immigrants originating from Asia, Africa and European countries outside EU/EEA, and for treatment of fractures, poisoning, self-harm and sports injuries.

Climate Change and Risk of Completed Suicide

Climate change is increasingly recognized as having multiple adverse mental health effects, many of which are just beginning to be understood. The elevated rates of suicides observed in some communities affected by climate change and rising rates of suicide in the United States as climate change intensifies have suggested the two may be associated. We searched PubMed and PsycInfo using the terms climate change and suicide, and provide here a review of the current literature on climate change and suicide that explores possible associations and methodological issues and challenges in this research.

Previous suicide attempt and subsequent risk of re-attempt and suicide: Are there differences in immigrant subgroups compared to Swedish-born individuals?

BACKGROUND

Studies investigating how suicide attempting refugees and non-refugee migrants differ from Swedish-born individuals in terms of re-attempts and suicide are missing. It remains unknown how mental disorders and labour market marginalization (LMM) impact on these associations.

METHODS

This longitudinal cohort study included Swedish residents aged 20-64 with suicide attempt in 2004-2012. In total, 42,684 individuals including 2017 refugees, and 2544 non-refugee migrants were included and followed until December 31, 2016. Risks of re-attempt and suicide were calculated as hazard ratios (HR) with 95% confidence intervals (CI), and adjusted for important confounders. Stratified analyses were to assess if mental disorders or LMM modified these associations.

RESULTS

In the adjusted models, refugees had an adjusted HR (aHR) of suicide re-attempt of 0.74 (CI: 0.67-0.81), and an aHR of 0.67 (CI: 0.53-0.86) for suicide death. These estimates were very similar to those of non-refugee migrants. Refugees and non-refugee migrants with suicide attempt had a lower prevalence of specialised health care due to mental disorders compared to Swedish-born attempters (48%, 44% and 61%, respectively). Mental disorders and LMM in terms of long-term sickness absence and disability pension increased the risk of re-attempt and suicide in all three groups.

LIMITATIONS

Only suicide attempts and mental disorders resulting in specialized in-and outpatient care were registered.

CONCLUSION

Migrants show considerably lower risks of re-attempt and suicide than Swedish-born individuals, with no differences between migrant groups. Despite vast differences in the prevalence of specific mental disorders, the role of mental disorders in the pathways to re-attempt and suicide does not appear to differ considerably between these groups.

Ethnic variations in falls and road traffic injuries resulting in hospitalisation or death in Scotland: the Scottish Health and Ethnicity Linkage Study

Objectives

To investigate ethnic differences in falls and road traffic injuries (RTIs) in Scotland.

Study design

A retrospective cohort of 4.62 million people, linking the Scottish Census 2001, with self-reported ethnicity, to hospitalisation and death records for 2001–2013.

Methods

We selected cases with International Classification of Diseases–10 diagnostic codes for falls and RTIs. Using Poisson regression, age-adjusted risk ratios (RRs, multiplied by 100 as percentages) and 95% confidence intervals (CIs) were calculated by sex for 10 ethnic groups with the White Scottish as reference. We further adjusted for country of birth and socio-economic status (SES).

Results

During about 49 million person-years, there were 275,995 hospitalisations or deaths from fall-related injuries and 43,875 from RTIs. Compared with the White Scottish, RRs for falls were higher in most White and Mixed groups, e.g., White Irish males (RR: 131; 95% CI: 122–140) and Mixed females (126; 112–143), but lower in Pakistani males (72; 64–81) and females (72; 63–82) and African females (79; 63–99). For RTIs, RRs were higher in other White British males (161; 147–176) and females (156; 138–176) and other White males (119; 104–137) and females (143; 121–169) and lower in Pakistani females (74; 57–98). The ethnic variations differed by road user type, with few cases among non-White motorcyclists and non-White female cyclists. The RRs were minimally altered by adjustment for country of birth or SES.

Conclusion

We found important ethnic variations in injuries owing to falls and RTIs, with generally lower risks in non-White groups. Culturally related differences in behaviour offer the most plausible explanation, including variations in alcohol use. The findings do not point to the need for new interventions in Scotland at present. However, as the ethnic mix of each country is unique, other countries could benefit from similar data linkage-based research.

•

Ethnic inequalities in injuries are demonstrated in Scotland based on a large sample size and a fine ethnic granularity.

•

White minority ethnic groups had the highest risks of fall-related injuries in Scotland.

•

Fall-related injuries were the least likely in the Pakistani population.

•

Ethnic differences in road traffic injuries varied by the type of road user.

•

Ethnic differences in injuries were not explained by socio-economic status or country of birth.

Big Data-Driven Approach for Health Inequalities in Foreign Patients with Injuries Visiting Emergency Rooms

Objectives

Foreign patients are more likely to receive inappropriate health service in the emergency room. This study aimed to investigate whether there is health inequality between foreigners and natives who visited emergency rooms with injuries and to examine its causes.

Methods

We analyzed clinical data from the National Emergency Department Information System database associated with patients of all age groups visiting the emergency room from 2013 to 2015. We analyzed data regarding mortality, intensive care unit admission, emergency operation, severity, area, and transfer ratio.

Results

A total of 4,464,603 cases of injured patients were included, of whom 67,683 were foreign. Injury cases per 100,000 population per year were 2,960.5 for native patients and 1,659.8 for foreign patients. Foreigners were more likely to have no insurance (3.1% vs. 32.0%, p < 0.001). Serious outcomes (intensive care unit admission, emergency operation, or death) were more frequent among foreigners. In rural areas, the difference between serious outcomes for foreigners compared to natives was greater (3.7% for natives vs. 5.0% for foreigners, p < 0.001). The adjusted odds ratio for serious outcomes for foreign nationals was 1.412 (95% confidence interval [CI], 1.336–1.492), and that for lack of insurance was 1.354 (95% CI, 1.314–1.394).

Conclusions

Injured foreigners might more frequently suffer serious outcomes, and health inequality was greater in rural areas than in urban areas. Foreign nationality itself and lack of insurance could adversely affect medical outcomes.

Mental disorders and suicidal behavior in refugees and Swedish-born individuals: is the association affected by work disability?

BACKGROUND

Among potential pathways to suicidal behavior in individuals with mental disorders (MD), work disability (WD) may play an important role. We examined the role of WD in the relationship between MD and suicidal behavior in Swedish-born individuals and refugees.

METHODS

The study cohort consisted of 4,195,058 individuals aged 16-64, residing in Sweden in 2004-2005, whereof 163,160 refugees were followed during 2006-2013 with respect to suicidal behavior. Risk estimates were calculated as hazard ratios (HR) with 95% confidence intervals (CI). The reference groups comprised individuals with neither MD nor WD. WD factors (sickness absence (SA) and disability pension (DP)) were explored as potential modifiers and mediators.

RESULTS

In both Swedish-born and refugees, SA and DP were associated with an elevated risk of suicide attempt regardless of MD. In refugees, HRs for suicide attempt in long-term SA ranged from 2.96 (95% CI: 2.14-4.09) (no MD) to 6.23 (95% CI: 3.21-12.08) (MD). Similar associations were observed in Swedish-born. Elevated suicide attempt risks were also observed in DP. In Swedish-born individuals, there was a synergy effect between MD, and SA and DP regarding suicidal behavior. Both SA and DP were found to mediate the studied associations in Swedish-born, but not in refugees.

CONCLUSION

There is an effect modification and a mediating effect between mental disorders and WD for subsequent suicidal behavior in Swedish-born individuals. Also for refugees without MD, WD is a risk factor for subsequent suicidal behavior. Particularly for Swedish-born individuals with MD, information on WD is vital in a clinical suicide risk assessment.

Postpartum self-inflicted injury, suicide, assault and homicide in relation to immigrant status in Ontario: a retrospective population-based cohort study

BACKGROUND

Intentional injury, including suicide and assault, is a leading cause of maternal morbidity and mortality. We aimed to determine whether immigrant and nonimmigrant women differ in their 1-year risk of intentional injury after birth.

METHODS

This population-based retrospective cohort study used administrative data from Ontario from 2002 to 2012. Risk of self-inflicted injury (self-harm or suicide), and injury inflicted by others (assault or homicide), were each analyzed within 1 year after delivery of a live-born infant for immigrant and nonimmigrant mothers. Relative risks (RRs) were adjusted for maternal age, parity, income, resource utilization and psychiatric history.

RESULTS

The study included 327 279 immigrant and 942 502 nonimmigrant mothers. Risk of self-inflicted injury was similar among immigrants and nonimmigrants (adjusted RR 0.91, 95% confidence interval [CI] 0.78-1.04), with no variation by duration of residence or refugee status. Immigrants were at lower risk than nonimmigrants for injury inflicted by others (adjusted RR 0.57, 95% CI 0.51-0.64); that risk was higher among refugees than among nonrefugee immigrants (adjusted RR 1.79, 95% CI 1.33-2.41), and it was higher among long-term (adjusted RR 2.27, 95% CI 1.76-2.91) and medium-term (adjusted RR 1.58, 95% CI 1.19-2.11) immigrants than among recent immigrants. Variability by country of origin was observed for both injury types.

INTERPRETATION

Immigrant mothers have a reported risk for self-inflicted injury after birth similar to that of their Canadian-born counterparts. The extent to which selective underreporting of intentional injury in immigrant women might explain our findings is a key consideration for future research.

Minorities and foreign born are disproportionately affected by injuries due to violence: an analysis based on a National Trauma Registry 2008-2017

BACKGROUND

Populations of different ethnicity and country of origin living in the same country may possess particular features of violence-related injuries. This study aims to compare violence-related injury characteristics and circumstances, hospital resource utilization and in-hospital mortality among the major ethnic groups in Israel.

METHODS

A study based on the Israeli National Trauma Registry database of patients hospitalized due to violence-related injuries between 2008 and 2017. Data included demographic, injury and hospitalization characteristics and in-hospital mortality. Statistical analysis included χ²-test and multiple logistic regression.

RESULTS

During the study period, 16,151 violence related-hospitalizations were reported, of which; 46.1% were Arab Israelis (AI), 3.2% were Israelis born in Ethiopia (IBE), 12.7% were Israelis born in the former Soviet Union (IBFSU) and 38.0% were all other Israelis (AOI). The proportion of violence-related hospitalizations among AI, IBE and IBFSU was greater than their respective proportion in the Israeli population. In comparison to the other groups, stab injuries were significantly greater among IBE (30% vs 39%); unarmed brawl-related injuries were greater among IBFSU (22-41% vs 49%) and firearm injuries were greatest among AI (2-8% vs 23%). These differences in violence mechanism persisted even after accounting for age, gender, injury place and time differences. The foreign born groups had higher rates for injuries sustained on the street/road (58% for IBE, 54% for IBFSU vs 46% for AI and AOI, each), with IBE also showing higher rates for weekend and weeknight injuries compared to the other groups (83% vs 71-75%). IBE were more likely to suffer from severe and critical injuries (19% vs 12-16%), to be admitted to the intensive care unit (17% vs 9-11%) and to have prolonged hospital stays of seven days or more (20% vs 16-17%), with no significant difference in in-hospital mortality between the comparison groups.

CONCLUSIONS

Characteristics of violence-related casualties differed significantly among diverse ethnic populations living in the same country. Each population group showed specific attributes regarding injury mechanism, circumstances, severity and hospital utilization. Violence prevention programs should be culturally adapted and take into account ethnicity and country of origin of the target population.

Pathways to and Results of Psychiatric Consultation for Patients Referred from the Emergency Department. Are there Differences between Migrant and Native Patients?

The aim of this study was to compare migrants and native Italians on the pathways to care and results of psychiatric consultation (PC) in the emergency department (ED). Patients who were referred from the ED for psychiatric consultation (EDPC) at the Maggiore della Carità Hospital between March 2008 and March 2015 were recruited consecutively. Socio-demographic, clinical and consultation variables were recorded along with information about suicidal behaviours; migrants ( n = 379; 42.74% males, 57.26% females; age: 45.38 ± 16.95 years) were compared with native Italians ( n = 2942; 43.51% males, 56.49% females; age: 42.08 ± 15.89 years). Migrants were younger, more likely to be unemployed and less likely to be already under the care of a psychiatrist. Symptoms related to use of alcohol or substances were more frequent in migrants, especially female migrants. Migrants were less likely than native Italians to be referred for PC because of the presence of psychiatric symptoms, however they were more likely to be referred because of self-harming behaviour. Nonetheless, migrant status was not identified as a risk factor for suicidal behaviour in the multivariate analysis. The outcome of EDPC showed differences between migrants and natives. In absolute terms migrants were less likely to be admitted to a psychiatric ward after the EDPC than native Italians, while they were more likely to be monitored in the ED before being discharged or referred to outpatient care. In a high percentage of psychiatric examinations of migrants, no psychiatric symptoms were identified. Further studies are warranted to disentangle the meaning of these findings.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study

BACKGROUND

Unintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.

METHODS

Population-based, cross-sectional study of children and youth (0-24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.

RESULTS

There were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).

INTERPRETATION

The observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

The shrinking health advantage: unintentional injuries among children and youth from immigrant families

BACKGROUND

Immigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury.

METHODS

Population-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0-5 years, intermediate: 6-10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries.

RESULTS

999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants.

CONCLUSIONS

Risk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development.

Characteristics and circumstances of injuries vary with ethnicity of different population groups living in the same country

OBJECTIVE

To examine whether characteristics and circumstances of injuries are related to ethnicity.

DESIGN

The study was based on the Israeli National Trauma Registry data for patients hospitalized between 2008 and 2011. Data included demographics, injury, hospital resource utilization characteristics and outcome at discharge. Univariate analysis followed by logistic regression models were undertaken to examine the relationship between injury and ethnicity.

RESULTS

The study included 116,946 subjects; 1% were Ethiopian Born Israelis (EBI), 11% Israelis born in the Former Soviet Union (FSUBI) and 88% the remaining Israelis (RI). EBI were injured more on street or at work place and had higher rates of penetrating and severe injuries. However, FSUBI were mostly injured at home, and had higher rates of fall injuries and hip fracture. Adjusted analysis showed that EBI and FSUBI were more likely to be hospitalized because of violence-related injuries compared with RI but less likely because of road traffic injuries. Undergoing surgery and referral for rehabilitation were greater among FSUBI, while admission to intensive care unit was greater among EBI.

CONCLUSION

Targeted intervention programmes need to be developed for immigrants of different countries of origin in accordance with the identified characteristics.

Remigration of migrants with severe disease: myth or reality?--a register-based cohort study

BACKGROUND

'Remigration bias' is often referred to when explaining low mortality outcomes among migrants compared with local-born. The hypothesis suggests that severely ill migrants tend to return to their country of origin, but it has hitherto not been tested in a large-scale epidemiological study. Consequently, we studied whether migrants with severe disease were more likely to emigrate compared with migrants without severe disease.

METHODS

A historic prospective cohort study was conducted based on all adult refugees and family reunification immigrants (n = 114,331) who obtained residence permission in Denmark between 1 January 1993 and 31 December 2010. Migrants with severe disease were identified through the Danish National Patient Register. Emigrations during follow-up (1 January 1993 to 31 December 2011) were identified using the Danish Civil Registration System. Hazard ratios were calculated for emigration among migrants with different levels of disease severity, adjusting for sex, age and income.

RESULTS

Results showed progressively fewer emigrations with increasing disease severity. Migrants with low (HR = 0.92; 95% CI: 0.80-1.06), moderate (HR = 0.84; 95% CI: 0.67-1.06) and high (HR = 0.70; 95% CI: 0.55-0.90) disease severity had fewer emigrations to 'country of origin' compared with migrants without disease. For emigration to 'any country', results likewise showed fewer emigrations among migrants with low (HR = 0.86; 95% CI: 0.78-0.95), moderate (HR = 0.73; 95% CI: 0.62-0.87) and high (HR = 0.64; 95% CI: 0.53-0.76) disease severity. This tendency was also observed by nationality and migrant status. On the disease-specific level, no uniform tendencies in emigration patterns were identified.

CONCLUSION

The results do not generally support the hypothesis of 'remigration bias' but rather suggest the opposite. Accordingly, remigration bias does not appear to explain lower mortality of migrants.

Suicide among immigrants in Europe--a systematic literature review

BACKGROUND

Concerns about increased suicide risk among immigrants to European countries have been raised. We review the scientific literature on differences in suicide among immigrants compared with the majority populations in Europe's major immigration countries.

METHODS

We searched the databases PubMed and PsycINFO for peer-reviewed epidemiological studies published in 1990-2011, which compared suicide risks of adult immigrant groups with the risks of the majority population in European countries. Hits were screened by two researchers.

RESULTS

We included 24 studies in the review. No generalizable pattern of suicide among immigrants was found. Immigrants from countries in which suicide risks are particularly high, i.e. countries in Northern and Eastern Europe, experienced higher suicide rates relative to groups without migration background. Gender and age differences were observed. Young female immigrants from Turkey, East Africa and South Asia are a risk group.

CONCLUSION

Immigrants 'bring along' their suicide risk, at least for the initial period they spend in the immigration country. Health-care planners and providers need to be aware of this 'imported risks'. However, most immigrant groups do not have an increased suicide risk relative to the local-born population; some may even experience substantially lower risks.