COVID-19 mortality among immigrants by duration of residence in Sweden: a population-based cohort study

BACKGROUND

Explanations for the disproportional COVID-19 burden among immigrants relative to host-country natives include differential exposure to the virus and susceptibility due to poor health conditions. Prior to the pandemic, immigrants displayed deteriorating health with duration of residence that may be associated with increased susceptibility over time. The aim of this study was to compare immigrant-native COVID-19 mortality by immigrants' duration of residence to examine the role of differential susceptibility.

METHODS

A population-based cohort study was conducted with individuals between 18 and 100 years old registered in Sweden between 1 January 2015 and 15 June 2022. Cox regression models were run to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Inequalities in COVID-19 mortality between immigrants and the Swedish-born population in the working-age group were concentrated among those of non-Western origins and from Finland with more than 15 years in Sweden, while for those of retirement age, these groups showed higher COVID-19 mortality HRs regardless of duration of residence. Both age groups of immigrants from Africa and the Middle East showed consistently higher COVID-19 mortality HRs. For the working-age population: Africa: HR<15: 2.46, 95%CI: 1.78, 3.38; HR≥15: 1.49, 95%CI: 1.01, 2.19; and from the Middle East: HR<15: 1.20, 95%CI: 0.90, 1.60; HR≥15: 1.65, 95%CI: 1.32, 2.05. For the retirement-age population: Africa: HR<15: 3.94, 95%CI: 2.85, 5.44; HR≥15: 1.66, 95%CI: 1.32, 2.09; Middle East: HR<15: 3.27, 95%CI: 2.70, 3.97; HR≥15: 2.12, 95%CI: 1.91, 2.34.

CONCLUSIONS

Differential exposure, as opposed to differential susceptibility, likely accounted for the higher COVID-19 mortality observed among those origins who were disproportionately affected by the pandemic in Sweden.

Social inequalities in the risk of giving birth to a small for gestational age child in Sweden 2010-16: a cross-sectional study adopting an intersectional approach

BACKGROUND

Well-established associations exist between the risk of small for gestational age (SGA) and unidimensional sociodemographic factors. We investigated social inequalities in SGA risk and adopted an intersectional approach that simultaneously considers different social categories. By doing so, we could assess heterogeneities in SGA risk within unidimensional sociodemographic categories.

METHODS

We included all live 679 694 singleton births in Sweden between 2010 and 2016. The outcome was SGA, and the exposures were age, maternal educational level, dichotomous migration status and civil status. Thirty-six possible combinations of these factors constituted the exposure in an intersectional model. We present odds ratios (ORs) with 95% confidence intervals (95% CIs) and the area under the receiver operating characteristic curve (AUC)-a measurement of discriminatory accuracy (i.e. the ability to discriminate the babies born SGA from those who are not).

RESULTS

Women with low education and women born outside Sweden had ORs of 1.46 (95% CI 1.38-1.54) and 1.50 (95% CI 1.43-1.56) in unidimensional analyses, respectively. Among women aged under 25 with low education who were born outside Sweden and unmarried, the highest OR was 3.06 (2.59-3.63). The discriminatory accuracy was low for both the unidimensional model that included all sociodemographic factors (AUC 0. 563) and the intersectional model (AUC 0.571).

CONCLUSIONS

The intersectional approach revealed a complex sociodemographic pattern of SGA risk. Sociodemographic factors have a low accuracy in identifying SGA at the individual level, even when quantifying their multi-dimensional intersections. This cautions against interventions targeted to individuals belonging to socially defined groups to reduce social inequalities in SGA risk.

Risk of long COVID and associated symptoms after acute SARS-COV-2 infection in ethnic minorities: A nationwide register-linked cohort study in Denmark

BACKGROUND

Ethnic minorities living in high-income countries have been disproportionately affected by Coronavirus Disease 2019 (COVID-19) in terms of infection rates, hospitalisations, and deaths; however, less is known about long COVID in these populations. Our aim was to examine the risk of long COVID and associated symptoms among ethnic minorities.

METHODS AND FINDINGS

We used nationwide register-based cohort data on individuals diagnosed with COVID-19 aged ≥18 years (n = 2,287,175) between January 2020 and August 2022 in Denmark. We calculated the risk of long COVID diagnosis and long COVID symptoms among ethnic minorities compared with native Danes using multivariable Cox proportional hazard regression and logistic regression, respectively. Among individuals who were first time diagnosed with COVID-19 during the study period, 39,876 (1.7%) were hospitalised and 2,247,299 (98.3%) were nonhospitalised individuals. Of the diagnosed COVID-19 cases, 1,952,021 (85.3%) were native Danes and 335,154 (14.7%) were ethnic minorities. After adjustment for age, sex, civil status, education, family income, and Charlson comorbidity index, ethnic minorities from North Africa (adjusted hazard ratio [aHR] 1.41, 95% confidence interval [CI] [1.12,1.79], p = 0.003), Middle East (aHR 1.38, 95% CI [1.24,1.55], p < 0.001), Eastern Europe (aHR 1.35, 95% CI [1.22,1.49], p < 0.001), and Asia (aHR 1.23, 95% CI [1.09,1.40], p = 0.001) had significantly greater risk of long COVID diagnosis than native Danes. In the analysis by largest countries of origin, the greater risks of long COVID diagnosis were found in people of Iraqi origin (aHR 1.56, 95% CI [1.30,1.88], p < 0.001), people of Turkish origin (aHR 1.42, 95% CI [1.24,1.63], p < 0.001), and people of Somali origin (aHR 1.42, 95% CI [1.07,1.91], p = 0.016). A significant factor associated with an increased risk of long COVID diagnosis was COVID-19 hospitalisation. The risk of long COVID diagnosis among ethnic minorities was more pronounced between January 2020 and June 2021. Furthermore, the odds of reporting cardiopulmonary symptoms (including dyspnoea, cough, and chest pain) and any long COVID symptoms were higher among people of North African, Middle Eastern, Eastern European, and Asian origins than among native Danes in both unadjusted and adjusted models. Despite including the nationwide sample of individuals diagnosed with COVID-19, the precision of our estimates on long COVID was limited to the sample of patients with symptoms who had contacted the hospital.

CONCLUSIONS

Belonging to an ethnic minority group was significantly associated with an increased risk of long COVID, indicating the need to better understand long COVID drivers and address care and treatment strategies in these populations.

Inequalities in COVID-19 severe morbidity and mortality by country of birth in Sweden

Migrants have been more affected by the COVID-19 pandemic. Whether this has varied over the course of the pandemic remains unknown. We examined how inequalities in intensive care unit (ICU) admission and death related to COVID-19 by country of birth have evolved over the course of the pandemic, while considering the contribution of social conditions and vaccination uptake. A population-based cohort study was conducted including adults living in Sweden between March 1, 2020 and June 1, 2022 (n = 7,870,441). Poisson regressions found that migrants from Africa, Middle East, Asia and European countries without EU28/EEA, UK and Switzerland had higher risk of COVID-19 mortality and ICU admission than Swedish-born. High risks of COVID-19 ICU admission was also found in migrants from South America. Inequalities were generally reduced through subsequent waves of the pandemic. In many migrant groups socioeconomic status and living conditions contributed to the disparities while vaccination campaigns were decisive when such became available.

Differences in incidence, nature of symptoms, and duration of long COVID among hospitalised migrant and non-migrant patients in the Netherlands: a retrospective cohort study

Background

Comprehensive data on long COVID across ethnic and migrant groups are lacking. We investigated incidence, nature of symptoms, clinical predictors, and duration of long COVID among COVID-19 hospitalised patients in the Netherlands by migration background (Dutch, Turkish, Moroccan, and Surinamese origin, Others).

Methods

We used COVID-19 admissions and follow up data (January 2021-July 2022) from Amsterdam University Medical Centers. We calculated long COVID incidence proportions per NICE guidelines by migration background and assessed for clinical predictors via robust Poisson regressions. We then examined associations between migration background and long COVID using robust Poisson regressions and adjusted for derived clinical predictors, and other biologically relevant factors. We also assessed long COVID symptom persistence at one-year post-discharge.

Findings

1886 patients were included. 483 patients had long COVID (26%, 95% CI 24-28%) at 12 weeks post-discharge. Symptoms like dizziness, joint pain, insomnia, and headache varied by migration background. Clinical predictors of long COVID were female sex, hospital admission duration, intensive care unit admission, and receiving oxygen, or corticosteroid therapy. Long COVID risk was higher among patients with migration background than Dutch origin patients after adjustments for derived clinical predictors, age, smoking, vaccination status, comorbidities and remdesivir treatment. Only 14% of long COVID symptoms persisted at one-year post-discharge.

Interpretation

There are significant differences in occurrence, nature of symptoms, and duration of long COVID by migration background. Studies assessing the spectrum of functional limitation and access to post-COVID healthcare are needed to help plan for appropriate and accessible healthcare interventions.

Funding

The Amsterdam UMC COVID-19 biobank is supported by the Amsterdam UMC Corona Research Fund and the Talud Foundation (Stichting Talud). The current analyses were supported by the Novo Nordisk Foundation [NNF21OC0067528].

Parental death and initiation of antidepressant treatment in surviving children and youth: a national register-based matched cohort study

Background

Population-based longitudinal studies on bereaved children and youth's mental health care use are scarce and few have assessed the role of surviving parents' mental health status.

Methods

Using register data of individuals born in Sweden in 1992-1999, we performed a matched cohort study (n = 117,518) on the association between parental death and subsequent initiation of antidepressant treatment among individuals bereaved at ages 7-24 years. We used flexible parametric survival models to estimate the hazard ratios (HRs) over time after bereavement, adjusting for individual and parental factors. We further examined if the association varied by age at loss, sex, parental sociodemographic factors, cause of death, and the surviving parents' psychiatric care.

Findings

The bereaved were more likely to initiate antidepressants treatment than the nonbereaved matched individuals during follow-up (incidence rate per 1000 person years 27.5 [26.5-28.5] vs. 18.2 [17.9-18.6]). The HRs peaked in the first year after bereavement and remained higher than the nonbereaved individuals until the end of the follow-up. The average HR over the 12 years of follow-up was 1.48 (95% confidence interval [1.39-1.58]) for father's death and 1.33 [1.22-1.46] for mother's death. The HRs were particularly high when the surviving parents received psychiatric care before bereavement (2.11 [1.89-2.56] for father's death; 2.14 [1.79-2.56] for mother's death) or treated for anxiety or depression after bereavement (1.80 [1.67-1.94]; 1.82 [1.59-2.07]).

Interpretation

The risk of initiating antidepressant treatment was the highest in the first year after parental death and remained elevated over the next decade. The risk was particularly high among individuals with surviving parents affected by psychiatric morbidity.

Funding

The Swedish Research Council.

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.

Suicide Around the Anniversary of a Parent's Death in Sweden

Importance

Bereavement following parental death experienced in adulthood may be associated with suicide over many years, but this risk has received scant attention.

Objective

To investigate whether the risk of suicide increases among adult children around the anniversary of a parent's death.

Design, Setting, and Participants

This case-crossover study used Swedish register-based longitudinal data from 1990 to 2016, based on the entire national population. Participants included all adults aged 18 to 65 years who experienced parental death and subsequently died by suicide. Conditional logistic regression was used to quantify the association between the anniversary (or preanniversary and postanniversary periods) and suicide, controlling for time-invariant confounding. All analyses were stratified by sex of the offspring. The analyses were also stratified by the sex of the deceased parent, time since parental death, age, and marital status. Data analyses were performed in June 2022.

Exposures

Anniversary of a parent's death (or preanniversary and postanniversary periods).

Main Outcomes and Measures

Suicide.

Results

Of 7694 individuals who died by suicide (76% intentional self-harm), 2255 (29%) were women, and the median (IQR) age at suicide was 55 (47-62) years. There was evidence of an anniversary reaction among women, with a 67% increase in the odds of suicide when exposed to the period from the anniversary to 2 days after the anniversary, compared with when not being exposed (odds ratio [OR], 1.67; 95% CI, 1.07-2.62). The risk was particularly pronounced among maternally bereaved women (OR, 2.29; 95% CI, 1.20-4.40) and women who were never married (OR, 2.08; 95% CI, 0.99-4.37), although the latter was not statistically significant. An increased risk of suicide from the day before up to the anniversary was observed among women bereaved between the ages of 18 and 34 years (OR, 3.46; 95% CI, 1.14-10.56) and between the ages of 50 and 65 years (OR, 2.53; 95% CI, 1.04-6.15). Men had an attenuated suicide risk for the period from the day before up to the anniversary (OR, 0.57; 95% CI, 0.36-0.92).

Conclusions and Relevance

These findings suggest that the anniversary of a parent's death is associated with an increased suicide risk among women. Women bereaved at younger or older ages, those who were maternally bereaved, and those who never married appeared to be particularly vulnerable. Families and social and health care professionals need to consider anniversary reactions in suicide prevention.

Caregiving and changes in health-related behaviour

Potential health risks for informal caregivers have been hypothesised to be partly related to adverse changes in health-related behaviour, but evidence is limited. We examined whether smoking, drinking, eating, physical activity or leisure pursuits change in relation to co-resident or out-of-home caregiving (for someone outside the household), and if associations differ by sex, educational attainment, and welfare state typology. We conducted a longitudinal study using six waves of the Survey of Health, Ageing and Retirement in Europe, collecting data repeatedly from 2004 to 2017 for adults aged 50 years and older living in 17 European countries (57,962 individuals). To control for measured and unmeasured within-individual time-invariant confounders, we used fixed effects logistic models to analyse the repeated measures of caregiving, behaviour and covariates and estimated odds ratios (OR) with 95% confidence intervals (95%CI). Among male participants, unhealthy eating increased while smoking decreased [ORs 1.26 (95%CI 1.01-1.58) and 0.53 (0.36-0.78), respectively] in survey waves in which they provided co-resident care, compared with the waves that they did not. Among female participants, there was little change in behaviour between waves with and without co-resident caregiving. When providing out-of-home care, lacks of physical activity and leisure pursuits declined. But in the same time, drinking increased both men and women, and especially among individuals with lower educational attainment and residing in non-Nordic countries. To conclude, overall, increased drinking when providing out-of-home care was most consistent, especially among individuals with lower educational attainment and residing in non-Nordic countries. Otherwise, the associations varied by the type of care, behaviour and population subgroups. These findings indicated that not all caregivers are susceptible to behavioural changes, and that not all behaviour may be involved similarly in linking caregiving to health risks. This opens possibilities to target specific behaviour and groups to prevent adverse changes in health behaviour in caregivers.

Differences in hospitalizations associated with severe COVID-19 disease among foreign- and Swedish-born

BACKGROUND

Differences in pre-existing health conditions are hypothesized to explain immigrants' excess COVID-19 mortality compared to natives. In this study, we evaluate whether immigrants residing in Sweden before the outbreak were more likely to be hospitalized for conditions associated with severe COVID-19 disease.

METHODS

A cohort study using population-register data was conducted with follow-up between 1 January 1997 and 31 December 2017. Poisson regression was fitted to estimate incidence rate ratio (RR) and 95% confident intervals (95% CI) for 10 causes of hospitalization.

RESULTS

Compared to Swedish-born individuals, most immigrant groups showed a decreased risk of hospitalization for respiratory chronic conditions, CVD, cancer, chronic liver conditions and neurological problems. All immigrant groups had increased risk of hospitalization for tuberculosis [RR between 88.49 (95% CI 77.21; 101.40) for the Horn of Africa and 1.69 (95% CI 1.11; 2.58) for North America], HIV [RR between 33.23 (95% CI 25.17; 43.88) for the rest of Africa and 1.31 (95% CI 0.93; 1.83) for the Middle East] and, with a few exceptions, also for chronic kidney conditions, diabetes and thalassemia.

CONCLUSIONS

Foreign-born individuals-including origins with excess COVID-19 mortality in Sweden-did not show increased risk of hospitalizations for most causes associated with severe COVID-19 disease. However, all groups showed increased risks of hospitalization for tuberculosis and HIV and, with exceptions, for chronic kidney conditions, diabetes and thalassemia. Although studies should determine whether these health conditions explain the observed excess COVID-19 mortality, our study alerts to an increased risk of hospitalization that can be avoidable via treatment or preventive measures.

Bereavement in childhood and young adulthood and the risk of atrial fibrillation: a population-based cohort study from Denmark and Sweden

BACKGROUND

Adverse childhood life events are associated with increased risks of hypertension, ischemic heart disease, and stroke later in life. Limited evidence also suggests that stress in adulthood may increase the risk of atrial fibrillation (AF). Whether childhood adversity may lead to the development of AF is unknown. We investigated whether the loss of a parent or sibling in childhood is associated with an increased risk of AF and compared this effect to that of similar losses in young adulthood.

METHODS

We studied 6,394,975 live-born individuals included in the Danish (1973-2018) and Swedish Medical Birth Registers (1973-2014). We linked data from several national registers to obtain information on the death of parents and siblings and on personal and familial sociodemographic and health-related factors. We analyzed the association between bereavement and AF using Poisson regression.

RESULTS

Loss of a parent or sibling was associated with an increased AF risk both when the loss occurred in childhood and in adulthood; the adjusted incident rate ratios and 95% confidence intervals were 1.24 (1.14-1.35) and 1.24 (1.16-1.33), respectively. Bereavement in childhood was associated with AF only if losses were due to cardiovascular diseases or other natural causes, while loss in adulthood was associated with AF not only in case of natural deaths, but also unnatural deaths. The associations did not differ substantially according to age at loss and whether the deceased was a parent or a sibling.

CONCLUSIONS

Bereavement both in childhood and in adulthood was associated with an increased AF risk.

Mental health by native–immigrant intermarriage in Sweden: a register-based retrospective cohort study

Background

Native–immigrant intermarriage is often regarded as a proxy for integration, given that intermarried immigrants are more socioeconomically and culturally similar to natives than intramarried immigrants. This study aimed to assess whether integration affects mental health and care-seeking behaviours, examining prescription hazards for psychotropic medications by native–immigrant marital composition in Sweden.

Methods

Total population register data were used to identify first-time married couples residing in Sweden between 31 December 2005 and 31 December 2016. Index persons were distinguished by gender and partners’ origin (native vs. immigrant), as well as by immigrants’ regions of origin, with intramarried natives as references. Using Cox regression, hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated for antidepressant and anxiolytic prescriptions and adjusted for socioeconomic factors, presence of children and length and quality of marriage.

Results

Intramarried immigrant women had higher psychotropic prescription hazards than intramarried native references (HR 1.11, 95% CI 1.10–1.12), whereas intermarried immigrant women had equal hazards. Immigrant women’s hazards were lower than native references after adjustment. Intramarried immigrant men had the greatest prescription hazards (HR 1.33, 95% CI 1.32–1.34), and intermarried immigrant men slightly higher hazards (HR 1.11, 95% CI 1.10–1.13), than intramarried natives. All were partly attenuated after adjustment. Intermarriage hazards increased by similarities in regions of origin, especially among men.

Conclusions

Integration indicated by intermarriage appears to be protective for the mental health of immigrants, especially for immigrant men. Future research should empirically disentangle the social, cultural and socioeconomic mechanisms underlying these health differences.

Bereavement and Prognosis in Heart Failure: A Swedish Cohort Study

BACKGROUND

The role of stress in the prognosis of heart failure (HF) is unclear. This study investigated whether the death of a close family member, a severe source of stress, is associated with mortality in HF.

OBJECTIVES

This study assessed whether the death of a close family member is associated with mortality in HF.

METHODS

Patients from the Swedish Heart Failure Registry during 2000-2018 and/or in the Swedish Patient Register with a primary diagnosis of HF during 1987-2018 (N = 490,527) were included in this study. Information was obtained on death of family members (children, partner, grandchildren, siblings, and parents), mortality, sociodemographic variables, and health-related factors from several population-based registers. The association between bereavement and mortality was analyzed by using Poisson regression.

RESULTS

Loss of a family member was associated with an increased risk of dying (adjusted relative risk: 1.29; 95% CI: 1.27-1.30). The association was present not only in case of the family member's cardiovascular deaths and other natural deaths but also in case of unnatural deaths. The risk was higher for 2 losses than for 1 loss and highest in the first week after the loss. The association between bereavement and an increased mortality risk was observed for the death of a child, spouse/partner, grandchild, and sibling but not of a parent.

CONCLUSIONS

Death of a family member was associated with an increased risk of mortality among patients with HF. Further studies are needed to investigate whether less severe sources of stress can also contribute to poor prognosis in HF and to explore the mechanisms underlying this association.

Health Risk Behaviours by Immigrants’ Duration of Residence: A Systematic Review and Meta-Analysis

Objectives: The aim was to systematically review and synthesise international evidence on changes in health risk behaviours by immigrants’ duration of residence.

Methods: We searched literature databases for peer-reviewed quantitative studies published from 2000 to 2019, examining alcohol, drug and tobacco use; physical inactivity; and dietary habits by duration of residence.

Results: Narrative synthesis indicated that immigrants tend to adopt health risk behaviours with longer residence in North America, with larger variation in effect sizes and directionality in other contexts. Random-effects meta-analyses examining the pooled effect across all receiving countries and immigrant groups showed lower odds of smoking (OR 0.54, 0.46–0.63, I² = 68.7%) and alcohol use (OR 0.61, 0.47–0.75, I² = 93.5%) and higher odds of physical inactivity (OR 1.71, 1.40–2.02, I² = 99.1%) among immigrants than natives, but did not provide support for a universal trend by duration of residence.

Conclusion: Findings suggest that duration of residence could serve as an effective instrument to monitor immigrants’ health changes. However, differences in receiving country contexts and immigrant populations’ composition seem to be important to predict the level and direction of behavioural change.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, PROSPERO CRD42018108881.

Death of a Parent and the Risk of Ischemic Heart Disease and Stroke in Denmark and Sweden

IMPORTANCE

Increasing evidence suggests that parental death is associated with unhealthy behaviors and mental ill-health. Knowledge regarding the link between parental death and the risk of ischemic heart disease (IHD) and stroke remains limited.

OBJECTIVES

To investigate whether parental death is associated with an increased risk of IHD and stroke and whether these associations differ by the characteristics of the loss.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study, involving linkages between several nationwide registers, included 3 766 918 individuals born between 1973 and 1998 in Denmark and between 1973 and 1996 in Sweden. Participants were followed up until 2016 in Denmark and 2014 in Sweden. Data were analyzed from December 2019 to May 2021.

EXPOSURES

Death of a parent.

MAIN OUTCOMES AND MEASURES

Diagnosis with or death due to IHD or stroke. Poisson regression was used to analyze the associations between parental death and IHD and stroke risk.

RESULTS

Altogether, 48.8% of the participants were women, and 42.7% were from Denmark. A total of 523 496 individuals lost a parent during the study period (median age at loss, 25 years; IQR, 17-32 years). Parental death was associated with a 41% increased risk of IHD (incidence rate ratio [IRR], 1.41; 95% CI, 1.33-1.51) and a 30% increased risk of stroke [IRR, 1.30; 95% CI, 1.21-1.38). The associations were observed not only if the parent died because of cardiovascular or other natural causes but also in cases of unnatural deaths. The associations were stronger when both parents had died (IHD: IRR, 1.87; 95% CI, 1.59-2.21; stroke: IRR, 1.64; 95% CI, 1.35-1.98) than when 1 parent had died (IHD: IRR, 1.37; 95% CI, 1.28-1.47; stroke: IRR, 1.27; 95% CI, 1.19-1.36) but did not differ substantially by the offspring's age at loss or the deceased parents' sex. The risk of acute myocardial infarction was highest in the first 3 months after loss.

CONCLUSIONS AND RELEVANCE

In this cohort study, parental death in the first decades of life was associated with an increased risk of IHD and stroke. The associations were observed not only in cases of parental cardiovascular and other natural deaths but also in cases of unnatural deaths. Family members and health professionals may need to pay attention to the cardiovascular disease risk among parentally bereaved individuals.

School Outcomes Among Children Following Death of a Parent

IMPORTANCE

To better support children with the experience of parental death, it is crucial to understand whether parental death increases the risk of adverse school outcomes.

OBJECTIVES

To examine whether parental death is associated with poorer school outcomes independent of factors unique to the family, and whether children of certain ages are particularly vulnerable to parental death.

DESIGN, SETTING, AND PARTICIPANTS

This population-based sibling cohort study used Swedish national register-based longitudinal data with linkage between family members. Register data were collected from January 1, 1990, to December 31, 2016. Data analyses were performed on July 14, 2021. The participants were all children born between 1991 and 2000 who lived in Sweden before turning age 17 years (N = 908 064).

EXPOSURE

Parental death before finishing compulsory school.

MAIN OUTCOMES AND MEASURES

Mean school grades (year-specific z scores) and ineligibility for upper secondary education on finishing compulsory school at age 15 to 16 years. Population-based cohort analyses were conducted to examine the association between parental death and school outcomes using conventional linear and Poisson regression models, after adjustment for demographic and parental socioeconomic and health indicators measured before childbirth. Second, using fixed-effect linear and Poisson regression models, children who experienced parental death before finishing compulsory school were compared with their siblings who experienced the death after. Third, the study explored the age-specific associations between parental death and school outcomes.

RESULTS

In the conventional population-based analyses, bereaved children (N = 22 634; 11 553 boys [51.0%]; 11 081 girls [49.0%]; mean [SD] age, 21.0 [2.8] years) had lower mean school grade z scores (adjusted β coefficient, -0.19; 95% CI, -0.21 to -0.18; P < .001) and a higher risk of ineligibility for upper secondary education than the nonbereaved children (adjusted risk ratio, 1.36; 95% CI, 1.32-1.41; P < .001). Within-sibling comparisons using fixed-effects models showed that experiencing parental death before finishing compulsory school was associated with lower mean school grade z scores (-0.06; 95% CI, -0.10 to -0.01; P = .02) but not with ineligibility for upper secondary education (adjusted risk ratio, 1.07; 95% CI, 0.93-1.23; P = .34). Independent of birth order, losing a parent at a younger age was associated with lower grades within a family.

CONCLUSIONS AND RELEVANCE

In this cohort study, childhood parental death was associated with lower school grades after adjustment for familial confounders shared between siblings. Children who lost a parent may benefit from additional educational support that could reduce the risk of adverse socioeconomic trajectories later in life.

Psychosocial and environmental determinants of physical activity in a Brazilian public university employees - ELDAF: A prospective cohort study protocol

Background

Increased physical activity levels and their determinations are essential issues worldwide. The Longitudinal Study of Physical Activity Determinants (ELDAF) aims to understand the roles of psychosocial and environmental factors in workers’ physical activity levels.

Methods

A prospective cohort study of non-faculty civil servants from a public university (approximately 1,200 individuals) will start in 2022 (baseline). The primary measurements will be accelerometer- and questionnaire-based physical activity, social support, social network, socioeconomic status, bereavement, job stress, body image, common mental disorders, depression, and neighborhood satisfaction. Additional measurements will include necessary sociodemographic, physical morbidity, lifestyle and anthropometric information. Participants’ places of residence will be geocoded using complete addresses. All participants will furnish written, informed consent before the beginning of the study. Pilot studies were performed to identify and correct potential problems in the data collection instruments and procedures. ELDAF will be the first cohort study conducted in Latin America to investigate physical activity and its determinants.

Investigating the salmon bias effect among international immigrants in Sweden: a register-based open cohort study

Background

Studies of migration and health have hypothesized that immigrants may emigrate when they develop poor health (salmon bias effect), which may partially explain the mortality advantage observed among immigrants in high-income countries. We evaluated the salmon bias effect by comparing the health of immigrants in Sweden who emigrated with those who remained, while also exploring potential variation by macro-economic conditions, duration of residence and region of origin.

Methods

A longitudinal, open cohort study design was used to assess risk of emigration between 1992 and 2016 among all adult (18+ years) foreign-born persons who immigrated to Sweden between 1965 and 2012 (n = 1 765 459). The Charlson Comorbidity Index was used to measure health status, using information on hospitalizations from the Swedish National Patient Register. Poisson regression models were used to estimate incidence rate ratios (RRs) with 95% confidence intervals (CIs) for emigrating from Sweden.

Results

Immigrants with low (RR = 0.83; 95% CI: 0.76–0.90) moderate (RR = 0.70; 95% CI: 0.62–0.80) and high (RR = 0.62; 95% CI: 0.48–0.82) levels of comorbidities had decreased risk of emigration relative to those with no comorbidities. There was no evidence of variation by health status in emigration during periods of economic recession or by duration of residence. Individuals with low to moderate levels of comorbidities from some regions of origin had an increased risk of emigration relative to those with no comorbidities.

Conclusions

The study results do not support the existence of a salmon bias effect as a universal phenomenon among international immigrants in Sweden.

Ethnic Composition of Couples and Mutual Health Benefit Receipt: Register-Based Evidence from Finland

The literature on health dependencies among partners typically ignores diversity of partnership characteristics. One salient example is the ethnic composition. We extend prior work on partnerships and health by investigating how married and cohabiting partners mutually influence each other's receipt of health-related benefits, focusing on how such correlations vary with the couple's ethnic composition. We study partners' mutual receipt of sickness allowance and disability pension in ethnically endogamous and exogamous couples in Finland. The population consists of native individuals in similar socioeconomic positions but belonging to two different ethnic groups-Finnish and Swedish speakers-who differ in health and family life. Using data from population registers, we estimate discrete-time hazard models for first-time benefit receipt, as related to partner's benefit receipt, among midlife couples. We found evidence of mutual receipt of health benefits in both endogamous and exogamous couples, the correlation being strongest for disability pension. Partner correlation in disability pension receipt is slightly stronger in endogamous Swedish than in endogamous Finnish couples, while women in exogamous couples are slightly less sensitive to men's receipt than vice versa. The results show that mutual health may be heterogeneous across couples that differ in ethnic composition.

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.

Death of a Parent During Childhood and the Risk of Ischemic Heart Disease and Stroke in Adult Men

OBJECTIVE

The death of a parent during childhood is a severe life event with potentially long-term consequences. Earlier studies have shown an increased risk of cardiovascular diseases (CVD) after the death of a spouse, child, or sibling. Whether parental death during childhood is associated with an increased risk of incident CVD is unknown and was investigated in this study.

METHODS

We studied 48,992 men born 1949 to 1951 and enlisted for military conscription in 1969 to 1970. We obtained information on death of a parent during childhood, CVD up to 2008, and covariates by linking the questionnaire and the clinical examination data from conscription with nationwide socioeconomic and health registers.

RESULTS

Men who lost a parent during childhood had an increased risk of ischemic heart disease (IHD; adjusted hazard ratio (HR) and 95% confidence interval [CI] = 1.30 [1.13-1.49]) but not of stroke during the 39-year follow-up (adjusted HR [95% CI] = 0.87 [0.66-1.15]). Maternal death was associated with IHD both when the loss was due to cardiovascular (adjusted HR [95% CI] = 2.04 [1.02-4.08]) and unnatural causes (adjusted HR [95% CI] = 2.50 [1.42-4.42]); in case of paternal death, an increased IHD risk was observed only when the loss was due to cardiovascular causes (adjusted HR [95% CI] = 1.82 [1.37-2.42]). There were no substantial differences in CVD according to the child's age at the loss.

CONCLUSIONS

Parental death during childhood was associated with an increased risk of IHD in men. If these associations are confirmed in future studies, the long-term effects of childhood bereavement may warrant attention.

Institutional and behaviour-change interventions to support COVID-19 public health measures: a review by the Lancet Commission Task Force on public health measures to suppress the pandemic

The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and contextualisation, and behavioural science evidence and theory on public health interventions from a range of sources, we outline evidence for a range of institutional measures and behaviour-change measures. We cite examples of measures adopted by a range of countries, but especially jurisdictions that have, thus far, achieved low numbers of COVID-19 deaths and limited community transmission of severe acute respiratory syndrome coronavirus 2. Finally, we highlight gaps in knowledge where research should be undertaken. As countries consider long-term measures, there is an opportunity to learn, improve the response and prepare for future pandemics.

Intermarriage and COVID-19 mortality among immigrants. A population-based cohort study from Sweden

OBJECTIVES

To evaluate the role of language proficiency and institutional awareness in explaining excess COVID-19 mortality among immigrants.

DESIGN

Cohort study with follow-up between 12 March 2020 and 23 February 2021.

SETTING

Swedish register-based study on all residents in Sweden.

PARTICIPANTS

3 963 356 Swedish residents in co-residential unions who were 30 years of age or older and alive on 12 March 2020 and living in Sweden in December 2019.

OUTCOME MEASURES

Cox regression models were conducted to assess the association between different constellations of immigrant-native couples (proxy for language proficiency and institutional awareness) and COVID-19 mortality and all other causes of deaths (2019 and 2020). Models were adjusted for relevant confounders.

RESULTS

Compared with Swedish-Swedish couples (1.18 deaths per thousand person-years), both immigrants partnered with another immigrant and a native showed excess mortality for COVID-19 (HR 1.43; 95% CI 1.29 to 1.58 and HR 1.24; 95% CI 1.10 to 1.40, respectively), which translates to 1.37 and 1.28 deaths per thousand person-years. Moreover, similar results are found for natives partnered with an immigrant (HR 1.15; 95% CI 1.02 to 1.29), which translates to 1.29 deaths per thousand person-years. Further analysis shows that immigrants from both high-income and low-income and middle-income countries (LMIC) experience excess mortality also when partnered with a Swede. However, having a Swedish-born partner is only partially protective against COVID-19 mortality among immigrants from LMIC origins.

CONCLUSIONS

Language barriers and/or poor institutional awareness are not major drivers for the excess mortality from COVID-19 among immigrants. Rather, our study provides suggestive evidence that excess mortality among immigrants is explained by differential exposure to the virus.

Disparities in Coronavirus Disease 2019 Mortality by Country of Birth in Stockholm, Sweden: A Total-Population-Based Cohort Study

Preliminary evidence points to higher morbidity and mortality from coronavirus disease 2019 (COVID-19) in certain racial and ethnic groups, but population-based studies using microlevel data are lacking so far. We used register-based cohort data including all adults living in Stockholm, Sweden, between January 31, 2020 (the date of the first confirmed case of COVID-19) and May 4, 2020 (n = 1,778,670) to conduct Poisson regression analyses with region/country of birth as the exposure and underlying cause of COVID-19 death as the outcome, estimating relative risks and 95% confidence intervals. Migrants from Middle Eastern countries (relative risk (RR) = 3.2, 95% confidence interval (CI): 2.6, 3.8), Africa (RR = 3.0, 95% CI: 2.2, 4.3), and non-Sweden Nordic countries (RR = 1.5, 95% CI: 1.2, 1.8) had higher mortality from COVID-19 than persons born in Sweden. Especially high mortality risks from COVID-19 were found among persons born in Somalia, Lebanon, Syria, Turkey, Iran, and Iraq. Socioeconomic status, number of working-age household members, and neighborhood population density attenuated up to half of the increased COVID-19 mortality risks among the foreign-born. Disadvantaged socioeconomic and living conditions may increase infection rates in migrants and contribute to their higher risk of COVID-19 mortality.

Unintended health consequences of Swedish parental leave policy (ParLeHealth): protocol for a quasi-experimental study

INTRODUCTION

Sweden has long been praised for a generous parental leave policy oriented towards facilitating a gender-equitable approach to work and parenting. Yet certain aspects of Swedish parental leave could also be responsible for the maintenance of (or even the increase in) health inequalities. Using a 'Health in All Policies' lens, this research project aims to assess the unintended health consequences of various components of Sweden's parental leave policy, including eligibility for and uptake of earnings based benefits.

METHODS AND ANALYSIS

We will use individual-level data from multiple Swedish registers. Sociodemographic information, including parental leave use, will be retrieved from the total population register, Longitudinal Integration Database for Health Insurance and Labour Market Studies and Social Insurance Agency registers. Health information for parents and children will be retrieved from the patient, prescribed drug, cause of death, medical birth and children's health registers. We will evaluate parents' mental, mothers' reproductive and children's general health outcomes in relation to several policy reforms aiming to protect parental leave benefits in short birth spacing (the speed premium) and to promote father's uptake (the father's quota) and sharing of parental leave days (the double days reform). We will also examine effects of increases in basic parental leave benefit levels. Using quasi-experimental designs, we will compare health outcomes across these reforms and eligibility thresholds with interrupted time series, difference-in-difference and regression discontinuity approaches to reduce the risk of health selection and assess causality in the link between parental leave use and health.

ETHICS AND DISSEMINATION

This project has been granted all necessary ethical permissions from the Stockholm Regional Ethical Review Board (Dnr 2019-04913) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access, high-impact peer-reviewed international journals, as well as press releases and policy briefs.

Death of a parent during childhood and blood pressure in youth: a population-based cohort study of Swedish men

OBJECTIVE

Compelling evidence suggests that childhood adversities are associated with an increased risk of hypertension in middle age and old age. The link between childhood adversities and blood pressure in youth is less clear. In this cohort study, we examined the association between death of a parent during childhood and blood pressure in early adulthood in men.

SETTING

Sweden.

PARTICIPANTS

We studied 48 624 men born in 1949-1951 who participated in the compulsory military conscription in 1969/1970 in Sweden. Information on death of a parent during childhood was obtained from population-based registers. Information on covariates was obtained from the questionnaire and the clinical examination completed at conscription and from population-based registers.

OUTCOME MEASURES

Blood pressure was measured at conscription according to standard procedures.

RESULTS

The multivariable least square means of systolic and diastolic blood pressure did not differ between bereaved (128.25 (127.04-129.46) and 73.86 (72.89-74.84) mm Hg) and non-bereaved study participants (128.02 (126.86-129.18) and 73.99 (73.06-74.93) mm Hg). Results were similar when considering the cause of the parent's death, the gender of the deceased parent or the child's age at loss. Loss of a parent in childhood tended to be associated with an increased hypertension risk (OR and 95% CI: 1.10 (1 to 1.20)); the association was present only in case of natural deaths.

CONCLUSION

We found no strong support for the hypothesis that stress following the loss of a parent during childhood is associated with blood pressure or hypertension in youth in men.

Social network characteristics and alcohol use by ethnic origin: An ego-based network study on peer similarity, social relationships, and co-existing drinking habits among young Swedes

The study explores how social network determinants relate to the prevalence and frequency of alcohol use among peer dyads. It is studied how similar alcohol habits co-exist among persons (egos) and their peers (alters) when socio-demographic similarity (e.g., in ethnic origin), network composition and other socio-cultural aspects were considered. Data was ego-based responses derived from a Swedish national survey with a cohort of 23-year olds. The analytical sample included 7987 ego-alter pairs, which corresponds to 2071 individuals (egos). A so-called dyadic design was applied i.e., all components of the analysis refer to ego-alter pairs (dyads). Multilevel multinomial-models were used to analyse similarity in alcohol habits in relation to ego-alter similarity in ethnic background, religious beliefs, age, sex, risk-taking, educational level, closure in network, duration, and type of relationship, as well as interactions between ethnicity and central network characteristics. Ego-alter similarity in terms of ethnic origin, age and sex was associated with ego-alter similarity in alcohol use. That both ego and alters were non-religious and were members of closed networks also had an impact on similarity in alcohol habits. It was concluded that network similarity might be an explanation for the co-existence of alcohol use among members of peer networks.

Inequalities in all-cause and cause-specific mortality across the life course by wealth and income in Sweden: a register-based cohort study

Background

Wealth inequalities are increasing in many countries, but their relationship to health is little studied. We investigated the association between individual wealth and mortality across the adult life course in Sweden.

Methods

We studied the Swedish adult population using national registers. The amount of wealth tax paid in 1990 was the main exposure of interest and the cohort was followed up for 18 years. Relative indices of inequality (RII) summarize health inequalities across a population and were calculated for all-cause and cause-specific mortality for six different age groups, stratified by sex, using Poisson regression. Mortality inequalities by wealth were contrasted with those assessed by individual and household income. Attenuation by four other measures of socio-economic position and other covariates was investigated.

Results

Large inequalities in mortality by wealth were observed and their association with mortality remained more stable across the adult life course than inequalities by income-based measures. Men experienced greater inequalities across all ages (e.g. the RII for wealth was 2.58 [95% confidence interval (CI) 2.54–2.63) in men aged 55–64 years compared with 2.29 (95% CI 2.24–2.34) for women aged 55–64 years), except among the over 85s. Adjustment for covariates, including four other measures of socio-economic position, led to only modest reductions in the association between wealth and mortality.

Conclusions

Wealth is strongly associated with mortality throughout the adult life course, including early adulthood. Income redistribution may be insufficient to narrow health inequalities—addressing the increasingly unequal distribution of wealth in high-income countries should be considered.

Psychosocial determinants of physical activity among workers: an integrative review

Knowledge of the psychosocial determinants of physical activity is critical to informing preventive and therapeutic interventions in the workplace. This study reviewed available evidence on psychosocial factors that have been associated with physical activity among workers. Studies were selected in December 2019 from the Scopus, Web of Science, and PubMed databases, with no date limits, using the following search terms: “physical activity”, “physical exercise”, “psychosocial”, “workers”, and “working-age”. Thirty-nine studies published between 1991 and 2019 were evaluated. The determinants of physical activity investigated among workers were smoking status, stress, psychosocial working conditions, depression, anxiety, social relationships, work ability, job satisfaction, burnout, and self-efficacy. Some consistencies and controversies were observed in the associations among these determinants and physical activity and are discussed, as are suggestions for future studies. The findings of this review may be of interest to physical activity interventions designed to reduce psychosocial risks factors in work environments.

Parental death in childhood and pathways to increased mortality across the life course in Stockholm, Sweden: A cohort study

BACKGROUND

Previous studies have shown that the experience of parental death during childhood is associated with increased mortality risk. However, few studies have examined potential pathways that may explain these findings. The aim of this study is to examine whether familial and behavioural factors during adolescence and socioeconomic disadvantages in early adulthood mediate the association between loss of a parent at age 0 to 12 and all-cause mortality by the age of 63.

METHODS AND FINDINGS

A cohort study was conducted using data from the Stockholm Birth Cohort Multigenerational Study for 12,615 children born in 1953, with information covering 1953 to 2016. Familial and behavioural factors at age 13 to 19 included psychiatric and alcohol problems in the surviving parent, receipt of social assistance, and delinquent behaviour in the offspring. Socioeconomic disadvantage in early adulthood included educational attainment, occupational social class, and income at age 27 to 37. We used Cox proportional hazard regression models, combined with a multimediator analysis, to separate direct and indirect effects of parental death on all-cause mortality. Among the 12,582 offspring in the study (men 51%; women 49%), about 3% experienced the death of a parent in childhood. During follow-up from the age of 38 to 63, there were 935 deaths among offspring. Parental death was associated with an elevated risk of mortality after adjusting for demographic and household socioeconomic characteristics at birth (hazard ratio [HR]: 1.52 [95% confidence interval: 1.10 to 2.08, p-value = 0.010]). Delinquent behaviour in adolescence and income during early adulthood were the most influential mediators, and the indirect associations through these variables were HR 1.03 (1.00 to 1.06, 0.029) and HR 1.04 (1.01 to 1.07, 0.029), respectively. After accounting for these indirect paths, the direct path was attenuated to HR 1.35 (0.98 to 1.85, 0.066). The limitations of the study include that the associations may be partly due to genetic, social, and behavioural residual confounding, that statistical power was low in some of the subgroup analyses, and that there might be other relevant paths that were not investigated in the present study.

CONCLUSIONS

Our findings from this cohort study suggest that childhood parental death is associated with increased mortality and that the association was mediated through a chain of disadvantages over the life course including delinquency in adolescence and lower income during early adulthood. Professionals working with bereaved children should take the higher mortality risk in bereaved offspring into account and consider its lifelong consequences. When planning and providing support to bereaved children, it may be particularly important to be aware of their increased susceptibility to delinquency and socioeconomic vulnerability that eventually lead to higher mortality.

Economic arguments in migrant health policymaking: proposing a research agenda

Welfare states around the world restrict access to public healthcare for some migrant groups. Formal restrictions on migrants’ healthcare access are often justified with economic arguments; for example, as a means to prevent excess costs and safeguard scarce resources. However, existing studies on the economics of migrant health policies suggest that restrictive policies increase rather than decrease costs. This evidence has largely been ignored in migration debates. Amplifying the relationship between welfare state transformations and the production of inequalities, the Covid-19 pandemic may fuel exclusionary rhetoric and politics; or it may serve as an impetus to reconsider the costs that one group’s exclusion from health can entail for all members of society.

The public health community has a responsibility to promote evidence-informed health policies that are ethically and economically sound, and to counter anti-migrant and racial discrimination (whether overt or masked with economic reasoning). Toward this end, we propose a research agenda which includes 1) the generation of a comprehensive body of evidence on economic aspects of migrant health policies, 2) the clarification of the role of economic arguments in migration debates, 3) (self-)critical reflection on the ethics and politics of the production of economic evidence, 4) the introduction of evidence into migrant health policymaking processes, and 5) the endorsement of inter- and transdisciplinary approaches. With the Covid-19 pandemic and surrounding events rendering the suggested research agenda more topical than ever, we invite individuals and groups to join forces toward a (self-)critical examination of economic arguments in migration and health, and in public health generally.

Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data

BACKGROUND

Housing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults.

METHODS

For this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m2) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education.

FINDINGS

Of 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (<66 years) was associated with increased COVID-19 mortality (hazard ratio 1·6; 95% CI 1·3-2·0). Living in a care home was associated with an increased risk of COVID-19 mortality (4·1; 3·5-4·9) compared with living in independent housing. Living in neighbourhoods with the highest population density (≥5000 individuals per km2) was associated with higher COVID-19 mortality (1·7; 1·1-2·4) compared with living in the least densely populated neighbourhoods (0 to <150 individuals per km2).

INTERPRETATION

Close exposure to working-age household members and neighbours is associated with increased COVID-19 mortality among older adults. Similarly, living in a care home is associated with increased mortality, potentially through exposure to visitors and care workers, but also due to poor underlying health among care-home residents. These factors should be considered when developing strategies to protect this group.

FUNDING

Swedish Research Council for Health, Working Life and Welfare (FORTE), Swedish Foundation for Humanities and Social Sciences.

Childhood bereavement and adult mortality: A 65-year follow-up of the Stockholm birth cohort

About 3% of children in Sweden, 4-5% in the UK, and 5% in the US experience the death of a parent during childhood. The event is highly unexpected and stressful and could have long-term social and health consequences across the life course. To alleviate grief, bereaved children may engage in health-damaging behaviours such as smoking, alcohol or drug abuse, violence, delinquency and risky sexual behaviour. Few studies have been able to study health consequences by childhood parental loss and mechanisms explaining associations across the life course. Using the Stockholm Birth Cohort Study (SBC), including all children born in 1953 in the metropolitan Stockholm area, we examined whether childhood bereavement is associated with all-cause mortality until age 63 and whether various pathways (e.g. economic, behavioral and social circumstances) account for the association. 15,117 individuals were followed between 1953 and 2018 using survey data and national registry data. We used Cox proportional hazard regression and mediation analysis for survival analysis to decompose direct and indirect effects. The death of a parent was associated with 40 to 50% elevated risk of mortality in offspring, and the association was mediated through delinquent behaviour in adolescence and income in adulthood especially for male offspring. Our findings suggest that parental loss has a life long impact on the mortality risk of bereaved children and that interventions targeting delinquency and socio-economic circumstances in bereaved children could be successful in reducing their excess mortality risk.

Key messages

Bereavement in childhood has a life-long impact on health. Interventions targeting delinquency and socio-economic circumstances could be successful in reducing the excess mortality risk.

Young people's labour market patterns and later mental health: A sequence analysis exploring the role of region of origin for young people's labour market trajectories and mental health

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Experiencing early employment disadvantage could lead to long-term labour market instability and labour market exclusion.

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Migrants showed more turbulent transitions between labour market states than natives.

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Belonging to a turbulent labour market trajectory is association with poor mental ill health in mid-life.

Rural life and suicide: Does the effect of the community context vary by country of birth? A Swedish registry-based multilevel cohort study

Contextual factors varying by residence in rural or urban areas may have different effects on the suicide of residents by nativity, but evidence on the urban-rural gap in suicide according to nativity is lacking. This study aims to evaluate the effect of cross-level interaction between nativity and rurality of residence on suicide risk, at two levels of aggregation (municipalities/neighborhoods). Study design was nationwide register-based cohort study in Sweden, 2011-2016. Participants were all residents 20 years or older. We calculated Incidence Rate Ratios comparing suicide incidence by nativity using three-level (individuals, neighborhoods, and municipalities) Poisson regression, stratified by gender. Among men, suicide incidences were the highest among those born in other Nordic countries, followed by those born in Sweden, other European countries, Middle Eastern countries, and the rest of the world. Residing in rural areas was associated with high IRR of suicide regardless of nativity, compared to residing in urban areas. When evaluating rurality at municipality level, we observed an increased suicide risk from living in rural areas in men born in other European (rural-urban ratio of nativity-specific IRRs: 1.39) and other Nordic (1.37) countries, followed by native Swedes (1.22). When evaluating rurality at neighborhood level, rurality was associated with increased suicide risk in men for all nativities, with the foreign-born showing higher risk than the Swedish-born. Individual sociodemographic characteristics explained the excess suicide risk in rural municipalities, but not the excess risk in rural neighborhoods. Among women, urban residents showed higher suicide incidence than rural residents. We found no consistent patterning of interaction with nativities among women. Foreign-born individuals residing in rural municipalities may have less access to economic resources and employment opportunities. Furthermore, ethnic discrimination, stigma, and exclusion from social networks and community may be more common in rural neighborhood contexts, leading to an increased risk of suicide.

Invited Commentary: Social Cohesion, Depression, and the Role of Welfare States

In this issue of the Journal, Baranyi et al. (Am J Epidemiol. 2019;000(00):000–000) examine the longitudinal associations of perceived neighborhood disorder and social cohesion with depressive symptoms among persons aged 50 years or more in 16 different countries. An important contribution of their article is that they study how neighborhood-level social capital relates to depression in different welfare-state contexts. Although the authors provide empirical evidence for some significant differences between welfare states in the relationship between social capital and depression, they say little about potential explanations. In this commentary, I draw attention to welfare-state theory and how it could provide us with a greater understanding of Baranyi et al.’s findings. I also discuss the potential downsides of grouping countries into welfare regimes. I primarily focus on the associations between social cohesion and depression, as these associations were generally stronger than those for neighborhood disorder and depression. Finally, I provide some suggestions for future research within the field and discuss whether the findings could be used to guide policies aimed at increasing social cohesion and health.

Status incongruence in human service occupations and implications for mild-to-severe depressive symptoms and register-based sickness absence: A prospective cohort study

Objective This study aimed to investigate the hypothesis that negative status incongruence may contribute to explain higher risk of mental ill-health and sickness absence in human service occupations (HSO). Methods Participants from the Swedish Longitudinal Occupational Survey of Health who responded to questionnaires in both 2014 and 2016 (N=11 814; 42% men, 58% women) were included. Status incongruence between register-based educational level and subjective social status was assessed. The association between employment in a HSO and status incongruence was estimated in linear regression analyses adjusted for age, income, work hours, sickness absence, childcare, and job qualification match. The prospective associations between status incongruence and mild-to-severe depressive symptoms and register-based sickness absence ≥31 days respectively were estimated with logistic regression analyses in models adjusted for age and outcomes at baseline. All analyses were stratified by gender. Results Employment in a HSO was associated with more negative status incongruence in both genders [standardized coefficient men 0.04, 95% confidence interval (CI) 0.02-0.07; women 0.06, 95% CI 0.04-0.09]. More negative status incongruence was furthermore associated with higher odds of mild-to-severe depressive symptoms (men OR 1.18, 95% CI 1.08-1.29; women OR 1.17, 95% CI 1.09-1.26) and sickness absence ≥31 days (men OR 1.40, 95% CI 1.23-1.59; women OR 1.17, 95% CI 1.07-1.28) two years later. Conclusion Status incongruence is somewhat higher among HSO than other occupations and associated with increased odds of depressive symptoms and sickness absence.

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.

Social network characteristics and alcohol use among young Swedes with different ethnic backgrounds

Background

The study explores how social network determinants relate to the prevalence and frequency of alcohol use of members of social networks. In a so-called dyadic design we study how similar alcohol habits co-exist among individuals (egos) and their peers (alters), when variables such as ethnic background, network composition, and other socio-cultural aspects are considered.

Methods

The data were derived from a Swedish survey entitled “Social Capital and Labor Market Integration: A Cohort Study.” The study participants (egos; n = 1989) were around age 23 at the time of the interview. A so-called dyadic design was applied, which means that all components of the analysis refer to ego-alter pairs (n = 7828).

The outcome variable considered how alcohol prevalence and frequency of binge-drinking co-exist between egos and their alters. The independent variables also measured mutual attributes and behaviors - whether egos and alters were at the same age and sex, had same ethnic background, were relatives or friends, had similar religious affiliations, or intensely interacted with friends.

Results

The analysis revealed that ego-alter similarity in terms of age, sex and ethnic background predict ego-alter similarity in alcohol use and binge-drinking. For example, if egos and alters shared a similar ethnic background, their risk of alcohol use was at least 30 percent higher as compared to those with different ethnic backgrounds. Relative to ego-alter pairs with mixed ethnic backgrounds, the odds of binge-drinking were highest for ego-alters pairs with Yugoslavian background (OR 1.76; 95% CI 1.27-2.42), followed by those with Iranian (OR 1.57; 1.04-2.35) and Swedish background (OR 1.28; 0.84-1.95).

Conclusions

We conclude that network similarity (i.e., homophily) is an important explanation for the co-existence of alcohol use among members of peer networks. Alcohol use is more common in homogeneous peer dyads representing population groups with higher use.

Key messages

Peer similarity predicts alcohol use and binge drinking. Ethnic similarity of peers is associated with increased alcohol use and binge drinking.

Effects of non-health-targeted policies on migrant health

This presentation will commence with a brief overview of the field of migration and health with the purpose of contextualizing the need for more policy-oriented research in this area, in so far as policy is a crucial -yet still overlooked- social determinant of health. In this context, we will present the main findings of a systematic review and meta-analysis recently published in the Lancet Global Health which looks at the effects of entry and integration policies on migrant health. The findings will, in turn, serve as a starting point to discuss how migration issues in general, and migration and health in particular, should be framed in relation to economic and human rights. Acknowledging the role of economic arguments in decision making, the presentation will end with a general reflection about the invisible contributions of migrants to wealth creation in a global economy and the difficulties of estimating such contributions.

In sickness or in health? Register-based evidence on partners' mutual receipt of sickness allowance and disability pension

Studies on partners' mutual receipt of benefits constitute a growing research field in the way individual health and health-related decisions depend on social relations. This paper provides the first study on the mutual receipt of sickness allowance. We analysed married and cohabiting couples' receipt of sickness allowance and disability pension by estimating discrete-time hazard models for individuals aged 40-65 years, using longitudinal register data from Finland. The data cover the period 1987-2011, and allowed us to explore socioeconomic and demographic variables at both the individual and couple level. We found strong and long-term interrelations in receipt behaviour and dependencies across benefit types. The risk of receiving sickness allowance increases by 50 per cent during the first years after the partner's first receipt of the same benefit, while the risk of receiving disability pension is twice as high even five years after the partner's receipt of the same. Women appear to be more instrumental than men in the production of health within the couple, even in a context of high level of state support, gender equality and female labour force participation. Their receipt of disability pension is more related to the male partner's receipt than vice versa. For sickness allowance receipt, the gender asymmetry is small. Mutual benefit receipt of benefits may relate not only to collateral health effects but also to shared preferences and partner selection. We cannot distinguish between the mechanisms. However, couples with more economic and social resources seem to be more efficient in joint decision making. Correlations are particularly strong in the immediate term, and for couples who are highly educated, for those with high income, and for those with children in the household. More effective policies may be needed to equalise information regarding benefits, and monitor the use, and potential misuse, of these health benefits.

Suicide risk among native- and foreign-origin persons in Sweden: a longitudinal examination of the role of unemployment status

PURPOSE

Prior research has documented an association between unemployment and elevated suicide risk. Yet, few Swedish studies have explicitly considered how such risk may vary by different migration background characteristics among persons of foreign-origin, who often experience diverse forms of labor market marginalization. This study examines the extent to which unemployment status may differentially influence suicide risk among the foreign-origin by generational status, region of origin, age at arrival, and duration of residence.

METHODS

Population-based registers were used to conduct a longitudinal, open cohort study of native-origin and foreign-origin Swedish residents of working age (25-64 years) from 1993 to 2008. Hazard ratios and 95% confidence intervals for suicide mortality were estimated using gender-stratified Cox proportional hazards models.

RESULTS

Elevated suicide risk observed among foreign-origin unemployed groups was generally of a similar or lower magnitude than that found in unemployed native-origin, although unemployed second-generation Swedish men demonstrated significantly greater (p < 0.05) excess risk of suicide than that observed among their native-origin counterparts. Unemployed foreign-born men with a younger age at arrival and longer duration of residence demonstrated an increased risk of suicide, while those who arrived as adults, and a shorter duration of residence did not show any increased risk. Among foreign-born women, excess suicide risk persisted regardless of age at arrival and duration of residence in the long-term unemployed.

CONCLUSIONS

Multiple migration background characteristics should be considered when examining relationships between employment status and suicide among the foreign-origin.

Social integration and mental health - a decomposition approach to mental health inequalities between the foreign-born and native-born in Sweden

Background

The increasing mental health inequalities between native- and foreign-born persons in Sweden is an important public health issue. Improving social integration has been stressed as a key strategy to combat this development. While a vast amount of studies have confirmed the importance of social integration for good mental health, less is known about the role of different types of social integration, and how they relate to mental health inequalities. This study aimed to examine the extent to which indicators of social integration explained mental health inequalities between the native- and foreign-born.

Methods

Based on the Health on Equal Terms survey from 2011/2015 in Västra Götaland, Sweden (n = 71,643), a non-linear Oaxaca–Blinder decomposition analysis was performed comparing native- and foreign-born individuals from Nordic-, European- and non-European countries. The General Health Questionnaire was used to assess psychological distress, while 11 items assessed employment conditions and economic disparities, social relations, and experiences of discrimination to measure different aspects of social integration.

Results

Differences in social integration explained large proportions of observed mental health differences between the native- and foreign-born. Important indicators included low levels of social activity (20%), trust in others (17%) and social support (16%), but also labour market disadvantages, such as being outside the labour market (15%), unemployment (10%) and experiencing financial strain (16%). In analyses stratified by region of origin, low trust in others and discrimination contributed to the mental health gap between the native-born and European-born (17 and 9%, respectively), and the native-born and non-European-born (19 and 10%, respectively). Precarious labour market position was a particularly important factor in the mental health gap between the native-born and Nordic-origin (22%), and non-European origin (36%) populations.

Conclusion

Social integration factors play a central role in explaining the mental health inequality between natives and migrants in Sweden. Our findings suggest that public health actions targeting mental health gaps could benefit from focusing on inequalities in social and economic recourses between natives and migrants in Sweden. Areas of priority include improving migrants’ financial strain, as well as increasing trust in others and social support and opportunities for civic engagement.

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.

FUNDING

Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office.

Stability and bidirectional relationship between physical activity and sedentary behaviours in Brazilian adolescents: Longitudinal findings from a school cohort study

Purpose

We investigated the stability, correlations and bidirectional relationship of light physical activities (PA), moderate and vigorous PA (MVPA), television viewing (TV) and video game/computer use (VG) in Brazilian adolescents.

Methods

Adolescent Nutritional Assessment Longitudinal Study-ELANA is a middle school cohort study conducted in Rio de Janeiro-Brazil in 2010–2012. Self-reported data on PA (International Physical Activity Questionnaire- IPAQ) and screen activities were obtained from 810 adolescents (mean ages of 10.9 years old (SD 0.78) for girls; 11 years old (SD 0.85) for boys) to perform autoregressive cross-lagged structural equation models in two time points for PA and three time points for screen activities.

Results

There was no significant stability of light PA and MVPA for boys and girls. Moderate stability of screen activities were found for both genders, with a significant coefficient of TV for boys (T1-T2:0.29; T2-T3:0.27 p<0.001); and VG for boys (T1-T2:0.33; T2-T3:0.35 p<0.001) and girls (T1-T2: 0.26; T2-T3:0.37 p<0.01). Significant lagged effects were obtained only among girls: light PA had effect on VG (-0.10 p<0.01), as well as in the opposite direction of TV on light PA (-0.03 p<0.01) and TV on MVPA (-0.11 p<0.01).

Conclusion

The light PA, MVPA and screen activities (among girls) did not demonstrate stability over time. A warning scenario was suggested by the stability of high amounts of screen activities among boys over time. Screen activities had bidirectional association with light PA and MVPA among girls over time.

Experience of sibling death in childhood and risk of psychiatric care in adulthood: a national cohort study from Sweden

Studies have found that sibling loss is associated with an increased risk of death from external causes (i.e. suicides, accidents and homicides). Increased psychiatric health problems following bereavement could underlie such an association. We studied the influence of sibling loss during childhood on psychiatric care in young adulthood, adjusting for psychosocial covariates shared by siblings in childhood. A national cohort born in Sweden in 1973-1982 (N = 701,270) was followed prospectively until 2013. Cox proportional hazards models were used to analyse the association between sibling loss during childhood and psychiatric inpatient and outpatient care identified by the Hospital Discharge Register. After adjustment for confounders, the HRs of psychiatric care in men who experienced sibling loss were 1.17 (95% CI 1.07-1.27) while the associations turned non-significant in women after adjustment for family-related psychosocial covariates, HR 1.07 (95% CI 0.99-1.16). An increased risk was found in men bereaved in early childhood (1.22 95% CI 1.07-1.38) and adolescence (1.27 95% CI 1.08-1.48). Among women, loss of a sibling during adolescence was significantly associated with psychiatric care (1.19 95% CI 1.03-1.36). Increased psychiatric health problems following bereavement could underlie the previously found association between sibling loss and mortality from external causes. Family-related psychosocial conditions shared by siblings in childhood may account for the association between sibling death and psychiatric care in adulthood.

Increasing income-based inequality in suicide mortality among working-age women and men, Sweden, 1990-2007: is there a point of trend change?

BACKGROUND

Income inequalities have risen from the 1990s to 2000s, following the economic recession in 1994, but little research has investigated socioeconomic inequalities in suicide mortality for working-age men and women (aged between 30 and 64 years) over the time using longitudinal data in Sweden.

METHODS

Using Swedish national register data between 1990 and 2007 as a series of repeated cohort studies with a 3-year follow-up (sample sizes were approximately 3.7 to 4.0 million in each year), relative and slope indices of inequality (RII and SII respectively) based on quintiles of individual disposable income were calculated and tested for temporal trends.

RESULTS

SII for the risk of suicide mortality ranged from 27.6 (95% CI 19.5 to 35.8) to 44.5 (36.3 to 52.6) in men and 5.2 (0.2 to 10.4) to 16.6 (10.7 to 22.4) in women (per 100 000 population). In men, temporal trends in suicide inequalities were stable in SII but increasing in RII by 3% each year (p=0.002). In women, inequalities tended to increase in both RII and SII, especially after the late-1990s, with 10% increment in RII per year (p<0.001).

CONCLUSIONS

Despite universal social security and generous welfare provision, income inequalities in suicide were considerable and have widened, especially in women. The steeper rise in women may be partially related to higher job insecurity and poorer working conditions in the female dominated public sector after the recession. To reduce health consequences following an economic crisis and widened income inequalities, additional measures may be necessary in proportion to the levels of financial vulnerability.