Ethnicity, self reported psychiatric illness, and intake of psychotropic drugs in five ethnic groups in Sweden

STUDY OBJECTIVE: This study hypothesises that the presumed increased risk of self reported longstanding psychiatric illness and intake of psychotropic drugs among Iranian, Chilean, Turkish, and Kurdish adults, when these groups are compared with Polish adults, can be explained by living alone, poor acculturation, unemployment, and low sense of coherence. DESIGN: Data from a national sample of immigrants/refugees, who were between the ages of 20-44 years old, upon their arrival in Sweden between 1980 and 1989. Unconditional logistic regression was used in the statistical modelling. SETTING: Sweden. PARTICIPANTS: 1059 female and 921 male migrants from Iran, Chile, Turkey, Kurdistan and Poland and a random sample of 3001 Swedes, all between the ages of 27-60 years, were interviewed in 1996 by Statistics Sweden. MAIN RESULTS: Compared with Swedes, all immigrants had an increased risk of self reported longstanding psychiatric illness and for intake of psychotropic drugs, with results for the Kurds being non-significant. Compared with Poles, Iranian and Chilean migrants had an increased risk of psychiatric illness, when seen in relation to a model in which adjustment was made for sex and age. The difference became non-significant for Chileans when marital status was taken into account. After including civil status and knowledge of the Swedish language, the increased risks for intake of psychotropic drugs for Chileans and Iranians disappeared. Living alone, poor knowledge of the Swedish language, non-employment, and low sense of coherence were strong risk factors for self reported longstanding psychiatric illness and for intake of psychotropic drugs. Iranian, Chilean, Turkish and Kurdish immigrants more frequently reported living in segregated neighbourhoods and having a greater desire to leave Sweden than their Polish counterparts. CONCLUSION: Evidence substantiates a strong association between ethnicity and self reported longstanding psychiatric illness, as well as intake of psychotropic drugs. This association is weakened by marital status, acculturation status, employment status, and sense of coherence.     

Psychological distress among Kurdish immigrants in Sweden

AIMS: To analyse whether there is an association between sex and poor self-reported health (SRH) and psychological distress in Kurdish immigrants. METHODS: This cross-sectional study is based on a sample consisting of immigrants, aged 27- 60 years, with self-reported Kurdish ethnicity (n=111, men; n=86, women) in Sweden originating from Iran and Turkey. It is based on data collected in 1996 from the first Swedish National Survey on the living conditions of immigrant groups conducted by Statistics Sweden. The prevalences of reporting poor health, sleeping difficulties, general fatigue and anxiety were estimated by sex. The association between sex and SRH and psychological distress was analysed by an unconditional logistic regression model estimating odds ratios (OR) with 95% confidence intervals. The final model was adjusted for age, marital status, education, housing and employment. Immigrant-specific migration-related variables were used to explore possible reasons for the sex differences. RESULTS: Kurdish men and women had a high prevalence of poor SRH and psychological distress. Age-adjusted odds ratios for anxiety were higher in Kurdish women. Sex differences in anxiety remained even when marital status, education, housing and employment were taken into account. CONCLUSIONS: Kurdish men and women report a high prevalence of poor SRH and indicators of psychological distress. Women had a higher risk for anxiety than men. Negative experiences of pre-migration as well as post-migration experiences, such as economic difficulties, preoccupation with the political situation in the home country, perceived discrimination, and feelings of poor control over one's life, were associated with the outcomes.     

Care Need Index,a useful tool for the distribution of primary health care resources

STUDY OBJECTIVE: To demonstrate how Care Need Index (CNI), a social deprivation index, may be used to allocate total primary health care resources. DESIGN: Cross sectional survey and register data. The CNI was based on sociodemographic factors: elderly persons living alone, children under age 5, unemployed people, people with low educational status, single parents, high mobility, and foreign born people. The CNI weights were calculated from the ratings of Swedish GPs of the impact of these factors on their workload. The CNI scale was transformed into a positive scale to avoid negative values. CNI weights were calculated for each decile of the study population. The risk of poor self reported health in the CNI deciles was estimated by means of a hierarchical logistic regression in the age range 25-74 (n=27 346). The MigMed database comprising all people living in Sweden was used to calculate the CNI for Stockholm. PARTICIPANTS: The Swedish population and the population in Stockholm County. MAIN RESULTS: The means of the CNI for deciles ranged from 61 (most affluent neighbourhoods) to 140 (most deprived) in Stockholm County. The ratio between the tenth and the first decile was 1.66. There was an approximately 150% increased risk of poor self reported health for people living in the most disadvantaged neighbourhoods (OR=2.50) compared with those living in the most affluent ones (OR=1). CNI ratios for the deciles corresponded approximately to the odds ratios of poor self reported health status. CONCLUSIONS: The CNI can be used to allocate total primary health care resources.     

Do biomarkers of stress mediate the relation between socioeconomic status and health?

OBJECTIVES: To test the relation between socioeconomic status (SES) and biomarkers of chronic stress, including basal cortisol, and to test whether these biomarkers account for the relation between SES and health outcomes. DESIGN: Cross sectional study using data from the 2000 social and environmental biomarkers of aging study (SEBAS). SETTING: Taiwan. PARTICIPANTS: Nationally representative sample of 972 men and women aged 54 and older. MAIN OUTCOME MEASURES: Highest risk quartiles for 13 biomarkers representing functioning of the neuroendocrine system, immune/inflammatory systems, and the cardiovascular system: cortisol, adrenaline (epinephrine), noradrenaline (norepinephrine), serum dihydroepiandrosterone sulphate (DHEA-S), insulin-like growth factor 1 (IGF1), interleukin 6 (IL6), albumin, systolic blood pressure, diastolic blood pressure, waist-hip ratio, total cholesterol-HDL ratio, HDL cholesterol, and glycosylated haemoglobin; self reported health status (1-5) and self reported mobility difficulties (0-6). RESULTS: Lower SES men have greater odds of falling into the highest risk quartile for only 2 of 13 biomarkers, and show a lower risk for 3 of the 13 biomarkers, with no association between SES and cortisol. Lower SES women have a higher risk for many of the cardiovascular risk factors, but a lower risk for increased basal readings of adrenaline, noradrenaline, and cortisol. Inclusion of all 13 biological markers does not explain the relation between SES and health outcomes in the sample. CONCLUSIONS: These data do not support the hypothesis that chronic stress, via sustained activation of stress related autonomic and neuroendocrine responses, is an important mediator in the relation between SES and health outcomes. Most notably, lower SES is not associated with higher basal levels of cortisol in either men or women. These results place an increased burden of proof on researchers who assert that psychosocial stress is an important pathway linking SES and health.     

Migration and self-rated health: a comparison between Finns living in Sweden and Finns living in Finland

AIMS: There is a lack of studies comparing health among immigrant groups with health among the population in their country of origin. This study compared the prevalence of self-rated poor health between Finns living in Sweden and Finns living in Finland. METHODS: Data were obtained from the Swedish Annual Level of Living Survey between 1996 and 2003 and the Finnish national survey "Health 2000'. Odds ratios (OR) of self-rated poor health were estimated adjusting for age, marital status, education, employment and smoking. The participants were 21,991 Swedes and 836 Finns living in Sweden, and 5,096 Finns living in Finland. RESULTS: For Finnish women living in Sweden the odds of self-rated poor health was significantly higher (OR=1.25, 95% CI=1.02-1.54) than for Finnish women living in Finland. An opposite pattern appeared among men; Finnish men living in Finland tended to have higher odds of self-rated poor health than Finnish men living in Sweden, although not to a statistically significant extent. In addition, Finns in Finland and in Sweden rated their health poorer than Swedes. CONCLUSIONS: Migration may have a different effect on Finnish men's and women's self-rated health. Further studies are needed to investigate the complex pathways between country of residence and self-rated health among immigrants.     

Health-related quality of life and migration: A cross-sectional study on elderly Iranians in Sweden

Background  

Although elderly Iranian immigrants in Sweden are the largest elderly group born outside Europe, little is known about their health-related quality of life (HRQL). The aim of this study was to examine the association between migration status and HRQL in a comparison of elderly Iranians in Iran, elderly Iranian immigrants in Sweden, and elderly Swedes in Sweden.     

Lags in behavioral change: A population based comparison of cardiovascular risk behavior in Poland and Sweden

One thousand and twenty Polish men and women and 1,011 Swedish men and women aged 50 and recruited through primary health care took part in a survey relating to their knowledge of health-related behaviour, attitudes to health-related behaviour and self-reported risk behaviour. The results reveal that Poles know as much about cardiovascular risk factors as Swedes, but that Swedes feel that it is more important to change their dietary habits and to influence factors in the working environment to avoid the risk of developing CVD than did Poles. Swedes also displayed less risk behaviour than Poles and more Swedes than Poles had successfully stopped smoking. These findings suggest that differences in stages of health-related behavior that have previously been observed at an individual level may sometimes also be discerned at a national level.     

The role of income differences in explaining social inequalities in self rated health in Sweden and Britain.

STUDY OBJECTIVE: To analyse to what extent differences in income, using two distinct measures-as distribution across quintiles and poverty-explain social inequalities in self rated health, for men and women, in Sweden and Britain. DESIGN: Series of cross sectional surveys, the Swedish Survey of Living Conditions (ULF) and the British General Household Survey (GHS), during the period 1992-95. PARTICIPANTS AND SETTING: Swedish and British men and women aged 25-64 years. Approximately 4000 Swedes and 12 500 Britons are interviewed each year in the cross sectional studies used. The sample contains 15 766 people in the Swedish dataset and 49 604 people in the British dataset. MAIN RESULTS: The magnitude of social inequalities in less than good self rated health was similar in Sweden and in Britain, but adjusting for income differences explained a greater part of these in Britain than in Sweden. In Britain the distribution across income quintiles explained 47% of the social inequalities in self rated health among women and 31% among men, while in Sweden it explained, for women 13% and for men 20%. Poverty explained 22% for British women and 8% for British men of the social inequalities in self rated health, while in Sweden poverty explained much less (men 2.5% and women 0%). CONCLUSIONS: The magnitude of social inequalities in self rated health was similar in Sweden and in Britain. However, the distribution of income across occupational social classes explains a larger part of these inequalities in Britain than in Sweden. One reason for this may be the differential exposure to low income and poverty in the two countries.     

Low intakes of energy,folate, iron,and calcium of child-bearing Korean women

The focus is on dietary diversity among United States (US) Hispanics, with attention given to differences by socioeconomic status (SES) and level of acculturation. The subjects of study were 18 to 74 years of age Mexican Americans (n = 3201), Cuban Americans (n = 831), and Puerto Ricans (n = 1224) included in the 1982–84 Hispanic Health and Nutrition Examination Survey (HHANES). Dietary diversity was assessed as ‘food group’ and ‘portion’ scores derived from single 24 hour recalls. Less than 10% of Hispanic men and 5% of women satisfy diversity recommendations (17 or more portions out of a possible 20) and patterns are as found in the general US population. Multivariate analysis suggest that among Mexican Americans and Puerto Ricans diversity is related to education and level of acculturation. Income is not related to diversity in any group. Generation of residency in the US is associated with less variety among Mexican Americans and Puerto Rican men. Socioeconomic status and acculturation are not significantly related to diversity among Cuban Americans. In conclusion, the diets of US Hispanics lack variety and this places these populations at long‐term health risk. While interventions need to consider the educational level and cultural differences among Hispanics, income levels are unrelated to diversity in all groups, and therefore, not an apparent limitation to change.     

The duration and timing of exposure: effects of socioeconomic environment on adult health

OBJECTIVES: This study investigated timing and duration effects of socioeconomic status (SES) on self-rated health at 33 years of age and established whether health risks are modified by changing SES and whether cumulative SES operates through education. METHODS: Data were from the 1958 British birth cohort. Occupational class at birth and at 16, 23, and 33 years of age was used to generate a lifetime SES score. RESULTS: At 33 years of age, 12% of men and women reported poor health. SES at birth and at 16, 23, and 33 years of age was significantly associated with poor health: all ages except 16 years in men made an additional contribution to the prediction of poor health. No large differences in effect sizes emerged, suggesting that timing was not a major factor. Odds of poor health increased by 15% (men) and 18% (women) with a 1-unit increase in the lifetime SES score. Strong effects of lifetime SES persisted after adjustment for education level. CONCLUSIONS: SES from birth to 33 years of age had a cumulative effect on poor health in early adulthood. This highlights the importance of duration of exposure to socioeconomic conditions for adult health.     

Food intake patterns, self rated health and mortality in Danish men and women. A prospective observational study

OBJECTIVE: To examine whether self rated health confounds or modifies the relation between a prudent food intake pattern and mortality and to study whether the prudent food intake pattern predicts subsequent changes in self rated health. DESIGN: A prospective cohort study with follow up of total mortality and changes in self rated health. Food intake patterns were identified by principal component analysis from a 28 item food frequency questionnaire, collected at baseline. SETTING: MONICA surveys, Copenhagen County, Denmark. PARTICIPANTS: A random sample of 3698 men and 3618 women aged 30-70 years were followed up from 1982 to 1998 (median 15 years). MAIN RESULTS: Among participants with complete information on all variables 18% had rated their health as poor (average or bad) at the baseline examination. Poor self rated health was related to a low score on the prudent food intake pattern, which was characterised by a frequent intake of wholemeal bread, fruit and vegetables. Three hundred and seventy six men and 210 women died during follow up. Poor self rated health and a low prudent food score were associated with increased mortality in both men and women. Self rated health did not modify the relation between diet and mortality. Of the 1098 men and 1048 women with good self rated health at baseline, 243 men and 297 women reported poor health during follow up. Low prudent food score, smoking, and high BMI increased the risk of developing poor health in both men and women, but in multivariate analysis the associations attenuated and were only significant for BMI. CONCLUSION: Both prudent food intake pattern and self reported health are independent predictors of mortality. Self rated health does not seem to modify the relation between diet and mortality.     

Major risk factors for cardiovascular disease in elderly migrants in Sweden

Objective. The knowledge of elderly migrants' health, particularly those who are retired or in transition to retirement is limited. The purpose of this study was to analyse the association between migration, socio-economic status (SES), and risk factors for cardiovascular disease (CVD). Design. A simple random sample of 253 foreign-born persons and 2847 Swedish-born persons aged 55-74 were drawn from the Swedish Population Registry. They were interviewed by Statistics Sweden in 1988-89. Outcome variables were leisure-time physical inactivity, smoker/non-smoker status, body mass index (BMI), hypertension, and diabetes mellitus. Explanatory variables were sex, age, marital status, migration status (country of birth), and SES (income). Logistic and linear regression were used. Results. Elderly foreign-born people ran an increased risk of engaging in no physical activity (men only), being a current smoker, and having an increased BMI after adjustment for background factors. In addition, a low income (first tertile) was an independent risk factor for physical inactivity (men only), as was being a current smoker (men only), BMI, hypertension, and diabetes mellitus. Thus, the burden of being an elderly migrant increases the risk of a disadvantaged lifestyle between 50 and 80% compared with Swedes. Conclusions. This study shows that migrants who are retired or in transition to retirement have a disadvantaged risk profile for cardiovascular disease. It might be possible to improve this situation by intervention, as for example by increasing a person's interest in walking.     

Social inequalities in health: are there gender differences?

Some studies suggest that socio-economic status (SES) inequalities in health are smaller in women than men, but the evidence is inconsistent as to whether this applies across various health measures and life stages. The first aim of this paper was to establish whether the magnitude of social inequality in health differs for men and women during early adulthood, specifically in respect to self rated health, limiting long-standing illness, psychological distress, respiratory symptoms, asthma/wheezing, height and obesity; second, to determine whether explanations for socioeconomic inequality in poor self rated health differ for men and women. Analyses are based on longitudinal data from the British 1958 birth cohort study using information from birth to age 33. When gender differences in inequalities were examined using social class, no significant differences emerged across the seven health measures examined at ages 23 and 33. SES inequalities based on education, however, showed greater inequality among men at age 33 for limiting long-standing illness and respiratory symptoms, but greater inequality among women for poor rated health at age 23 and psychological distress at age 33. Hence, gender differences in the magnitude of health inequality were inconsistent across age and health measures. An analysis of the contribution of explanatory factors to social class differences in self-rated health suggested that causes of inequality were similar for men and women. However, some discrepancies emerged, notably in the greater contribution of job insecurity to class differences for men and in the greater contribution of age at first child for women. The magnitude and explanations for gender differences in SES health inequalities are likely to vary according to life stage and health measure.     

Country of birth,instrumental activities of daily living,self-rated health and mortality: a Swedish population-based survey of people aged 55-74

There is scant knowledge of the effects of country of birth on the health of individuals in the years prior to and after retirement. The aim of this study was to consider country of birth in relation to health status, instrumental activities of daily living (IADL) and all-cause mortality when adjusted for socioeconomic status (SES). Cross-sectional data were collected between 1986 and 1991 on 8959 individuals between the ages of 55 and 74. Self-reported data were analysed using a logistic regression model while the mortality data were analysed by means of a proportional hazard model. In the present study, immigrants from Southern Europe, Eastern Europe and Finland carried significantly increased risks of poor health even after adjustment for SES. Southern Europeans, refugees from Developing countries and Finns exhibited an increased risk of impaired IADL compared to Swedes, even after adjustment for SES. In conclusion, country of birth was associated with poor health status and impaired IADL. This association remained after adjustment for SES. In accordance with pre-study expectations, mortality was predicted by impaired IADL and male gender. Country of birth was not associated with all-cause mortality.     

Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox

Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES. Results provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified.     

Sex Guilt and Life Satisfaction in Iranian-American Women

Although the experience of sex guilt has been considered among a variety of ethnic groups, the area has not yet been empirically explored among Iranian American women. The present study investigated the relationship between sexual self-schema (i.e., beliefs about the sexual aspects of oneself), acculturation, and sex guilt, and it further examined the association between sex guilt and life satisfaction in Iranian American women. A total of 65 Iranian American women, with a mean age of 31.3 years (SD = 11.7), completed five self-administered questionnaires. Findings indicated a significant inverse correlation between sexual self-schema and sex guilt. More specifically, women who endorsed negative self-views regarding their sexual self reported higher levels sex guilt. Results revealed that acculturation was unrelated to sex guilt, when the effect of being Muslim or non-Muslim was controlled. Women with high sex guilt reported significantly lower levels of life satisfaction. Moreover, analyses for mediation effects supported sex guilt as a partially mediating variable between sexual self-schema and life satisfaction. Levels of sex guilt were higher among Muslim women when compared to women of other religious affiliations. Additionally, Muslim women appeared to be significantly less acculturated to Western ideals than other religious groups. The present findings suggest that mental health professionals who provide services to Iranian American women need to consider the negative effects of sex guilt, particularly among Muslim women.     

Women's right to health in Iran: Domestic implementation of international human rights law

In Iran, discrimination based on gender in enjoyment of the right to health is prohibited. Making health services physically and financially accessible to the entire population and removing social and cultural barriers of women's access to health services are main considerations of the health laws and policies of Iran. The health of Iranian women has improved considerably in recent years. But there are disparities in health status and access of women to health services around the country. Some groups of women, including the poor, the elderly, the disabled, the illegal immigrant, and those without an appropriate male guardian, and rural women have limited access to health services in Iran. To realize women's right to health, this country should immediately remove the disparities and use all the necessary means including legislative, administrative, budgetary, promotional, and judicial measures. National plans on women's empowerment and support should be interpreted in provincial programs and action plans. Moreover, a monitoring system and certain benchmarks for tracing the progress of the plans should be established. Realizing other economic, social, and cultural rights including the rights to food, shelter, education, work, social security, and participation in society will improve the Iranian women's enjoyment of their right.     

Eating disorder symptoms and body image concerns in Iran: comparisons between Iranian women in Iran and in America.

OBJECTIVE: Rates of eating disorder symptoms were compared between Iranian women living in Iran and Iranian women living in America, in order to assess the impact of Western culture on eating disorders. Women in Iran are mandated by law to cover their bodies with a long veil or overcoat and they have little legal exposure to Western culture and media. METHOD: Fifty-nine female Iranian students living in Tehran and 45 female students of Iranian descent living in Los Angeles were surveyed with the Eating Disorder Examination-Questionnaire and the Figure Rating Scale. RESULTS: Few differences were found between participants in the two samples, despite ample power to detect them. Participants in Iran reported as much disordered eating as participants who had immigrated to America. DISCUSSION: Neither exposure to Western media nor acculturation to Western norms appeared to be related to symptoms of disordered eating and body image concerns in this sample.     

Body weight,perceived weight stigma and mental health among women at the intersection of race/ethnicity and socioeconomic status: insights from the modified labelling approach

With increasing rates of obesity in the United States, attention to life chances and psychological consequences associated with weight stigma and weight‐based discrimination has also intensified. While research has demonstrated the negative effects of weight‐based discrimination on mental health, little is known about whether different social groups are disproportionately vulnerable to these experiences. Drawing on the modified labelling theory, the focus of this paper is to investigate the psychological correlates of body weight and self‐perceived weight‐based discrimination among American women at the intersection of race/ethnicity and socioeconomic status (SES). Analyses use data from the National Health Measurement Study (NHMS), a national multi‐stage probability sample of non‐institutional, English‐speaking adults, ages 35 to 89 in 2005–2006. Our findings demonstrate that the effect of weight‐based discrimination on psychological well‐being is highly contingent on social status. Specifically, the psychological consequences of discrimination on Hispanic women and women in the lowest household income group is significantly greater relative to White women and women with higher household income, controlling for obesity status and self‐rated health. These results suggest that higher social status has a buffering effect of weight stigma on psychological well‐being.     

Neighborhood deprivation and cardiovascular disease risk factors: protective and harmful effects

AIMS: To determine whether neighborhood-level deprivation is independently associated with cardiovascular disease (CVD) health behaviors/risk factors in the Swedish population. METHODS: Pooled cross-sectional data, Swedish Annual Level of Living Survey (1996-2000) linked with indicators of neighborhood-level (i.e. Small Area Market Statistics areas) deprivation (1997), to examine the association between neighborhood-level deprivation and individual-level smoking, physical inactivity, obesity, diabetes, and hypertension among women and men, aged 25-64 (n = 18,081). Data were analyzed with a series of logistic regression models that adjusted for individual-level age, gender, marital status, immigration status, urbanization, and a comprehensive measure of socioeconomic status (SES). Interactions were tested to determine whether neighborhood effects varied by SES or length of neighborhood exposure. RESULTS: Living in a neighborhood with low deprivation was protective (i.e. lower odds) for smoking, while living in a neighborhood with high deprivation was harmful (i.e. higher odds) for smoking, physical inactivity, and obesity (compared with living in a neighborhood with moderate deprivation). These associations were significant after adjustment for individual-level characteristics. There was no evidence that the neighborhood deprivation associations varied by individual-level SES or length of neighborhood exposure. CONCLUSIONS: Neighborhood-level deprivation exerted important protective and harmful associations with health behaviors/risk factors related to CVD. The significance to public health is substantial because of the number of persons at risk as well as the serious health consequences of CVD. These results suggest that interventions focusing on changing contextual aspects of neighborhoods, in addition to changing individual behaviors, may have a greater impact on CVD than a sole focus on individuals.