Mental health of immigrants from the former Soviet Bloc: a future problem for primary health care in the enlarged European Union? A cross-sectional study

Background  

Enlargement of the European Union has caused worries about the possibility of increased migration from its new members, the former Soviet countries, and consequently increased demands on the health care systems of the host countries. This study investigated whether or not earlier immigrants from the former Soviet Bloc have poorer self-reported mental health, measured as self-reported psychiatric illness and psychosomatic complaints, than the host population in Sweden. It also examined the particular factors which might determine the self-reported mental health of these immigrants.     

Contextual and individual determinants of health among Aussiedler and native Germans

Aussiedler, also referred to as ethnic German immigrants from countries of the former Soviet Union and other parts of Eastern Europe, constitute one of the largest immigrant groups in Germany. Little is known about their health relative to the health of native Germans. Using the German Microcensus 2005, which includes information about the health of 10,022 Aussiedler and 322,813 native Germans aged 20+ we find that in both groups high regional centrality depresses health, as does living in a region with low GDP. The proportion of foreigners does not have any consistent effect. The two groups differ with respect to educational gradients in health: there is none for Aussiedler, while there is a steep gradient for native Germans. Aussiedler who have lived in Germany for less than 15 years are healthier than native Germans which supports the healthy migrant hypothesis. Their deteriorating health status by duration of stay suggests that migration, deprivation and discrimination may have negative effects on the health of Aussiedler.     

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.     

Societal characteristics and health in the former communist countries of Central and Eastern Europe and the former Soviet Union: a multilevel analysis

OBJECTIVES: To examine whether, in former communist countries that have undergone profound social and economic transformation, health status is associated with income inequality and other societal characteristics, and whether this represents something more than the association of health status with individual socioeconomic circumstances. DESIGN: Multilevel analysis of cross-sectional data. SETTING: 13 Countries from Central and Eastern Europe and the former Soviet Union. PARTICIPANTS: Population samples aged 18+ years (a total of 15 331 respondents). MEAN OUTCOME MEASURES: Poor self-rated health. RESULTS: There were marked differences among participating countries in rates of poor health (a greater than twofold difference between the countries with the highest and lowest rates of poor health), gross domestic product per capita adjusted for purchasing power parity (a greater than threefold difference), the Gini coefficient of income inequality (twofold difference), corruption index (twofold difference) and homicide rates (20-fold difference). Ecologically, the age- and sex-standardised prevalence of poor self-rated health correlated strongly with life expectancy at age 15 (r = -0.73). In multilevel analyses, societal (country-level) measures of income inequality were not associated with poor health. Corruption and gross domestic product per capita were associated with poor health after controlling for individuals' socioeconomic circumstances (education, household income, marital status and ownership of household items); the odds ratios were 1.15 (95% confidence interval 1.03 to 1.29) per 1 unit (on a 10-point scale) increase in the corruption index and 0.79 (95% confidence interval 0.68 to 0.93) per $5000 increase in gross domestic product per capita. The effects of gross domestic product and corruption were virtually identical in people whose household income was below and above the median. CONCLUSION: Societal measures of prosperity and corruption, but not income inequalities, were associated with health independently of individual-level socioeconomic characteristics. The finding that these effects were similar in persons with lower and higher income suggests that these factors do not operate exclusively through poverty.     

Self-rated health status and health care utilization among immigrant and non-immigrant Israeli Jewish women.

INTRODUCTION: Since 1989, Israel has absorbed over 700,000 Jewish immigrants from the former Soviet Union, among them about 375,000 women. Immigrants are known to have greater and/or different health needs than non-immigrant residents, and to face unique barriers to receiving care. However, research addressing the specific health problems of these immigrant women has been scarce. OBJECTIVES: To compare self-reported health status and health care utilization patterns among immigrant and non-immigrant Israeli Jewish women; and to explore ways to overcome existing barriers to their care. METHODS: A telephone survey was conducted in September and October 1998 among a random national sample of women age 22 and over, using a standard questionnaire. In all, 849 interviews were completed, with a response rate of 84%. In this article we present comparative data from a sub-set that included 760 immigrant respondents from the former Soviet Union and non-immigrant Jewish respondents. RESULTS: A greater proportion of immigrant versus non-immigrant women reported poor perceived health status (17% vs. 4%), chronic disease (61% vs. 38%), disability (31% vs. 18%) and depressive mood symptoms (52% vs. 38%). Lower rates of immigrant women visited a gynecologist regularly (57% vs. 83%) and were satisfied with their primary care physician. Lower rates of immigrants reported discussing health promotion issues such as smoking, diet, physical activity, HRT, and calcium intake with their physician. The article concludes with a discussion of the implications of the findings for designing services that will effectively promote immigrant women's health, both in Israel and elsewhere.     

Unity or diversity?: Task profiles of general practitioners in Central and Eastern Europe

Background: The countries of Central and Eastern Europe, where- until the end of the 1980s - the Semashko health care systemprevailed, are often perceived as a homogeneous group. If thishighly centralized system, with its tight state control, togetherwith the ‘equalizing’ influence of communism, hasled to a uniformity in the provision of health services, thiscould be reflected in the service profiles of general practitioners(GPs). The aim of this paper was to find out whether this pictureis justified and investigate differences between the formercommunist countries. Methods: In 1993 and 1994, standardizedquestionnaires were sent to (mostly random) samples of GPs (7,233in total) in 30 European countries. Four areas of service provisionwere measured: the GPs' position in first contact with healthproblems and their involvement in the application of medicaltechniques, disease management and preventive medicine. Variationpatterns and mean scores were analyzed by way of multilevelanalysis. Results: There is no more uniformity in Central andEastern Europe than in Western Europe. In Eastern Europe thereare in fact considerable differences: GPs in former Yugoslaviahave the most comprehensive service profile, whereas the lowestscores were found among doctors in the former Soviet Union.The countries which had a social insurance system before theSecond World War, such as the Czech republic and Hungary, aresituated in between. Conclusions: There are distinctive nationaldifferences in GPs' task profiles in Central and Eastern Europe,which provide clues for the country-specific design and implementationof primary care-oriented reforms.     

Eastern Europe and the former Union of Soviet Socialist Republics: animal health systems in transition

The economic transition in Eastern Europe and the former Union of Soviet Socialist Republics (USSR) during the last decade has profoundly changed the agricultural sector and the well-being of people in rural areas. Farm ownership changed; selected farm assets, including livestock, were transferred to farm workers or others, and the social and service structures of rural society are in a state of uncertainty. The transition has, in general, led to the deterioration of rural services. Animal health services have also deteriorated. This decline is associated with the contraction of the livestock inventory, the fragmentation of farms, higher transaction costs for service providers, and the overall decline of the rural economy which has, so far, lowered the demand for animal health services. There are considerable differences in the way that these countries are coping with the economic transition and its aftermath. Among the determining factors in the former USSR are, as follows: the speed of recovery from the legacies of large State-controlled farming and a centrally planned animal health system, the efforts made to address poverty reduction, the choice on whether to become a Member of the World Trade Organization and the requirements of such membership, the ability to provide low-cost services to a fragmented and unskilled livestock production sector. In Eastern Europe, the requirements for joining the European Union (EU) are an additional and important determining factor. In the short term, the choice of a veterinary system to serve the livestock sector may differ from country to country, depending on the legacies of the past, the status of reforms and the proximity of Western markets. Lower-income countries with an oversupply of veterinarians may support labour-intensive, low-cost systems which focus on food security and public health. The better-endowed EU accession countries may focus rather on improved disease surveillance, production enhancement, quality assurance and increased food safety. Such choices may also determine the investment made by these countries in upgrading their State system, laboratories and veterinary education facilities.     

Ethnic differences in self-reported lack of access to a regular doctor: a population-based study

Objective: The aim of this study was to investigate ethnic differences in self-reported lack of access to a regular doctor in Malmö, Sweden. Design: The public health survey in Malmö 1994 was a cross sectional population study. Data were collected from 5600 people aged 20-80 years using a postal questionnaire. The participation rate was 71%. The population was categorised according to country of birth: born in Sweden, other Nordic countries, other Western countries, Yugoslavia, Eastern Europe, Arabic speaking countries and other countries. Multivariate logistic regression analysis was performed in order to investigate the importance of possible confounders on the differences by country of origin in lack of access to a regular doctor. Results: A 56.3% proportion of all men and 48.8% of all women lacked access to a regular doctor. The odds ratios of lacking access were significantly higher among men born in Nordic countries, Arabic countries and other countries compared to men born in Sweden but disappeared after adjustment for age. The same patterns were observed for women born in Eastern Europe, Arabic countries and other countries compared to women born in Sweden, and remained after adjustment for age. In the multivariate analysis including age, education, ability to pay bills every month and self-reported health, no significant differences in lack of access to a regular doctor remained among men, while the odds ratios were significantly lower among women born in other Western countries, but still significantly higher among women born in Arabic speaking countries and all other countries. Conclusion: Self-reported lack of access to a regular doctor was significantly higher among men born in Nordic countries, Arabic countries and other countries compared to men born in Sweden, but all these differences disappeared after adjument for age and in the multivariate analysis. Women born in Arabic speaking countries and other countries lacked access to a regular doctor to a significantly higher extent compared with women born in Sweden, and these differences remained in the multivariate analysis.     

Mortality from external causes among ethnic German immigrants from former Soviet Union countries, in Germany

BACKGROUND: Diaspora migration flows from the former Soviet Union to Western Europe and Israel have increased since the late 1980s. Risk factors responsible for the East-West mortality gap and post-migration factors may lead to higher mortality from external causes of death like suicide amongst such Diaspora immigrants. We investigated whether ethnic German immigrants from the former Soviet Union had increased mortality from external causes compared to native Germans. METHODS: We conducted a retrospective cohort study of 34 393 adults, so-called Aussiedler who arrived in Germany's largest federal state between 1990 and 2001. We ascertained vital status and causes of death from registry data. Standardized mortality ratios (SMRs) were calculated using the native German population as comparison. Multivariate effects were assessed using Poisson regression. RESULTS: 1 657 members (4.8%) died, 88 from external causes. Overall SMR was 1.29 (95% confidence intervals 1.05-1.61). Males had a 39% higher mortality from all external causes and accidents, and a 30% higher mortality from suicide than German males. Females had slightly higher mortality from accidents but comparable mortality from all external causes. Aussiedler aged <65 years had rate ratios above one for external causes and accidents in multivariate models. SMRs for suicide and all external causes decreased with length of stay. CONCLUSION: While ethnic German immigrants have a mortality disadvantage compared to the NRW population, it is on a much lower scale than expected if they were representative of their source populations in former Soviet Union countries.     

Changing trends of diseases in Eastern Europe: closing the gap

One of the greatest challenges in Europe at the beginning of the 21st Century is the wide east-west health gap. In 2008, the difference in life expectancy between men in some Western European countries and Russia was 20 years. Whilst trends for life expectancy at birth have improved in many areas around the world, those for Russia, as well as those for some other former Soviet Union countries, have fluctuated greatly and have not shown signs of growth since the middle of the 20th Century. This problem is most acute in Russia and former Soviet Union countries, but is also far from being solved in the states that have made significant progress since 1990 and joined the European Union in the 21st Century. One of the priorities of the Polish presidency of the European Union, which began in July 2011, is the call for a European solidarity for health that could help to close the health gap dividing Europe.     

Psychological Distress and Problem Drinking

We examine the influence of harmful alcohol use on mental health using a flexible two‐step instrumental variables approach and household survey data from nine countries of the former Soviet Union. Using alcohol advertisements to instrument for alcohol, we show that problem drinking has a large detrimental effect on psychological distress, with problem drinkers exhibiting a 42% increase in the number of mental health problems reported and a 15% higher chance of reporting very poor mental health. Ignoring endogeneity leads to an underestimation of the damaging effect of excessive drinking. Findings suggest that more effective alcohol polices and treatment services in the former Soviet Union may have added benefits in terms of reducing poor mental health. Copyright © 2015 John Wiley & Sons, Ltd.     

Women,international migration and self-reported health. A population-based study of women of reproductive age

Although our knowledge of the relationship between migration and health in women is increasing, we still have a limited knowledge of the migration and health of women of reproductive age. A cross-sectional analysis of a simple random sample of 10,661 women aged 20-49 in Sweden in 1980-1985 and 9585 such women in 1992-1997 was carried out to assess their health. The risk factors for self-reported, poor health and psychosomatic complaints for female refugees and women from Finland, Southern Europe, Western countries and Sweden were examined. Country of birth was a significant risk factor for poor self-reported health and psychosomatic complaints, with women from Southern Europe, female refugees and Finnish women being at higher risk in this respect than Swedish women. The increased risk remained significant after adjustment for demographic and socio-economic factors. Swedish-born women, female refugees, and Finnish women reported poorer health and had more psychosomatic complaints (not Finns) in the 1990s than in the 1980s.     

The social production of substance abuse and HIV/HCV risk: an exploratory study of opioid-using immigrants from the former Soviet Union living in New York City

Background  

Several former Soviet countries have witnessed the rapid emergence of major epidemics of injection drug use (IDU) and associated HIV/HCV, suggesting that immigrants from the former Soviet Union (FSU) may be at heightened risk for similar problems. This exploratory study examines substance use patterns among the understudied population of opioid-using FSU immigrants in the U.S., as well as social contextual factors that may increase these immigrants' susceptibility to opioid abuse and HIV/HCV infection.     

Health behaviour, risk awareness and emotional well-being in students from Eastern Europe and Western Europe.

Life expectancy and other indices of health have deteriorated markedly in the former socialist countries of Eastern Europe over recent decades. The possible roles of lifestyles, knowledge about health and behaviour, emotional wellbeing and perceptions of control were assessed in a cross-sectional survey of young adults of similar educational status in Eastern and Western Europe. As part of the European Health and Behaviour Survey, data were collected in 1989-1991 from 4170 university students aged 18-30 years from Austria, Belgium, the Federal Republic of Germany, the Netherlands and Switzerland, and from 2293 students from the German Democratic Republic, Hungary and Poland. Measures were obtained of health behaviours, awareness of the role of lifestyle factors in health, depression, social support, health locus of control, and the value placed on health. After adjustment for age and sex, East European students had less healthy lifestyles than Western Europeans according to a composite index of 11 health behaviours, with significant differences for seven activities: regular exercise, drinking alcohol, avoiding dietary fat, eating fibre, adding salt to food, wearing a seat-belt, and using sunscreen protection. East European students were less likely to be aware of the relationship between lifestyle factors (smoking, exercise, fat and salt consumption) and cardiovascular disease risk. In addition, they were more depressed (adjusted odds of elevated scores on the Beck Depression Inventory of 2.46, 95% C.I. 1.95-3.09), reported lower social support, and had higher beliefs in the "chance" and "powerful others" locus of control. Internal locus of control levels did not differ across regions, and Eastern Europeans placed a higher valuation on their health. Unhealthy lifestyles associated with lack of information about health and behaviour, greater beliefs in uncontrollable influences, and diminished emotional well-being, may contribute to poor health status in Eastern Europe.     

'Avoidable' mortality among immigrants in Sweden

BACKGROUND: The concept of studying 'avoidable' mortality as an indicator of the outcome of health care has been applied mainly in studies of time-trends and geographical and socio-economic variation. METHODS: In this study, indicators of 'avoidable' mortality among immigrants in Sweden have been studied. Comparisons of death rates among immigrants and those born in Sweden were made using a linkage of the Population Census and the Cause of Death Register, nationwide sources. RESULTS: For a group of health policy indicators, such as liver cirrhosis and malignant neoplasms of the trachea, bronchus and lung, death rates were about 40-100% higher among immigrants from other Nordic countries, Yugoslavia and Eastern Europe than among the Swedish born population. For causes of death considered amenable to medical care intervention there were, however, small differences. For some conditions, such as cerebrovascular disease, malignant neoplasms of colon and rectum, chronic bronchitis and emphysema, high death rates were found among immigrants from other Nordic countries. For immigrants from other countries, there were no high death rates based on medical care indicators when compared to the Swedish-born population. CONCLUSION: There were few indications of inequity reflected in the mortality outcome of medical care. The variation found in death rates from health policy indicators may reflect differences in smoking and alcohol habits.     

The European health divide: a matter of financial or social capital?

The 'European east--west health divide' has been documented both for mortality and for self-rated health. The reason for this divide, however, remains to be explained. The aim of this study is, firstly, to investigate whether in 1995-97 differences in self-rated health persisted between countries in central and eastern Europe, the former Soviet Union, and western Europe. A further aim is to try to explain these differences with reference to people's financial status and social capital. This study found substantial differences in self-rated health between countries in western Europe, in central and eastern Europe, and in the former Soviet Union (where self-rated health seems to be poorest in general). There were also substantial differences between areas in terms of economic and social capital, with western Europe doing better in all the analysed circumstances. In economic terms people in the former Soviet Union seemed to be more dissatisfied than those living in central and eastern Europe. When one looks at differences in social capital between the two post-communist areas the picture is more mixed. Economic satisfaction was demonstrated to have a strong and significant effect on people's self-rated health, with a higher satisfaction reducing the odds of 'poor' health. When this factor was controlled for the area, differences in self-rated health were reduced dramatically, for both men and women. Organisational activity (men only), trust in people, and confidence in the legal system also reduced the odds of 'less than good health', but were not as important in explaining the health differences between areas. One can conclude that economic factors as well as some aspects of social capital play a role for area differences in self-rated health. Of these it would appear that economic factors are the more important.     

Induced abortion: a world review, 1990

The worldwide trend toward liberalization of abortion laws has continued in the last four years with changes in Canada, Czechoslovakia, Greece, Hungary, Romania, the Soviet Union and Vietnam. Forty percent of the world's population now lives in countries where induced abortion is permitted on request, and 25 percent lives where it is allowed only if the woman's life is in danger. In 1987, an estimated 26 to 31 million legal abortions and 10 to 22 million clandestine abortions were performed worldwide. Legal abortion rates ranged from a high of at least 112 abortions per 1,000 women of reproductive age in the Soviet Union to a low of five per 1,000 in the Netherlands. In recent years, abortion rates have been increasing in Czechoslovakia, England and Wales, New Zealand and Sweden and declining in China, France, Iceland, Italy, Japan and the Netherlands. In most Western European and English-speaking countries, about half of abortions are obtained by young, unmarried women seeking to delay a first birth, while in Eastern Europe and the developing countries, abortion is most common among married women with two or more children. Mortality from legal abortion averages 0.6 deaths per 100,000 procedures in developed countries with data. Abortion services are increasingly being provided outside of hospitals, and for those performed in hospitals, overnight stays are becoming less common. National health insurance covers abortions needed to preserve the health of a pregnant woman in all developed countries except the United States, where Medicaid and federal insurance programs do not cover abortion unless the woman's life is in danger.     

Reported health,lifestyles, and use of health care of first generation immigrants in The Netherlands: do socioeconomic factors explain their adverse position?

OBJECTIVE: Differences in health, lifestyles, and use of health care between groups of varying ethnic origin can have important implications for preventive and curative health care. This paper studies whether socioeconomic factors explain ethnic differences in these outcomes. DESIGN: Data on health status, lifestyles, and use of health care were obtained from interviews with 3296 people aged 16-64 years (response: 60.6%), among whom were 848 first generation immigrants. Ethnic differences in these outcomes were examined with and without adjustment for socioeconomic factors, using logistic regression. SETTING: General population of Amsterdam, the Netherlands. MAIN OUTCOME MEASURES: Health status (self rated health, General Health Questionnaire, functional limitations), lifestyles (smoking, alcohol), and use of health care (general practice, pharmaceuticals, hospitalisations). MAIN RESULTS: Immigrants from Turkey, Morocco and (former) Dutch colonies report a poorer health and a higher use of health care, especially primary health care among the elderly. An adverse socioeconomic position partially explains the poor health of these immigrants. In turn, their poor health explains most of their higher use of health care. CONCLUSIONS: Cultural factors and poor living conditions seem to contribute to the poor health of immigrants, besides an adverse socioeconomic position. The pressure on various health services will increase in future because of the relatively high increase in immigrants' needs at older ages and their presently low mean age.

 

     

The Relation Between Discrimination,Sense of Coherence and Health Varies According to Ethnicity: A Study Among Three Distinct Populations in Israel

Self-reported experiences of discrimination and sense of coherence (SOC) have been found to be associated with health. A face-to-face survey of Long Term Jewish Residents (LTJR), Arabs and former Soviet Union (fSU) immigrants in Israel was performed. Respondents reported their physical and mental health, self-reported experiences of discrimination, SOC and socioeconomic status. Multivariable logistic regressions and bootstrapping path analyses were performed. Discrimination was associated with health after adjusting for all other variables. SOC was also associated with health. SOC did not mediate the strong association between discrimination and health among Israeli LTJR, but was a significant mediator among Arabs and fSU immigrants. Discrimination seems to have a direct effect on health only among the majority and not among minority populations. High levels of SOC may reduce the negative effects of discrimination on health by serving as a coping resource, however only among minorities.     

Observations on health care issues in the former Soviet Union

With the demise of the Soviet Union, the health care systems that remain in the component countries face many problems not seen in Western countries since the late 1800s or early 1900s. The author traveled to several countries of the newly independent states (NIS) of the former Soviet Union and observed problems in hospital sanitation, public health, medical equipment and supply distribution, food quality and safety, and the delivery of medical services.The author makes several suggestions to improve the delivery and quality of health care services in the NIS. His recommendations include: developing health care standards similar those that were first implemented in the U.S. by the American College of Surgeons in 1919; the use of practice guidelines and outcomes measures; building on organizational structures from the old state health system for professional and public health education; and restructuring the old delivery system to form a new delivery model based on centers of excellence and group practice managed care. Because of so many needs, the author stresses keeping reforms as simple as possible so as not to overburden the health professionals. The author also calls on Western countries, particularly the U.S., to assist with the rebuilding of the health care delivery system of its Cold War adversary as it helped Germany and Japan after World War II. Such aid should be viewed as humanitarian in nature and should be distributed to private/public partnership efforts. The author says recent Congressional proposals to cut off aid in order to influence the Russian government's position on nuclear technology sales to Iran and the Chechen war are short sighted and will only hurt the citizens of these countries while having little or no impact on the leadership.Stephen L. Davidow is a Chicago-based health policy analyst and communications consultant who has traveled to several countries among the newly independent states (NIS) of the former Soviet Union. He has toured health facilities and consulted with health officials in the NIS. He also made a presentation on standards setting at the Universal Health Conference in Samarkand, Uzbekistan. Mr. Davidow's undergraduate degree from St. Olaf College is in Russian Studies, and he studied Russian language at Boston University's Russian Studies Institute and Moscow State Pedagogical Institute. He has also done graduate coursework in health policy and administration at the University of Chicago. His consulting practice specializes in practices guidelines, outcomes measurement, public policy, and public health education.