Mortality in Adult Offspring of Immigrants: A Swedish National Cohort Study
Mortality in Adult Offspring of Immigrants: A Swedish National Cohort Study
Hlio Manhica 0 1
Susanna Toivanen 0 1
Anders Hjern 0 1
Mikael Rostila 0 1
0 1 Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden, 2 Department of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden, 3 Department of Sociology and Centre for Health Equity Studies, Stockholm University , Stockholm , Sweden
1 Academic Editor: Karin Bammann, University of Bremen , GERMANY
Higher risks of psychiatric disorders and lower-than-average subjective health in adulthood have been demonstrated in offspring of immigrants in Sweden compared with offspring of native Swedes, and linked to relative socioeconomic disadvantage. The present study investigated mortality rates in relation to this inequity from a gender perspective.
Data Availability Statement: This study is based on
multiple-linked data of national Swedish routine
registers including the total population register (TPR),
National Population and Housing Censuses, the
Longitudinal Data Base on Education, Income and
Employment (LOUISE) and the Cause of Death
registers. The data is maintained at the Centre for
Health Equity Studies (CHESS) in Stockholm and
was approved by the Regional Ethical Review board
of Karolinska Institutet on 2002-11-11. CHESS my be
contacted at: CHESS, Centre for Health Equity
Studies, SE-106 91 Stockholm, Phone: +46 8 16 20
We used data from national registers covering the entire Swedish population aged 18-65
years. Offspring of foreign-born parents who were either Swedish born or had received
residency in Sweden before school age (<7 years) were defined as offspring of immigrants.
We used Cox regression models to examine the association between parental country of
birth and mortality between 1990 and 2008, with adjustment for education, income, age and
Male offspring of immigrants from the Middle East (HR:2.00, CI:1.66-2.26), other
nonEuropean countries (HR:1.80, CI:1.36-2.36) and Finland (HR:1.56, CI:1.48-1.65) showed
an age-adjusted excess mortality risk from all causes of death when compared to offspring
with Swedish-born parents. Income, but not education, greatly attenuated these increased
mortality risks. No excess mortality rates were found among female offspring of immigrants,
with the exception of external cause of death among offspring of Finnish immigrants.
The study demonstrates high mortality rates in male offspring of immigrants from Finland
and non-European countries that are associated with economic, but not educational,
disadvantage. No increased mortality rates were found among female offspring of immigrants.
Future studies are needed to explain this gender differential and why income, but not
education, predicts mortality in male offspring of immigrants.
Funding: This study was supported by the Swedish
Council for Health, Working Life and Welfare. The
study received funding from the Swedish National
Board of Health and Welfare, grant #2012-1190. The
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
Competing Interests: The authors have declared
that no competing interests exist.
Immigrants in Sweden, as well as their offspring, have been found to have higher risks of
various health problems: psychiatric morbidity, self-inflicted injuries , suicide , psychotic
disorders , illicit drug abuse, as well as less favorable subjective health [5,6]. Studies have
linked this higher burden of ill health to social inequity. Immigrants and their offspring have
been singled out as a social category with difficult living conditions in Sweden, especially in the
aftermath of the recession in the early 1990s , when unemployment rates increased more
among immigrants and their offspring than among other segments of the population .
Some studies have suggested that female immigrants and offspring of immigrants are
particularly vulnerable to health problems associated with the social disadvantage of migration
[9,10]. There are both socioeconomic and behavioral explanations for potential health
differentials by gender among offspring of foreign-born individuals. The situation of immigrant
women is worse than that of men as regards gaining access to the labor market, and women
have greater difficulty finding jobs that correspond to their qualifications [11,12]. Research
into social inequalities in health shows that women are more vulnerable to developing
depression when exposed to socioeconomic disadvantage [12,13]. Women also report less favorable
subjective health in general when exposed to a low socioeconomic position . Gender
intersects with income, racial and ethnic hierarchies as well as with a number of other work-related
social markers . For instance, employment, access to the labor market and time in paid and
unpaid work influence health differently in women than in men. With regard to behavioral
risk factors, studies conducted in Sweden have shown that women smoke and drink less than
men do, especially women from certain non-European countries . Deaths from
smokingrelated diseases are more common among men than among women . Health problems
related to obesity are more common among non-European migrant women than among
Swedish-born women [17,18]. Moreover, obesity may influence womens and mens labor market
attachment differently, which may translate into lower earnings among women. Research
shows that obese women have a higher risk of unemployment than do women of normal
weight, yet similar results were not found among men .
The socio-historical context of immigration in Sweden
Migration patterns to Sweden have changed character during the post-war period, and we
might expect the composition of offspring with a foreign background to largely have followed
these changes. Throughout the economic boom of the 1960s and 1970s, immigration to
Sweden was dominated by a foreign labor force from the neighboring Nordic countries, in
particular from Finland. However there was also labor immigration from other European countries
such as Germany, Austria, Italy, Yugoslavia, Greece and Turkey. The global economic crisis in
the 1970s together with changes in Swedish migration policy brought about changes in the
immigration patterns as the demand for foreign labor declined significantly. Since that period,
Sweden has experienced growing flows of asylum seekers and their families coming from
nonEuropean countries. In the 1970s, the majority of refugees came from Latin America.
Throughout the 1980s, most refugees came from Iran and Iraq, and in the 1990s, Sweden also received a
large number of refugees from the former Yugoslavia along with North Africa [6,20].
Experiences of discrimination, social exclusion and socioeconomic disadvantages have been
considered common challenges faced by migrants in Sweden, especially among non-European
migrants. A recent Swedish study shows that many specific groups are disadvantaged in terms
of income and occupational status, despite their fairly high educational level . However,
whether a similar pattern is discernible among children of immigrants is not clear.
Although numerous studies have examined health and mortality among foreign-born
individuals , data on the situation of their offspring are still limited. Thus, here we will study
mortality among the offspring of foreign-born individuals in Sweden. Using unique
longitudinal registry data covering the total Swedish population, we wished to investigate whether the
socioeconomic inequity associated with having immigrant parents translates into mortality
differentials and, if so, whether these patterns differ between men and women.
The present study is based on multiple-linked data from national Swedish routine registers
including the total population register (TPR), National Population and Housing Censuses, the
Longitudinal Data Base on Education, Income and Employment (LOUISE) and the Cause of
Death register. The data are maintained at the Centre for Health Equity Studies (CHESS) in
The specific aims of the present study were approved by the Central Ethical Review Board of
Stockholm (decision no. 2012/126031). All data used here were anonymous, and the
researchers did not have access to any personal information that could identify study participants (e.g.,
personal identity number, home address, etc.). Consequently, it was not possible to trace
specific individuals included in the dataset.
The study population included all Swedish residents who were in the age range 18 to 65 during
19902008 according to the Register of the Total Population and who fulfilled the studys
parental country of birth criteria. The normal retirement age in Sweden is 65 years, and persons
were excluded from the analysis when they turned 65 because we wished to study the influence
of socioeconomic determinants of mortality among offspring of immigrants in the working age
population. The cohort was followed for all-cause mortality and mortality due to external and
natural causes by record linkage to the Cause of Death Register during 19902008. The study
cohort consisted of 4,648,143 persons (see Table 1).
We defined offspring of immigrants as individuals with two foreign-born parents who were
either born in Sweden or had immigrated to Sweden before school age (06 years). Offspring
of two Swedish-born parents were also included in the study population as a comparison
group, while offspring of two parents from different countries of birth were excluded from
the study because we were less interested in children of mixed ethnic origin. Individuals who
immigrated to Sweden before school age were studied together with Swedish-born children
with two foreign-born parents, as previous Swedish studies have demonstrated that their health
patterns are similar [3,22]. To ascertain that this held true in the present study as well, we
performed an additional sensitivity analysis.
We distinguished deaths from all causes, natural causes (ICD9 codes 00007969 or ICD10
codes A00-R99) and external causes of death (ICD9 codes 80009999 or ICD10 codes
V01Y98) using the Cause of Death Register. We used information on the year and month of death.
For a description of the distribution of specific causes of death among groups of children of
immigrants, see S1 Appendix.
Germany, Belgium, France, Netherlands, Luxembourg, Norway, Island,
Denmark, England, Italy, Switzerland, USA and other Western
Poland, Hungary, Bulgaria and other Eastern European countries
Yugoslavia, Slovenia, Croatia, Bosnia-Herzegovina, Macedonia
Africa, Latin America and South Asia
Turkey, Iran, Iraq, Syria, Lebanon and other Middle East
Gender: Indicates whether the person is a man or woman.
Age: Is a continuous variable and includes adults of working age, which is between the ages
of 18 and 65, at any time during the follow-up period.
Education: Is classified into three levels: Primary consists of compulsory school and
presecondary education of less than 9 years, secondary covers three years of upper secondary
school and university comprises tertiary education at university colleges.
Family type: Is divided into 3 levels: other family status, married/cohabiting with at least
one child, and single parents.
Disposable income: This variable is based on information on the individual part of the
households annual disposable income and comprises various sources of income after tax. The
variable is equally divided into 5 quintiles: Quintile 1 compromises those whose income is in
the lowest 20% of the total income range, while quintile 5 corresponds to those whose income
is in the highest 20%.
The analysis was based on person-time measured from January 1990 to December 2008.
Person-time was measured from January 1990 or the year the individual turned 18, until
December 2008 or when he/she died, emigrated or turned 65.
Cox proportional hazards of gender-stratified models were estimated to contrast all-cause,
as well as cause-specific, mortality rates among individuals by parents country of birth
categories. All co-variates were introduced as time-dependent variables on a yearly basis in the
models. All models were adjusted for age. Model 2 was also adjusted for income only, Model 3
also for education only, and the final model included all aforementioned variables and family
type (Model 4). The proportional hazards assumption was formally assessed using a
Grambsch-Therneau test performed on the basis of the Schoenfeld residuals from each Cox
regression model 
Table 1 presents the study population by parents country/region of birth. The largest group of
immigrant offspring was found among Finns, with 93,629 individuals born in Sweden or
having immigrated to Sweden under the age of 7, with both parents born in Finland. The
smallest group was those with both parents born in Africa, Latin America and South Asia,
accounting for a total of 12,946 individuals. A total of 75,011,165 person-months were analyzed, and
there were 145,228 deaths during the follow-up period. The distribution of the most common
causes of death by parents country of birth is presented in S1 Appendix. Table 2 describes the
socioeconomic indicators of the study population. The table reveals that offspring of
immigrants from the Middle East and the former Yugoslavian republics had the lowest mean age
compared to other immigrant offspring. The table also shows that there are no major
educational differences within the study population. On the other hand, we found a considerable
difference in distribution of income across the study population. In fact, descendants of
immigrants from the Middle East and other non-European countries are overrepresented
among those with the lowest total income. When socioeconomic conditions (i.e., education
and income) were stratified by gender (see S2 Appendix), the results indicated that the
proportion with a university-level education was somewhat higher among women than among men.
We also found higher percentages of men with a primary education compared to women.
Despite higher education, women descendants of immigrants had a lower income than their male
Table 3 shows a gender-stratified Cox regression for all-cause mortality. Model 1 shows that
male offspring of immigrants from the Middle East (HR: 2.00, 95% CI: 1.662.46), other
nonEuropean countries (HR: 1.80, 95% CI: 1.362.36) and Finland (HR: 1.56, 95% CI: 1.481.65)
experienced higher mortality risks than Swedish males did. When income was adjusted for in
Model 2, the mortality risks were attenuated considerably in all groups except among Finnish
offspring of immigrants (HR: 1.53, 95% CI: 1.451.62). In contrast, there was only marginal
attenuation of these mortality risks when education, but not income, was adjusted for in Model
3. Finally, in Model 4 (fully adjusted for family type, education, age and income), patterns were
similar to the income-only adjusted model (Model 2).
Unadjusted mortality patterns among female offspring of immigrants in Table 3 reveal no
excessive mortality risks. In female offspring of Finnish immigrants, however, a slightly
increased risk is present in the adjusted models (Model 24). For all other female offspring of
immigrants, the fully adjusted models generally show no or even lower mortality risks compared
with offspring of native Swedes, although the results are not statistically significant.
In Table 4, mortality risks are presented separately for external and natural causes for men
only. Mortality rates and attenuation after adjustment for income were similar for these two
broad causes of death, as compared to deaths from all causes. For offspring of Finnish women,
there was a notable difference, with a crude increased HR in external causes of death 1.47
(1.271.72), which increased further to 1.65 (1.451.90) with adjustment for income, while
there were no increased mortality risks for natural causes. These results are not shown in the
tables, as they were not significant for all other offspring of immigrants.
A sensitivity analysis was performed, where the crude estimates for Swedish-born offspring
of immigrants only were compared with those including children who came to Sweden before
age 7. The results (not shown in the table) indicated that male offspring of immigrants from
the Middle East (HR: 1.78, CI: 1.292.38), other non-European countries (HR: 1.82, CI:
1.162.86), former Yugoslavian republics (HR: 1.19, CI: 1.231.73) and Finland (HR: 1.76, CI:
1.641.89) experienced higher mortality risks than Swedish males did. The estimated results
decreased considerably when income was adjusted for, except among offspring of Finnish
immigrants: HR = 1.69 (1.581.82). No excess risk mortality patterns were found among female
offspring of immigrants. To conclude, including offspring who arrived before school age into
our analyses did not alter the overall findings.
The results of the present study on a national cohort of adult offspring of immigrants in
Sweden demonstrate twofold increased mortality among offspring of non-European immigrants
and more modestly increased mortality rates among offspring of immigrants from Finland and
the former Yugoslavia compared with the majority population. These increased risks were
greatly attenuated after adjustment for income, but not for education. For female offspring no
increased risks were found, with the exception of increased mortality in external cause death
Parents country/region of birth
Parents country/region of birth
for offspring of Finnish immigrants, which was not attenuated either by income or
One major finding in the present study was that income, but not education, attenuated the
mortality differentials between male offspring of immigrants compared with the majority
population. This effect was particularly strong among the offspring of non-European immigrants,
where mortality rates were the highest. Offspring of non-European immigrants are easy to
identify in a Swedish context, owing to their physical appearance and non-Swedish names.
Studies in Canada , Sweden [23,27], the US  and Germany  have also shown that
native Blacks and other offspring of non-European immigrants experience significant
disadvantages in earnings as a consequence of discrimination on the employment market and within
certain occupational sectors. Thus, discrimination on the labor market, which results in
education not paying off in the same way as it does in the majority population, is congruent with the
income-education pattern found here. Numerous studies [30,31] have suggested that perceived
discrimination is a chronic stressor that leads to ill health, and we may speculate that chronic
stress of this kind is also important in understanding the present findings of higher mortality
rates among Swedish residents of non-European origin. Accordingly, it has been argued that
occupational mismatch per se is associated with poor mental health, for instance through
feelings of shame . This may especially influence the health of overeducated workers with
an immigrant background, who are more likely to experience occupational mismatch and its
potential consequences in the form of psychological stress and shame . Further studies are
needed to confirm this hypothesis.
The present study confirms a large body of previous studies describing an excess risk of ill
health among Swedish residents of Finnish origin [2,3539]. Alcohol abuse and high smoking
rates have been implicated as important risk factors for this increased morbidity and mortality
in the Finnish population in Sweden [40,41]. Our findings also suggest that higher mortality
rates among offspring of Finnish immigrants are in accord with the mortality risk of their
foreign-born parents .
The higher mortality risks of male offspring of non-European immigrants are in stark
contrast to the lower mortality rates observed in their parents in a previous Swedish study.
Considering that first-generation non-European immigrants have been found to have
considerably lower incomes compared with their offspring, socioeconomic factors cannot be expected
to be important in explaining this differential. A healthy migrant hypothesis , on the other
hand, would fit this pattern, assuming that individuals with good health in the country of origin
were more prone to migrate to Sweden, while their offspring were not selected in this manner.
Accordingly, previous evidence from the US suggests that the offspring of immigrants
experience poorer health than their foreign-born parents do and that second-generation migrants
have adopted a mortality pattern equivalent to that of the native population .
The present study did not confirm hypotheses about female vulnerability to the health
consequences of socioeconomic disadvantage associated with migration. On the contrary, men
with non-European parents were found to have the highest mortality rates for external as well
as natural causes. In general, scholars have argued that women are more vulnerable to
socioeconomic disadvantage than men are and that this is a consequence of gender discrimination,
unemployment and conflicting gender role expectations [44,45]. Nevertheless, our findings
indicated that men were more likely than women to experience higher mortality risks. It is
plausible that the excess mortality risks faced particularly by Finnish as well as non-European
offspring could be explained by disparities in gender differences in behavioral factors related to
one socioeconomic position . Smoking is one risk factor that could fit such a pattern,
where men with a Middle Eastern heritage have been found to have particularly high rates,
while women with a Middle Eastern heritage have been shown to have lower rates compared to
the majority population . Use and abuse of illicit drugs is another factor that shows a similar
pattern . To a certain extent, men and women compete on different labor markets, which
could be another factor of interest in explaining these gender differences .
Besides the obvious strengths of our study, such as the use of population register data, the
extent of the study period and longitudinal follow-up, there are some methodological concerns
and limitations that should be raised. The concept offspring of immigrants could be
questioned, as individuals who immigrated under the age of 7 years were included in this group.
We do believe, however, that children who immigrate before school age have more in common
with children born after resettlement of the family than do adult or teenage immigrants, and
this is corroborated by studies of educational achievement in the US . This assumption was
supported by the sensitivity test reported above.
Furthermore, we restricted our study population to children of immigrants in the working
age population, i.e. 1865 years. We decided not to include old-age pensioners, because they
may have health issues that are different from those found in the working population.
Including persons over the age of 65 years would also involve difficulties in interpreting the
contribution of confounders and especially income to the association of primary interest, because
income would have been related to the retirement pension system rather than to current
employment. Finally, within this restricted population of children of immigrants, the majority of
whom arrived in Sweden after the 1950s and 1960s, very few individuals are older than
65 years. Data on age distribution showed that the proportion of children of immigrants above
the age of 65 is very low (less than 1%). Yet this age restriction means that we can only
generalize our results to the working age population and not to people of retirement age.
One general shortcoming of register data is that essential information about the
mechanisms underlying associations is lacking. For instance, the data used in our study did not
contain information related to health behavior, social support or measurement of different types of
discrimination related to gender and ethnic background that could account for the effect of
individuals sociodemographic characteristics on the observed gender and ethnic mortality
pattern. Thus, our study needs to be complemented by other studies that include such variables.
The present study demonstrates increased mortality risks among adult male offspring of
immigrants from non-European countries in Sweden, and a more modest increase among offspring
of immigrants from the former Yugoslavia and Finland. This increased mortality in male
offspring of immigrants was greatly attenuated by adjustment for income, but not education.
Female offspring of immigrants, in contrast, had similar or even lower mortality rates compared
with the majority population, with the exception of female offspring of immigrants from
Finland. Further studies, with more detailed data on work and employment history, are needed to
elucidate the mechanisms underlying these striking differentials in mortality among the
offspring of immigrants.
S1 Appendix. Distribution of the common cause of death presented as proportions (%).
S2 Appendix. Distribution of income and education by gender presented as proportions
Conceived and designed the experiments: HM MR AH. Performed the experiments: HM MR.
Analyzed the data: HM AH. Contributed reagents/materials/analysis tools: HM MR AH ST.
Wrote the paper: HM MR AH ST.
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