Earlier studies have shown that mortality and morbidity vary in different parts of a country both in European countries and the US [
Previous longitudinal studies of mortality, morbidity, and heath care utilization among foreign- and native-born Swedes during 1970–1999 have found increased mortality, dissimilarities in mortality pattern, and differences in utilization of hospital care [
In Sweden, geographical differences in mortality and morbidity of the total population have been described [
Swedish society has changed during the last century due to international migration and foreign-born people living in Sweden constituted 2004 11.5 percent of the total population [
The differences in health found in previous investigations, among foreign-born and native Swedes, could be a general pattern or vary in different parts of Sweden. Whether differences in healthcare services between county council areas are related to mortality among foreign born is unknown. In accordance with the Swedish Health and Medical Services Act, there should be no differences in healthcare services [
The aim of this study was to describe and compare the county distribution of mortality among foreign- and Swedish-born persons during the years 1970–1999. The pattern will be discussed in relation to gender, year of birth, and age at death, testing the null hypothesis that no county differences in mortality exist between foreign-born and native Swedes.
Data from Statistics Sweden (SCB) and the National Board of Health and Welfare Centre for Epidemiology covering the period 1970–1999 was analysed
A Swedish matched control could not be found for 20,518 of the foreign-born persons due to the matching criteria. Exclusion criteria were as follows: if no information was available or if a person had emigrated or migrated back (“remigrated”), thus in total 163,896 persons were excluded from the database. Persons were then also excluded if the information from the control subject was missing due to migration. In total 182,614 persons, 109,458 men and 73,156 women, were excluded from the database; see Table
Excluded and analysed persons related to country of birth, sex, and age.
Excluded male persons | Analysed male persons | Excluded female persons | Analysed female persons | |||||||
---|---|---|---|---|---|---|---|---|---|---|
|
Mean age 1970 | Proportion excluded % |
|
Mean age 1970 |
|
Mean age 1970 | Proportion excluded % |
|
Mean age 1970 | |
Swedish | 54 729 | 31.5 | 24.5 | 168 702 | 39.4 | 36 578 | 32.2 | 15.9 | 193 272 | 42.0 |
Denmark | 3 285 | 34.8 | 17.4 | 15 627 | 43.0 | 2 054 | 34.4 | 13.0 | 13 795 | 44.1 |
Finland | 27 193 | 29.3 | 30.8 | 60 959 | 34.8 | 18 035 | 29.9 | 17.9 | 82 544 | 37.4 |
Norway/Iceland | 3 654 | 32.9 | 21.6 | 13 236 | 45.7 | 2 875 | 33.4 | 11.4 | 22 413 | 48.0 |
Yugoslavia | 3 518 | 32.6 | 23.3 | 11 598 | 31.8 | 2 519 | 33.1 | 23.2 | 8 362 | 31.1 |
Poland | 462 | 35.4 | 9.8 | 4 253 | 44.6 | 354 | 35.2 | 6.7 | 4 925 | 44.6 |
Germany | 2 613 | 34.6 | 15.5 | 14 291 | 41.6 | 2 123 | 36.4 | 9.7 | 19 675 | 45.0 |
Other European | 10 442 | 34.2 | 23.2 | 34 510 | 42.0 | 6 577 | 34.9 | 18.9 | 28 229 | 46.0 |
Non-European | 3 496 | 32.4 | 19.9 | 14 035 | 45.0 | 1 966 | 33.9 | 13.1 | 13 081 | 51.7 |
Stateless/unknown | 66 | 30.6 | 25.5 | 193 | 50.2 | 75 | 30.7 | 23.2 | 248 | 55.8 |
| ||||||||||
Total | 109 458 | 100 | 337 404 | 73 156 | 386 544 |
The largest group of excluded foreign- born persons, 45,228 persons, consisted of persons born in Finland. In the original database 44,067 of them were coded as migrated (remigrated) and mortality among 37,904 (86%) of them could be analysed with data from the Population Register Centre in Finland. The analysis showed the same mortality risk among the excluded group as the Finnish-born persons who stayed in Sweden [
The database used for analysis finally consisted of 723,948 persons, 361,974 foreign-born and 361, 974 Swedish controls. Latest county of residence was used to distribute the study population in different geographical areas in Sweden. Mobility in Sweden between different counties showed a similar pattern. Among persons still living in 1990, 27.2% of foreign-born and 25.5% of Swedes had lived in the same county during 1970–1990 (
The 24 counties in Sweden differ with regard to population and area. The population varies from the largest one (Stockholm) with 1,860,872 inhabitants to the smallest (Gotland) with 57,535 inhabitants (SCB, 2004). The four most densely populated counties are, as in 1970, Stockholm, Göteborg och Bohus, Malmöhus, and Östergötland. Gotland, Blekinge, Kronoberg, and Kalmar represent the less populated and could be considered as more rural counties according to the national classification [
Values from the total cohort sample are given as numbers, means, and percentages. Comparisons were made by tests of significance with Mann-Whitney
Cox regression analysis was performed in two age groups: persons aged 60–69 years and 80 years or more. The analysis was adjusted for sex and age and tested the importance of being foreign born and latest county of residence (categorical). Uppsala was also in this analysis used as reference.
All analyses were performed using SPSS (Statistical Package for Social Sciences), version 11.5.
Approval of the study was granted from the Ethics Committee of Lund University, Sweden, after a reviewing process from all other university ethics committees in Sweden.
The study population was geographically distributed among the 24 different county council areas that made up the regional organization of Sweden in 1970. The major groups of foreign-born persons were found in the counties of Stockholm, Göteborg och Bohus, and Malmöhus; see Table
Population in relation to sex and latest County Council of residence.
County council | Proportion of foreign-born of total population 1970 | Men foreign-born | Swedish-born | Women foreign-born | Swedish-born | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|
% |
|
% |
|
% |
|
|
% |
|
% |
| |
Stockholm | 10.5 | 50 683 | 45.5 | 45 955 | 45.1 | 0.218 | 60 677 | 54.5 | 55 986 | 54.9 | 0.278 |
Uppsala | 6.1 | 4 016 | 46.5 | 4 178 | 46.3 | 0.512 | 4 614 | 53.5 | 4 849 | 53.7 | 0.278 |
Södermanland | 9.5 | 7 100 | 49.1 | 7 271 | 49.6 | 0.658 | 7 350 | 50.9 | 7 394 | 50.4 | 0.663 |
Östergötland | 5.0 | 5 444 | 47.8 | 6 048 | 47.9 | 0.913 | 5 942 | 52.2 | 6 570 | 52.1 | 0.918 |
Jönköping | 5.1 | 4 180 | 46.9 | 4 593 | 47.1 | 0.868 | 4 728 | 53.1 | 5 153 | 52.9 | 0.878 |
Kronoberg | 5.0 | 2 117 | 48.6 | 2 626 | 49.8 | 0.504 | 2 238 | 51.4 | 2 649 | 50.2 | 0.513 |
Kalmar | 3.4 | 2 352 | 48.5 | 2 915 | 47.9 | 0.746 | 2 502 | 51.5 | 3 167 | 52.1 | 0.758 |
Gotland | 2.5 | 441 | 38.1 | 561 | 38.8 | 0.811 | 717 | 61.9 | 886 | 61.2 | 0.861 |
Blekinge | 5.1 | 1 957 | 49.0 | 2 329 | 49.7 | 0.701 | 2 035 | 51.0 | 2 354 | 50.3 | 0.706 |
Kristianstad | 3.8 | 3 543 | 46.3 | 3 832 | 46.1 | 0.876 | 4 112 | 53.7 | 4 484 | 53.9 | 0.888 |
Malmöhus | 7.3 | 17 990 | 48.8 | 17 002 | 48.6 | 0.778 | 18 893 | 51.2 | 17 984 | 51.4 | 0.785 |
Halland | 4.7 | 3 583 | 46.8 | 3 887 | 47.3 | 0.685 | 4 079 | 53.2 | 4 331 | 52.7 | 0.708 |
Göteborg och Bohus | 8.4 | 19 041 | 50.5 | 18 097 | 50.0 | 0.439 | 18 664 | 49.5 | 18 093 | 50.0 | 0.436 |
Älvsborg | 7.8 | 8 761 | 44.7 | 9 121 | 44.9 | 0.868 | 10 827 | 55.3 | 11 180 | 55.1 | 0.757 |
Skaraborg | 3.9 | 2 966 | 46.2 | 3 339 | 46.3 | 0.945 | 3 452 | 53.8 | 3 871 | 53.7 | 0.950 |
Värmland | 4.6 | 4 365 | 43.5 | 4 782 | 44.5 | 0.338 | 5 681 | 56.5 | 5 962 | 55.5 | 0.415 |
Örebro | 6.2 | 5 148 | 48.7 | 5 568 | 48.8 | 0.923 | 5 418 | 51.3 | 5 834 | 51.2 | 0.925 |
Västmanland | 11.6 | 8 931 | 50.1 | 8 653 | 50.6 | 0.602 | 8 900 | 49.9 | 8 457 | 49.4 | 0.599 |
Dalarna | 4.8 | 4 805 | 48.4 | 5 535 | 48.3 | 0.978 | 5 126 | 51.6 | 5 913 | 51.7 | 0.977 |
Gävleborg | 3.7 | 3 468 | 49.0 | 4 027 | 48.9 | 0.976 | 3 611 | 51.0 | 4 200 | 51.1 | 0.977 |
Västernorrland | 2.5 | 2 365 | 44.1 | 2 675 | 44.9 | 0.601 | 2 996 | 55.9 | 3 282 | 55.1 | 0.651 |
Jämtland | 2.3 | 973 | 39.2 | 1 344 | 42.7 | 0.088 | 1 511 | 60.8 | 1 807 | 57.3 | 0.180 |
Västerbotten | 1.9 | 1 323 | 35.7 | 1 622 | 37.9 | 0.163 | 2 383 | 64.3 | 2 655 | 62.1 | 0.329 |
Norrbotten | 4.5 | 3 150 | 31.6 | 2 742 | 30.6 | 0.292 | 6 816 | 68.4 | 6 211 | 69.4 | 0.532 |
| |||||||||||
Total | 168 702 | 168 702 | 193 272 | 193 272 |
Population in relation to age (1970) and latest county council of residence.
County council | Foreign-born men | Swedish-born men | Foreign-born women | Swedish-born women | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Age (mean) | 95% CI | Age (mean) | 95% CI |
|
Age (mean) | 95% CI | Age (mean) | 95% CI |
| |
Stockholm | 39.9 | 39.8, 40.0 | 40.6 | 40.4, 40.7 | 0.000 | 43.0 | 42.9, 43.2 | 43.7 | 43.6, 43.8 | 0.000 |
Uppsala | 36.6 | 36.2, 37.1 | 36.7 | 36.2, 37.1 | 0.884 | 39.2 | 38.7, 39.6 | 39.0 | 38.6, 39.4 | 0.524 |
Södermanland | 38.5 | 38.2, 38.8 | 38.6 | 38.3, 38.9 | 0.670 | 40.0 | 39.7, 40.4 | 40.2 | 39.9, 40.6 | 0.487 |
Östergötland | 38.8 | 38.4, 39.1 | 38.1 | 37.7, 38.4 | 0.008 | 40.9 | 40.5, 41.3 | 40.4 | 40.0, 40.7 | 0.037 |
Jönköping | 38.3 | 37.8, 38.7 | 37.6 | 37.2, 38.1 | 0.026 | 40.5 | 40.0, 40.9 | 39.9 | 39.5, 40.3 | 0.029 |
Kronoberg | 39.0 | 38.4, 39.7 | 38.3 | 37.7, 38.8 | 0.088 | 40.9 | 40.3, 41.6 | 40.1 | 39.5, 40.7 | 0.055 |
Kalmar | 40.6 | 40.0, 41.2 | 39.0 | 38.4, 39.5 | 0.000 | 42.9 | 42.3, 43.5 | 41.0 | 40.4, 41.5 | 0.000 |
Gotland | 45.7 | 44.1, 47.3 | 42.6 | 41.2, 44.0 | 0.002 | 47.7 | 46.5, 48.9 | 44.6 | 43.5, 45.8 | 0.000 |
Blekinge | 39.4 | 38.8, 40.1 | 38.1 | 37.5, 38.7 | 0.001 | 42.1 | 41.3, 42.8 | 41.1 | 40.2, 41.8 | 0.068 |
Kristianstad | 40.6 | 40.1, 41.0 | 39.7 | 39.3, 40.2 | 0.009 | 42.6 | 42.1, 43.1 | 41.8 | 41.4, 42.3 | 0.022 |
Malmöhus | 39.7 | 39.5, 40.0 | 39.8 | 39.6, 40.0 | 0.725 | 42.5 | 42.3, 42.8 | 42.7 | 42.5, 43.0 | 0.377 |
Halland | 38.6 | 38.2, 39.1 | 38.2 | 37.7, 38.6 | 0.093 | 40.8 | 40.3, 41.3 | 40.1 | 39.7, 40.6 | 0.037 |
Göteborg och Bohus | 39.1 | 38.9, 39.3 | 39.5 | 39.3, 39.7 | 0.002 | 42.3 | 42.1, 42.6 | 42.6 | 42.4, 42.9 | 0.080 |
Älvsborg | 39.0 | 38.7, 39.2 | 38.7 | 38.4, 39.0 | 0.071 | 40.8 | 40.5, 41.1 | 40.6 | 40.3, 40.9 | 0.172 |
Skaraborg | 37.6 | 37.1, 38.1 | 37.0 | 36.5, 37.5 | 0.074 | 40.0 | 39.5, 40.5 | 39.4 | 38.9, 39.9 | 0.061 |
Värmland | 44.1 | 43.6, 44.6 | 43.0 | 42.6, 43.5 | 0.001 | 45.4 | 45.0, 45.8 | 44.8 | 44.3, 45.2 | 0.034 |
Örebro | 38.9 | 38.5, 39.3 | 38.6 | 38.2, 38.9 | 0.195 | 40.9 | 40.5, 41.3 | 40.5 | 40.1, 40.9 | 0.122 |
Västmanland | 37.7 | 37.4, 38.0 | 38.0 | 37.6, 38.3 | 0.138 | 39.0 | 38.7, 39.3 | 39.5 | 39.2, 39.8 | 0.009 |
Dalarna | 39.3 | 39.0, 39.7 | 39.0 | 38.7, 39.4 | 0.253 | 41.0 | 40.6, 41.4 | 40.5 | 40.2, 40.9 | 0.072 |
Gävleborg | 38.0 | 37.6, 38.5 | 37.6 | 37.2, 38.0 | 0.230 | 40.6 | 40.1, 41.1 | 39.8 | 39.4, 40.3 | 0.038 |
Västernorrland | 38.6 | 38.1, 39.2 | 38.5 | 38.0, 39.0 | 0.880 | 42.0 | 41.4, 42.5 | 41.5 | 40.9, 42.0 | 0.222 |
Jämtland | 42.8 | 41.9, 43.8 | 40.4 | 39.6, 41.2 | 0.000 | 44.1 | 43.3, 44.8 | 42.5 | 41.8, 43.2 | 0.002 |
Västerbotten | 37.8 | 37.0, 38.6 | 37.0 | 36.4, 37.7 | 0.389 | 41.4 | 40.8, 42.0 | 41.2 | 40.6, 41.7 | 0.625 |
Norrbotten | 38.8 | 38.3, 39.3 | 39.7 | 39.1, 40.3 | 0.022 | 43.5 | 43.1, 43.9 | 44.7 | 44.3, 45.1 | 0.000 |
| ||||||||||
Total |
During the studied period 1970–1999, a total of 116,063 foreign-born and 104,865 Swedish control persons had died. There was significant higher mortality for foreign-born persons than native Swedes in all counties with one exception, Norrbotten. The highest percentage of deceased among foreign-born persons was found in Gotland (43%), Värmland (40.0%), and Jämtland (37.4%). The largest difference in deceased subjects, with higher mortality among foreign-born than Swedish-born persons, was found in the rural counties of Gotland (7.6%), Blekinge (7.1%), Kalmar (5.9%), and Kronoberg (5.7%).
There was significant higher mortality in all counties for men and in 19 of the 24 counties for women (Tables
(a) Deceased men in relation to latest county council of residence, (b) Deceased women in relation to latest to county council of residence.
County council |
Foreign-born men | Swedish-born men | ||||
---|---|---|---|---|---|---|
|
% |
|
% |
|
% difference | |
Gotland | 219 | 49.7 | 215 | 38.3 | 0.000 | 11.4 |
Blekinge | 697 | 35.6 | 620 | 26.6 | 0.000 | 9.0 |
Jämtland | 402 | 41.3 | 449 | 33.4 | 0.000 | 7.9 |
Jönköping | 1 366 | 32.7 | 1 155 | 25.1 | 0.000 | 7.6 |
Västernorrland | 809 | 34.2 | 723 | 27.0 | 0.000 | 7.2 |
Kronoberg | 700 | 33.1 | 686 | 26.1 | 0.000 | 7.0 |
Älvsborg | 3 060 | 34.9 | 2 542 | 27.9 | 0.000 | 7.0 |
Örebro | 1 776 | 34.5 | 1 553 | 27.9 | 0.000 | 6.6 |
Östergötland | 1 821 | 33.4 | 1 632 | 27.0 | 0.000 | 6.4 |
Kalmar | 830 | 35.3 | 841 | 28.9 | 0.000 | 6.4 |
Stockholm | 18 214 | 39.9 | 15 613 | 34.0 | 0.000 | 5.9 |
Värmland | 1 976 | 45.3 | 1 899 | 39.7 | 0.000 | 5.6 |
Södermanland | 2 482 | 35.0 | 2 142 | 29.5 | 0.000 | 5.5 |
Kristianstad | 1 214 | 34.3 | 1 105 | 28.8 | 0.000 | 5.5 |
Skaraborg | 891 | 30.0 | 829 | 24.8 | 0.000 | 5.2 |
Dalarna | 1 668 | 34.7 | 1 634 | 29.5 | 0.000 | 5.2 |
Halland | 1 077 | 30.1 | 981 | 25.2 | 0.000 | 4.9 |
Gävleborg | 1 149 | 33.1 | 1 134 | 28.2 | 0.000 | 4.9 |
Göteborg och Bohus | 6 816 | 35.8 | 5 610 | 31.0 | 0.000 | 4.8 |
Västerbotten | 392 | 29.6 | 422 | 26.0 | 0.029 | 3.6 |
Malmöhus | 6 311 | 35.1 | 5 354 | 31.5 | 0.000 | 3.6 |
Västmanland | 2 737 | 30.6 | 2 343 | 27.1 | 0.000 | 3.5 |
Uppsala | 1 117 | 27.8 | 1 026 | 24.6 | 0.001 | 3.2 |
Norrbotten | 1096 | 34.8 | 883 | 32.2 | 0.036 | 2.6 |
| ||||||
Total | 58 820 | 51 391 |
County council | Foreign-born women | Swedish-born women | ||||
---|---|---|---|---|---|---|
|
% |
|
% |
|
% difference | |
Kalmar | 770 | 30.8 | 807 | 25.5 | 0.000 | 5.3 |
Blekinge | 640 | 31.4 | 617 | 26.2 | 0.000 | 5.2 |
Kronoberg | 617 | 27.6 | 604 | 22.8 | 0.000 | 4.8 |
Gotland | 282 | 39.3 | 301 | 34.0 | 0.027 | 4.7 |
Kristianstad | 1 239 | 30.1 | 1 155 | 25.8 | 0.000 | 4.3 |
Jönköping | 1 220 | 25.8 | 1 152 | 22.4 | 0.000 | 3.4 |
Älvsborg | 3 009 | 27.8 | 2 768 | 24.8 | 0.000 | 3.0 |
Gävleborg | 982 | 27.2 | 1 015 | 24.2 | 0.002 | 3.0 |
Östergötland | 1 647 | 27.7 | 1 632 | 24.8 | 0.000 | 2.9 |
Malmöhus | 5 791 | 30.7 | 5 014 | 27.9 | 0.000 | 2.8 |
Halland | 1 028 | 25.2 | 977 | 22.6 | 0.004 | 2.6 |
Västerbotten | 669 | 28.1 | 681 | 25.6 | 0.052 | 2.5 |
Örebro | 1 483 | 27.4 | 1 466 | 25.1 | 0.007 | 2.3 |
Dalarna | 1 397 | 27.3 | 1 478 | 25.0 | 0.007 | 2.3 |
Göteborg och Bohus | 5 723 | 30.7 | 5 200 | 28.7 | 0.000 | 2.0 |
Uppsala | 1 099 | 23.8 | 1 057 | 21.8 | 0.019 | 2.0 |
Västernorrland | 905 | 30.2 | 925 | 28.2 | 0.078 | 2.0 |
Värmland | 2 046 | 36.0 | 2 040 | 34.2 | 0.042 | 1.8 |
Södermanland | 1 954 | 26.6 | 1 846 | 25.0 | 0.025 | 1.6 |
Skaraborg | 843 | 24.4 | 887 | 22.9 | 0.130 | 1.5 |
Norrbotten | 2 235 | 32.8 | 2 090 | 33.6 | 0.298 | 0.8 |
Stockholm | 19 140 | 31.5 | 17 289 | 30.9 | 0.015 | 0.6 |
Västmanland | 2 065 | 23.2 | 1 927 | 22.8 | 0.515 | 0.4 |
Jämtland | 459 | 30.4 | 546 | 30.2 | 0.920 | 0.2 |
| ||||||
Total | 57 243 | 53 474 |
Mean age at time of death was significantly lower for foreign- than Swedish-born men in all counties, ranging from 1.0 to 4.4 years, except for Kalmar and Gotland (Table
Deceased in relation to age at time of death and latest county council of residence.
County council | Foreign-born men | Swedish-born men | Foreign-born women | Swedish-born women | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Age (mean) | 95% CI | Age (mean) | 95% CI |
|
Age (mean) | 95% CI | Age (mean) | 95% CI |
| |
Stockholm | 67.5 | 67.3, 67.7 | 70.6 | 70.4, 70.8 | 0.000 | 75.0 | 74.8, 75.2 | 76.9 | 76.7, 77.1 | 0.000 |
Uppsala | 66.0 | 65.1, 66.8 | 69.1 | 68.2, 70.0 | 0.000 | 73.7 | 72.9, 74.5 | 75.2 | 74.4, 76.0 | 0.004 |
Södermanland | 65.7 | 65.2, 66.3 | 70.1 | 69.5, 70.6 | 0.000 | 72.6 | 72.0, 73.2 | 74.8 | 74.2, 75.4 | 0.000 |
Östergötland | 66.2 | 65.5, 66.9 | 70.5 | 69.9, 71.1 | 0.000 | 73.5 | 72.8, 74.2 | 75.1 | 74.4, 75.7 | 0.002 |
Jönköping | 66.3 | 65.6, 67.1 | 70.2 | 69.5, 71.0 | 0.000 | 72.9 | 72.1, 73.7 | 74.2 | 73.4, 75.0 | 0.013 |
Kronoberg | 68.5 | 67.4, 69.5 | 71.5 | 70.6, 72.5 | 0.000 | 73.3 | 72.1, 74.4 | 75.5 | 74.5, 76.5 | 0.008 |
Kalmar | 68.7 | 67.7, 69.7 | 70.4 | 69.6, 71.3 | 0.060 | 75.5 | 74.6, 76.4 | 75.8 | 75.0, 76.7 | 0.626 |
Gotland | 72.4 | 70.7, 74.1 | 73.6 | 71.9, 75.2 | 0.310 | 78.0 | 76.6, 79.3 | 77.9 | 76.6, 79.3 | 0.979 |
Blekinge | 67.9 | 66.9, 68.9 | 71.3 | 70.3, 72.3 | 0.000 | 74.4 | 73.3, 75.5 | 76.6 | 75.7, 77.6 | 0.005 |
Kristianstad | 69.7 | 68.9, 70.4 | 72.2 | 71.5, 72.9 | 0.000 | 74.9 | 74.2, 75.7 | 76.8 | 76.1, 77.5 | 0.001 |
Malmöhus | 67.9 | 67.5, 68.2 | 70.6 | 70.3, 70.9 | 0.000 | 74.4 | 74.1, 74.8 | 76.7 | 76.4, 77.1 | 0.000 |
Halland | 67.8 | 67.1, 68.6 | 70.7 | 69.9, 71.6 | 0.000 | 74.4 | 73.5, 75.2 | 76.3 | 75.5, 77.1 | 0.001 |
Göteborg och Bohus | 65.9 | 65.5, 66.2 | 69.7 | 69.3, 70.0 | 0.000 | 73.9 | 73.6, 74.3 | 76.0 | 75.7, 76.3 | 0.000 |
Älvsborg | 67.1 | 66.6, 67.7 | 71.3 | 70.8, 71.8 | 0.000 | 73.9 | 73.5, 74.4 | 76.1 | 75.6, 76.6 | 0.000 |
Skaraborg | 67.0 | 66.0, 67.9 | 70.5 | 69.7, 71.4 | 0.000 | 73.4 | 72.4, 74.3 | 74.6 | 73.8, 75.4 | 0.105 |
Värmland | 70.3 | 69.8, 70.9 | 72.7 | 72.2, 73.2 | 0.000 | 75.5 | 75.0, 76.1 | 76.8 | 76.3, 77.3 | 0.001 |
Örebro | 66.6 | 65.9, 67.2 | 70.2 | 69.5, 70.8 | 0.000 | 72.3 | 71.7, 73.0 | 74.0 | 73.4, 74.7 | 0.000 |
Västmanland | 65.7 | 65.2, 66.2 | 69.5 | 69.0, 70.0 | 0.000 | 71.8 | 71.2, 72.3 | 73.0 | 72.4, 73.6 | 0.002 |
Dalarna | 66.6 | 65.9, 67.2 | 70.8 | 70.2, 71.4 | 0.000 | 72.5 | 71.8, 73.2 | 74.2 | 73.5, 74.8 | 0.001 |
Gävleborg | 64.8 | 64.0, 65.6 | 68.6 | 67.9, 69.3 | 0.000 | 72.6 | 71.7, 73.4 | 74.5 | 73.7, 75.2 | 0.005 |
Västernorrland | 66.4 | 65.5, 67.3 | 70.4 | 69.5, 71.3 | 0.000 | 73.7 | 72.8, 74.5 | 74.2 | 73.4, 75.1 | 0.340 |
Jämtland | 70.3 | 69.0, 71.6 | 71.3 | 70.1, 72.4 | 0.000 | 75.3 | 74.2, 76.5 | 74.8 | 73.8, 75.8 | 0.558 |
Västerbotten | 67.7 | 66.3, 69.1 | 70.0 | 68.8, 71.2 | 0.003 | 72.4 | 71.4, 73.4 | 74.4 | 73.5, 75.3 | 0.008 |
Norrbotten | 67.1 | 66.3, 67.9 | 70.8 | 70.0, 71.6 | 0.000 | 74.7 | 74.2, 75.2 | 76.0 | 75.5, 76.5 | 0.000 |
Logistic regression analysis studying the influence of being foreign-born and latest county of residence on mortality showed that being foreign-born was, adjusted for age and sex, an independent influencing factor (
Multifactorial influence of being foreign-born on mortality adjusted for age and gender with latest county council of residence as independent categorical variable using Uppsala county council as reference.
County council |
|
SE |
|
OR | 95% CI for Exp. |
---|---|---|---|---|---|
Stockholm | 0.180 | 0.023 | 0.000 | 1.197 | 1.144, 1.253 |
Södermanland | 0.197 | 0.028 | 0.000 | 1.218 | 1.154, 1.286 |
Östergötland | 0.116 | 0.029 | 0.000 | 1.123 | 1.061, 1.189 |
Jönköping | 0.063 | 0.031 | 0.041 | 1.065 | 1.003, 1.131 |
Kronoberg | 0.013 | 0.037 | 0.736 | 1.013 | 0.941, 1.089 |
Kalmar | 0.062 | 0.035 | 0.079 | 1.064 | 0.993, 1.140 |
Gotland | 0.194 | 0.059 | 0.001 | 1.214 | 1.081, 1.362 |
Blekinge | 0.113 | 0.038 | 0.003 | 1.119 | 1.038, 1.206 |
Kristianstad | 0.022 | 0.032 | 0.482 | 1.023 | 0.961, 1.089 |
Malmöhus | 0.157 | 0.025 | 0.000 | 1.170 | 1.115, 1.228 |
Halland | −0.053 | 0.032 | 0.099 | 0.948 | 0.890, 1.010 |
Göteborg och Bohus | 0.210 | 0.025 | 0.000 | 1.233 | 1.175, 1.294 |
Älvsborg | 0.106 | 0.027 | 0.000 | 1.112 | 1.055, 1.172 |
Skaraborg | 0.047 | 0.034 | 0.159 | 1.049 | 0.982, 1.120 |
Värmland | 0.255 | 0.029 | 0.000 | 1.291 | 1.218, 1.367 |
Örebro | 0.158 | 0.029 | 0.000 | 1.171 | 1.106, 1.240 |
Västmanland | 0.087 | 0.027 | 0.001 | 1.091 | 1.035, 1.151 |
Dalarna | 0.157 | 0.029 | 0.000 | 1.170 | 1.105, 1.239 |
Gävleborg | 0.215 | 0.032 | 0.000 | 1.240 | 1.165, 1.319 |
Västernorrland | 0.186 | 0.034 | 0.000 | 1.204 | 1.125, 1.288 |
Jämtland | 0.194 | 0.043 | 0.000 | 1.214 | 1.116, 1.321 |
Västerbotten | 0.126 | 0.039 | 0.001 | 1.134 | 1.051, 1.224 |
Norrbotten | 0.230 | 0.030 | 0.000 | 1.259 | 1.187, 1.336 |
The major findings in this study were that latest county of residence was an independent factor influencing mortality and that a variation with significantly higher mortality was found in all but one Swedish county among foreign-born persons compared with native Swedes. The highest difference compared to native controls of deceased foreign-born was found in counties with a more rural structure. Several factors might explain the noted differences, such as the size of the foreign-born population, differences in the healthcare system’s ability to deliver healthcare, social network, stress, and economic resources.
The study of regional differences in mortality among foreign-born and native Swedes 1970–1999 was based on data from Statistics Sweden and from the National Board of Health and Welfare Centre for Epidemiology.
The data used to establish the database originated from the Population and Housing Census of 1970, which is considered to be a total census as it was compulsory by law to take part. The number of dropouts has not been estimated for the total census, only for some of the variables such as “occupation”, which Statistics Sweden estimates to be 3.5–4.5%. One can only speculate about whether participation in the census is related to health problems and whether dropout might differ between foreign-born and native healthy Swedes. It seems unlikely that the proportion of healthy foreign-born should be higher than native Swedes and thereby introduce selection bias. Another reason why migrants do not participate in the census could be language problems.
A Swedish matched control could not be found for 20,518 of the foreign-born persons due to the matching criteria. The geographical distribution of the excluded persons was not different from the distribution in the database used.
The excluded group varies in proportion with regard to country/region of birth. Excluded persons from Finland constitute the largest proportion (30.8%). A followup of Finns who had remigrated was performed and showed no differences in mortality from the group of Finns included in the study [
Selection bias has to be considered. The excluded persons had a lower mean age than the persons in the database, with the exception of persons born in the former Yugoslavia, but their Swedish control person of the same age was also excluded. Only 8.1% of the excluded persons had reached the age of 60–69 and 2.6% the age of 80+. There is no reason to assume that the excluded persons influenced the survival analysis using these two age groups, due to the low proportion of excluded persons above 60 years of age.
Latest county of residence has been used as a variable. Migration within Sweden might have occurred and labour migration by healthier persons to urban areas could explain the higher mortality in rural counties. However, the pattern of internal migration within Sweden showed similarities between foreign-born and native Swedes. Among foreign-born persons still living in Sweden 1990, 53.9% had changed county of residence during 1979–1999 but moved back to the same county 1990 as the one they lived in 1970, corresponding proportion for native Swedes was 60%.
The rural counties had in common that the proportion of foreign-born persons in their populations was low compared to the more urban counties. For some ethnic groups higher density in an area of persons from the same ethnic group has been shown to have a positive effect on self-rated health, limiting long-standing illness [
Another explanatory factor could be differences in social networks in different geographical areas [
Generally no significantly higher mortality among migrants was found in Norrbotten, but mortality was higher for men when men and women were analysed separately.
This county has close cultural contacts with Finland [
The differences in mortality in all Swedish counties, with one exception, among foreign-born persons compared with native Swedes could indicate differences in economic resources and needs in the population. One measure of economic resources in the county was the local tax rate. In the middle of the studied period (1985), local tax per unit differed from 28.46% (Kristianstad) to 32.00% in Blekinge of taxable income [
More healthcare needs are connected with an elderly population [
There are a strong connection between increased mortality and increased age [
Other explanatory factors could be work environment and type of employment. Foreign-born men have to a higher degree been employed in private manufacturing industry, which is often found in rural counties like Kronoberg, Kalmar, and Blekinge [
In most counties and especially for men, the mean age at time of death is lower among foreign-born persons than native Swedes. The mean age at time of death of foreign- born men in the two counties Norrbotten and Värmland with highest OR was 2.4 to 3.7 years lower than native Swedes and correspondingly 1.3 to 1.8 years lower for women. Cox regression analysis also confirms a lower survival time for foreign-born persons in the counties of Norrbotten and Värmland for the age group 60–69.
In conclusion, county of residence influences mortality, and the study indicates a tendency to higher mortality among foreign-born persons than native Swedes in counties with a more rural structure. Further studies are needed to explore possible explanations and to establish the county-specific characteristics to explain variations between county council areas.
This work was supported by grants from the research profile AMERY (labour market, migration, and ethnic relations) Växjö University, Sweden, the KIP Pension & Forsaking (The Pension Insurance Institute of the Co-operative Societies), Sweden, and Rådet för Hälos-och sjukvårdsforskning i södra Sverige HSF (the Council for Health and HealthCare Research in Southern Sweden).