TA-4.6-Johnson-Ethnic.ppt EUPHA-MEMH Conference 23-25 June 2016 Immigrant density and mental health in Stockholm County Charisse Johnson*, Antonio Ponce de Leon, Mikael Rostila, Yvonne Försell, Karin Engström *Presenting author
Immigrant mental health in Sweden Demographics 1 : o Swedish population is nearly 10 million people o 17% foreign-born o 22% foreign-background (with two foreign-born parents) Inequalities in mental health status between some immigrant groups and Swedes 2 Most immigrant health research focuses on individual factors Need for focus on the contextual determinants of health 3 Charisse Johnson 30 juni 2016 2
Ethnic Density Theoretical background Economic segregation is detrimental to mental health, but less clear with regards to ethnic segregation 4-6 Ethnic density hypothesis: a protective effect in regards to mental health Social dynamics Decreased discrimination Residential segregation hypothesis: a detrimental effect with regards to mental health Poor material and social resources/information that affect access Poor opportunity Social selection versus social causation 7 Charisse Johnson 30 juni 2016 3
Ethnic Density Empirical Application Distinctions between definitions of ethnic density: Overall and own-group Foreign-born/immigrant and foreign-background Only one Swedish study has investigated the association between ethnic density and mental health 8 Specifically looking at Iraqi ethnic enclave and risk of psychotic and affective disorders Found that Iraqis living in enclaves did have elevated risk, but it was entirely due to individual factors and neighborhood deprivation Found that Swedes who lived in Iraqi enclaves had elevated risk of psychosis, despite control for individual and neighbourhood factors Namn Efternamn 30 juni 2016 4
Aim Stockholm is characterised by both neighbourhood ethnic density and economic segregation This study investigates: 1. The association between neighbourhood immigrant density (proportion of foreign-born) on mental health 2. The effect of individual and contextual-level socioeconomic confounders on this relationship Namn Efternamn 30 juni 2016 5
Methodology Setting: Stockholm country Population (2002-2010) 1 : 1.85-2.05 million, 18-21% foreign-born Design: Cross-sectional Data: Baseline information from the 2002, 2006, 2010 Stockholm Public Health Cohort 9, linked registries Sample population: 56,064 adults, ages 18-64, 18% foreignborn Namn Efternamn 30 juni 2016 6
Methodology: Individual covariates Age Sex Country of birth Occupational class Education Disposable family income Employment Family constellation Outcome: Risk of Psychological Distress as measured by the General Health Questionnaire-12 - Symptoms of anxiety or depression in past few weeks - Presented as Prevalence Ratios Namn Efternamn 30 juni 2016 7
Methodology: Contextual covariates Neighbourhood economic deprivation Percentage of individuals living on less than 60% of the median income of Stockholm County Main Exposure: Neighbourhood immigrant density Immigrant density: proportion of foreign-born, range 0-86% Neighbourhood unit: Small Area Marketing Statistics (SAMS) 10 ~ 900 in Stockholm County On average 1000 people each Namn Efternamn 30 juni 2016 8
Immigrant Density in Stockholm County 2002 2006 2010 Charisse Johnson 30 juni 2016 9
Methodology: Analysis Two-level model using multi-level poisson regression with robust variances 11 Random intercept model Individuals nested within neighbourhoods SAS version 9.3 Variance explained by the neighbourhood level: 0.057 (se 0.0077) Namn Efternamn 30 juni 2016 10
Results 1 Charisse Johnson 30 juni 2016 11
Results 2a Charisse Johnson 30 juni 2016 12
Results 2b Charisse Johnson 30 juni 2016 13
Some Strengths and Limitations Large sample size Nearly representative foreign-born proportion Robust statistical methods Not possible to use weights to correct for stratified sampling and slightly lower representation of immigrants in the study sample Generalizability: Foreign-born are a large and heterogeneous group Immigrant density effect could possibly vary between ethnic groups Namn Efternamn 30 juni 2016 14
Conclusion First paper that investigating immigrant density and mental health outcomes in Sweden Overall, immigrant density is only associated with psychological distress above a threshold of 60% at the neighbourhood level Individual and contextual socioeconomic factors explain the risk of psychological distress below this threshold, which favors residential segregation hypothesis The remaining affect above this threshold could be due to social selection Policy implications for addressing socioeconomic inequalities, while also avoiding high ethnic isolation Charisse Johnson 30 juni 2016 15
References 1. Statistics Sweden, http://www.scb.se/en_/finding-statistics/statistics-by-subjectarea/population/population-composition/population-statistics/#c_li_be0101e 2. Gilliver SC, Sundquist J, Li X, Sundquist K: Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health 2014, 24 Suppl 1:72 9. 3. Phelan JC, Link BG, Tehranifar P: Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav 2010, 51 Suppl:S28 40 4. Pickett KE, Wilkinson RG: People like us: ethnic group density effects on health. Ethn Health 2008, 13:321 34 5. Shaw RJ, Pickett KE: The association between ethnic density and poor selfrated health among US Black and Hispanic people. Ethn Health 2011, 16:225 44 6. Becares L: The ethnic density effect on the health of ethnic minority people in the United Kingdom: a study of hypothesised pathways. University College London; 2009 Namn Efternamn 30 juni 2016 16
References continued 7. Halpern D: Minorities and Mental Health. Int J Soc Psychiatry 1993, 36:597 607 8. Mezuk B, Li X, Cederin K, Concha J, Kendler KS, Sundquist J, Sundquist K. Ethnic enclaves and risk of psychiatric disorders among first- and secondgeneration immigrants in Sweden. Soc Psychiatry Psychiatr Epidemiol 2015, 50:1713 22 9. Svensson AC, Fredlund P, Laflamme L, Hallqvist J, Alfredsson L, Ekbom A, Feychting M, Forsberg B, Pedersen NL, Vågerö D, Magnusson C: Cohort profile: The Stockholm Public Health Cohort. Int J Epidemiol 2013, 42:1263 72 10. Statistics Sweden Market Profiles, Product Catalogue 2016, p 15. http://www.scb.se/grupp/produkter_tjanster/skraddarsydd/regionala_produkte r/marknadsprofiler/product%20catalogue%202016.pdf 11. Barros AJD, Hirakata VN. Alternatives for logistic regression in crosssectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003, 3:1-13 Namn Efternamn 30 juni 2016 17
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Immigrant Density in Stockholm County 2002 2006 2010 Charisse Johnson 30 juni 2016 21