Matthew Wallace

Introduction: Younger working age children of migrants have higher mortality risks relative to younger working age non-migrants in Europe. Yet, these are unique ages of mortality where the absolute risk of death is low and driven by external causes (ie, accidents, injuries and suicides). It remains unclear whether this higher mortality risk presents among older working age children of migrants—ages at which the absolute risk of death begins to increase exponentially and becomes dictated by chronic morbidities. We aim to fill this gap. Methods: We fit survival models on Swedish total population register data using an extended, competing risks approach. We investigate all-cause and mortality from natural causes and external causes, drugs and alcohol among the children of migrants, migrants and non-migrants aged 15–44 and 45–64 from 1990 to 2023. We report both HRs and regression-standardised cumulative probabilities of death. Results: Younger working age children of migrants from an array of origins exhibit higher external, drug and alcohol mortality relative to non-migrants that drives their higher all-cause mortality risk. Older working age children of migrants from multiple origins also present with a higher risk of external, drug and alcohol mortality, but only exhibit comparable all-cause mortality to non-migrants, owing to their similar to lower mortality from natural causes. Disparities in socioeconomic background largely attenuate these risks. A diverse range of younger and older working age migrants exhibit lower all-cause, natural, and external, drug and alcohol mortality than non-migrants do. Conclusions: Interventions should be made to address the elevated avoidable and preventable external, drugs and alcohol mortality that presents among both older and younger working age children of migrants. Doing so will generate reductions in their all-cause mortality risk.

Introduction: Empirical evidence on migrant morbidity suggests that migrant populations have a higher burden of disease compared to non-migrants in high-income destination countries. Yet, empirical evidence on migrant mortality typically shows a lower risk of death compared to non-migrants. Migrants might be living longer lives in worse health—a ‘migrant “morbidity-mortality” paradox’. Sources of data: Peer-reviewed, English-language publications. Areas of agreement: The paradox has been reported in different destinations, across different migrant groups, and across different health outcomes. It presents most consistently among migrants and women born in low and middle-income countries, and/or when morbidity is self-reported. Areas of controversy: The majority of the evidence is based upon unlinked, aggregated, cross-sectional prevalence data that has well-known limitations. Nearly all the studies to date have been descriptive, and there is a lack of understanding concerning what might explain this paradox among migrants. Growing points: That migrants are living longer subject to a higher burden of diseases is a social and public health concern that needs to be further explored and understood through more research. Areas timely for developing research: We need more evidence of the paradox based upon linked individual-level, incidence-based data that compares the morbidity and mortality risks of the same migrant and non-migrant populations using objective data on morbidity from primary care (general practitioners) or secondary care (hospitalizations). We need to know how widespread the paradox is, which migrant populations are most affected by it, and the potential mechanisms responsible for it.

Introduction: The native-born children of migrants represent one of the fastest-growing and most diverse young populations in the world today. A growing body of research highlights an elevated young adult mortality risk in this ‘second generation’ (G2) relative to the majority population at the same ages. Previous studies have tried to understand this increased risk by examining its association with inequality in the adult socioeconomic background (SEB) of the G2. Here, we instead analyse the association of second-generation status with childhood SEB. Methods: We use administrative register data from Sweden to fit multistate, competing-risk, flexible parametric survival models on a data set of 13 404 deaths in 2.35 million young adults. We examine mortality from all causes and specific causes of death at the generational level and by parental region of birth, both before and after having adjusted for childhood SEB. Results: The G2 have higher all-cause mortality hazard rates (HR=1.29 (95% CIs=1.23 to 1.34)) than the majority population before adjusting for childhood SEB. Following adjustment, the size of the hazard rate is smaller, but remains higher than the majority population (aHR=1.16 (95% CIs=1.11 to 1.21)). The G2 additionally experience persistent and higher hazard rates of mortality from suicide (aHR=1.29 (95% CIs=1.20 to 1.39)), substance misuse (aHR=1.41 (95% CIs=1.26 to 1.58)) and assault (aHR=2.54 (95% CIs=2.02 to 3.20)). By parental origins, similar patterns to those described are documented among G2 that have at least one parent born in Finland, the other Nordic countries, former Yugoslavia, the rest of Europe, sub-Saharan Africa, Northern Africa, and Iran and Iraq. However, higher all-cause (aHR=1.42 (95% CIs=1.33 to 1.51)) and external-cause hazard rates of mortality (aHR=1.59 (95% CIs=1.48 to 1.72)) only persist among G2 with parent(s) born in Finland. Conclusions: G2 with various parental origins have higher mortality rates than the majority population do, and this difference is partly explained by their childhood SEB.

The ‘second-generation’ (i.e. the children of migrants) represent one of the fastest growing subpopulations of the child and young adult populations in Europe today. The research so far appears to indicate that their mortality risk is elevated relative to people with non-migrant backgrounds. Peer-reviewed publications. Second-generation status is a clear marker of elevated mortality risk in Europe in early life (including stillbirth, perinatal, neonatal and infant mortality) and adulthood, particularly if the parent(s) were born outside of Europe. Socioeconomic inequality plays an important, albeit rarely defining, role in these elevated risks. It remains unclear what causes-of-death are driving these elevated mortality risks. The exact influence of (non-socioeconomic) explanatory factors (e.g. health care, racism & discrimination, and factors related to integration) on the elevated mortality risks of the second-generation also remains unclear. The second-generation will continue to grow and diversify in Europe; we must intervene to address these inequalities now. Place more emphasis on the complexity of migration background, specific causes-of-death, and understanding the roles of explanatory factors beyond socioeconomic background.

Migrants have been more affected by the COVID-19 pandemic. Whether this has varied over the course of the pandemic remains unknown. We examined how inequalities in intensive care unit (ICU) admission and death related to COVID-19 by country of birth have evolved over the course of the pandemic, while considering the contribution of social conditions and vaccination uptake. A population-based cohort study was conducted including adults living in Sweden between March 1, 2020 and June 1, 2022 (n = 7,870,441). Poisson regressions found that migrants from Africa, Middle East, Asia and European countries without EU28/EEA, UK and Switzerland had higher risk of COVID-19 mortality and ICU admission than Swedish-born. High risks of COVID-19 ICU admission was also found in migrants from South America. Inequalities were generally reduced through subsequent waves of the pandemic. In many migrant groups socioeconomic status and living conditions contributed to the disparities while vaccination campaigns were decisive when such became available.

While a sizeable body of research has focused upon the ‘migrant mortality advantage’ (lower mortality among migrants compared to native-born populations), it has lacked a dedicated age perspective that investigates how mortality varies among migrants across age. This is especially true for older ages. In this chapter, evidence on the mortality of older migrants is summarised utilising the prevailing theoretical framework. The chapter first explores how mortality varies among migrants over age, positioning the mortality patterns of older migrants in the context of younger migrants. Next, it focuses in older migrants to explore heterogeneity in their mortality by sex, age at arrival, and length of stay. Studies that explore the quality of the years lived by older migrants are then summarised, followed by those that evaluate the reliability of mortality estimates among older migrants. The chapter concludes with a synopsis of the condition of the literature on older migrant mortality, followed by suggestions to build on and improve existing evidence.

A small but growing body of studies have documented the alarming mortality situation of adult descendants of migrants in a number of European countries. Nearly all of them have focused on all-cause mortality to reveal these important health inequalities. This paper takes advantage of the Swedish population registers to study all-cause and cause-specific mortality among men and women aged 15–44 in Sweden from 1997 to 2016 to a level of granularity unparalleled elsewhere. It adopts a multi-generation, multi-origin and multi-cause-of-death approach. Using extended, competing-risks survival models, it aims to show (1) how the all-cause mortality of immigrants arriving as adults (the G1), immigrants arriving as children (the G1.5) and children of immigrants born in Sweden to at least one immigrant parent (the G2) differs versus ancestral Swedes and (2) what causes-of-deaths drive these differentials. For all-cause mortality, most G1 (not Finns or Sub-Saharan Africans) have a mortality advantage. This contrasts with a near systematic reversal in the mortality of the G1.5 and G2 (notably among men), which is driven by excess accident and injury, suicide, substance use and other external cause mortality. Given that external causes-of-death are preventable and avoidable, the findings raise questions about integration processes, the levels of inequality immigrant populations are exposed to in Sweden and ultimately, whether the legacy of immigration has been positive. Strengths of the study include the use of quality data and advanced methods, the granularity of the estimates, and the provision of evidence that highlights the precarious mortality situation of the seldom-studied G1.5.