Employment status and risk of all-cause mortality among native- and foreign-origin persons in Sweden

Employment status and risk of all-cause mortality among native- and foreign-origin persons in Sweden Background The association between exposure to unemployment and increased risk of mortality is well established. Yet migrants and their children often experience a number of stressors in the country of residence which could exacerbate the negative effects of job loss or unemployment. This study examined the extent to which region of origin and generational status modified associations between employment status and risk of all-cause mortality. Methods Using population-based registers, an open cohort of 2 178 321 individuals aged 25–64 years was followed from 1993 to 2008. Hazard ratios for mortality were calculated using Cox regression. Employment status and socio-demographic covariates were included as time-varying variables in all models. Results Relative to employed native-origin Swedes, excess risk of mortality was found among most groups of unemployed persons. The excess risk of mortality found among African women exposed to long-term unemployment (HR = 3.26, 95% CI: 2.30–4.63), Finnish men exposed to short-and long-term unemployment (HR = 2.74, 95% CI: 2.32–3.24 and HR = 2.39, 95% CI: 2.12–2.69), and second generation Swedish men exposed to short-term unemployment (HR = 2.34, 95% CI: 2.06–2.64) was significantly greater (P < 0.05) than that found among their unemployed native-origin counterparts. Excess risk of mortality among the unemployed in other foreign-origin groups was of a similar or lower magnitude to that found in unemployed native-origin Swedes. A decreased risk of mortality was observed among the employed in nearly all foreign-origin groups. Conclusions With some exceptions, mortality risk in foreign-origin individuals across all categories of employment status was generally similar to or lower than the risk observed in native-origin Swedes. Introduction Foreign-origin persons often experience greater labor market marginalization and exclusion than their native-origin counterparts.1 In Sweden, the unemployment rate is higher among the foreign-origin than the native-origin (15.5% vs. 5.1%, respectively),2 although rates vary by region of origin.3,4 Numerous factors have been shown to contribute to these disparities, including discriminatory hiring practices,5 lack of human capital,4 as well as difficulties surrounding recognition of skills or educational qualifications and learning a new language.6 For persons of foreign-origin, employment may also act as a marker of successful resettlement or social inclusion, with protective effects for health.7 Thus, consideration of the consequences of unemployment in this population is an important public health priority. Relationships between unemployment and poor health,8 including mortality,9–11 are well established. Unemployment has been theorized to influence health through several unique yet interrelated mechanisms, including economic deprivation,12,13 psychosocial stress,12,13 and maladaptive health behaviors.13 In addition to higher unemployment rates,1,2 some foreign-origin groups may also have less social capital or fewer social networks than their native-origin counterparts.14 This could exacerbate the negative effects of job loss among the foreign-origin, as these resources may provide both instrumental and emotional support to those who become unemployed. Yet only a paucity of Swedish research has compared associations between unemployment and health in native- and foreign-origin persons.15–17 The aim of the current study was to examine the extent to which foreign-origin background modified relationships between employment status and mortality. Given that foreign-born persons experience a number of disadvantages which could strengthen the negative effects of job loss or unemployment, we also examined the health impact of unemployment among the children of migrants (second generation), who should have fewer labor market integration challenges than their parents but have been relatively overlooked in the migrant health literature. In this study we also assessed unemployment as a time-varying covariate, which provided a more precise estimation of exposure to unemployment during the follow-up period. Methods Data, study population and study design Register data from the Swedish Work and Mortality Data (HSIA) were utilized. HSIA contains information on the total population of Sweden born before 1986 who were alive in 1980 or 1990, as well as foreign-born persons who arrived in Sweden between 1990 and 2002. A random sample of native-origin Swedes (persons born in Sweden with two native-born parents, N = 1 000 000) was taken to decrease statistical processing time. Persons with missing information on education, income or civil status in all years of follow-up and foreign-born persons with missing information on first entry date in Sweden were excluded. The relationship between employment status and all-cause mortality among individuals aged 25–64 years was analyzed between 1 January 1993 and 31 December 2008. An open cohort study design was utilized to allow for the inclusion of foreign-born persons who immigrated to Sweden through 2002. All residents in Sweden aged 25+ years during the follow-up period were eligible for inclusion. Person-time at risk was thus calculated from: age 25, age at follow-up commencement, or age at arrival (if 25+ years). Follow-up continued until age 65, death, emigration, or end of follow-up, whichever came first. Ethical approval to conduct the study was granted by the Regional Ethical Review Board in Stockholm, Sweden (approval number 2012/1260-31). Foreign-origin background Foreign-born persons were categorized into nine groups according to birth country or region, as follows: Finland, Other Nordic countries, Former Yugoslavia, Eastern Europe, Other European countries, Africa, the Middle East, South/Latin America and Other Non-European countries. Native-born Swedes with at least one foreign-born parent were coded as second generation. Employment status Information on recorded employment, earned annual income, sickness and early retirement benefits, and the number of unemployment days/year was used to construct a measure of annual employment status. Persons categorized as ‘employed’ (i) were coded as employed in the register; (ii) had zero days of annual unemployment; (iii) had a minimum annual earned income (56 000 SEK in 1993, adjusted for inflation) and (iv) received no more than a maximum amount of financial benefits (27 500 SEK in 1993, adjusted for inflation). Persons categorized as ‘unemployed’ (i) were coded as unemployed in the register; (ii) had 1+ days of annual unemployment and (iii) did not receive sickness or disability benefits in excess of a maximum annual amount (27 500 SEK in 1993, adjusted for inflation). These restrictive criteria were utilized in order to (i) minimize misclassification bias, by ensuring that persons classified as employed were gainfully employed and (ii) reduce potential health selection effects into unemployment, by ensuring that those who might have poorer health (e.g. those who received higher financial benefits) were not classified as unemployed. The income and benefits thresholds used corresponded with those from prior Swedish research on unemployment and mortality.11 Individuals who did not fulfill these criteria or who had missing income or benefits information were categorized as ‘other/unknown’ (results not presented for this category). As unemployment spell duration can influence associations with mortality,10 unemployment was further categorized into ‘short-term’ (<90 days/year) and ‘long-term’ (≥90 days/year) spells of annual unemployment, using cut-off thresholds from prior research11,18 to facilitate comparability. Statistical analyses Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for all-cause mortality. Employment status and additional covariates (calendar period, education level, civil status and disposable income quintile) were included as time-varying variables in order to account for calendar effects and changes in demographic characteristics during the follow-up period. All models include multiplicative interaction terms for foreign-origin background and employment status to examine how the association between employment status and mortality was modified by generational status and region of origin. HRs were calculated using linear combinations of coefficients to compare differences in the relative risk of mortality, using ‘Sweden (native-origin) employed’ as the reference group. Post-estimation linear hypothesis tests compared HR estimates between unemployed native-origin and foreign-origin groups in order to assess for statistically significant (P < 0.05) differences in these estimates. Tests of the proportional hazards assumption showed that non-proportional hazards were included in our models; HRs should therefore be interpreted as average effects over time. Results During the study period there were 20 698 deaths among women and 34 320 among men. Table 1 provides the person-time, number of deaths and mortality rates/1000 person-years with 95% CI for women and men included in the sample across the study variable categories. Apart from women and men from Finland and Other Nordic countries and men from Eastern Europe, all foreign-origin groups demonstrated lower mortality rates compared with native-origin Swedes. Long-term unemployed persons showed the highest mortality rates across employment status categories. Table 1 Study population person-time, number of deaths, and mortality rates (MR) per 1000 person-years with 95% confidence intervals Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  a Person-time and mortality information for the ‘Other/Unknown’ employment status category is reported only for completion. Table 1 Study population person-time, number of deaths, and mortality rates (MR) per 1000 person-years with 95% confidence intervals Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  a Person-time and mortality information for the ‘Other/Unknown’ employment status category is reported only for completion. HR estimates and 95% CI from fully adjusted models are plotted in figure 1. Short- and long-term unemployed foreign-born women demonstrated similar mortality risks to those found among their native-origin counterparts, as did long-term unemployed second generation women. Relative to their native-origin counterparts, short-term unemployed second generation men had a significantly greater (P = 0.00) excess mortality risk, whereas excess risk among long-term unemployed foreign-born men was significantly lower (P = 0.00). Decreased mortality risk was observed among employed second generation and foreign-born women and men. Figure 1 View largeDownload slide Hazard ratios with 95% CI for all-cause mortality among women and men by native-origin/generational status and employment status combinations. Models adjusted for calendar period, education level, civil status and disposable income quintile. Attained age was used as the time scale in all analyses Figure 1 View largeDownload slide Hazard ratios with 95% CI for all-cause mortality among women and men by native-origin/generational status and employment status combinations. Models adjusted for calendar period, education level, civil status and disposable income quintile. Attained age was used as the time scale in all analyses Table 2 shows results from minimally adjusted (Model 1) and fully adjusted (Model 2) models. Short- and long-term unemployed women from Sweden, Finland, Other Nordic countries and Africa demonstrated increased HRs for mortality. Among Eastern European and second generation women, elevated HRs were found only in the long-term unemployed, whereas among women from Other Non-European countries elevated risk was seen only in the short-term unemployed. Long-term unemployed women from Africa demonstrated the highest mortality risk (Model 2, HR = 3.26, 95% CI: 2.30–4.63), which was significantly greater than the risk observed among long-term unemployed native-origin women (P = 0.00). Apart from employed women from Africa and Other Non-European countries, employed foreign-origin women had a lower mortality risk compared with employed native-origin women. Table 2 Hazard ratios for all-cause mortality among women and men by native-origin/foreign-origin background and employment status combinations   Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56    Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56  Model 1: adjusted for calendar period; Model 2: adjusted for calendar period, education level, civil status, and disposable income quintile. The reference group in all analyses was employed, native-born persons with two native-born parents. Attained age was used as the time scale in all analyses. a HR estimate was significantly different (P < 0.05) from the HR estimate for short-term unemployed native-origin Swedes. b HR estimate was significantly different (P < 0.05) from the HR estimate for long-term unemployed native-origin Swedes. Table 2 Hazard ratios for all-cause mortality among women and men by native-origin/foreign-origin background and employment status combinations   Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56    Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56  Model 1: adjusted for calendar period; Model 2: adjusted for calendar period, education level, civil status, and disposable income quintile. The reference group in all analyses was employed, native-born persons with two native-born parents. Attained age was used as the time scale in all analyses. a HR estimate was significantly different (P < 0.05) from the HR estimate for short-term unemployed native-origin Swedes. b HR estimate was significantly different (P < 0.05) from the HR estimate for long-term unemployed native-origin Swedes. A health advantage was also observed among employed second generation men and men from Other Nordic countries, Other European countries, the Middle East, South/Latin America and Other Non-European countries. A slightly elevated mortality risk was seen among employed Finnish men. Most men exposed to both short- and long-term unemployment demonstrated elevated mortality risk, with the exception of: (i) men from the Middle East and South/Latin America; (ii) long-term unemployed men from Other Non-European countries and (iii) short-term unemployed men from Other European countries. Finnish men had the highest mortality risk across both unemployment categories (Model 2, HR = 2.74, 95% CI: 2.32–3.24 and HR = 2.39, 95% CI: 2.12–2.69), followed by second generation men (Model 2, HR = 2.34, 95% CI: 2.06–2.64 and HR = 2.11, 95% CI: 1.90–2.34). Both short-term and long-term unemployed Finnish and second generation men had significantly higher risk estimates compared with unemployed native-origin men in Model 1; however, in the fully adjusted model, the difference became statistically insignificant (P = 0.11) among long-term unemployed second generation men. Sensitivity analyses A key limitation of migrant health studies is that out-migration may not be recorded, resulting in potential denominator bias.19 Sensitivity analyses in which persons who had missing information on income for two consecutive years were censored as a proxy for unrecorded out-migration, showed only minimal differences compared with the main findings (see Supplementary Appendix S1). Although not assessed in the current study, these analyses may also help to account for possible health selection among those who potentially emigrated during follow-up. A recent study from Denmark showed a successively lower risk of out-migration among migrants with low, moderate, and high disease severity compared with those without disease, which provides some evidence against health selection in out-migration.20 As we used native-origin Swedes as the reference category in our analyses, we were unable to control for migrants’ arrival period in Sweden in our models, due to problems of collinearity. We therefore conducted supplementary analyses to determine if arrival in Sweden during a time of economic recession (1992–1996) may have differentially impacted mortality risk among migrants. These results were largely in line with those presented in figure 1 (see Supplementary Appendix S2). Discussion This study examined the extent to which foreign-origin background modified associations between employment status and all-cause mortality among persons of working age in Sweden. A decreased mortality risk was found among the majority of employed foreign-origin persons relative to employed native-origin Swedes. Excess mortality risk was observed among most foreign-origin persons exposed to unemployment, in accordance with previous findings that have demonstrated a link between unemployment and poor health.8,15,21 However, most unemployed foreign-origin groups demonstrated similar or lower excess risk than their native-origin counterparts, with some notable exceptions to the contrary. Thus, these findings overall suggest the existence of a mortality health advantage (i.e. equal or lower mortality risk) among the foreign-origin population across all categories of employment status. Excess risk of mortality was found among many foreign-origin groups exposed to unemployment. Unemployed women from most European countries (i.e. Finland, Other Nordic countries, Eastern Europe and second generation women) as well as Other Non-European countries, and men from Other Nordic countries and Eastern Europe demonstrated excess mortality risk that was generally of a similar magnitude to that observed among the native-origin unemployed. This is in line with previous Swedish research16 which showed no increased mortality risk among unemployed migrants relative to unemployed natives (excepting Nordic men). However, our utilization of the employed native-origin as the reference group, rather than the unemployed, allowed us to assess mortality risk across all employment status categories, and enabled us to demonstrate the presence of excess mortality risk in native- and foreign-origin unemployment groups alike. Still, some foreign-origin groups did not show any excess mortality risk despite exposure to unemployment. This was most notable among women from former Yugoslavia and Other European countries, and both women and men from the Middle East and South/Latin America. These findings are relatively consistent with previously observed lower mortality risks among migrants to Sweden from non-European countries, as well as former Yugoslavia.22 Given prior findings which have suggested lower mortality risk among non-European migrants to Sweden, 22 the excess mortality risk found among women from Africa, particularly the long-term unemployed, was unexpected. Prior research has suggested that African women have more difficulty entering the Swedish labor market than African men.23 This may help to explain the divergent results between long-term unemployed African women and men, whereby women showed significantly greater and men showed significantly lower levels of excess risk relative to long-term unemployed native-origin Swedes. Among men, the greatest excess risk was observed in short-term and long-term unemployed Finnish and second generation men. However, while employed men from Finland also demonstrated excess risk of mortality, employed second generation men showed a health advantage. This suggests that unemployment could be particularly detrimental to second generation men, and that the health impact of unemployment may be influenced by the overall mortality advantage or disadvantage within a given population. Higher rates of unemployment have also been found among some second generation groups in Sweden24 and other research has suggested that the increased mortality risk among some groups of second-generation men may be explained by income,25 which is partly determined by employment status. Taken together, these findings suggest that ensuring employment among second generation men may be of particular public health importance. Differences in the meaning and experience of unemployment may also help to explain mortality risk differentials between native- and foreign-origin persons. Some foreign-origin groups may be more likely to experience barriers to employment5 or unmet expectations of social mobility or work opportunities in the destination country26 than others. Unmet expectations and frustrations over labor market integration can adversely impact health via psychosocial stress processes.27 Such stress might be more severe among certain groups, such as second generation individuals, who should expect the same opportunities as the native-origin yet may still experience employment disparities, or even labor migrants, who might have higher labor market expectations given that employment is their primary motivation for migration. In line with previous research,16,22 a health advantage was observed in several foreign-origin groups. This advantage was found most consistently among the employed, and was somewhat more evident among women than men in analyses which accounted for region of origin. Apart from a possible health selection effect into employment,28 these findings suggest that employment could play an essential role in promoting and protecting health among persons of foreign-origin. While those who are employed may benefit from the health promoting latent functions of employment29,30 (e.g. self-esteem, interpersonal contacts), health among the unemployed may be negatively influenced by feelings of stigmatization or social isolation. Still, employment alone may not be sufficient to promote health. Poor working life conditions have been associated with poorer health outcomes among both native- and foreign-origin workers,31,32 which might negate some of the health benefits of employment. Although prior research has shown that longer periods of unemployment are often associated with greater risk of mortality10,11 and poor mental health,8 the current study provided only partial support for these findings. Men from Other European countries and second generation and Eastern European women were the only groups for whom exposure to long-term, but not short-term, unemployment was associated with increased mortality risk. This might reflect a more precarious employment position among some foreign-origin persons or more frequent transition in and out of employment,1,4 which can be detrimental to health.33,34 Strengths and limitations To the authors’ knowledge, this is the first study in Sweden to longitudinally examine the relationship between unemployment and mortality among generational status and region of origin groups while also measuring employment status as a time-varying exposure. However, despite the use of high quality population-based register data, information on first entry date was missing among many foreign-born who immigrated before 1960, who were thus excluded. These persons were generally older, were predominantly European (Finnish in particular), and had higher mortality rates compared with native-origin Swedes. Therefore, HRs for some European groups in the study may be slightly underestimated. Variation in visa requirements and reason for migration among migrants from different world regions may also differentially impact migrants’ labor market trajectories. However, we were unable to investigate these factors as such information is not available in the HSIA data. Although we utilized a restrictive definition of employment status to limit health selection effects, we cannot rule out the potential role of health selection into unemployment which could have influenced our findings. However, previous studies of unemployment and mortality in the Swedish context have suggested that there is at least a partial causal effect of unemployment on excess mortality risk,10,21,35 and that direct health selection may explain a more modest portion of this relationship.10,21 In addition, information on days spent in unemployment was recorded annually; therefore, depending on the timing of unemployment, some persons who experienced a spell of long-term unemployment may have been misclassified as short-term unemployed for two consecutive years. This limitation might also help to explain the lack of difference in findings by unemployment spell duration. Employment status alone may be insufficient to assess migrant’s health without also considering occupation and working conditions. Unfortunately, such information was not available to us, but we encourage future studies to explore these issues to better control for heterogeneity that might exist in our findings. Yet part of migrants’ segregation into jobs with poorer working conditions36 might to some extent be reflected in lower salaries. The inclusion of income as a time-varying covariate to account for annual changes in income during the follow-up period represents a valid contribution, as many studies only assess income at follow-up commencement. Conclusions Our findings provide evidence for a mortality health advantage among the foreign-origin population in Sweden. Most foreign-origin groups demonstrated similar or lower mortality risk relative to their native-origin counterparts, although a minority showed greater excess risk than the native-origin. Still, the excess mortality risk observed among the unemployed overall warrants the increased consideration of employment as an important determinant of health. As migration is increasingly being recognized as a social determinant of health in its own right,37,38 future studies of unemployment and health among foreign-origin persons should also assess the role of additional migration background characteristics to better elucidate how such factors may influence both employment and health status. Supplementary data Supplementary data are available at EURPUB online. Funding This study was funded by the Swedish Research Council (grant no. 2011-1649) and the Swedish Research Council for Health, Working Life and Welfare (grant no. 2016-07128). Conflicts of interest: None declared. Key points Relative to employed native-origin Swedes, excess risk of mortality was observed in most groups of foreign-origin persons exposed to unemployment, however, the magnitude of risk varied across foreign-origin groups. 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Employment status and risk of all-cause mortality among native- and foreign-origin persons in Sweden

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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
eISSN
1464-360X
D.O.I.
10.1093/eurpub/cky090
Publisher site
See Article on Publisher Site

Abstract

Background The association between exposure to unemployment and increased risk of mortality is well established. Yet migrants and their children often experience a number of stressors in the country of residence which could exacerbate the negative effects of job loss or unemployment. This study examined the extent to which region of origin and generational status modified associations between employment status and risk of all-cause mortality. Methods Using population-based registers, an open cohort of 2 178 321 individuals aged 25–64 years was followed from 1993 to 2008. Hazard ratios for mortality were calculated using Cox regression. Employment status and socio-demographic covariates were included as time-varying variables in all models. Results Relative to employed native-origin Swedes, excess risk of mortality was found among most groups of unemployed persons. The excess risk of mortality found among African women exposed to long-term unemployment (HR = 3.26, 95% CI: 2.30–4.63), Finnish men exposed to short-and long-term unemployment (HR = 2.74, 95% CI: 2.32–3.24 and HR = 2.39, 95% CI: 2.12–2.69), and second generation Swedish men exposed to short-term unemployment (HR = 2.34, 95% CI: 2.06–2.64) was significantly greater (P < 0.05) than that found among their unemployed native-origin counterparts. Excess risk of mortality among the unemployed in other foreign-origin groups was of a similar or lower magnitude to that found in unemployed native-origin Swedes. A decreased risk of mortality was observed among the employed in nearly all foreign-origin groups. Conclusions With some exceptions, mortality risk in foreign-origin individuals across all categories of employment status was generally similar to or lower than the risk observed in native-origin Swedes. Introduction Foreign-origin persons often experience greater labor market marginalization and exclusion than their native-origin counterparts.1 In Sweden, the unemployment rate is higher among the foreign-origin than the native-origin (15.5% vs. 5.1%, respectively),2 although rates vary by region of origin.3,4 Numerous factors have been shown to contribute to these disparities, including discriminatory hiring practices,5 lack of human capital,4 as well as difficulties surrounding recognition of skills or educational qualifications and learning a new language.6 For persons of foreign-origin, employment may also act as a marker of successful resettlement or social inclusion, with protective effects for health.7 Thus, consideration of the consequences of unemployment in this population is an important public health priority. Relationships between unemployment and poor health,8 including mortality,9–11 are well established. Unemployment has been theorized to influence health through several unique yet interrelated mechanisms, including economic deprivation,12,13 psychosocial stress,12,13 and maladaptive health behaviors.13 In addition to higher unemployment rates,1,2 some foreign-origin groups may also have less social capital or fewer social networks than their native-origin counterparts.14 This could exacerbate the negative effects of job loss among the foreign-origin, as these resources may provide both instrumental and emotional support to those who become unemployed. Yet only a paucity of Swedish research has compared associations between unemployment and health in native- and foreign-origin persons.15–17 The aim of the current study was to examine the extent to which foreign-origin background modified relationships between employment status and mortality. Given that foreign-born persons experience a number of disadvantages which could strengthen the negative effects of job loss or unemployment, we also examined the health impact of unemployment among the children of migrants (second generation), who should have fewer labor market integration challenges than their parents but have been relatively overlooked in the migrant health literature. In this study we also assessed unemployment as a time-varying covariate, which provided a more precise estimation of exposure to unemployment during the follow-up period. Methods Data, study population and study design Register data from the Swedish Work and Mortality Data (HSIA) were utilized. HSIA contains information on the total population of Sweden born before 1986 who were alive in 1980 or 1990, as well as foreign-born persons who arrived in Sweden between 1990 and 2002. A random sample of native-origin Swedes (persons born in Sweden with two native-born parents, N = 1 000 000) was taken to decrease statistical processing time. Persons with missing information on education, income or civil status in all years of follow-up and foreign-born persons with missing information on first entry date in Sweden were excluded. The relationship between employment status and all-cause mortality among individuals aged 25–64 years was analyzed between 1 January 1993 and 31 December 2008. An open cohort study design was utilized to allow for the inclusion of foreign-born persons who immigrated to Sweden through 2002. All residents in Sweden aged 25+ years during the follow-up period were eligible for inclusion. Person-time at risk was thus calculated from: age 25, age at follow-up commencement, or age at arrival (if 25+ years). Follow-up continued until age 65, death, emigration, or end of follow-up, whichever came first. Ethical approval to conduct the study was granted by the Regional Ethical Review Board in Stockholm, Sweden (approval number 2012/1260-31). Foreign-origin background Foreign-born persons were categorized into nine groups according to birth country or region, as follows: Finland, Other Nordic countries, Former Yugoslavia, Eastern Europe, Other European countries, Africa, the Middle East, South/Latin America and Other Non-European countries. Native-born Swedes with at least one foreign-born parent were coded as second generation. Employment status Information on recorded employment, earned annual income, sickness and early retirement benefits, and the number of unemployment days/year was used to construct a measure of annual employment status. Persons categorized as ‘employed’ (i) were coded as employed in the register; (ii) had zero days of annual unemployment; (iii) had a minimum annual earned income (56 000 SEK in 1993, adjusted for inflation) and (iv) received no more than a maximum amount of financial benefits (27 500 SEK in 1993, adjusted for inflation). Persons categorized as ‘unemployed’ (i) were coded as unemployed in the register; (ii) had 1+ days of annual unemployment and (iii) did not receive sickness or disability benefits in excess of a maximum annual amount (27 500 SEK in 1993, adjusted for inflation). These restrictive criteria were utilized in order to (i) minimize misclassification bias, by ensuring that persons classified as employed were gainfully employed and (ii) reduce potential health selection effects into unemployment, by ensuring that those who might have poorer health (e.g. those who received higher financial benefits) were not classified as unemployed. The income and benefits thresholds used corresponded with those from prior Swedish research on unemployment and mortality.11 Individuals who did not fulfill these criteria or who had missing income or benefits information were categorized as ‘other/unknown’ (results not presented for this category). As unemployment spell duration can influence associations with mortality,10 unemployment was further categorized into ‘short-term’ (<90 days/year) and ‘long-term’ (≥90 days/year) spells of annual unemployment, using cut-off thresholds from prior research11,18 to facilitate comparability. Statistical analyses Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for all-cause mortality. Employment status and additional covariates (calendar period, education level, civil status and disposable income quintile) were included as time-varying variables in order to account for calendar effects and changes in demographic characteristics during the follow-up period. All models include multiplicative interaction terms for foreign-origin background and employment status to examine how the association between employment status and mortality was modified by generational status and region of origin. HRs were calculated using linear combinations of coefficients to compare differences in the relative risk of mortality, using ‘Sweden (native-origin) employed’ as the reference group. Post-estimation linear hypothesis tests compared HR estimates between unemployed native-origin and foreign-origin groups in order to assess for statistically significant (P < 0.05) differences in these estimates. Tests of the proportional hazards assumption showed that non-proportional hazards were included in our models; HRs should therefore be interpreted as average effects over time. Results During the study period there were 20 698 deaths among women and 34 320 among men. Table 1 provides the person-time, number of deaths and mortality rates/1000 person-years with 95% CI for women and men included in the sample across the study variable categories. Apart from women and men from Finland and Other Nordic countries and men from Eastern Europe, all foreign-origin groups demonstrated lower mortality rates compared with native-origin Swedes. Long-term unemployed persons showed the highest mortality rates across employment status categories. Table 1 Study population person-time, number of deaths, and mortality rates (MR) per 1000 person-years with 95% confidence intervals Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  a Person-time and mortality information for the ‘Other/Unknown’ employment status category is reported only for completion. Table 1 Study population person-time, number of deaths, and mortality rates (MR) per 1000 person-years with 95% confidence intervals Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  Total (N = 2 178 321)  Women (N = 1 082 046)   Men (N = 1 096 275)     Person-years  Deaths  MR  95% CI  Person-years  Deaths  MR  95% CI  Total  12 400 665  20 698  1.67  1.65–1.69  12 516 679  34 320  2.74  2.71–2.77  Migration background      Sweden (native-origin)  53 73 068  11 416  2.12  2.09–2.16  5 570 371  18 169  3.26  3.21–3.31      Second generation  2 395 843  2 326  0.97  0.93–1.01  2 537 849  4296  1.69  1.64–1.74      Finland  1 108 812  2 626  2.37  2.28–2.46  825 498  4397  5.33  5.17–5.49      Other Nordic  326 834  715  2.19  2.03–2.35  290 409  923  3.18  2.98–3.39      Eastern Europe  511 818  893  1.74  1.63–1.86  317 190  1061  3.34  3.15–3.55      Former Yugoslavia  578 534  768  1.33  1.24–1.42  616 933  1566  2.54  2.42–2.67      Other European  505 663  642  1.27  1.18–1.37  662 293  1442  2.18  2.07–2.29      Middle East  559 235  330  0.59  0.53–0.66  769 991  986  1.28  1.20–1.36      Africa  219 813  227  1.03  0.91–1.18  308 698  566  1.83  1.69–1.99      Latin America  266 841  241  0.90  0.80–1.02  260 016  387  1.49  1.35–1.64      Other Non-European  554 205  514  0.93  0.85–1.01  357 431  527  1.47  1.35–1.61  Employment status      Employed  7 018 350  4 021  0.57  0.56–0.59  7 791 294  8640  1.11  1.09–1.13      Short-term unemployed  766 249  377  0.49  0.44–0.54  699 873  1196  1.71  1.61–1.81      Long-term unemployed  962 567  722  0.75  0.70–0.81  1 218 190  2387  1.96  1.88–2.04      Other/unknowna  3 653 499  15 578  4.26  4.20–4.33  2 807 322  22 097  7.87  7.77–7.98  Education      Primary  2 595 399  7882  3.04  2.97–3.10  2 864 548  13 768  4.81  4.73–4.89      Secondary  5 716 568  8768  1.53  1.50–1.57  5 963 271  15 236  2.55  2.51–2.60      Tertiary  3 982 032  4048  1.02  0.99–1.05  3 576 131  5316  1.49  1.45–1.53      Missing  106 666  0      112 729  0      Civil status      Partner  2 595 399  9853  1.50  1.47–1.52  6 076 775  13 842  2.28  2.24–2.32      Divorced  5 716 568  5172  2.62  2.55–2.70  1 548 979  8096  5.23  5.11–5.34      Single  3 982 032  4358  1.23  1.19–1.27  4 813 060  11 775  2.45  2.40–2.49      Widowed  106 666  1315  4.41  4.17–4.65  77 426  607  7.84  7.24–8.49      Missing  282  0      439  0      Disposable income      Quintile 1 (lowest)  1 802 848  3906  2.17  2.10–2.24  1 556 863  5302  3.41  3.32–3.50      Quintile 2  2 209 535  6085  2.75  2.69–2.82  1 521 004  8466  5.57  5.45–5.69      Quintile 3  3 361 831  5223  1.55  1.51–1.60  2 173 683  7530  3.46  3.39–3.54      Quintile 4  2 990 352  3378  1.13  1.09–1.17  3 287 077  6768  2.06  2.01–2.11      Quintile 5 (highest)  2 035 819  2106  1.03  0.99–1.08  3 977 612  6254  1.57  1.53–1.61      Missing  282  0      439  0      Calendar period      1993–1996  2 882 427  4083  1.42  1.37–1.46  2 929 641  7301  2.49  2.44–2.55      1997–2000  3 074 058  5203  1.69  1.65–1.74  3 113 456  8650  2.78  2.72–2.84      2001–2004  3 215 333  5627  1.75  1.70–1.80  3 239 159  9214  2.84  2.79–2.90      2005–2008  3 228 847  5785  1.79  1.75–1.84  3 234 421  9155  2.83  2.77–2.89  a Person-time and mortality information for the ‘Other/Unknown’ employment status category is reported only for completion. HR estimates and 95% CI from fully adjusted models are plotted in figure 1. Short- and long-term unemployed foreign-born women demonstrated similar mortality risks to those found among their native-origin counterparts, as did long-term unemployed second generation women. Relative to their native-origin counterparts, short-term unemployed second generation men had a significantly greater (P = 0.00) excess mortality risk, whereas excess risk among long-term unemployed foreign-born men was significantly lower (P = 0.00). Decreased mortality risk was observed among employed second generation and foreign-born women and men. Figure 1 View largeDownload slide Hazard ratios with 95% CI for all-cause mortality among women and men by native-origin/generational status and employment status combinations. Models adjusted for calendar period, education level, civil status and disposable income quintile. Attained age was used as the time scale in all analyses Figure 1 View largeDownload slide Hazard ratios with 95% CI for all-cause mortality among women and men by native-origin/generational status and employment status combinations. Models adjusted for calendar period, education level, civil status and disposable income quintile. Attained age was used as the time scale in all analyses Table 2 shows results from minimally adjusted (Model 1) and fully adjusted (Model 2) models. Short- and long-term unemployed women from Sweden, Finland, Other Nordic countries and Africa demonstrated increased HRs for mortality. Among Eastern European and second generation women, elevated HRs were found only in the long-term unemployed, whereas among women from Other Non-European countries elevated risk was seen only in the short-term unemployed. Long-term unemployed women from Africa demonstrated the highest mortality risk (Model 2, HR = 3.26, 95% CI: 2.30–4.63), which was significantly greater than the risk observed among long-term unemployed native-origin women (P = 0.00). Apart from employed women from Africa and Other Non-European countries, employed foreign-origin women had a lower mortality risk compared with employed native-origin women. Table 2 Hazard ratios for all-cause mortality among women and men by native-origin/foreign-origin background and employment status combinations   Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56    Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56  Model 1: adjusted for calendar period; Model 2: adjusted for calendar period, education level, civil status, and disposable income quintile. The reference group in all analyses was employed, native-born persons with two native-born parents. Attained age was used as the time scale in all analyses. a HR estimate was significantly different (P < 0.05) from the HR estimate for short-term unemployed native-origin Swedes. b HR estimate was significantly different (P < 0.05) from the HR estimate for long-term unemployed native-origin Swedes. Table 2 Hazard ratios for all-cause mortality among women and men by native-origin/foreign-origin background and employment status combinations   Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56    Women   Men     Model 1    Model 2   Model 1   Model 2     HR  95% CI  HR  95% CI  HR  95% CI  HR  95% CI  Sweden (native-origin)      Employed  1.00    1.00    1.00    1.00        Short-term unemployed  1.48  1.25–1.73  1.38  1.17–1.63  2.01  1.82–2.21  1.67  1.51–1.84      Long-term unemployed  1.90  1.68–2.14  1.76  1.56–1.99  2.46  2.30–2.63  1.92  1.72–2.06  Second generation      Employed  0.76  0.69–0.84  0.75  0.68–0.82  0.83  0.78–0.88  0.82  0.77–0.87      Short-term unemployed  1.07  0.81–1.42  0.99a  0.75–1.31  2.87a  2.54–3.24  2.34a  2.06–2.64      Long-term unemployed  1.85  1.51–2.25  1.66  1.36–2.02  2.78b  2.51–3.08  2.11  1.90–2.34  Finland                      Employed  0.91  0.82–1.00  0.87  0.79–0.97  1.30  1.21–1.39  1.19  1.10–1.28      Short-term unemployed  1.70  1.25–2.31  1.59  1.17–2.15  3.46a  2.92–4.09  2.74a  2.32–3.24      Long-term unemployed  2.04  1.65–2.53  1.85  1.50–2.30  3.21b  2.86–3.61  2.39b  2.12–2.69  Other Nordic      Employed  0.81  0.66–0.98  0.80  0.66–0.98  0.85  0.73–0.98  0.85  0.73–0.98      Short-term unemployed  2.09  1.29–3.37  2.04  1.27–3.29  2.04  1.43–2.92  1.73  1.21–2.48      Long-term unemployed  2.00  1.37–2.92  1.91  1.30–2.79  2.07  1.62–2.65  1.65  1.29–2.11  Eastern Europe      Employed  0.79  0.66–0.94  0.84  0.70–1.00  0.88  0.77–1.02  0.97  0.84–1.11      Short-term unemployed  1.05  0.66–1.67  1.13  0.71–1.80  2.29  1.68–3.12  2.16  1.58–2.95      Long-term unemployed  1.80  1.38–2.36  1.90  1.45–2.48  1.94b  1.56–2.42  1.72  1.38–2.14  Former Yugoslavia      Employed  0.74  0.59–0.93  0.77  0.61–0.97  0.84  0.74–0.96  0.89  0.78–1.02      Short-term unemployed  0.86a  0.53–1.39  0.95  0.59–1.53  1.35a  1.05–1.74  1.40  1.09–1.80      Long-term unemployed  1.11b  0.77–1.60  1.20  0.83–1.74  1.36b  1.12–1.65  1.33b  1.09–1.61  Other European      Employed  0.66  0.53–0.81  0.68  0.55–0.83  0.72  0.65–0.81  0.75  0.68–0.84      Short-term unemployed  0.72a  0.37–1.39  0.75  0.39–1.44  1.15a  0.84–1.57  1.07a  0.78–1.48      Long-term unemployed  1.04b  0.67–1.59  1.06b  0.69–1.63  1.53b  1.26–1.86  1.36b  1.11–1.65  Middle East      Employed  0.38  0.25–0.57  0.41  0.27–0.61  0.49  0.40–0.58  0.53  0.45–0.65      Short-term unemployed  0.69a  0.42–1.14  0.78a  0.48–1.28  1.17a  0.93–1.46  1.20b  0.96–1.51      Long-term unemployed  0.68b  0.46–1.02  0.76b  0.50–1.13  1.01b  0.86–1.20  1.00a  0.85–1.19  Africa      Employed  1.14  0.82–1.59  1.12  0.80–1.57  0.82  0.67–1.00  0.83  0.68–1.02      Short-term unemployed  1.93  1.16–3.21  1.98  1.19–3.28  1.70  1.26–2.31  1.66  1.22–2.24      Long-term unemployed  3.22b  2.27–4.56  3.26b  2.30–4.63  1.55b  1.24–1.93  1.45b  1.16–1.81  South/Latin America      Employed  0.52  0.37–0.74  0.52  0.37–0.73  0.74  0.61–0.90  0.70  0.58–0.85      Short-term unemployed  0.97  0.52–1.81  0.96  0.52–1.79  1.00a  0.65–1.56  0.87a  0.56–1.35      Long-term unemployed  1.04  0.62–1.76  1.01b  0.60–1.72  0.88b  0.62–1.25  0.73b  0.51–1.03  Other Non-European      Employed  0.91  0.74–1.11  0.94  0.77–1.15  0.73  0.61–0.87  0.80  0.67–0.96      Short-term unemployed  1.41  0.97–2.03  1.51  1.05–2.19  1.77  1.29–2.42  1.77  1.29–2.43      Long-term unemployed  1.29  0.92–1.81  1.37  0.98–1.93  1.21b  0.90–1.61  1.17b  0.88–1.56  Model 1: adjusted for calendar period; Model 2: adjusted for calendar period, education level, civil status, and disposable income quintile. The reference group in all analyses was employed, native-born persons with two native-born parents. Attained age was used as the time scale in all analyses. a HR estimate was significantly different (P < 0.05) from the HR estimate for short-term unemployed native-origin Swedes. b HR estimate was significantly different (P < 0.05) from the HR estimate for long-term unemployed native-origin Swedes. A health advantage was also observed among employed second generation men and men from Other Nordic countries, Other European countries, the Middle East, South/Latin America and Other Non-European countries. A slightly elevated mortality risk was seen among employed Finnish men. Most men exposed to both short- and long-term unemployment demonstrated elevated mortality risk, with the exception of: (i) men from the Middle East and South/Latin America; (ii) long-term unemployed men from Other Non-European countries and (iii) short-term unemployed men from Other European countries. Finnish men had the highest mortality risk across both unemployment categories (Model 2, HR = 2.74, 95% CI: 2.32–3.24 and HR = 2.39, 95% CI: 2.12–2.69), followed by second generation men (Model 2, HR = 2.34, 95% CI: 2.06–2.64 and HR = 2.11, 95% CI: 1.90–2.34). Both short-term and long-term unemployed Finnish and second generation men had significantly higher risk estimates compared with unemployed native-origin men in Model 1; however, in the fully adjusted model, the difference became statistically insignificant (P = 0.11) among long-term unemployed second generation men. Sensitivity analyses A key limitation of migrant health studies is that out-migration may not be recorded, resulting in potential denominator bias.19 Sensitivity analyses in which persons who had missing information on income for two consecutive years were censored as a proxy for unrecorded out-migration, showed only minimal differences compared with the main findings (see Supplementary Appendix S1). Although not assessed in the current study, these analyses may also help to account for possible health selection among those who potentially emigrated during follow-up. A recent study from Denmark showed a successively lower risk of out-migration among migrants with low, moderate, and high disease severity compared with those without disease, which provides some evidence against health selection in out-migration.20 As we used native-origin Swedes as the reference category in our analyses, we were unable to control for migrants’ arrival period in Sweden in our models, due to problems of collinearity. We therefore conducted supplementary analyses to determine if arrival in Sweden during a time of economic recession (1992–1996) may have differentially impacted mortality risk among migrants. These results were largely in line with those presented in figure 1 (see Supplementary Appendix S2). Discussion This study examined the extent to which foreign-origin background modified associations between employment status and all-cause mortality among persons of working age in Sweden. A decreased mortality risk was found among the majority of employed foreign-origin persons relative to employed native-origin Swedes. Excess mortality risk was observed among most foreign-origin persons exposed to unemployment, in accordance with previous findings that have demonstrated a link between unemployment and poor health.8,15,21 However, most unemployed foreign-origin groups demonstrated similar or lower excess risk than their native-origin counterparts, with some notable exceptions to the contrary. Thus, these findings overall suggest the existence of a mortality health advantage (i.e. equal or lower mortality risk) among the foreign-origin population across all categories of employment status. Excess risk of mortality was found among many foreign-origin groups exposed to unemployment. Unemployed women from most European countries (i.e. Finland, Other Nordic countries, Eastern Europe and second generation women) as well as Other Non-European countries, and men from Other Nordic countries and Eastern Europe demonstrated excess mortality risk that was generally of a similar magnitude to that observed among the native-origin unemployed. This is in line with previous Swedish research16 which showed no increased mortality risk among unemployed migrants relative to unemployed natives (excepting Nordic men). However, our utilization of the employed native-origin as the reference group, rather than the unemployed, allowed us to assess mortality risk across all employment status categories, and enabled us to demonstrate the presence of excess mortality risk in native- and foreign-origin unemployment groups alike. Still, some foreign-origin groups did not show any excess mortality risk despite exposure to unemployment. This was most notable among women from former Yugoslavia and Other European countries, and both women and men from the Middle East and South/Latin America. These findings are relatively consistent with previously observed lower mortality risks among migrants to Sweden from non-European countries, as well as former Yugoslavia.22 Given prior findings which have suggested lower mortality risk among non-European migrants to Sweden, 22 the excess mortality risk found among women from Africa, particularly the long-term unemployed, was unexpected. Prior research has suggested that African women have more difficulty entering the Swedish labor market than African men.23 This may help to explain the divergent results between long-term unemployed African women and men, whereby women showed significantly greater and men showed significantly lower levels of excess risk relative to long-term unemployed native-origin Swedes. Among men, the greatest excess risk was observed in short-term and long-term unemployed Finnish and second generation men. However, while employed men from Finland also demonstrated excess risk of mortality, employed second generation men showed a health advantage. This suggests that unemployment could be particularly detrimental to second generation men, and that the health impact of unemployment may be influenced by the overall mortality advantage or disadvantage within a given population. Higher rates of unemployment have also been found among some second generation groups in Sweden24 and other research has suggested that the increased mortality risk among some groups of second-generation men may be explained by income,25 which is partly determined by employment status. Taken together, these findings suggest that ensuring employment among second generation men may be of particular public health importance. Differences in the meaning and experience of unemployment may also help to explain mortality risk differentials between native- and foreign-origin persons. Some foreign-origin groups may be more likely to experience barriers to employment5 or unmet expectations of social mobility or work opportunities in the destination country26 than others. Unmet expectations and frustrations over labor market integration can adversely impact health via psychosocial stress processes.27 Such stress might be more severe among certain groups, such as second generation individuals, who should expect the same opportunities as the native-origin yet may still experience employment disparities, or even labor migrants, who might have higher labor market expectations given that employment is their primary motivation for migration. In line with previous research,16,22 a health advantage was observed in several foreign-origin groups. This advantage was found most consistently among the employed, and was somewhat more evident among women than men in analyses which accounted for region of origin. Apart from a possible health selection effect into employment,28 these findings suggest that employment could play an essential role in promoting and protecting health among persons of foreign-origin. While those who are employed may benefit from the health promoting latent functions of employment29,30 (e.g. self-esteem, interpersonal contacts), health among the unemployed may be negatively influenced by feelings of stigmatization or social isolation. Still, employment alone may not be sufficient to promote health. Poor working life conditions have been associated with poorer health outcomes among both native- and foreign-origin workers,31,32 which might negate some of the health benefits of employment. Although prior research has shown that longer periods of unemployment are often associated with greater risk of mortality10,11 and poor mental health,8 the current study provided only partial support for these findings. Men from Other European countries and second generation and Eastern European women were the only groups for whom exposure to long-term, but not short-term, unemployment was associated with increased mortality risk. This might reflect a more precarious employment position among some foreign-origin persons or more frequent transition in and out of employment,1,4 which can be detrimental to health.33,34 Strengths and limitations To the authors’ knowledge, this is the first study in Sweden to longitudinally examine the relationship between unemployment and mortality among generational status and region of origin groups while also measuring employment status as a time-varying exposure. However, despite the use of high quality population-based register data, information on first entry date was missing among many foreign-born who immigrated before 1960, who were thus excluded. These persons were generally older, were predominantly European (Finnish in particular), and had higher mortality rates compared with native-origin Swedes. Therefore, HRs for some European groups in the study may be slightly underestimated. Variation in visa requirements and reason for migration among migrants from different world regions may also differentially impact migrants’ labor market trajectories. However, we were unable to investigate these factors as such information is not available in the HSIA data. Although we utilized a restrictive definition of employment status to limit health selection effects, we cannot rule out the potential role of health selection into unemployment which could have influenced our findings. However, previous studies of unemployment and mortality in the Swedish context have suggested that there is at least a partial causal effect of unemployment on excess mortality risk,10,21,35 and that direct health selection may explain a more modest portion of this relationship.10,21 In addition, information on days spent in unemployment was recorded annually; therefore, depending on the timing of unemployment, some persons who experienced a spell of long-term unemployment may have been misclassified as short-term unemployed for two consecutive years. This limitation might also help to explain the lack of difference in findings by unemployment spell duration. Employment status alone may be insufficient to assess migrant’s health without also considering occupation and working conditions. Unfortunately, such information was not available to us, but we encourage future studies to explore these issues to better control for heterogeneity that might exist in our findings. Yet part of migrants’ segregation into jobs with poorer working conditions36 might to some extent be reflected in lower salaries. The inclusion of income as a time-varying covariate to account for annual changes in income during the follow-up period represents a valid contribution, as many studies only assess income at follow-up commencement. Conclusions Our findings provide evidence for a mortality health advantage among the foreign-origin population in Sweden. Most foreign-origin groups demonstrated similar or lower mortality risk relative to their native-origin counterparts, although a minority showed greater excess risk than the native-origin. Still, the excess mortality risk observed among the unemployed overall warrants the increased consideration of employment as an important determinant of health. As migration is increasingly being recognized as a social determinant of health in its own right,37,38 future studies of unemployment and health among foreign-origin persons should also assess the role of additional migration background characteristics to better elucidate how such factors may influence both employment and health status. Supplementary data Supplementary data are available at EURPUB online. Funding This study was funded by the Swedish Research Council (grant no. 2011-1649) and the Swedish Research Council for Health, Working Life and Welfare (grant no. 2016-07128). Conflicts of interest: None declared. Key points Relative to employed native-origin Swedes, excess risk of mortality was observed in most groups of foreign-origin persons exposed to unemployment, however, the magnitude of risk varied across foreign-origin groups. 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The European Journal of Public HealthOxford University Press

Published: May 30, 2018

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