Jacob Spallek

What do we have to know from migrants' past exposures to understand their health status? a life course approach

Empirical findings show that morbidity and mortality risks of migrants can differ considerably from those of populations in the host countries. However, while several explanatory models have been developed, most migrant studies still do not consider explicitly the situation of migrants before migration. Here, we discuss an extended approach to understand migrant health comprising a life course epidemiology perspective.The incorporation of a life course perspective into a conceptual framework of migrant health enables the consideration of risk factors and disease outcomes over the different life phases of migrants, which is necessary to understand the health situation of migrants and their offspring. Comparison populations need to be carefully selected depending on the study questions under consideration within the life course framework.Migrant health research will benefit from an approach using a life course perspective. A critique of the theoretical foundations of migrant health research is essential for further developing both the theoretical framework of migrant health and related empirical studies.

Prevention among immigrants: the example of Germany

BackgroundA large and increasing part of the European population has a history of migration. Germany, for example, is home to about 15 million people with migrant background, which amounts to 19% of its population. Migrants may have differences in their lifestyle, health beliefs and risk factors compared to the autochthonous populations.DiscussionAs for example studies on childrens participation in routine prevention activities have shown, these differences can have a relevant impact on the access of migrants to the health care system and are likely to lower their participation in prevention programs compared to the autochthonous population. To increase the uptake of prevention programs, barriers to access must be identified and approaches to reduce them must be developed.SummaryTaking the example of Germany, a need exists for prevention programs that include (migrant sensitive) and specifically address (migrant specific) migrants. These should be of sufficient scale, evidence-based, sustainable and evaluated at regular intervals.

Stillbirth differences according to regions of origin: an analysis of the German perinatal database, 2004-2007

BackgroundStillbirth is a sensitive indicator for access to, and quality of health care and social services in a society. If a particular population group e.g. migrants experiences higher rates of stillbirth, this might be an indication of social deprivation or barriers to health care. This study examines differences in risk of stillbirth for women of different regions of origin compared to women from Germany in order to identify high risk groups/target groups for prevention strategies.MethodsWe used the BQS dataset routinely compiled to examine perinatal outcomes in Germany nationwide. Participation of hospitals and completeness of data has been about 98% in recent years. Data on all live births and stillbirths were obtained for the period 2004 to 2007 (N = 2,670,048). We calculated crude and stratified mortality rates as well as corresponding relative mortality risks.ResultsA significantly elevated stillbirth rate was found for women from the Middle East and North Africa (incl. Turkey) (RR 1.34, CI 1.22-1.55). The risk was slightly attenuated for low SES. An elevated risk was also found for women from Asia (RR 1.18, CI 1.02-1.65) and from Mediterranean countries (RR 1.14, CI 0.93-1.28). No considerable differences either in use and timing of antenatal care or preterm birth and low birthweight were observed between migrant and non-migrant women. After stratification for light for gestational age, the relative risk of stillbirth for women from the Middle East/North Africa increased to 1.63 (95% CI 1.25-2.13). When adjusted for preterm births with low birthweight, women from Eastern Europe and the Middle East/North Africa experienced a 26% (43%) higher risk compared with women from Germany.ConclusionsWe found differences in risk of stillbirth among women from Middle East/North Africa, especially in association with low SES and low birthweight for gestational age. Our findings suggest a need for developing and evaluating socially and culturally sensitive health promotion and prevention programmes for this group. The findings should also stimulate discussion about the quality and appropriateness of antenatal and perinatal care of pregnant women and newborns with migrant backgrounds.

Addressing health-related interventions to immigrants: migrant-specific or diversity-sensitive?

Immigrants and their offspring are often disadvantaged in terms of health and access to health care including preventive interventions, relative to the majority populations (Smith Nielsen and Krasnik 2010; Spallek et al. 2010; Harris 2012). There is broad agreement by now that this health disadvantage is to a substantial part explained by the same social determinants that also operate on the host populations (Reijneveld 2010; Razum and Stronks 2014). But besides tackling social determinants (Graham and Kelly 2004), we also need to make sure that immigrants receive culturally appropriate health care without discrimination (Reijneveld 2010). How can this be achieved? Addressing immigrant populations could follow two rather different strategies: implementing services and interventions specifically addressed at this group, a somewhat ‘‘exclusive’’ strategy; or by adapting the existing routine health and preventive services, a more ‘‘inclusive’’ approach. Some people see the exclusive strategy as more appropriate, believing it can be tailored to distinctive needs of immigrants. We argue, however, that immigrants and their offspring should not be treated as a separate, detached group, but be covered by improved routine health services. Migrant-specific, ‘‘exclusive’’ approach

Cancer incidence rate ratios of Turkish immigrants in Hamburg, Germany: A registry based study

The aim of this study was to estimate cancer incidence rate ratios for Turkish migrants in Hamburg, Germany. We used a name-based approach and identified 1346 cases with Turkish names (as a proxy of Turkish origin) among 140,249 cases of cancer registered in the cancer registry Hamburg during 1990-2005. To estimate the size of the denominator population, we applied the name-based approach to the population of Hamburg as well. The cancer incidence of specific cancer sites was compared between Turkish and non-Turkish cases using incidence rate ratios (IRR), stratified by gender and birth cohort. Our main findings are that cancer of the respiratory organs is diagnosed less frequent among Turkish men in older birth cohorts but with higher frequency in the younger birth cohorts. Malignant neoplasms of lymphoid, haematopoietic and related tissues are slightly higher in most male Turkish men birth cohorts, and even considerably higher for the birth cohort 1961 to <1971 (IRR=1.8). Among women, incidence rates for Turkish women are lower than for non-Turkish women for cancer of the respiratory system, skin cancer and cancer of genital organs. Also, breast cancer incidence rates of Turkish women are lower than for non-Turkish women, especially in older birth cohorts. Incidence rate ratios of neoplasms of lymphoid, haematopoietic and related tissues are low in the 1931 to <1941 cohort (IRR=0.71) but increase in younger birth cohorts. In conclusion, we found differences in cancer risks between cases with and without Turkish names for specific cancer sites. These results are consistent with the findings of studies from other countries.

Pflege türkischer Migranten

Obwohl die Bevolkerungsgruppe mit turkischem Migrationshintergrund in Deutschland zurzeit noch ein vergleichsweise niedriges Durchschnittsalter aufweist, wachst der Anteil alterer Menschen unter den turkischen Migrantinnen und Migranten. Vor diesem Hintergrund gewinnen Fragen zur Pflegeversorgung dieser Bevolkerungsgruppe stark an Bedeutung, uber die bisher in Deutschland kaum wissenschaftlich abgesicherte Erkenntnisse existieren. Das folgende Kapitel beschreibt die besondere Situation von Menschen mit turkischem Migrationshintergrund, die in Deutschland leben, und gibt so erste Einblicke in dieses noch junge aber wichtige Forschungsfeld und stellt einen Einstieg in die weitere Forschung zu diesem Thema dar.

[Social inequality and health: Status and prospects of socio-epidemiological research in Germany].

Social differences in morbidity and mortality have always been a central topic in public health research. In recent years, there has been a growing research interest that has clearly resonated with the general public and the political arena as well. This article describes the development and establishment of social epidemiology in Germany and presents the current status of research. In addition, it describes different models for explaining health inequalities. On this basis, selected challenges and prospects of socio-epidemiological research are demonstrated. The reason why the analysis of social differences in morbidity and mortality will continue to be a key task of public health research in the national and international context in the future is also explained.ZusammenfassungSoziale Unterschiede in der Morbidität und Mortalität stellen seit jeher einen zentralen Gegenstand der Public-Health-Forschung dar. In den letzten Jahren ist ein zunehmendes Forschungsinteresse festzustellen, das in der breiten Öffentlichkeit und auch in der Politik einen deutlichen Widerhall findet. Der vorliegende Beitrag beschreibt die Entwicklung und Etablierung der Sozialepidemiologie in Deutschland und stellt den aktuellen empirischen Forschungsstand dar. Außerdem werden verschiedene Modelle zur Erklärung der gesundheitlichen Ungleichheit beschrieben. Auf dieser Grundlage werden anschließend ausgewählte Herausforderungen und Perspektiven der sozialepidemiologischen Forschung aufgezeigt und anhand dieser verdeutlicht, weshalb die Analyse der sozialen Unterschiede in der Morbidität und Mortalität auch künftig eine zentrale Aufgabe der Public-Health-Forschung im nationalen sowie internationalen Kontext darstellen wird.AbstractSocial differences in morbidity and mortality have always been a central topic in public health research. In recent years, there has been a growing research interest that has clearly resonated with the general public and the political arena as well. This article describes the development and establishment of social epidemiology in Germany and presents the current status of research. In addition, it describes different models for explaining health inequalities. On this basis, selected challenges and prospects of socio-epidemiological research are demonstrated. The reason why the analysis of social differences in morbidity and mortality will continue to be a key task of public health research in the national and international context in the future is also explained.

Psychosocial and behavioural factors in the explanation of socioeconomic inequalities in adolescent health: a multilevel analysis in 28 European and North American countries

Background The relative contribution of different pathways leading to health inequalities in adolescence was rarely investigated, especially in a cross-national perspective. The aim of the study is to analyse the contribution of psychosocial and behavioural factors in the explanation of inequalities in adolescent self-rated health (SRH) by family wealth in 28 countries. Methods This study was based on the international WHO ‘Health Behaviour in School-aged Children’ (HBSC) study carried out in 2005/2006. The total sample included 117 460 adolescents aged 11–15 in 28 European and North American countries. Socioeconomic position was measured using the Family Affluence Scale (FAS). Multilevel logistic regression models were conducted to analyse the direct (independent) and indirect contribution of psychosocial and behavioural factors on SRH. Results Across all countries, adolescents from low affluent families had a higher risk of reporting fair/poor SRH (OR1.76, CI 1.69 to 1.84). Separate adjustments for psychosocial and behavioural factors reduced the OR of students with low family affluence by 39% (psychosocial) and 22% (behavioural). Together, both approaches explained about 50–60% of inequalities by family affluence in adolescent SRH. Separate analyses showed that relationship to father and academic achievement (psychosocial factors) as well as physical activity and consumption of fruits/vegetables (behavioural factors) were the most important factors in explaining inequalities in SRH. Conclusions More than half of the inequalities by family affluence in adolescent SRH were explained by an unequal distribution of psychosocial and behavioural factors. Combining both approaches showed that the contribution of psychosocial factors was higher due to their direct (independent) and indirect impact through behavioural factors.

Cancer mortality patterns among Turkish immigrants in four European countries and in Turkey

The aim of this study on cancer mortality among Turkish immigrants, for the first time, traditional comparisons in migrant health research have been extended simultaneously in two ways. First, comparisons were made to cancer mortality from the immigrants’ country of origin and second, cancer mortality among Turkish immigrants across four host countries (Belgium, Denmark, France and the Netherlands) was compared. Population-based cancer mortality data from these countries were included. Age-standardized mortality rates were computed for the local-born and Turkish population of each country. Relative differences in cancer mortality were examined by fitting country-specific Poisson regression models. Globocan data on cancer mortality in Turkey from 2008 were used in order to compare mortality rates of Turkish immigrants with those from their country of origin. Turkish immigrants had lower all-cancer mortality than the local-born populations of their host countries, and mortality levels comparable to all-cancer mortality rates in Turkey. In the Netherlands and France breast cancer mortality was consistently lower in Turkish immigrants women than among local-born women. Lung cancer mortality was slightly lower in Turkish immigrants in the Netherlands and France but varied considerably between migrants in these two host countries. Stomach cancer mortality was significantly higher in Turkish immigrants when compared to local-born French and Dutch. Our findings indicate that exposures both in the country of origin and in the host country can have an effect on the cancer mortality of immigrants. Despite limitations affecting any cross-country comparison of mortality, the innovative multi-comparison approach is a promising way to gain further insights into determinants of trends in cancer mortality of immigrants.

Cancer patterns among children of Turkish descent in Germany: A study at the German Childhood Cancer Registry

BackgroundCancer risks of migrants might differ from risks of the indigenous population due to differences in socioeconomic status, life style, or genetic factors. The aim of this study was to investigate cancer patterns among children of Turkish descent in Germany.MethodsWe identified cases with Turkish names (as a proxy of Turkish descent) among the 37,259 cases of childhood cancer registered in the German Childhood Cancer Registry (GCCR) during 1980–2005. As it is not possible to obtain reference population data for children of Turkish descent, the distribution of cancer diagnoses was compared between cases of Turkish descent and all remaining (mainly German) cases in the registry, using proportional cancer incidence ratios (PCIRs).ResultsThe overall distribution of cancer diagnoses was similar in the two groups. The PCIRs in three diagnosis groups were increased for cases of Turkish descent: acute non-lymphocytic leukaemia (PCIR 1.23; CI (95%) 1.02–1.47), Hodgkins disease (1.34; 1.13–1.59) and Non-Hodgkin/Burkitt lymphoma (1.19; 1.02–1.39). Age, sex, and period of diagnosis showed no influence on the distribution of diagnoses.ConclusionNo major differences were found in cancer patterns among cases of Turkish descent compared to all other cases in the GCCR. Slightly higher proportions of systemic malignant diseases indicate that analytical studies involving migrants may help investigating the causes of such cancers.