Coordinator

Master's programme in Public Health Sciences: Individual and societal perspectives.

In-Practice (IP) seminar series

Course manager

Introduction to public health sciences (advanced level, 7,5 credits)

Master thesis course in public health sciences (advanced level, 30 credits)

Introduction to Public Health Sciences: A brief overview (PhD level, 3 credits)

Supervision

I supervise master's and doctoral level students

Major Research areas

• Health inequities
• Social determinants of health
• Migration and health
• Maternal and child health
• Life-course epidemiology
• Welfare policies
• COVID-19

My main research line revolves around health inequities, with a special focus on the presence of the “healthy migrant paradox” in Europe. Also, I examine the determinants and long-standing consequences of outcomes derived from birthweight and gestational age. More recently, I investigate the effect of governmental policies on health.

Ongoing research projects:

Principal investigator of the FORTE-project: Explaining COVID-19 mortality among immigrants in Sweden: A social determinants of health perspective (#2021-00271). Duration: 2022-2024; Total: 4,970,000SEK

Principal investigator of the VR-project: The unintended consequences of Swedish parental leave policy: A health equity perspective (#2018-01825). Duration: 2019-2022; Total: 5,604,000SEK

Coordinator of the FORTE-programme: Social determinants of health among individuals with foreign background: Societal and individual perspectives and project leader of a subproject on Social policies (PI: Mikael Rostila, FORTE # 2016-07128). Duration: 2017-2022; Total: 18,000,000 SEK

Since 2005, I have participated in more than 18 (co-applicant of 8) national and international research projects.

I urval från Stockholms universitets publikationsdatabas

• Unintended Perinatal Health Consequences Associated With a Swedish Family Policy

  2024. Enrico Debiasi (et al.). JAMA pediatrics

  Artikel

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• The effect of parental leave on parents’ mental health: a systematic review

  2023. Amy Heshmati, Helena Honkaniemi, Sol Pia Juárez. The Lancet Public Health 8 (1), e57-e75

  Artikel

  Mental health disorders during the post-partum period are a common morbidity, but parental leave might help alleviate symptoms by preventing or reducing stress. We aim to summarise available evidence on the effect of different types of parental leave on mental health outcomes among parents. For this systematic review, we searched Ovid MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus from database inception to Aug 29, 2022, for peer-reviewed, quantitative studies written in English. We included studies if the exposure was postnatal parental leave; a relevant comparison group was present (eg, paid vs unpaid leave); and if indicators related to general mental health, including depression, anxiety, stress, and suicide, for either parent were evaluated or recorded at any time after childbirth. The Review is registered with PROSPERO (registration number CRD42021227499). Of the 3441 records screened, 45 studies were narratively synthesised. Studies were done in high-income countries, and they examined generosity by any parental leave (n=5), benefit amount (n=13), and leave duration (n=31). 38 studies were of medium or high quality. Improved mental health was generally observed among women (referred to as mothers in this Review) with more generous parental leave policies (ie, leave duration and paid vs unpaid leave). For example, increased duration of leave was generally associated with reduced risk of poor maternal mental health, including depressive symptoms, psychological distress and burnout, and lower mental health-care uptake. However, the association between fathers’ leave and paternal mental health outcomes was less conclusive as was the indirect effect of parental leave use on partners’ mental health.

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• Effects of non-health-targeted policies on migrant health

  2019. Sol Juárez (et al.). The Lancet Global Health

  Artikel

  Background: Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health. Methods: We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104. Findings: We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13–0·75; I²=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor selfrated health (OR 1·67, 95% CI 1·35–1·98; I²=82·0%) and mortality (1·38, 1·10–1·65; I²=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85–0·98; I²=0·0%), but did not reduce public health insurance coverage (0·89, 0·71–1·07; I²=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90–1·21; I²=54·9%). Interpretation: Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective.

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• Psychiatric consequences of a father’s leave policy by nativity: a quasi-experimental study in Sweden

  2022. Helena Honkaniemi (et al.). Journal of Epidemiology and Community Health 76 (4), 367-373

  Artikel

  Background Parental leave use has been found to promote maternal and child health, with limited evidence of mental health impacts on fathers. How these effects vary for minority populations with poorer mental health and lower leave uptake, such as migrants, remains under-investigated. This study assessed the effects of a Swedish policy to encourage fathers’ leave, the 1995 Father’s quota, on Swedish-born and migrant fathers’ psychiatric hospitalisations.

  Methods We conducted an interrupted time series analysis using Swedish total population register data for first-time fathers of children born before (1992–1994) and after (1995–1997) the reform (n=198 589). Swedish-born and migrant fathers’ 3-year psychiatric hospitalisation rates were modelled using segmented negative binomial regression, adjusting for seasonality and autocorrelation, with stratified analyses by region of origin, duration of residence, and partners’ nativity.

  Results From immediately pre-reform to post-reform, the proportion of fathers using parental leave increased from 63.6% to 86.4% of native-born and 37.1% to 51.2% of migrants. Swedish-born fathers exhibited no changes in psychiatric hospitalisation rates post-reform, whereas migrants showed 36% decreased rates (incidence rate ratio (IRR) 0.64, 95% CI 0.47 to 0.86). Migrants from regions not predominantly consisting of Organisation for Economic Cooperation and Development countries (IRR 0.50, 95% CI 0.19 to 1.33), and those with migrant partners (IRR 0.23, 95% CI 0.14 to 0.38), experienced the greatest decreases in psychiatric hospitalisation rates.

  Conclusion The findings of this study suggest that policies oriented towards promoting father’s use of parental leave may help to reduce native–migrant health inequalities, with broader benefits for family well-being and child development.Data availability statement

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• Health Risk Behaviours by Immigrants’ Duration of Residence: A Systematic Review and Meta-Analysis

  2022. Sol P. Juárez (et al.). International Journal of Public Health 67

  Artikel

  Objectives: The aim was to systematically review and synthesise international evidence on changes in health risk behaviours by immigrants’ duration of residence.

  Methods: We searched literature databases for peer-reviewed quantitative studies published from 2000 to 2019, examining alcohol, drug and tobacco use; physical inactivity; and dietary habits by duration of residence.

  Results: Narrative synthesis indicated that immigrants tend to adopt health risk behaviours with longer residence in North America, with larger variation in effect sizes and directionality in other contexts. Random-effects meta-analyses examining the pooled effect across all receiving countries and immigrant groups showed lower odds of smoking (OR 0.54, 0.46–0.63, I2 = 68.7%) and alcohol use (OR 0.61, 0.47–0.75, I2 = 93.5%) and higher odds of physical inactivity (OR 1.71, 1.40–2.02, I2 = 99.1%) among immigrants than natives, but did not provide support for a universal trend by duration of residence.

  Conclusion: Findings suggest that duration of residence could serve as an effective instrument to monitor immigrants’ health changes. However, differences in receiving country contex

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• Immigrant ancestry and birthweight across two generations born in Sweden: an intergenerational cohort study

  2022. Siddartha Aradhya, Srinivasa Vittal Katikireddi, Sol Pia Juárez. BMJ Global Health 7 (4)

  Artikel

  Introduction Differences in birthweight are often seen between migrants and natives. However, whether migrant-native birthweight inequalities widen, narrow or remain persistent across generations when comparing the descendants of immigrants and natives remains understudied. We examined inequalities in birthweight of mothers (G2) and daughters (G3) of foreign-born grandmothers (G1) compared with those of Swedish-born grandmothers.

  Methods We used population registers with multigenerational linkages to identify 314 415 daughters born in Sweden during the period 1989–2012 (G3), linked to 246 642 mothers (G2) born in Sweden during 1973–1996, and to their grandmothers (G1) who were Swedish or foreign-born. We classified migrants into non-western, Eastern European, the rest of Nordic and Western. We used multivariable methods to examine mean birthweight and low birthweight (<2500 g; LBW).

  Results Birthweight between individuals with Swedish background (G1) and non-western groups increased from -80 g to -147 g between G2 (mothers) and G3 (daughters), respectively. Furthermore, the odds of LBW increased among the G3 non-western immigrants compared with those with Swedish grandmothers (OR: 1.38, 95% CI 1.12 to 1.69). Birthweight increased in both descendants of Swedes and non-western immigrants, but less so in the latter (83 g vs 16 g).

  Conclusion We observed an increase in birthweight inequalities across generations between descendants of non-western immigrants and descendants of Swedes. This finding is puzzling considering Sweden has been lauded for its humanitarian approach to migration, for being one of the most egalitarian countries in the world and providing universal access to healthcare and education.

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• Investigating the salmon bias effect among international immigrants in Sweden: a register-based open cohort study

  2022. Andrea Dunlavy (et al.). European Journal of Public Health 32 (2), 226-232

  Artikel

  Background: Studies of migration and health have hypothesized that immigrants may emigrate when they develop poor health (salmon bias effect), which may partially explain the mortality advantage observed among immigrants in high-income countries. We evaluated the salmon bias effect by comparing the health of immigrants in Sweden who emigrated with those who remained, while also exploring potential variation by macro-economic conditions, duration of residence and region of origin. Methods: A longitudinal, open cohort study design was used to assess risk of emigration between 1992 and 2016 among all adult (18+ years) foreign-born persons who immigrated to Sweden between 1965 and 2012 (n = 1 765 459). The Charlson Comorbidity Index was used to measure health status, using information on hospitalizations from the Swedish National Patient Register. Poisson regression models were used to estimate incidence rate ratios (RRs) with 95% confidence intervals (CIs) for emigrating from Sweden. Results: Immigrants with low (RR = 0.83; 95% CI: 0.76-0.90) moderate (RR = 0.70; 95% CI: 0.62-0.80) and high (RR = 0.62; 95% CI: 0.48-0.82) levels of comorbidities had decreased risk of emigration relative to those with no comorbidities. There was no evidence of variation by health status in emigration during periods of economic recession or by duration of residence. Individuals with low to moderate levels of comorbidities from some regions of origin had an increased risk of emigration relative to those with no comorbidities. Conclusions: The study results do not support the existence of a salmon bias effect as a universal phenomenon among international immigrants in Sweden.

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• All-cause mortality, age at arrival, and duration of residence among adult migrants in Sweden

  2018. Sol P. Juárez (et al.). SSM - Population Health 6, 16-25

  Artikel

  Background: A mortality advantage has been observed among recently arrived immigrants in multiple national contexts, even though many immigrants experience more social disadvantage compared to natives. This is the first study to investigate the combined influence of duration of residence and age at arrival on the association between region of origin and all-cause mortality among the adult immigrant population in Sweden.

  Methods: Using population-based registers, we conducted a follow-up study of 1,363,429 individuals aged 25-64 years from 1990 to 2008. Gompertz parametric survival models were fitted to derive hazard ratios (HR) for all-cause mortality.

  Results: Compared to native Swedes, we observed a health advantage in all group of immigrants, with the exception of individuals from Finland. However, when information on age at arrival and duration of residence was combined, an excess mortality risk was found among immigrants who arrived before age 18, which largely disappeared after 15 years of residence in Sweden. Non-European immigrants over age 18 showed similar or lower mortality risks than natives in all categories of age at arrival, regardless of duration of residence.

  Conclusions: The findings suggest that the mortality advantage commonly observed among immigrants is not universal. Combined information on age at arrival and duration of residence can be used to identify sensitive periods and to identify possible selection bias. The study also suggests that young immigrants are a vulnerable subpopulation. Given the increased number of unaccompanied minors arriving in Europe, targeted health or integration policies should be developed or reviewed.

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• Intermarriage and COVID-19 mortality among immigrants. A population-based cohort study from Sweden

  2021. Siddartha Aradhya (et al.). BMJ Open 11 (9)

  Artikel

  Objectives To evaluate the role of language proficiency and institutional awareness in explaining excess COVID-19 mortality among immigrants.Design Cohort study with follow-up between 12 March 2020 and 23 February 2021.

  Setting Swedish register-based study on all residents in Sweden.

  Participants 3 963 356 Swedish residents in co-residential unions who were 30 years of age or older and alive on 12 March 2020 and living in Sweden in December 2019.

  Outcome measures Cox regression models were conducted to assess the association between different constellations of immigrant-native couples (proxy for language proficiency and institutional awareness) and COVID-19 mortality and all other causes of deaths (2019 and 2020). Models were adjusted for relevant confounders.

  Results Compared with Swedish-Swedish couples (1.18 deaths per thousand person-years), both immigrants partnered with another immigrant and a native showed excess mortality for COVID-19 (HR 1.43; 95%CI 1.29 to 1.58 and HR 1.24; 95%CI 1.10 to 1.40, respectively), which translates to 1.37 and 1.28 deaths per thousand person-years. Moreover, similar results are found for natives partnered with an immigrant (HR 1.15; 95%CI 1.02 to 1.29), which translates to 1.29 deaths per thousand person-years. Further analysis shows that immigrants from both high-income and low-income and middleincome countries (LMIC) experience excess mortality also when partnered with a Swede. However, having a Swedish-born partner is only partially protective against COVID-19 mortality among immigrants from LMIC origins.

  Conclusions Language barriers and/or poor institutional awareness are not major drivers for the excess mortality from COVID-19 among immigrants. Rather, our study provides suggestive evidence that excess mortality among immigrants is explained by differential exposure to the virus.

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• Being a refugee or having a refugee status? Birthweight and gestational age outcomes among offspring of immigrant mothers in Sweden

  2018. Sol Juárez, Eleonora Mussino, Anders Hjern. Scandinavian Journal of Public Health

  Artikel

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• Acculturation or unequal assimilation? Smoking during pregnancy and duration of residence among migrants in Sweden

  2019. Josefin Klöfvermark, Anders Hjern, Sol Juárez. SSM - Population Health 8

  Artikel

  A growing corpus of evidence reveals that smoking patterns of migrant women tend to converge with that of the host population over time ('acculturation paradox'). In this paper we aim to adopt a health equity perspective by studying the extent to which this pattern reflects a convergence with the group of natives who are more socioeconomically disadvantaged. Using population-based registers, we study 1,194,296 women who gave birth in Sweden between 1991 and 2012. Using logistic regression, we estimated odds ratios to assess the effect of duration of residence on the association between smoking during pregnancy and women's origin (classified according to inequality-adjusted Human Development Index (iHDI) of the country of birth). Sibling information and multilevel models were used to assess the extent to which our results might be affected by the cross-sectional nature of the data. Smoking during pregnancy increases with duration of residence among migrants from all levels of iHDI to such an extent that they tend to converge or increase in relation to the levels of the Swedish population with low education and low income, leaving behind the native population with high education and income. The results are robust to possible selection bias related to the cross-sectional nature of the data. Our findings indicate the need of a health equity perspective and suggest the use of 'unequal assimilation' rather than 'acculturation paradox' as a more suitable framework to interpret these findings.

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• Migration background characteristics and the association between unemployment and suicide

  2017. Andrea Dunlavy (et al.). European Journal of Public Health 27 (Suppl. 3)

  Artikel

  Background

  Persons of foreign-origin have higher rates of unemployment compared to those of native-origin, yet few studies have assessed relationships between unemployment and mental health in persons of foreign-origin relative to the native-origin. This study aims to examine the extent to which generational status, region of origin, age at arrival, and duration of residence modify the relationship between employment status and suicide risk.

  Methods

  Population-based registers were used to conduct a longitudinal, open cohort study of native-origin and foreign-origin Swedish residents of working age (25-64 years) from 1993-2008. Hazard ratios and 95% confidence intervals for suicide mortality were estimated using gender-stratified Cox proportional hazards models.

  Results

  Elevated hazard ratios for suicide were observed among the majority of foreign-origin persons exposed to unemployment. Second generation Swedish men exposed to unemployment demonstrated significantly greater (p < 0.05) excess risk of suicide (HR = 3.63, 95% CI: 2.90-4.54) than that observed among native-origin Swedish men exposed to unemployment (HR = 1.67, 95% CI: 1.29-2.16). In unemployed foreign-born men, younger age at arrival and longer duration of residence were associated with increased risk of suicide, whereas unemployed foreign-born men who arrived as adults and had a shorter duration of residence did not demonstrate excess suicide risk.

  Conclusions

  Analyses indicated that the majority of the foreign-origin exposed to unemployment demonstrated excess risk of suicide that was of a similar magnitude to that observed among their native-origin counterparts. Yet there were notable differences in patterns of association by generational status, region of origin, age at arrival, and duration of residence. The high excess risk observed in unemployed second generation men suggests that ensuring employment among this group may be of particular public health importance.

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• The weight of inequalities

  2017. Sol P. Juárez, Anders Hjern. Social Science and Medicine 175, 81-90

  Artikel

  In this study we assessed the effect duration of residence on the association between maternal origin and birthweight in Sweden. Considering sibling information, we also investigated how far the presence or lack of such an effect could be biased by the use of cross-sectional data, since there may be a selection among those mothers who decide to have a child soon after moving to the country (e.g. those with a more stable family situation). Using the Swedish Medical Birth Register for the period 1992-2012, we performed linear and multinomial regressions, multilevel linear regressions, and random effect meta-analysis. Offspring of foreign-born mothers were lighter on average (−120 g [-143,-60]) and had a higher risk of having low birthweight (RRR:1.70 [1.61,1.80]) compared to those with Swedish-born mothers. The variation of birthweight by duration of residence was small (less than 50 g) compared to the gradient found between countries grouped according to the human development index (HDI), where the difference between countries with low and very high HDI was of 105 g. Moreover, no clear pattern toward a convergence with the Swedish population was observed after nine years in the country, which was confirmed when we compared the between- and within-mother analyses by HDI categories. Overall, our results support the thesis that contextual early life conditions have an impact on adult health (reproductive health in this case) with consequences in the next generation that cannot be buffered by the situation experienced in the host country.

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• Caesarean Birth is Associated with Both Maternal and Paternal Origin in Immigrants in Sweden

  2017. Sol P. Juárez (et al.). Paediatric and Perinatal Epidemiology 31 (6), 509-521

  Artikel

  Background

  To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden.

  Methods

  Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity.

  Results

  Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10–2.19; multiparous OR 1.13–2.02) and planned caesarean (primiparous OR 1.18–2.25; multiparous OR 1.13–2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76–0.86; multiparous OR 0.74–0.86. Planned; primiparous OR 0.75–0.82; multiparous OR 0.60–0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women.

  Conclusions

  Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors.

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• Revisiting the Healthy Migrant Paradox in Perinatal Health Outcomes Through a Scoping Review in a Recent Host Country

  2017. Sol P. Juárez (et al.). Journal of Immigrant and Minority Health 19 (1), 205-214

  Artikel

  Ample evidence shows that, in many developed countries, immigrants have similar or better perinatal health outcomes than natives despite facing socioeconomic disadvantages in the host country (“healthy migrant paradox” –HMP). This scoping review aims to: (1) summarize the literature on perinatal health among immigrants and natives in Spain and (2) examine whether there is evidence of the HMP in a context of recent migration. A total of 25 articles published between 1998 and 2014 were reviewed. Overall, we found evidence of the HMP in low birthweight and to a lesser extent in preterm, though the patterns vary by origin, but not in macrosomia and post-term. The results are consistent across settings, levels of adjustment, and birth year. Policies should be oriented towards identifying the modifiable risk factors leading to a higher risk of macrosomia and post-term among immigrants.

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• Social hållbarhet i kollektivtrafiken

  2017. Helena Honkaniemi (et al.). Metoder och verktyg för sociala nyttoberäkningar i kollektivtrafiken, 9-53

  Kapitel

  Med skärpt fokusering på hållbar utveckling blir såväl politiskt ansvariga som akademiker allt mer sysselsatta inte enbart med infrastrukturens inverkan på ekonomi och miljö utan även dess sociala inverkan. Denna breda litteraturstudie har undersökt den sociala hållbarhetens roll i kollektivtrafikens infrastruktur. Den har siktat på att urskilja de olika komponenter i social hållbarhet som ingår i denna kontext, kvalitativa respektive kvantitativa analytiska metoder och deras krav på data samt tillämpbarheten av dessa rön i den svenska kontexten. Översikten utfördes med hjälp av indexeringstjänsten Web of Science, en kombinerad snöbollsmetod samt interna rekommendationer och analyser med hjälp av ett teoretiskt ramverk för hållbarhet anpassat från United Nations Environment Programme. Rönen ådagalade många kvantitativa tillvägagångssätt, däribland kostnads-/nyttoanalys [cost-benefit analyses (CBA)], tillämpningar av geografiska informationssystem (GIS), och jämlikhetsanalyser m.fl. Variabler för kollektivtrafik såsom tillgänglighet och rörlighet behandlades oftast tillsammans med sociala bestämningsfaktorer, liksom sociala utfallsvariabler däribland socialt utanförskap och socialt kapital. Kvalitativa infallsvinklar används däremot mer sällan i den här kontexten trots deras betydelse för att hjälpa till att fånga in användares erfarenheter och att urskilja nya sociala variabler. Utifrån dessa resultat och den rådande preferensen för kvantitativa metoder i svenska analyser av kollektivtrafik rekommenderar författarna mera fokus på de sociala utfallen av kollektivtrafikens infrastruktur genom att använda en blandning av kvantitativa och kvalitativa infallsvinklar.

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• From cradle to grave

  2016. Sol P. Juárez, Anna Goodman, Ilona Koupil. Journal of Epidemiology and Community Health 70 (6), 569-575

  Artikel

  Background: Ample evidence has shown that early-life social conditions are associated with mortality later in life. However, little attention has been given to the strength of these effects across specific age intervals from birth to old age. In this paper, we study the effect of the family's socioeconomic position and mother's marital status at birth on all-cause mortality at different age intervals in a Swedish cohort of 11 868 individuals followed across their lifespan.

  Methods: Using the Uppsala Birth Cohort Multigenerational Study, we fitted Cox regression models to estimate age-varying HRs of all-cause mortality according to mother's marital status and family's socioeconomic position.

  Results: Mother's marital status and family's socioeconomic position at birth were associated with higher mortality rates throughout life (HR 1.18 (95% CI 1.12 to 1.26) for unmarried mothers; 1.19 (95% CI 1.12 to 1.25) for low socioeconomic position). While the effect of family's socioeconomic position showed little variation across different age groups, the effect of marital status was stronger for infant mortality (HR 1.47 (95% CI 1.23 to 1.76); p=0.04 for heterogeneity). The results remained robust when early life and adult mediator variables were included.

  Conclusions: Family's socioeconomic position and mother's marital status involve different dimensions of social stratification with independent effects on mortality throughout life. Our findings support the importance of improving early-life conditions in order to enhance healthy ageing.

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• Exploring the 'healthy migrant paradox' in Sweden

  2016. Sol Pía Juárez, Bárbara A. Revuelta-Eugercios. Journal of Immigrant and Minority Health 18 (1), 42-50

  Artikel

  Evidence shows that in some contexts immigrants have better health than natives in spite of coming from poorer socioeconomic contexts and of facing socioeconomic disadvantages in the host country. However, this is a country or origin- and outcome-specific phenomenon. This study compares different health outcomes derived from birthweight and gestational age among different migrant groups residing in Sweden. Cross-sectional study based on the Swedish Medical Birth Register for years 1987–1993. Multinomial regression models were performed to obtain crude and adjusted Odd Ratios and their 95 % Confidence Intervals. Overall, immigrants show a higher risk of LBW and preterm and a lower risk of macrosomia and post-term. Moreover, some groups performed worse than natives even in indicators at the two ends of the distribution. The healthy migrant paradox is also outcome-specific within different perinatal indicators and the selection explanation cannot fully account for this phenomenon.

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• Does Maternal Country of Birth Matter for Understanding Offspring's Birthweight? A Multilevel Analysis of Individual Heterogeneity in Sweden

  2015. Shai Mulinari (et al.). PLoS ONE 10 (5)

  Artikel

  Background Many public health and epidemiological studies have found differences between populations (e.g. maternal countries of birth) in average values of a health indicator (e.g. mean offspring birthweight). However, the approach based solely on population-level averages compromises our understanding of variability in individuals' health around the averages. If this variability is high, the exclusive study of averages may give misleading information. This idea is relevant when investigating country of birth differences in health. Methods and Results To exemplify this concept, we use information from the Swedish Medical Birth Register (2002-2010) and apply multilevel regression analysis of birthweight, with babies (n = 811,329) at the first, mothers (n = 571,876) at the second, and maternal countries of birth (n = 109) at the third level. We disentangle offspring, maternal and maternal country of birth components of the total offspring heterogeneity in birthweight for babies born within the normal timespan (37-42 weeks). We found that of such birthweight variation about 50% was at the baby level, 47% at the maternal level and only 3% at the maternal countries of birth level. Conclusion In spite of seemingly large differences in average birthweight among maternal countries of birth (range 3290-3677g), knowledge of the maternal country of birth does not provide accurate information for ascertaining individual offspring birthweight because of the high inter-offspring heterogeneity around country averages. Our study exemplifies the need for a better understanding of individual health diversity for which group averages may provide insufficient and even misleading information. The analytical approach we outline is therefore relevant to investigations of country of birth (and ethnic) differences in health in general.

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• Quality of the Spanish Vital Statistics to Estimate Perinatal Health Outcomes

  2015. Sol Pía Juárez. Revista Española de Salud Pública 89 (1), 85-91

  Artikel

  Background: Relative measures of birthweight (small and large-for-gestational age, SGA-LGA) are increasingly preferred to absolute measures (low birthweight, macrosomia). In this study we assess whether the national vital statistics provided by the Spanish National Statistical Institute (INE) reliably estimate SGA and LGA. Also, we will assess whether missing data (selection) and misreported information (bias) are systematically associated with parental socioeconomic information. Methods: We linked the information on 6,339 births at the Hospital Clínico San Carlos of Madrid (2005-06) with the vital statistics records (successful for the 95% of the observation). Validity measures and concordance were estimated for low birthweight (LBW, <2500 gr), macrosomia (>4500 gr), SGA (<10th percentile) and LGA (>90 percentile). Logistic regressions were fitted. Results: The prevalence estimated with the hospital data were: LBW (6%), macrosomia (0.5%) SGA (1%) and LGA (15%) and, with the data from INE: 5% 0.5% 2% 12% respectively. Kappa statistics: LBW (83%), macrosomia (79%), PEG (24%) and LGA (82%). Missing and misreported data vary with parental nationality and their situation in the labor market (OR between 1.5 y 2.2). Conclusions: Vital statistics overestimate the prevalence of SGA and underestimate the prevalence of LGA. The concordance between the sources is very good for low birthweight, macrosomia and LGA, and moderately good for SGA. Both missing and misreported birthweight and gestational age are associated with parental socioeconomic characteristics.

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• Is It Who You Are or Where You Live? Community Effects on Net Fertility at the Onset of Fertility Decline

  2017. Martin Dribe, Sol Pía Juárez, Francesco Scalone. Population, Space and Place 23 (2)

  Artikel

  This paper studies contextual effects on fertility at the onset of fertility decline in Sweden. We argue that the community exerts an influence on fertility when individuals belonging to a certain community are more similar to one another (within-area) in their reproductive behaviour than individuals living in another community (between-area). Our hypotheses are that community had a strong influence in the past but that it decreased over time as more individualistic values grew in importance. We expect that the community exerted a greater impact in the low socioeconomic groups as the elite were less constrained by proximity and, therefore, more exposed to new ideas crossing community borders. Using micro-census data from 1880, 1890, and 1900, we use multilevel analysis to estimate measures of intra-class correlation within areas. We measure net fertility by the number of own children under five living in the household to currently married women with their spouses present. Parish is used as proxy for community. Our results indicate that despite average differences in fertility across parishes, the correlation between individuals belonging to the same community is less than 2.5%, that is, only a negligible share of the number of children observed is attributable to true community effects. Contrary to our expectation, we do not find any substantial change over time. However, as expected, community has a greater impact in the low socioeconomic groups. Our findings suggest that it is who you are rather than where you live which explains fertility behaviour during the initial stages of the transition.

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

  Andrea Dunlavy, Sol Juarez, Mikael Rostila.

  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 study of 2,178,321 individuals aged 25-64 was followed from 1993-2008. 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 foreign-origin persons exposed to unemployment. 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. Decreased risk of mortality was observed among the employed in nearly all foreign-origin groups.

  Conclusions: Our findings suggest that the mortality health advantage often observed among foreign-origin groups is most evident among the employed, while the magnitude of excess risk for mortality in the foreign-origin exposed to unemployment varies by generational status and region of origin.

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

  2018. Andrea C. Dunlavy, Sol Juárez, Mikael Rostila. European Journal of Public Health 28 (5), 891-897

  Artikel

  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.

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• Hospital care for viral gastroenteritis in socio-economic and geographical context in Sweden 2006-2013

  2018. Johannes Lind (et al.). Acta Paediatrica 107 (11), 2011-2018

  Artikel

  AIM: We investigated socio-economic and geographical determinants of hospital care for viral gastroenteritis in young children.

  METHOD: This is a register-based study in a national birth cohort of 752 078 children 0-5 years of age in Sweden during 2006-2012. Hazard ratios (HR) of time to first admission and first episode of outpatient emergency department (ED) care with a diagnosis of viral gastroenteritis were estimated with Cox regression.

  RESULTS: The adjusted HRs for hospital admission with a diagnosis of viral gastroenteritis were increased when the mother was below 25 years at the birth of the child, 1.30 (95% CI: 1.24-1.35), had a short (<=9 years) education, 1.18 (95% CI: 1.12-1.23), a psychiatric disorder, 1.34 (95% CI: 1.30-1.39), and/or when parents were born outside Europe, 1.23 (95% CI: 1.18-1.29). In contrast, the disposable income of the family was only marginally associated with such hospital admissions. The pattern of HRs for outpatient ED hospital care was similar. Hospital care incidences for viral gastroenteritis differed considerably between Swedish counties.

  CONCLUSION: Parental indicators associated with a lower level of health literacy increase the risk for hospital care due to gastroenteritis in young children. Information about oral rehydration should be provided in ways that are accessible to these parents.

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• Length of residence and caesarean section in migrant women in Sweden

  2018. Sol Juárez (et al.). European Journal of Public Health 28 (6), 1073-1079

  Artikel

  Background

  Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden.

  Methods

  Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence.

  Results

  Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR_≤1=1.41 (1.32–1.50); OR_>1–<6=1.49 (1.42–1.57); OR_6–<10=1.61 (1.50–1.72); OR_≥10=1.71 (1.64–1.79) and planned caesarean section [OR_≤1=1.14 (0.95–1.36); OR_>1–<6=1.30 (1.13–1.51); OR_6–<10=1.97 (1.64–2.37]; OR_≥10=1.82 (1.67–1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings.

  Conclusions

  The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.

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• Out-of-Home Care and Subsequent Preterm Delivery

  2018. Can Liu (et al.). Pediatrics 142 (2)

  Artikel

  OBJECTIVES: Adverse early-life experience may affect preterm delivery later in life through priming of stress response. We aim to investigate the links between out-of-home care (OHC) experience in childhood, as a proxy of severe adversities, on subsequent risk of preterm delivery. METHODS: A register-based national cohort of all women born in Sweden between 1973 and 1977 (N = 175 821) was crosslinked with information on these women's subsequent deliveries as recorded in the Swedish medical birth register. During 1986-2012, 343 828 livebirths of these women were identified. The associations between women's OHC experience and her risk of preterm delivery were analyzed through logistic regression models, adjusting for women's own preterm birth, intrauterine growth, and childhood socioeconomic situation. RESULTS: Compared with women that never entered OHC, women with OHC experience up to and after age 10 were both associated with increased risks of preterm delivery (adjusted odds ratio [aOR] = 1.23 [95% confidence interval 1.08-1.40] and aOR = 1.29 [1.13-1.48], respectively). Women who experienced OHC before or at 10 years of age had increased risk of both spontaneous and medically indicated preterm delivery (aOR = 1.19 [1.03-1.38] and aOR = 1.27 [1.02-1.59], respectively). Women who experienced OHC after age 10 had a more pronounced risk of medically indicated preterm delivery (aOR = 1.76 [1.44-2.16]) than for spontaneous preterm delivery (aOR = 1.08 [0.92-1.27]). CONCLUSIONS: Women who were placed in OHC in childhood had increased risk of preterm delivery independent from their own perinatal history. Stress response, as 1 consequence of early life adversities, may take its toll on women's reproductive health and their offspring, calling for integrative efforts in preventing early life adversity.

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• Social inequalities in Low Birth Weight among Spanish mothers during the economic crisis (2007-2015)

  2018. José Manuel Teran (et al.). Nutrición Hospitalaria 5 (35), 129-141

  Artikel

  Objective: to evaluate the impact of the economic crisis on the disparities in the prevalence and risk of low birth weight (LBW) according to the maternal socioeconomic profile.

  Methods: the data analysed corresponds to 1,779,506 single births to Spanish mothers in the years 2007, 2009, 2011, 2013 and 2015. The temporal changes in available maternal-foetal variables are described. Secondly, the possible increase in disparities in prevalence and risk of LBW due to the occupation and education of the mother is evaluated, taking 2007 as the reference year.

  Results: a trend of the maternal profile is described among women who had children during this period, with an increasing contribution of highly qualified professional and educated women, a trend already existing before the economic crisis, but which was deepened by the recession. The prevalence of LBW increased in all socio-economic groups, with a marked increase in disparities during the worst years of the economic crisis.

  Conclusion: results confirm the persistence of social inequalities in perinatal health described prior to the economic crisis, as well as a possibly negative effect of the recession between 2007 and 2015. Results also confirm that disparities in LBW are more clearly associated with the educational level of mothers than with their occupation.

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• Suicide risk among native- and foreign-origin persons in Sweden

  2018. Andrea C. Dunlavy (et al.). Social Psychiatry and Psychiatric Epidemiology

  Artikel

  PURPOSE: Prior research has documented an association between unemployment and elevated suicide risk. Yet, few Swedish studies have explicitly considered how such risk may vary by different migration background characteristics among persons of foreign-origin, who often experience diverse forms of labor market marginalization. This study examines the extent to which unemployment status may differentially influence suicide risk among the foreign-origin by generational status, region of origin, age at arrival, and duration of residence.

  METHODS: Population-based registers were used to conduct a longitudinal, open cohort study of native-origin and foreign-origin Swedish residents of working age (25-64 years) from 1993 to 2008. Hazard ratios and 95% confidence intervals for suicide mortality were estimated using gender-stratified Cox proportional hazards models.

  RESULTS: Elevated suicide risk observed among foreign-origin unemployed groups was generally of a similar or lower magnitude than that found in unemployed native-origin, although unemployed second-generation Swedish men demonstrated significantly greater (p < 0.05) excess risk of suicide than that observed among their native-origin counterparts. Unemployed foreign-born men with a younger age at arrival and longer duration of residence demonstrated an increased risk of suicide, while those who arrived as adults, and a shorter duration of residence did not show any increased risk. Among foreign-born women, excess suicide risk persisted regardless of age at arrival and duration of residence in the long-term unemployed.

  CONCLUSIONS: Multiple migration background characteristics should be considered when examining relationships between employment status and suicide among the foreign-origin.

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• Non-European migrants often have similar or better health than natives

  2017. Sol Juarez, Mikael Rostila. Sociologisk forskning 54 (4), 323-327

  Artikel

  Sweden has experienced a sharp increase in migration flows in the last decades. Projections estimate that the migrant population rate will continue to grow in the near future. Given the centrality of health for the successful engagement of individuals in society, health aspects of migration have emerged as an important area of study. In this research note, we present a brief overview of current knowledge and argue in favour of developing a social determinants perspective on health in future research.

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