Dr. Snorri B. Rafnsson ( University of Edinburgh, UK )

1. Migrant and Ethnic Health Observatory (MEHO) – Work Package 6Circulatory disease mortality by country of birth in six European countries Dr. Snorri B. Rafnsson (University of Edinburgh, UK) Professor Raj S. Bhopal (University of Edinburgh, UK) Professor Johan P. Mackenbach (Erasmus University, The Netherlands) Dr. Irene Stirbu (Erasmus University, The Netherlands) Professor Anton E. Kunst (Amsterdam University, The Netherlands) For the MEHO-CVD Working Group* This project is funded under the framework of Public Health Programme 2003-2008 of the European Commission (contract number 2005122)

2. Migrant and Ethnic Health Observatory (MEHO) The MEHO-CVD Working Group Charles Agyemang, Netherlands Anne Fagot-Campagna, France Simona Giampaoli, Italy Niklas Hammar, Sweden Ebba Hedlund, Sweden Knud Juel, Denmark Paola Primatesta, UK Sarah Wild, UK Project website: www.meho.eu.com

3. Migrant and Ethnic Health Observatory (MEHO) Background • Cardiovascular diseases (esp. IHD and stroke) are major causes of morbidity and mortality in Europe. • Europe’s ethnic composition has changed as a result of emigration and immigration. • Comparable, ethnically disaggregated data on morbidity and mortality from chronic diseases (esp. CVD) are lacking for most European countries. • Many EU countries have national death registers which can be used to examine inequalities in all-cause and cause-specific mortality by country of birth (COB). Project website: www.meho.eu.com

4. Objectives To examine, for each of the EU member states, within-country differences in mortality (i.e. mortality rate ratios) by country of birth. To examine between-country differences in age-standardised mortality rates for selected countries of birth. Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

5. Methods Study countries & design: 1) Denmark, England & Wales, France, Italy, Netherlands, Scotland 2) Cross-sectional vs. longitudinal Death register data: 1) Demographic variables: Age, sex, COB, number of deaths 2) Causes of death: i) Total circulatory disease: ICD9: 390-459, ICD10: I00-I99 ii) Ischaemic heart disease: ICD9: 410-414, ICD10: I20-I25 iii) Cerebrovascular disease: ICD9: 430-438, ICD10: I60-I69 Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

6. Population data: 1) Demographic variables: Age, sex, COB, number of subjects at Census 2) Person-years at risk (PYR) COB classification criteria: 1) COB groups originating outside Western Europe & OECD countries 2) Number of deaths in different COB groups within each study country 3) Correspondence between study countries Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

7. Statistical analysis: -Mortality rate ratios 1) Multivariate Poisson regression models to examine differences in mortality risk between each COB and the native population (as reference) in each study country. 2) Regression model components: (i) Dependent variable: number of deaths (ii) Independent variables: COB, age, sex (iii) Offset variable: PYR 3) The following analyses were performed (for each cause of death): (i) Mortality rate ratios (MRR) for both sexes combined, adjusting for age and sex (ii) Mortality rate ratios (MRR) for each sex separately, adjusting for age Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

8. Statistical analysis (cont.): -Age-standardised mortality rates (ASMR) 1) Age-specific mortality rates for men and women 2) Standard population: WHO World Standard population 2000-2025 3) Directly ASMR per 1000 PYR for men and women aged 35-74 years Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

9. Migrant and Ethnic Health Observatory (MEHO) Results I – Mortality rate ratios Denmark – Total circulatory disease mortality Project website: www.meho.eu.com

10. Migrant and Ethnic Health Observatory (MEHO) England & Wales – Total circulatory disease mortality Project website: www.meho.eu.com

11. Migrant and Ethnic Health Observatory (MEHO) France – Total circulatory disease mortality Project website: www.meho.eu.com

12. Migrant and Ethnic Health Observatory (MEHO) Italy – Total circulatory disease mortality Project website: www.meho.eu.com

13. Migrant and Ethnic Health Observatory (MEHO) Netherlands – Total circulatory disease mortality Project website: www.meho.eu.com

14. Migrant and Ethnic Health Observatory (MEHO) Scotland – Total circulatory disease mortality Project website: www.meho.eu.com

15. Migrant and Ethnic Health Observatory (MEHO) Results II – Age-standardised mortality rates Men – Total circulatory disease mortality Project website: www.meho.eu.com

16. Migrant and Ethnic Health Observatory (MEHO) Women – Total circulatory disease mortality Project website: www.meho.eu.com

17. Discussion Within-country mortality differences – main findings Substantial inequalities in total circulatory disease mortality by COB evident in most countries, and among both sexes. For example, very high risk (up to eight-fold) for African-born women residing in France. Relatively low risk (or no difference) for migrant and minority ethnic groups residing in Italy and Scotland. Between-country mortality differences – main findings Higher ASMR in some migrant/minority ethnic groups across countries e.g. Turkish migrants residing in Denmark and the Netherlands. Picture still very patchy – reflects different migration histories/patterns in different European countries. Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

18. Discussion Explanations? Chance Bias Confounding Data comparability Access/quality of health care, lifestyle and risk factors, genetics… Migrant and Ethnic Health Observatory (MEHO) Project website: www.meho.eu.com

19. Thank you!