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Journal of Public Health Advance Access originally published online on April 24, 2007
Journal of Public Health 2007 29(2):191-198; doi:10.1093/pubmed/fdm010
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003



S.H. Wild, Senior Lecturer1,

C. Fischbacher, Consultant in Public Health Medicine2

A. Brock, Research Officer3

C. Griffiths, Principal Research Officer3

R. Bhopal, Professor1
1 Public Health Sciences, University of Edinburgh, Teviot Place EH8 9AG, UK
2 Information Services Division, NHS National Services, Gyle Square, Edinburgh EH12 9EP, UK
3 Mortality Statistics, Office for National Statistics, Drummond Gate, London SW1V 2QQ, UK

Address correspondence to S.H. Wild, E-mail: sarah.wild{at}ed.ac.uk

Background Differences in mortality by country of birth in England and Wales in people under 70 years of age have been demonstrated previously. Changes in age distribution of migrants and in migration patterns have occurred subsequently.

Methods All-cause and circulatory disease mortality for people aged 20 years and over in England and Wales by country of birth were examined using population data from the 2001 Census and mortality data for 2001–2003. Indirect standardization was used to estimate sex-specific standardized mortality ratios (SMRs) and 95% confidence intervals (CI) in comparison to mortality for England and Wales as a whole.

Results SMRs for all-cause mortality were statistically significantly higher than the national average for people born in Ireland, Scotland, East Africa and West Africa and lower for people born in China and Hong Kong. SMRs for circulatory disease were highest among people born in Bangladesh and lowest among people born in China and Hong Kong. Patterns of ischaemic heart disease and cerebrovascular disease mortality differed by country of birth.

Conclusions Mortality, particularly due to ischaemic heart disease and stroke, differs markedly by country of birth in all age groups including the ≥70-year-old group.

Keywords: mortality, country of birth, ethnicity, cardiovascular disease


   Background
TOP
 Background
Methods
 Results
 Discussion
 Conclusion
 References
 
Analyses of mortality of migrants to England and Wales have been performed around three previous censuses in 1971, 1981 and 1991 and showed that mortality varied widely by country of birth.1–4 We also have recently analysed data for Scotland around the 2001 census.5 These data have been useful for a variety of purposes, including health needs assessment, prioritization, policy formulation, health-care delivery and development of hypotheses regarding the aetiology of disease.4 The proportion of elderly migrants among established groups in England and Wales is increasing, and migration patterns have changed in recent years. The aim of this analysis was to provide information on mortality from all causes, circulatory disease, ischaemic heart disease and cerebrovascular disease in England and Wales by country of birth for 2001–2003. Cancer mortality data for this period have already been published.6 We have examined data separately for the oldest age group (≥70 years of age) and have included a wider range of countries of birth (e.g. Eastern Europe and the Middle East) than in the 1991 analysis.3 Geographical areas were identifed for inclusion in the analysis if there were over 1000 deaths among adults (>20 years of age) from all causes in England and Wales between 2001 and 2003 among people born in each region or country.


   Methods
TOP
 Background
 Methods
Results
 Discussion
 Conclusion
 References
 
Population data by age, sex and region or country of birth were obtained from the 2001 Census of England and Wales. We studied data for people born in the following regions and countries (in alphabetical order): Bangladesh, China and Hong Kong, East Africa, Eastern Europe, England and Wales, India, Ireland, Middle East, North Africa, Pakistan, Scotland, West Africa and the West Indies. Details of the countries included in each group are listed in Table 1 of the cancer mortality paper.6 Age groups were defined as 20–44, 45–59 and 60–69 years for consistency with previous similar analyses but a further age group of ≥70 years was added.


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  		Table 1 Numbers of deaths and all–cause SMRs by sex and country of birth for people aged 20 years and over

 
Data on deaths for the years 2001–2003 by age, sex, region or country of birth and underlying cause of death were obtained for England and Wales from the Office for National Statistics (ONS). The analysis was restricted to deaths from 2001 onwards so that all data were coded according to the tenth revision of International Classification of Diseases (ICD-10).7 For some causes of death, including cerebrovascular disease, data from 2001 onwards are not directly comparable with those prior to 2001, which were coded using ICD-9 codes.8 Definitions of cause-specific mortality were defined using ICD-10 codes as follows: circulatory disease I0–I99, ischaemic heart disease I20–I25, cerebrovascular disease I60–I69.

Indirect standardization was used to adjust for differences in age distribution between populations of interest using the population structure of England and Wales by sex and 5-year age group up to 85 + years of age as the standard. The standard for mortality was based, as for previous similar analyses, on data for deaths registered in England and Wales as a whole. Conventional methods were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) by sex and country of birth.9

Results are presented in an order defined by geographical groupings and are regarded as statistically significant if the 95% CIs around SMRs did not include 100. As people born in England and Wales form a large majority of the study population SMRs for this group tend to be close to 100, indicating little difference from the population as a whole. However, as a consequence of the large numbers of deaths among people born in England and Wales, small differences tend to be statistically significant and no further comment is made on the findings for people born in England and Wales.


   Results
TOP
 Background
 Methods
 Results
Discussion
 Conclusion
 References
 
The populations included in this study represent 99.5% of the adults aged 20 years or older enumerated in the 2001 Census of England and Wales. Age structures differ between populations with individuals born in Bangladesh and West Africa having a particularly large proportion of people in the 20–44-year age group (data not shown but available from www.statistics.gov.uk).

SMRs for deaths from all causes for the broad group of 20 years of age and over are shown in Table 1. SMRs for all-cause mortality were statistically significantly higher than for England and Wales as a whole for: men and women born in Ireland, Scotland, East Africa or West Africa; men born in Bangladesh; women born in India or Pakistan. SMRs for all-cause mortality in this broad age group were statistically significantly below the national average for men and women born in China or Hong Kong, for men born in India and for women born in Eastern Europe.

For most populations, similar patterns were seen when narrower age bands were examined, with differences persisting into the oldest age group (≥70 years) as shown in Table 2. The exceptions were for men born in Bangladesh who had a statistically significantly low SMR in the 20–44-year age group but high SMRs in the older age groups, men born in Eastern Europe who had statistically significantly high SMRs in the 20–44- and 45–59-year age groups but SMRs similar to that of the national average in the oldest two age groups and women born in West Africa who had a significantly elevated SMR for the broad age group (≥20 years) but a statistically significantly lower SMR for all-cause mortality among the oldest age group.


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  		Table 2 Numbers of deaths and all–cause SMRs by sex, country of birth and age (20–44 years, 45–59 years, 60–69 years, 70 + years)

 
Mortality by country of birth and sex for all circulatory disease is shown in Table 3. Circulatory disease mortality was high among people born in Ireland, Scotland, Eastern Europe, East and West Africa, Bangladesh, India or Pakistan, men born in the Middle East and women born in North Africa and was low among people born in China or Hong Kong. However, these data mask differences in ischaemic heart disease and cerebrovascular disease by country of birth as described below.


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  		Table 3 Numbers of deaths and circulatory disease (ICD–10 I0–I99) SMRs by sex and country of birth for people aged 20 years and over

 
Table 4 shows that high ischaemic heart disease (IHD) SMRs were observed among men and women aged ≥20 years born in Ireland, East Africa, Bangladesh, Pakistan or India, men born in Eastern Europe or the Middle East and women born in Scotland. Low SMRs for IHD were observed among men born in West Africa or the West Indies and both men and women born in China or Hong Kong. In young adults (20–44 years of age), very high mortality from IHD (indicating over double the expected number of deaths) was seen for men born in Eastern Europe (SMR 235; 95% CI 151–350) or Pakistan (SMR 261; 95% CI 203–330) based on 24 and 70 deaths, respectively (full table not shown but data available from authors). SMRs for IHD for men born in Eastern Europe or Pakistan were elevated in other age groups but the difference from the standard was less marked at older ages.


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  		Table 4 Numbers of deaths and IHD (ICD–10 I20–I25) SMRs by sex and country of birth for people aged 20 years and over

 
Cerebrovascular disease mortality was statistically significantly elevated among men born in all the countries analysed apart from the Middle East as shown in Table 5. SMRs were also significantly elevated for women born in Ireland, Scotland, West Africa, Bangladesh, India, Pakistan or the West Indies. Particularly, high SMRs for cerebrovascular disease were seen for men and women born in Bangladesh and for men born in West Africa.


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  		Table 5 Numbers of deaths and cerebrovascular disease (ICD–10 I60–I69) SMRs by sex and country of birth for people 20 + years of age

 

   Discussion
TOP
 Background
 Methods
 Results
 Discussion
Conclusion
 References
 
Main findings of this study
This analysis has demonstrated marked differences in mortality by country of birth, particularly for IHD and stroke, thereby consolidating and extending similar observations in the UK and other parts of the world.1–4;10–13 Inequalities are demonstrable in all the age groups studied including, for the first time in the UK, the oldest age group (≥70 years of age). Further evidence has been provided for the heterogeneity between people born in different countries of the Indian sub-continent as predicted in previous theoretical and empirical papers examining risk factor patterns14,15 and as previously shown in 1991-based data.4

In young adult men (aged 20–44 years), the highest all-cause mortality was observed in those born in Eastern Europe and the West Indies. Previous research has found that the most common causes of death in this age group in men in England and Wales are from external causes of injury and poisoning which include accidents and suicides.16 Young adult men from Eastern Europe and Pakistan in this analysis also had very high mortality ratios from IHD. It is important to establish whether this is a consistent finding in the light of increasing migration of young people to the UK from Eastern Europe.

What is already known on this topic
Differences in mortality by country of birth have previously been demonstrated using data from the 1971, 1981 and 1991 censuses of England and Wales.1–4 People born in the Indian sub-continent, Scotland and Ireland who have migrated to England and Wales have higher mortality from both IHD and cerebrovascular disease than the national average. People born in the West Indies/Caribbean or West Africa have lower mortality from IHD but higher mortality from cerebrovascular disease than the national average.

What this study adds
There were wide and persisting differences in mortality by country of birth in England and Wales for 2001–2003 even for migrants above 70 years of age. The range of countries of birth included in the analysis has been extended to include the Middle East and Eastern Europe and the data show high relative IHD mortality among men born in both these regions and suggest particularly high IHD mortality among young men born in Eastern Europe. Data for people born in Bangladesh, India and Pakistan are presented separately for the first time and show heterogeneity between these populations.

Limitations of this study
Ethnicity is not recorded in death certificates in England and Wales at present and so it is not possible to investigate mortality of second and subsequent generations of migrants using routine data. Country of birth reflects ethnicity reasonably well among older people from most ethnic groups but is likely to be an unreliable proxy measure of ethnicity for younger people. It is not currently possible to investigate to what extent mortality patterns by country of birth reflect mortality patterns by ethnicity in large, nationally representative populations. Data from the ONS Longitudinal Study allow the study of mortality by ethnic group as reported at census 1991 in England and Wales but include a relatively small number of people from ethnic minorities. Preliminary analyses of these data suggest that the major causes of disease by ethnic group are similar to those in country of birth analysis. Mortality among the children of migrants born in Pakistan was relatively high, with a major contributor to this finding being high mortality among children under 16 years of age.17 Mortality in the largest minority ethnic sub-group, the Irish, was high compared with that of other Longitudinal Study members, and mortality differentials rose progressively across three generations of Irish people.17,18 The recording of ethnicity in hospital records in the UK is improving and in future it may be possible to analyse morbidity associated with hospital admissions by ethnicity.

Potential sources of bias in country of birth analyses include the healthy migrant effect which is particularly likely to influence mortality among younger age groups, differentially inaccurate reporting of cause of death between different populations, numerator–denominator bias (which may occur due to errors in population estimates or when country of birth for an individual is recorded differently in the Census and in a death certificate) and return migration. In the 20–44-year age group, low SMRs for all-cause mortality particularly in the Indian sub-continent born populations provide evidence of a healthy migrant effect. It is possible that some ill people migrate to England and Wales for treatment but it is not possible to quantify any such effect from the available data. Misclassification bias may occur if, for example, IHD is more likely to be recorded as the cause of death among people born in South Asia than in other populations when the cause of death is unclear. Cohort studies are required to establish whether this is an important phenomenon.

Under-enumeration of the population in the Census is more marked among some sub-groups of the population, for example, young men living in inner cities. It is possible that mortality excesses, particularly in younger men, arise from an underestimation of the denominator occurring disproportionately in some country of birth groups. As censuses take only place every 10 years, restricting analysis of mortality to years close to the Census helps to limit a mismatch between the numerator and the denominator due to population changes. A study in London suggested that current population numbers of older people are also underestimated (leading to over-estimation of SMRs) with a particularly marked effect among people born in East Africa, Scotland or Ireland.19

Estimates of mortality of older migrants are potentially susceptible to bias due to return migration. In Sweden, low mortality rates among people born outside the Nordic countries were found to be partially explained by population over-estimation. When the population estimates were adjusted using information on income and social benefits, it appeared that mortality was underestimated for people born in Southern Europe, Latin America, Asia and Africa.20 This bias may explain the lack of association between country of birth and all-cause mortality in a study of older migrants in Sweden which did not adjust population estimates.21 The only suggestion of potential return migration bias in the results of this study was among women born in West Africa.

Country of birth among older people who were born in what was India at the time but is now Pakistan or Bangladesh may have been misclassified because territories have been renamed, leading to numerator–denominator bias. It is not possible to establish whether this has occurred or not from the available data. Separate analysis of data for people born in Indian sub-continent countries is important in assessing the predicted effects of heterogeneity in socio-economic circumstances and risk factors. Examining heterogeneity within the eastern European region, Africa, China and the West Indies is not feasible with relatively small numbers of deaths in England and Wales of people born in these regions.

Generally, immigrants are less affluent than the population as a whole and analyses of relative mortality could be confounded by socio-economic status. Examining the impact of socio-economic factors including educational status on differences in mortality by ethnicity and country of birth is difficult because of the absence of validated indicators that can be applied to national data sets and small numbers of individuals in each stratum, particularly when cause-specific mortality is being examined.22 The study based on the 1971 census by Marmot et al.1 did not support a major relationship between mortality, country of birth and social class1. An analysis of data around the 1991 Census suggested that mortality is inversely associated with socio-economic status in most ethnic minority populations, as it is in the population as a whole.23 Adjusting all-cause mortality among men 20–64 years of age for social class had little effect on differences by country of birth.23 The finding that people from ethnic minorities have a lower income than white people in the same class and that some groups had poorer quality housing than whites regardless of tenure emphasize the difficulty of properly adjusting for social economic factors using simple markers.24 Migrants tend to live in urban areas and this may provide a further confounding factor of the relationship with mortality but this hypothesis has not been examined in this or other studies.

Marital status appears to have an important influence on mortality in most population groups regardless of country of birth (with women born in the Caribbean being the only exception) in that people who were not married tend to have higher mortality than those who were married.25 However, SMRs adjusted for marital status were similar to unadjusted estimates and marital status does not appear to be an important confounding factor in the relationship between mortality and country of birth.25

Health service utilization and quality could also have an impact on mortality differentials. Mortality is a function of incidence and survival, and both can be influenced by health services. Both incidence and case fatality for myocardial infarction have been reported to be higher among South Asians than white patients.26 The Whitehall II prospective study of civil servants found no evidence that low socio-economic position or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independent of clinical need.27 In contrast, there is evidence to suggest that Bangladeshi patients are more likely to present with atypical symptoms of acute myocardial infarction which may lead to delays in treatment.28 Age-adjusted rates of coronary revascularization were lower in South Asian than in white patients among a group of patients for whom revascularization was deemed appropriate but this did not affect risk of subsequent mortality and non-fatal myocardial infarction.29 Mortality after coronary artery bypass grafting appears to be significantly higher among South Asian populations than European populations and the higher prevalence of diabetes among South Asians appears to be an important factor in this relationship.30 The higher stroke mortality among Afro-Caribbean populations than among white populations appears to be due to higher incidence of stroke, as survival is reported to be similar.31

It is beyond the scope of this paper to discuss the complex combination of environmental (and possibly genetic) factors that contribute to differences in mortality by country of birth. Many lifestyle factors that influence health including cigarette smoking, physical activity, nutrition and alcohol consumption vary between ethnic groups (e.g. see Health Survey for England 32). It is likely that these factors make a major contribution to ethnic/country of birth mortality differences. Variations in lung cancer mortality by country of birth are consistent with cigarette consumption patterns.6 Large-scale cohort studies (which do not exist in the UK) or linkage between cross-sectional studies of lifestyles and mortality data are required to assess rigorously the role of lifestyle factors in country of birth/ethnic inequalities in mortality.


   Conclusion
TOP
 Background
 Methods
 Results
 Discussion
 Conclusion
References
 
We have shown important variations in mortality by country of birth that are central to policies on health inequalities. These data show differences in all-cause and cardiovascular disease mortality that are unlikely to be explained by data artefact and that contribute information for both developing hypotheses into disease aetiology and for health policy, health needs assessment and health-care delivery. Investigation of whether similar patterns are observed by ethnicity will not be possible unless information on ethnicity can be linked to information in death certificates, either by directly collecting the information at death registration or by linkage with other data sources.


   References
TOP
 Background
 Methods
 Results
 Discussion
 Conclusion
 References
 

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