Participation of Turkish Migrants in an Epidemiological Study: Does the Recruitment Strategy Affect the Sample Characteristics?

Migrants are often poorly represented in epidemiological studies which limits the generalizability of the results of population-based studies. This study aimed to assess whether a community-based sampling (CBS) of persons of Turkish origin leads to differences in the participants' characteristics compared to a register-based sampling (RBS). The two sampling strategies were used to recruit participants in three cities in Germany (CBS: n = 641; RBS: n = 578). We compared sociodemographic, migration- and health-related characteristics. Census data were used as an external reference. Lower German language skills and a lower acculturation status were more prevalent in the CBS than in the RBS. While age and sex adjusted obesity prevalence differed [CBS: 37.8 (33.6-42.4); RBS 30.0 (26.3-34.0); census data 19.1 (18.2-20.1)], most other health indicators were similar across the samples. In conclusion, the CBS approach led to a greater representation of persons of Turkish origin with lower language skills and lower acculturation status. Nevertheless, both recruitment strategies provided similar estimates of health status indicators.

[Becoming breastfeeding friendly in Germany-an international research project to assess the readiness to scale up breastfeeding]. / Das internationale Forschungsvorhaben Becoming Breastfeeding Friendly. Untersuchung von Rahmenbedingungen zur Stillförderung.

Despite known positive effects for breastfed children and their mothers, only one third of children under four months of age are breastfed exclusively. In addition, an overview of structures, actors, and measures to promote breastfeeding in Germany is missing. In a two-year international research project entitled Becoming Breastfeeding Friendly (BBF), the current status of German breastfeeding support is systematically evaluated on the basis of the Breastfeeding Gear Model (BFGM) which was developed by the Yale School of Public Health. Therefore, committee members with expertise in the healthcare sector, science, policy, and communication evaluate 54 benchmarks of the eight relevant gears: advocacy, political will, legislation & policies, funding & resources, training & program delivery, promotion, research & evaluation, coordination, and goals & monitoring. Based on the identified strengths and needs, concrete calls to action for scaling up breastfeeding promotion are derived and prioritized. BBF started in September 2017 and is conducted in cooperation with the Yale School of Public Health by the Healthy Start - Young Family Network as well as the National Breastfeeding Committee as an initiative of the Federal Ministry of Nutrition and Agriculture. The project assesses the framework conditions for breastfeeding and thus makes a valuable contribution to the health promotion of mother and child and to breastfeeding protection in Germany.

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study.

OBJECTIVE: Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). DESIGN: Cross-sectional study. SETTING: Three obstetric hospitals in Berlin, Germany. METHODS: Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. RESULTS: The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). CONCLUSIONS: We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery).

Acculturation and health-related quality of life: results from the German National Cohort migrant feasibility study.

OBJECTIVES: We assessed the association between acculturation and health-related quality of life (HRQoL) among persons with a Turkish migrant background in Germany. METHODS: 1226 adults of Turkish origin were recruited in four German cities. Acculturation was assessed using the Frankfurt Acculturation Scale resulting in four groups (integration, assimilation, separation and marginalization). Short Form-8 physical and mental components were used to assess the HRQoL. Associations were analysed with linear regression models. RESULTS: Of the respondents, 20% were classified as integrated, 29% assimilated, 29% separated and 19% as marginalized. Separation was associated with poorer physical and mental health (linear regression coefficient (RC) = -2.3, 95% CI -3.9 to -0.8 and RC = -2.4, 95% CI -4.4 to -0.5, respectively; reference: integration). Marginalization was associated with poorer mental health in descendants of migrants (RC = -6.4, 95% CI -12.0 to -0.8; reference: integration). CONCLUSIONS: Separation and marginalization are associated with a poorer HRQoL. Policies should support the integration of migrants, and health promotion interventions should target separated and marginalized migrants to improve their HRQoL.

The association of pre-pregnancy overweight and obesity with delivery outcomes: a comparison of immigrant and non-immigrant women in Berlin, Germany.

OBJECTIVES: To analyse the influence of maternal overweight/obesity on delivery outcomes among first- and second-generation immigrant women and non-immigrant women. METHODS: We used perinatal data from Berlin/Germany (n = 1987 first generation, n = 687 second generation, n = 2185 non-immigrants; gestational age: 24+ weeks; maternal age: 18+ years). Poisson models were fitted to estimate the effect of pre-pregnancy overweight/obesity (categorised according to WHO) on mode of delivery (vaginal vs. emergency caesarean section (ECS)) and labour onset (spontaneous vs. induced). RESULTS: First generation, second generation and non-immigrant women were more likely to have their labour induced when obese [first generation: RR = 1.41 (95 % CI: 1.15-1.72); second generation: RR = 1.51 (95 % CI: 1.14-2.00); non-immigrants: RR = 1.53 (95 % CI: 1.28-1.81)] compared to normal weight. There were also indications of obese women being more likely to deliver by ECS than women of normal weight, irrespective of migrant status. CONCLUSIONS: An elevated RR for obese and in parts for overweight women of labour induction and ECS pertains irrespective of migrant status. This warrants further research looking into pathophysiological in addition to health-system factors. Weight control interventions addressed at overweight/obese women planning pregnancies are urgently needed.

Effect of Length of Stay on Smoking among Turkish and Eastern European Immigrants in Germany--Interpretation in the Light of the Smoking Epidemic Model and the Acculturation Theory.

BACKGROUND: We analyzed changes in smoking by length of stay among immigrants in Germany and related them to the "smoking epidemic" model and the acculturation theory. METHODS: We used data from a longitudinal survey (German Socio-economic Panel). Immigrants were identified by country of birth (Turkey: respondents n = 828, observations n = 3871; Eastern Europe: respondents n = 2009, observations n = 7202; non-immigrants: respondents n = 34,011, observations n = 140,701). Smoking status data was available for nine years between 1998 and 2012. Length of stay (LOS, in years) was used as proxy for acculturation. We calculated smoking prevalences, prevalence ratios and a random intercept multilevel logistic regression model. RESULTS: With each year spent in Germany, smoking prevalence increases among Turkish women (OR = 1.14 (95%CI = 1.06-1.21)) and slightly decreases among men. Recently immigrated Turkish women smoke less than non-immigrant women (0-5 years: SPR = 0.25 (95%CI = 0.10-0.57)); prevalences converge with increasing LOS (31+ years: SPR = 1.25 (95%CI = 1.06-1.48)). Among Eastern European immigrants no significant changes were apparent. CONCLUSIONS: Immigrants from Turkey "import" their smoking prevalence from a country which is in the earlier stages of the "smoking epidemic". With increasing LOS (thus, advancing acculturation), they "move" to the later stages. Anti-smoking interventions should consider different smoking attitudes in Turkey/Germany and need to discourage women from initiating smoking. Future research should also identify reasons for the possible differences between immigrant groups.

Contribution of overweight and obesity to adverse pregnancy outcomes among immigrant and non-immigrant women in Berlin, Germany.

BACKGROUND: Maternal excessive weight and smoking are associated with an increased risk of pregnancy complications and adverse pregnancy outcomes. In Germany, immigrant women have a higher prevalence of pre-pregnancy overweight/obesity compared with autochthonous women. We compared the contribution of pre-pregnancy overweight/obesity to adverse pregnancy outcomes among immigrant and autochthonous women in Berlin/Germany. METHODS: Data from 2586 immigrant women (from Turkey, Lebanon, other countries of origin) and 2676 autochthonous women delivering in three maternity hospitals of Berlin within 12 months (2011/2012) was used. Cox regression models were applied to estimate the association between overweight/obesity and smoking with the outcomes large-for-gestational-age (LGA), small-for-gestational-age (SGA), preterm birth (PTB) and extreme preterm-birth (E-PTB). Population attributive fractions (PAF) were calculated to quantify the proportion of the outcomes attributable to overweight/obesity and smoking, respectively. RESULTS: Prevalence of overweight and obesity was 33.4% among autochthonous and 53.6% among Turkish women. Prevalence risk ratios of excessive weight were highest for LGA infants among immigrant and autochthonous women. The PAFs were -11.8% (SGA), +16.3% (LGA), +3.6% (PTB) and +16.5% (E-PTB) for the total study population. CONCLUSIONS: Overweight/obesity is strongly associated with an increased risk of delivering an LGA infant among both immigrant and autochthonous women. Compared with autochthonous women, the contribution of excessive weight to LGA is even higher among immigrant women, in whom PAFs of overweight/obesity even exceed those of smoking for some outcomes.

Factors associated with smoking in immigrants from non-western to western countries - what role does acculturation play? A systematic review.

INTRODUCTION: We aimed to identify factors associated with smoking among immigrants. In particular, we investigated the relationship between acculturation and smoking, taking into consideration the stage of the 'smoking epidemic' in the countries of origin and host countries of the immigrants. METHODS: We searched PubMed for peer-reviewed quantitative studies. Studies were included if they focused on smoking among adult immigrants (foreign-born) from non-western countries now residing in the USA, Canada, Ireland, Germany, the Netherlands, Norway, the UK, and Australia. Studies were excluded if, among others, a distinction between immigrants and their (native-born) offspring was not made. RESULTS: We retrieved 27 studies published between 1998 and 2013. 21 of the 27 studies focused on acculturation (using bidimensional multi-item scales particularly designed for the immigrant group under study and/or proxy measures such as language proficiency or length of stay in host country) and 16 of those found clear differences between men and women: whereas more acculturated women were more likely to smoke than less acculturated women, the contrary was observed among men. CONCLUSION: Immigrants' countries of origin and host countries have reached different stages of the 'smoking epidemic' where, in addition, smoking among women lags behind that in men. Immigrants might 'move' between the stages as (I) the (non-western) countries of origin tend to be in the early phase, (II) the (western) host countries more in the advanced phase of the epidemic and (III) the arrival in the host countries initiates the acculturation process. This could explain the 'imported' high (men)/low (women) prevalence among less acculturated immigrants. The low (men)/high (women) prevalence among more acculturated immigrants indicates an adaptation towards the social norms of the host countries with ongoing acculturation.

Smoking during pregnancy among Turkish immigrants in Germany-are there associations with acculturation?

INTRODUCTION: We analyzed the association between different acculturation measures and smoking among pregnant immigrant women from Turkey and compared smoking rates between Turkish and German women. METHODS: Perinatal data from a project on the influence of migration and acculturation on pregnancy and birth in Berlin was analyzed. An acculturation index (FRAKK) and two proxy measures (German language proficiency, length of stay in Germany) were used. We performed logistic regression models and calculated age-standardized prevalence ratios (SPR). RESULTS: Smoking prevalence was 19.8% among pregnant Turkish women (n = 702) and 17.8% among German women (n = 2,999). The chance of being a smoker was significantly higher among Turkish women with a length of stay of ≥20 years compared to 0-4 years (OR = 3.63, 95% CI = 1.64-8.05); with good/very good language skills compared to none/minor skills; with high levels of acculturation compared to low levels (the latter only among 18-29-year-old women). Compared to German women, Turkish women with a short length of stay, low acculturation scores and none/minor language skills had lower smoking rates. This finding inverts with long length of stay, high acculturation scores and good/very good language skills (≥20 years: SPR = 2.14, 95% CI = 1.56-2.94). CONCLUSIONS: Smoking among pregnant Turkish women increases with increasing acculturation. Additionally, immigrant women with a low acculturation level are less often smokers and women with a high level are more often smokers than German women. Prevention measures have to prevent women with a low acculturation from starting to smoke and to induce those with a high acculturation to quit. As smoking and acculturation are group phenomena, it is necessary to involve immigrant communities.

Pathways between perceived discrimination and health among immigrants: evidence from a large national panel survey in Germany.

OBJECTIVE: Discrimination is an important determinant of health, and its experience may contribute to the emergence of health inequalities between immigrants and nonimmigrants. We examine pathways between perceived discrimination and health among immigrants in Germany: (1) whether perceptions of discrimination predict self-reported mental and physical health (SF-12), or (2) whether poor mental and physical health predict perceptions of discrimination, and (3) whether discrimination affects physical health via mental health. DESIGN: Data on immigrants come from the German Socio-Economic Panel (SOEP) from the years 2002 to 2010 (N = 8,307), a large national panel survey. Random and fixed effects regression models have been estimated. RESULTS: Perceptions of discrimination affect mental and physical health. The effect of perceived discrimination on physical health is mediated by its effect on mental health. Our analyses do not support the notion that mental and physical health predict the subsequent reporting of discrimination. Different immigrant groups are differentially exposed to perceived discrimination. CONCLUSION: In spite of anti-discrimination laws, the health of immigrants in Germany is negatively affected by perceived discrimination. Differential exposure to perceived discrimination may be seen as a mechanism contributing to the emergence of health inequalities in Germany.

How immigrants adapt their smoking behaviour: comparative analysis among Turkish immigrants in Germany and the Netherlands.

BACKGROUND: Smoking behaviour among immigrants is assumed to converge to that of the host country's majority population with increasing duration of stay. We compared smoking prevalence among Turkish immigrants residing in two different countries (Germany (DE)/the Netherlands (NL)) between and within countries by time spent in Turkey and DE/NL. METHODS: The German 2009 micro-census and the Dutch POLS database (national survey, 1997-2004) were analysed. An interaction variable with dichotomised length of stay (LOS) in Turkey (age: 0-17; 18+) and categorised LOS in the host country (immigration year: 1979 and earlier, 1980-1999, 2000-2009; the latter only for Germany) was generated. Age standardised smoking prevalences and sex-specific logistic regression models were calculated. RESULTS: 6,517 Turkish participants were identified in Germany, 2,106 in the Netherlands. Age-standardised smoking prevalences were higher among Turkish immigrants in the Netherlands compared to those in Germany: 62.3% vs. 53.1% (men/lower education); 30.6% vs. 23.0% (women/lower education). A similar trend was observed for the majority population of both countries. The chance of being a smoker was lower among Turkish men with short LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with short LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 0.57[95% CI = 0.36-0.89]; DE: OR = 0.73[95% CI = 0.56-0.95]). Contrary to that, the chance of being a smoker was higher among Turkish men with long LOS in Turkey and middle LOS in Germany/the Netherlands compared to those with long LOS in Turkey and long LOS in Germany/the Netherlands (NL: OR = 1.35[95% CI = 0.79-2.33]; DE: OR = 1.44[95% CI = 1.03-2.02]). The effects for Turkish women were similar, but smaller and often non-significant. CONCLUSION: Turkish immigrants adapt their smoking behaviour towards that of the Dutch/German majority population with increasing duration of stay. This was particularly obvious among those who left Turkey before the age of 18 years - a group that needs tailored interventions to prevent further increases in smoking. Those who left Turkey as adults and spent a short time in the host countries show 'imported' smoking patterns. A limitation of this study is the use of cross-sectional data: a cohort effect cannot be ruled out. Our findings have to be confirmed with longitudinal data.

Comparing sampling strategies to recruit migrants for an epidemiological study. Results from a German feasibility study.

BACKGROUND: In 2011, almost 20.0% of the population of Germany had a migration background. Studies on their health tend to have low participation rates. The aim of our study was to compare different sampling strategies and to test different approaches to recruit migrants for an epidemiological study. METHODS: Four recruitment centres of the German National Cohort recruited persons of Turkish origin and ethnic German immigrants from former Soviet Union countries. A register-based (random samples from residents' registration offices) and a community-orientated strategy were applied. Participants underwent a medical examination and self-completed a questionnaire. RESULTS: Used approaches: The community-orientated strategies comprised the acquisition of key persons from migrant networks to support the recruitment, invitation talks and distribution of study materials in migrant settings, etc. The identifying variables in the registry data were name, nationality or country of birth. All but one centres used bilingual study material and study staff. PARTICIPATION: When comparing the two strategies, the register-based participation rates ranged from 10.1 to 21.0% (n = 668 participants) and the community-oriented recruitment resulted in 722 participants. CONCLUSION: Register-based recruitment should use a combination of name, nationality and country of birth in order not to be limited to identifying persons with a foreign nationality. However, according to the study staff, the community-oriented approach involving key persons of the same cultural background leads to a better acceptance by the participants. Also, it covers a more heterogeneous group. Yet, it is time-consuming and needs considerably more staff. Further research should establish the effectiveness of a combination of both strategies.

Assessing the effect of regional deprivation on mortality avoiding compositional bias: a natural experiment.

BACKGROUND AND OBJECTIVE: We assessed the effect of regional deprivation on individual mortality by making use of a natural experiment: we followed up ethnic German resettlers from Former Soviet Union countries who were quasi-randomly distributed across the socioeconomically heterogeneous counties of Germany's federal state North Rhine-Westphalia (NRW). METHODS: We used data from the retrospective cohort study 'AMOR' on the mortality of resettlers in NRW (n=34 393). Based on the postcode of the last known residence we linked study participants to the 54 counties of NRW, which were aggregated in six deprivation clusters. Mortality rates and standardised mortality ratios (SMRs) were calculated for each cluster. After a mean follow-up of 10 years, 2580 resettlers were deceased. RESULTS: For male and female cohort members, mortality rates and SMRs were highest in the cluster 'poverty poles' (SMR men: 1.21, 95% CI 1.04 to 1.41; SMR women: 1.17, 95% CI 0.99 to 1.37), whereas they were lowest in the cluster 'prospering regions and suburban counties' (SMR women: 0.86, 95% CI 0.70 to 1.05) as well as in the cluster 'heterogeneous counties' (SMR men: 0.73, 95% CI 0.61 to 0.88). CONCLUSIONS: The population which was quasi-randomly distributed to counties of differing socioeconomic status experienced different levels of mortality. It was highest in regions with the highest level of regional deprivation. Previous studies describing this positive relationship between mortality and regional deprivation could not differentiate between compositional and contextual effects. Thus, our findings indicate that in terms of mortality, regional deprivation does matter.

'Imported risk' or 'health transition'? Smoking prevalence among ethnic German immigrants from the Former Soviet Union by duration of stay in Germany - analysis of microcensus data.

BACKGROUND: It can be assumed that resettlers (ethnic German immigrants from the Former Soviet Union) show similar smoking patterns as persons in their countries of origin at the time of migration. We analysed how the smoking prevalence among resettlers differs from that among the general population of Germany and whether the prevalence differs between groups with increasing duration of stay. METHODS: To estimate the smoking prevalence we used the scientific-use-file (n = 477,239) of the German 2005 microcensus, an annual census representing 1% of all German households. Participation in the microcensus is obligatory (unit-nonresponse <7%). We stratified the prevalence of smoking among resettlers and the comparison group (population of Germany without resettlers) by age, sex, educational level and duration of stay. In total, 14,373 (3% of the total) persons were identified as resettlers. RESULTS: Female resettlers with short duration of stay had a significantly lower smoking prevalence than women in the comparison group. With increasing duration of stay their smoking prevalence appears to converge to that of the comparison group (e.g.: high educational level, age group 25-44 years: short duration of stay 15%, long duration of stay 24%, comparison group 28%). In contrast, the smoking prevalence among male resettlers with short duration of stay was significantly higher than that among men in the comparison group, but also with a trend towards converging (e.g.: high educational level, age group 25-44 years: short duration of stay 44%, long duration of stay 35%, comparison group 36%). Except for female resettlers with short duration of stay, the participants with low educational level had on average a higher smoking prevalence than those with a high educational level. CONCLUSIONS: This is the first study estimating the smoking prevalence among resettlers by duration of stay. The results support the hypothesis that resettlers brought different smoking habits from their countries of origin shortly after migration. The observed convergence of the smoking habits with increasing duration of stay is in line with the hypothesis of migration as 'health transition'. However, due to the cross-sectional design of the study, further research is needed to confirm these findings.