{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T11:19:24Z","timestamp":1782991164890,"version":"3.54.5"},"reference-count":31,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2020,12,1]],"date-time":"2020-12-01T00:00:00Z","timestamp":1606780800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Icelandic Research Fund","award":["185287-051"],"award-info":[{"award-number":["185287-051"]}]},{"name":"European Research Council","award":["726413"],"award-info":[{"award-number":["726413"]}]},{"name":"Icelandic Research Fund","award":["163362-051"],"award-info":[{"award-number":["163362-051"]}]},{"DOI":"10.13039\/100010431","name":"The Lupina Foundation","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100010431","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100004359","name":"Swedish Research Council","doi-asserted-by":"crossref","award":["2017-00957"],"award-info":[{"award-number":["2017-00957"]}],"id":[{"id":"10.13039\/501100004359","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100001275","name":"The Oak Foundation","doi-asserted-by":"crossref","award":["OCAY-18-442"],"award-info":[{"award-number":["OCAY-18-442"]}],"id":[{"id":"10.13039\/100001275","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>In recent decades, millions of refugees and migrants have fled wars and sought asylum in Europe. The aim of this study was to quantify the risk of mortality and major diseases among migrants during the 1991\u20132001 Balkan wars to Sweden in comparison to other European migrants to Sweden during the same period.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>We conducted a register-based cohort study of 104,770 migrants to Sweden from the former Yugoslavia during the Balkan wars and 147,430 migrants to Sweden from 24 other European countries during the same period (1991\u20132001). Inpatient and specialized outpatient diagnoses of cardiovascular disease (CVD), cancer, and psychiatric disorders were obtained from the Swedish National Patient Register and the Swedish Cancer Register, and mortality data from the Swedish Cause of Death Register. Adjusting for individual-level data on sociodemographic characteristics and emigration country smoking prevalence, we used Cox regressions to contrast risks of health outcomes for migrants of the Balkan wars and other European migrants. During an average of 12.26 years of follow-up, being a migrant of the Balkan wars was associated with an elevated risk of being diagnosed with CVD (HR 1.39, 95% CI 1.34\u20131.43, <jats:italic>p<\/jats:italic> &lt; 0.001) and dying from CVD (HR 1.45, 95% CI 1.29\u20131.62, <jats:italic>p<\/jats:italic> &lt; 0.001), as well as being diagnosed with cancer (HR 1.16, 95% CI 1.08\u20131.24, <jats:italic>p<\/jats:italic> &lt; 0.001) and dying from cancer (HR 1.27, 95% CI 1.15\u20131.41, <jats:italic>p<\/jats:italic> &lt; 0.001), compared to other European migrants. Being a migrant of the Balkan wars was also associated with a greater overall risk of being diagnosed with a psychiatric disorder (HR 1.19, 95% CI 1.14\u20131.23, <jats:italic>p<\/jats:italic> &lt; 0.001), particularly post-traumatic stress disorder (HR 9.33, 95% CI 7.96\u201310.94, <jats:italic>p<\/jats:italic> &lt; 0.001), while being associated with a reduced risk of suicide (HR 0.68, 95% CI 0.48\u20130.96, <jats:italic>p<\/jats:italic> = 0.030) and suicide attempt (HR 0.57, 95% CI 0.51\u20130.65, <jats:italic>p<\/jats:italic> &lt; 0.001). Later time period of migration and not having any first-degree relatives in Sweden at the time of immigration were associated with greater increases in risk of CVD and psychiatric disorders. Limitations of the study included lack of individual-level information on health status and behaviors of migrants at the time of immigration.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Our findings indicate that migrants of the Balkan wars faced considerably elevated risks of major diseases and mortality in their first decade in Sweden compared to other European migrants. War migrants without family members in Sweden or with more recent immigration may be particularly vulnerable to adverse health outcomes. Results underscore that persons displaced by war are a vulnerable group in need of long-term health surveillance for psychiatric disorders and somatic disease.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1003392","type":"journal-article","created":{"date-parts":[[2020,12,1]],"date-time":"2020-12-01T13:46:34Z","timestamp":1606830394000},"page":"e1003392","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":22,"title":["Mortality and major disease risk among migrants of the 1991\u20132001 Balkan wars to Sweden: A register-based cohort study"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3775-9611","authenticated-orcid":true,"given":"Edda Bjork","family":"Thordardottir","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li","family":"Yin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4253-1059","authenticated-orcid":true,"given":"Arna","family":"Hauksdottir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5227-0721","authenticated-orcid":true,"given":"Ellenor","family":"Mittendorfer-Rutz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1246-5804","authenticated-orcid":true,"given":"Anna-Clara","family":"Hollander","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina M.","family":"Hultman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Lichtenstein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Weimin","family":"Ye","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1317-2093","authenticated-orcid":true,"given":"Filip K.","family":"Arnberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fang","family":"Fang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7319-3112","authenticated-orcid":true,"given":"Emily A.","family":"Holmes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Unnur Anna","family":"Valdimarsdottir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2020,12,1]]},"reference":[{"key":"pmed.1003392.ref001","volume-title":"Global trends. Forced displacement in 2018","author":"United Nations High Commissioner for Refugees","year":"2019"},{"key":"pmed.1003392.ref002","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1186\/s12914-015-0064-9","article-title":"Long-term mental health of war-refugees: a systematic literature review","volume":"15","author":"M Bogic","year":"2015","journal-title":"BMC Int Health Hum Rights"},{"key":"pmed.1003392.ref003","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1001\/jama.294.5.602","article-title":"Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis","volume":"294","author":"M Porter","year":"2005","journal-title":"JAMA"},{"key":"pmed.1003392.ref004","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1186\/1471-2458-12-757","article-title":"Inequalities in mortality among refugees and immigrants compared to native Danes-a historical prospective cohort study","volume":"12","author":"M Norredam","year":"2012","journal-title":"BMC Public Health"},{"key":"pmed.1003392.ref005","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1097\/EDE.0000000000000669","article-title":"The impact of forced migration on mortality.","volume":"28","author":"J Haukka","year":"2017","journal-title":"Epidemiology"},{"key":"pmed.1003392.ref006","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1093\/ije\/dys072","article-title":"Longitudinal study of mortality among refugees in Sweden","volume":"41","author":"AC Hollander","year":"2012","journal-title":"Int J Epidemiol"},{"key":"pmed.1003392.ref007","first-page":"51","article-title":"The \u201chealthy migrant\u201d effect","volume":"90","author":"K Fennelly","year":"2007","journal-title":"Minn Med"},{"key":"pmed.1003392.ref008","volume-title":"Transitional justice in the former Yugoslavia","author":"International Center for Transitional Justice","year":"2009"},{"key":"pmed.1003392.ref009","unstructured":"Swedish Initiative for Research on Microdata in the Social and Medical Sciences. SIMSAM. Swedish Initiative for Research on Microdata in the Social and Medical Sciences; 2019 [cited 2019 Aug 1]. Available from: https:\/\/simsam.nu\/."},{"key":"pmed.1003392.ref010","volume-title":"International migration law: glossary on migration","author":"A Sironi","year":"2019"},{"key":"pmed.1003392.ref011","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1007\/s10654-017-0316-1","article-title":"The Swedish cause of death register","volume":"32","author":"HL Brooke","year":"2017","journal-title":"Eur J Epidemiol"},{"key":"pmed.1003392.ref012","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1186\/1471-2458-11-450","article-title":"External review and validation of the Swedish national inpatient register","volume":"11","author":"JF Ludvigsson","year":"2011","journal-title":"BMC Public Health"},{"key":"pmed.1003392.ref013","doi-asserted-by":"crossref","first-page":"e031964","DOI":"10.1136\/bmjopen-2019-031964","article-title":"Validation study of randomly selected cases of PTSD diagnoses identified in a Swedish regional database compared with medical records: is the validity sufficient for epidemiological research?","volume":"9","author":"AC Hollander","year":"2019","journal-title":"BMJ Open"},{"key":"pmed.1003392.ref014","article-title":"Suicide","author":"H Ritchie","year":"2020","journal-title":"Our World in Data"},{"key":"pmed.1003392.ref015","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1097\/NMD.0000000000000576","article-title":"Psychiatric disorders and predictors hereof among refugee children in early adulthood: a register-based cohort study","volume":"206","author":"A Barghadouch","year":"2018","journal-title":"J Nerv Ment Dis"},{"key":"pmed.1003392.ref016","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1017\/S2045796016000445","article-title":"The use of psychiatric services by young adults who came to Sweden as teenage refugees: a national cohort study.","volume":"26","author":"H Manhica","year":"2016","journal-title":"Epidemiol Psychiatr Sci"},{"key":"pmed.1003392.ref017","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1080\/13623699.2010.513655","article-title":"Pre- and post-displacement stressors and time of migration as related to self-rated health among Iraqi immigrants and refugees in southeast Michigan","volume":"26","author":"H Jamil","year":"2010","journal-title":"Med Confl Surviv"},{"key":"pmed.1003392.ref018","doi-asserted-by":"crossref","first-page":"21059","DOI":"10.3402\/gha.v6i0.21059","article-title":"Social inequalities in mental health and mortality among refugees and other immigrants to Sweden\u2014epidemiological studies of register data","volume":"6","author":"AC Hollander","year":"2013","journal-title":"Glob Health Action"},{"key":"pmed.1003392.ref019","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/S0140-6736(11)60050-0","article-title":"Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors","volume":"379","author":"RV Reed","year":"2012","journal-title":"Lancet"},{"key":"pmed.1003392.ref020","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1097\/GME.0000000000001036","article-title":"Trauma exposure and endothelial function among midlife women","volume":"25","author":"RC Thurston","year":"2018","journal-title":"Menopause"},{"key":"pmed.1003392.ref021","first-page":"430","article-title":"The effect of war-induced stress in Croatia on the incidence and mortality of acute ischemic heart disease","volume":"142","author":"M Bergovec","year":"1992","journal-title":"Wien Med Wochenschr"},{"key":"pmed.1003392.ref022","doi-asserted-by":"crossref","first-page":"2647","DOI":"10.1016\/j.ejca.2010.07.050","article-title":"Cancer risk diversity in non-western migrants to Europe: an overview of the literature","volume":"46","author":"M Arnold","year":"2010","journal-title":"Eur J Cancer"},{"key":"pmed.1003392.ref023","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1007\/s12026-014-8517-0","article-title":"Effects of stress on immune function: the good, the bad, and the beautiful","volume":"58","author":"FS Dhabhar","year":"2014","journal-title":"Immunol Res"},{"key":"pmed.1003392.ref024","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1002\/9781118993811.ch7","volume-title":"The handbook of stress and health: a guide to research and practice","author":"C Johansen","year":"2017"},{"key":"pmed.1003392.ref025","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1037\/10723-009","volume-title":"Trauma and health: physical health consequences of exposure to extreme stress","author":"AA Rheingold","year":"2004"},{"key":"pmed.1003392.ref026","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/S2352-4642(17)30147-5","article-title":"Preventive mental health interventions for refugee children and adolescents in high-income settings","volume":"2","author":"M Fazel","year":"2018","journal-title":"Lancet Child Adolesc Health"},{"key":"pmed.1003392.ref027","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/S2215-0366(17)30032-9","article-title":"Pre-migration and post-migration factors associated with mental health in humanitarian migrants in Australia and the moderation effect of post-migration stressors: findings from the first wave data of the BNLA cohort study","volume":"4","author":"W Chen","year":"2017","journal-title":"Lancet Psychiatry"},{"key":"pmed.1003392.ref028","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1016\/j.eurpsy.2012.06.001","article-title":"Trauma and suicidality in war affected communities","volume":"28","author":"J Jankovic","year":"2013","journal-title":"Eur Psychiatry"},{"key":"pmed.1003392.ref029","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1080\/13811110600582406","article-title":"The Balkan Piedmont: male suicide rates pre-war, wartime, and post-war in Serbia and Montenegro","volume":"10","author":"S Selakovic-Bursic","year":"2006","journal-title":"Arch Suicide Res"},{"key":"pmed.1003392.ref030","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1093\/eurpub\/cku121","article-title":"Suicide among immigrants in Europe\u2014a systematic literature review","volume":"25","author":"J Spallek","year":"2015","journal-title":"Eur J Public Health"},{"key":"pmed.1003392.ref031","article-title":"Suicide attempt and suicide in refugees in Sweden\u2014a nationwide population-based cohort study","author":"R Amin","year":"2019","journal-title":"Psychol Med"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003392","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,12,1]],"date-time":"2020-12-01T13:47:03Z","timestamp":1606830423000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003392"}},"subtitle":[],"editor":[{"given":"Paul","family":"Spiegel","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2020,12,1]]},"references-count":31,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2020,12,1]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1003392","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,12,1]]}}}