IJE Advance Access originally published online on September 3, 2007
International Journal of Epidemiology 2007 36(6):1265-1272; doi:10.1093/ije/dym162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The health effects of emigration on those who remain at home
1Department of Public Health, Faculty of Medicine, Tirana, Albania.
2Cardiology Department, University Hospital Centre ‘Mother Teresa’, Tirana, Albania.
3United Nations HIV/AIDS Program, Geneva, Switzerland.
4Hebrew University-Hadassah School of Public Health and Community Medicine, Ein Kerem, Jerusalem.
* Corresponding author. Faculty of Medicine, Rr. ‘Dibres’, No. 371, Tirana, Albania. E-mail: gburazeri{at}yahoo.com
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Background The health effects of emigration on relatives staying behind has received little attention in the recent literature. Our aim was to assess the association of spouse and offspring emigration with acute coronary syndrome (ACS) in Albania, a country which is undergoing a particularly rapid socio-economic transition accompanied by intensive emigration.
Methods A population-based case–control study, conducted in Tirana, Albania, in 2003–06, included 467 non-fatal consecutive ACS patients (370 men, 97 women; 88% response) and 737 population-representative controls (469 men, 268 women; 69% response) aged 35–74 years. Information on emigration of family members and financial support, socio-demographic characteristics and conventional coronary risk factors was obtained by a structured questionnaire and examination. Associations of emigrational variables with ACS were assessed by logistic regression.
Results Forty five percent of female and 25% of male patients, and 17 and 15% of controls, respectively, reported emigration of a close family member. These were younger and of lower education, income and social status than controls without emigrants. Forty nine percent of patient emigrants vs 76% of control emigrants remitted funds. Excess risk of ACS was confined to individuals whose emigrant relatives did not remit monies home [multivariable-adjusted odds ratio (OR) = 10.8, 95% confidence interval (CI) = 2.6–44.8 in women, and OR = 2.0, 95% CI = 0.9–4.3 in men; P for sex-interaction = 0.03] and was attributable largely to spouse emigration.
Conclusions Our findings, which require confirmation, suggest that emigration of close family, but especially of spouses, coupled with non-remittance of financial support is associated with marked health effects in the spouse or parent left behind, and that women are more vulnerable than men.
Keywords Acute coronary syndrome, coronary heart disease, emigration, financial support, sex differences, social support, transitional country
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Migration, both within-countries or between-countries, either voluntary or involuntary, has become an important determinant of global health with direct implications for the health care systems of countries affected by this phenomenon.1 Migration poses serious health challenges, including those associated with displacement, resettlement and adsorption.1,2 It is argued that migration has health implications both for those who move and those who remain behind.1 While there is a considerable body of literature related to health of the migrants themselves,3–6 the health effects on their close relatives staying behind has received little attention in recent times, although this phenomenon was studied as early as the 1940s.7
Albania was the most isolated country in Europe until the breakdown of the Stalinist regime in 1990. Subsequently, Albania experienced a major social, political and economic upheaval.8,9 The particularly rapid process of transition in Albania over the past 15 years was associated with intensive internal and external migration.9,10 Thus, not only was there an unprecedented level of internal migration from rural to urban areas,9 but large numbers of people also left the country—over 750 000 between 1990 and 1999,9,10 representing about 20% of the entire population. This emigration process continues unabated, both legally and illegally,9 mostly to Greece and Italy.10 Consequently, according to the census conducted in 2001, the population of Albania (approximately 3.1 million) decreased slightly between 1989–2001,11 notwithstanding the country's high fertility and relatively low mortality rates.9 The country's poor economic situation and the lack of rapid economic expansion due to limited domestic resources remains the most important determinant of emigration of Albanian adults.10
The possible health effects of such rapid transition in Albania, including those of emigration, remain unclear. Coronary heart disease (CHD) mortality and morbidity, for example, appear to have increased over the past decade.12,13 In this context, we aimed to assess the association of the emigration of spouse or offspring with CHD among residents of Tirana, the Albanian capital city, controlling for recognized determinants of CHD. In particular, we hypothesized a deleterious effect of emigration of a close family member due to loss of a source of emotional support, and the possible amelioration of this effect by instrumental support expressed by remittance of funds by the emigrants, support so crucial to the family and national economies of Albania.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Study population
A population-based case–control study of acute coronary syndrome (ACS) was conducted in Tirana residents aged 35–74 years in 2003–06. Details of the study population, sampling procedures, sample size and case definition are described elsewhere.14 We recruited 467 non-fatal ACS cases from consecutive patients with unstable angina, Q-wave acute myocardial infarction (MI) or non-Q-wave acute MI admitted to the University Hospital Centre (370 men aged 59.1 ± 8.7 years, and 97 women 63.3 ± 7.1 years; 88% response). The definition of ACS was based on combinations of clinical signs and symptoms (location, patterns and duration of pain), sequential ECGs (ST-T changes, major Q-wave evolution), echocardiographic criteria (complementary examination for assessment of disorders of segmental kinesis and left ventricular function) and elevated cardiac enzymes in selected patients.14 301 patients experienced a first ACS event [238 men and 63 women of whom 116 (38%) had unstable angina, 168 (56%) had Q-wave MI and 17 (6%) had non-Q-wave MI] and 166 had repeat events [132 men and 34 women of whom 85 (51%) had unstable angina, 63 (38%) had Q-wave MI and 18 (11%) had non-Q-wave MI]. The control group comprised an age-stratified population-based sample of Tirana residents (469 men aged 53.1 ± 10.4 years, and 268 women 54.0 ± 10.9 years), with an overall response rate of 69.2% (737/1065).14 Female non-respondents did not differ by age, religion, employment status or education. Male non-respondents were moderately older than respondents and were more likely to be retired [odds ratio(OR) = 3.8, 95% confidence interval (CI) = 1.8–7.7], but were similar regarding religion and education.
Data collection
The interview used a structured questionnaire which assessed demographic, socio-economic and psychosocial characteristics, including emigration variables, and classical coronary risk factors. The examination included standardized measurements of blood pressure, weight, height and waist and hip circumferences.
Emigration variables
Participants were asked whether any of their close family members (spouse or offspring) had emigrated after 1990, following the breakdown of the communist regime. Additional questions included: (i) the number of their emigrant offspring; (ii) the elapsed time since emigration of their spouse and/or first offspring, and (iii) whether participants were receiving financial support from their family members who had emigrated.
Covariates
Information on education (self-reported years of completed formal schooling), current employment status (employed, unemployed or retired), relative income and social position was collected. To assess relative income participants were informed about the average per capita income in Albania (according to the last available official data); they were asked to rank their personal income on a 5-point scale which we grouped in the analysis into three (much lower/lower, about the same and higher/much higher than the average). To assess subjective social position participants were shown a 5-step ladder depicting where people stand in Albanian society.15 The top of the ladder represented people who were the best off (those who have the most money, most education and the best jobs) and the bottom rung, those worst off. Participants were asked to position themselves on this ladder.15 In the analysis, we categorized social position into lower (scores 1–2), middle and upper (scores 4–5).
The analysis also included information on self-reported hypertension and diabetes, family history of CHD, body mass index, waist-to-hip ratio, smoking14 and daily energy expenditure from leisure-time exercise calculated according to Taylor.16
The study was approved by the Albanian Committee of Medical Ethics. Participants gave written consent after being informed about the aims and procedures of the study.
Statistical analysis
Fifty-four of the 737 control respondents with evidence of pre-existing CHD were excluded from the analysis as were 40 individuals who reported never having been married (12 ACS patients and 28 controls). Of the remaining 1110 individuals, 1054 participants (96%) provided data on emigration and most covariates (450 cases and 604 controls, 749 men and 305 women). The other 56 participants either did not provide data on any emigration variables (N = 8), or did not provide information on many covariates (N = 48). Inclusion in key age-adjusted analyses of these 48 individuals who had data on emigration variables did not affect the estimates. Therefore, we report results after exclusion of all 56 participants with important missing data.
Sex-specific binary logistic regression was used to assess the association of emigration variables with covariates (recognized risk factors for CHD). Age-adjusted ORs, their 95% CIs and P-values were calculated. Subsequently, all covariates were entered together with the emigration variables into logistic models (with ACS as the dependent variable) and removed in a backward stepwise procedure if P > 0.10. For the final models, multivariable-adjusted ORs, their 95% CIs and P-values were calculated, separately in men and women. Analyses were repeated separately for first ACS events and for repeat events, and with exclusion of retirees for whom there was evidence for selection bias in men. Interactions of age and sex with emigration variables were tested by introducing product terms of age or sex with emigration variables. All analyses met the goodness-of-fit criterion as appraised by the Hosmer–Lemeshow test.17 The Statistical Package for Social Sciences (SPSS for windows, version 11.0, Chicago, Illinois, USA) was used.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Association of emigration variables with covariates in the control group
Among the controls, 16% reported emigration of either spouse or offspring. Such emigration was higher among the least educated (age–sex adjusted P = 0.09) and in those who reported low income and low social position (P = 0.06 and P = 0.02, respectively)(Table 1). Similar associations were noted in ACS patients (data not shown). About one quarter of the control emigrants did not remit money home. There was weak evidence for an association between financial support and reported income among controls with an emigrant family member (and none in the ACS patients). There were no noteworthy associations of emigration or remittance of funds with any of the classical CHD risk factors (data not shown in tables), except for a positive relationship of financial support with family history of CHD (OR = 0.2, 95% CI = 0.1–0.8).
|
Associations of emigration variables with ACS
Unadjusted data
Emigration of the spouse was frequent among women with ACS (19%) compared with controls (7%), but was far lower among spouses of men with and without ACS (4 and 3%, respectively)(Table 2–upper panel). On the other hand, emigration of offspring was highly prevalent in both male and female ACS cases (23 and 34%, respectively), and was lower but substantial among offspring of male and female controls (13 and 11%, respectively). Consequently, the crude prevalence of emigration of a spouse or offspring was considerably higher in cases than controls: 45 vs 17% in women and 25 vs 15% in men. Among individuals who reported emigration of their close relatives, ACS patients were less likely to receive financial support than controls: 47 vs 75% in men, and 51 vs 78% in women.
|
Age-adjustment
Emigration of close relatives was positively associated with age in both ACS patients (P = 0.19) and controls (P < 0.01). In age-adjusted analyses (Table 2–upper panel), there was an association of spouse emigration with ACS in both sexes (OR = 2.2, 95% CI = 0.9–5.1 in men, and OR = 6.6, 95% CI = 2.7–16.2 in women; P for sex-interaction = 0.26). Similarly, there was an association in both sexes with offspring emigration, but weaker than for spouse emigration (OR = 1.4, 95% CI = 0.9–2.1 in men, and OR = 2.1, 95% CI = 1.1–4.2 in women). There was no significant association with the number of emigrant offspring per family. A pooled analysis of emigration of either the spouse or offspring showed a positive association with ACS, more so in women (OR = 1.4, 95% CI = 0.96–2.1 in men, and OR = 3.1, 95% CI = 1.7–5.8 in women; P for sex-interaction = 0.03). Among families with emigrants, lack of remittance of financial support from the emigrant to the family member back home was strongly associated with ACS in both sexes (OR = 3.2, 95% CI = 1.6–6.7 in men, and OR = 3.8, 95% CI = 1.3–11.0 in women). In a model that compared individuals with emigrants who remitted funds, those who did not and those with no emigrant member, the excess risk of ACS appeared to be almost entirely restricted to people with an emigrant who did not remit funds (OR = 3.0, 95% CI = 1.6–5.8 in men and OR = 8.8, 95% CI = 3.1–24.9 in women compared with non-migrants; P for sex-interaction = 0.08). There was no association with the time elapsed since emigration of either spouse or offspring. This variable was not further considered in the analysis.
Multivariable-adjustment
Associations of conventional risk factors with ACS in this study population have been reported14 and are largely consistent with findings elsewhere.
In multivariable-adjusted logistic models (Table 2–lower panel), the association with emigration of a spouse persisted undiminished, whereas that of the offspring was eliminated. The association with pooled spouse and offspring migration disappeared in men, but persisted in women largely due to the strong relationship with spouse emigration (OR = 1.1, 95% CI = 0.7–1.7 in men, and OR = 2.5, 95% CI = 1.2–5.3 in women; P for sex-interaction = 0.02). A stronger association was displayed in the younger (<55 years old) than the older ages (P = 0.01 in men and P = 0.02 in women for the age-interaction). Further, adjustment for number of offspring living in Albania, an indicator of familial social support (data not shown), attenuated the association with emigration in women (OR = 1.5, 95% CI = 0.6–3.7). The association with financial support was strengthened in multivariable analysis (Table 2–lower panel). As before, in a model that compared migrants who remitted funds, those who did not, and non-migrant families, the excess risk was limited to participants whose emigrant family member did not remit funds (OR = 2.0, 95% CI = 0.9–4.3 in men, and OR = 11.0, 95% CI = 2.6–44.8 in women compared with non-migrants; P for comparison of remitters vs non-remitters = 0.04 in men and P = 0.01 in women; P for sex-interaction = 0.03). In women, this relationship was attenuated upon further adjustment for number of offspring living in Albania (OR = 7.0, 95% CI = 1.5–32.8), but not so in men (OR = 1.96, 95% CI = 0.89–4.35; P for sex-interaction = 0.03). In men, the findings persisted unaltered upon exclusion of retirees from the analysis (OR = 2.1, 95% CI = 0.8–5.8).
In women, a multinomial logistic model suggested a stronger association with emigration of spouse or offspring for repeat ACS events than for first events (age-adjusted OR = 5.1, 95% CI = 2.1–12.0, and OR = 2.5, 95% CI = 1.2–4.9, respectively). The excess risk that was confined to individuals whose emigrant relatives did not remit money home tended to be higher for repeat events (age-adjusted OR = 13.2, 95% CI = 3.7–47.7 in women and 3.4, 95% CI (OR = 1.6–7.3 in men) than for first events (OR = 7.3, 95% CI = 2.4–22.1 in women, and OR = 2.8, 95% CI = 1.4–5.6 in men; P for difference in ORs = 0.26 in a multivariable sex-adjusted multinomial model).
In both sexes(data not shown), the association with emigration of spouse or offspring was similar for MI events (Q-wave and non-Q-wave)[multivariable-adjusted OR = 1.2, 95% CI = 0.7–2.0 in men, and OR = 2.9, 95% CI = 1.1–7.7 in women] and for unstable angina (OR = 1.1, 95% CI = 0.6–2.0 in men, and OR = 2.1, 95% CI = 0.9–5.1 in women).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
The main finding of our study was that migration of a close family member was associated with an increased risk of ACS, but that this association seemed to be largely conditional on lack of provision of financial support by the emigrant. Thus, among individuals who reported emigration of their close relatives, there was no evidence of excess risk if the emigrant remitted money back home. These findings persisted after multivariable adjustment for recognized predictors of CHD–demographic, socioeconomic and conventional risk factors. The excess risk associated with the absence of financial support by the emigrant was particularly evident in several subgroups: women, younger people and possibly those with previous CHD. Women were more vulnerable than men, and loss of their spouses to migration seemed to have a larger impact than loss of their offspring. Counter to our expectation that the generally more vulnerable elderly would be at greater risk, those aged <55 years appeared to be more susceptible to the effects of close family migration. Pending confirmation, we do not offer an explanation other than chance for this association. Patients with a recurrent ACS event, who are likely to be less healthy or resilient than patients who experienced a first ACS event, may be more vulnerable than the latter.
Social support has been operationalized as a combined product of four dimensions including emotional/informational support, affectionate support, tangible support and positive social interaction.18,19 Lack of social support and social networks has been linked to CHD incidence,20,21 mortality22,23 and case-fatality.24,25 Emigrants can provide support to their close family members back home though emotional support alone (by visiting home, or indirectly via telephone, mail, etc.); financial support only (by remitting funds) or both emotional and financial support.26 Financial support aside, it seems logical to assume that individuals whose close family members have not emigrated would tend to enjoy a higher degree of emotional/informational support as compared with their counterparts who report emigration of spouses and/or offspring. One interpretation of our findings is that the loss of emotional support through emigration of close relatives influences CHD mainly when coupled with lack of tangible/instrumental support (remittances). Adjustment for the number of offspring living in Albania, a proxy for family social contact and emotional support, moderately attenuated the association in women. The financial support provided by emigrants may operate primarily through amelioration of financial hardship of their close family members and secondly, through improvement of emotional and psychosocial well-being. The fact that we adjusted in the analysis for income, social position and employment status suggests that non-remittance of funds might be perceived of as lack of caring (i.e. absence of emotional support). It is plausible that such families may be dysfunctional and that lack of financial support may serve as a marker of unhealthy family relationships that place members at increased risk. However, residual confounding by socioeconomic and psychosocial factors, as well as chance effects, cannot be excluded as explanations of the findings.
Potential mechanisms of the harmful effect of lack of emotional support have been suggested to operate either directly through the neuro-endocrine system, or indirectly through induction of unhealthy behaviours such as smoking, excessive alcohol consumption, unhealthy diet and sedentary lifestyle.25,27 The persistence of our findings after controlling for such lifestyle factors as smoking, leisure-time physical exercise and overweight, suggests that such mediation does not explain the associations, although intervening effects by blood lipids which were not measured, cannot be excluded.
Our study has the potential limitations of case–control studies of this nature which may be susceptible to biases of selection and information. Although we obtained a satisfactory response rate among cases (88%), that in the controls was lower (69%), allowing for the possibility of selection bias. Our data on non-responders does not entirely resolve this issue, although among women (in whom our findings were strongest) there was no evidence for such bias. Among men, non-respondents were older and less likely to be employed. Nevertheless, exclusion of retirees from the analysis had no effect on the findings. Furthermore, with regard to education, which is considered as the best available socio-economic predictor of health in the former communist countries of Central and Eastern Europe,28,29 respondents and non-respondents were similar in both sexes. Emigration was not associated with employment status of the family member back home, but was associated with education (Table 1). Therefore, the absence of an educational difference in respondents and non-respondents in both sexes tends to be reassuring. However, self-reported data on emigration and other information obtained by interview might have been affected by case status. Also, the relationship with non-remittance was associated with broad confidence intervals due to the modest sample size. Evidence from cohort studies as well as larger case–control studies is needed to confirm and extend our findings on the health impact of emigration on family members left behind.
In conclusion, our findings suggest a deleterious effect of emigration on those who stay behind. However, the associations were complex in that the effects appeared to be conditional on repatriation of financial support, seemingly independent of social position, education and financial situation. Thus, emigration of a close family member, especially the husband, and lack of financial remittance may serve as an independent risk marker for CHD. Our study provides novel evidence on an issue of special importance to countries affected by heavy emigration, one that has received little attention.
|
Acknowledgements |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
Genc Burazeri was a recipient of an Irma Milstein International Doctoral Fellowship at the Hebrew University–Hadassah Braun School of Public Health and Community Medicine, Jerusalem, Israel. The study was supported by the Irma Milstein Doctoral Program.
Special thanks to Mrs Milva Ekonomi, former director of the Institute of Statistics in Tirana, for her help and valuable support in drawing a population-representative control group from the census conducted in Albania in 2001.
Conflict of interest: None declared.
KEY MESSAGES
|
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionAcknowledgementsReferences |
|---|
1 Carballo M, Divino JJ, Zeric D. Migration and health in the European Union. Trop Med Int Health (1998) 3:936–44.[CrossRef][Web of Science][Medline]
2 Gilgen D, Maeusezahl D, Salis Gross C, et al. Impact of migration on illness experience and help-seeking strategies from Turkey and Bosnia in primary health care in Basel. Health Place (2005) 11:261–73.[CrossRef][Web of Science][Medline]
3 Hyman I. Setting the stage: reviewing current knowledge on the health of Canadian immigrants: what is the evidence and where are the gaps? Can J Public Health (2004) 95:14–8.
4 Greenhalpg P. Diabetes in British South Asians: nature, nurture and culture. Diabet Med (1997) 14:10–8.[Medline]
5 Bollini P, Siem H. No real progress towards equity: health of migrants and ethnic minorities on the eve of the year 2000. Soc Sci Med (1995) 41:819–28.[CrossRef][Web of Science][Medline]
6 Sakala C. Migrant and seasonal farm workers in the United States: a review of health hazards, status, and policies. Int Migr Rev (1987) 21:659–87.[CrossRef][Web of Science][Medline]
7 Kark JD, Abramson JH. Sidney Kark's contributions to epidemiology and community medicine. Int J Epidemiol (2003) 32:882–4.
8 Rechel B, McKee M. Healing the Crisis: a Prescription for Public Health Action in South Eastern Europe (2003) New York: Open Society Institute Press.
9 Nuri B, Tragakes E (eds). Health care systems in transition: Albania, Copenhagen: European Observatory on Health Care Systems, 2002. Available at: www.who.dk/document/E80089.pdf. (Accessed on February 19, 2007).
10 United Nations Development Program. Albanian Human Development Report 2000. In: Tirana, 2000. (Accessed on February 19, 2007). Available at: www.al.undp.org/download/pdf/nhdr2000.pdf.
11 Institute of Statistics of Albania. Results of the Population and Housing Census (2001) Tirana: INSTAT.
12 Institute of Statistics of Albania. Health Indicators for Years 1994-1998 (2001) Tirana: INSTAT.
13 Institute of Statistics of Albania. Causes of Deaths for the Year 2000 (2001) Tirana: INSTAT.
14 Burazeri G, Goda A, Sulo G, Stefa J, Roshi E, Kark JD. Conventional risk factors and acute coronary syndrome during a period of transition: a population-based case-control study in Tirana, Albania. Croat Med J (2007) 48:225–33.[Web of Science][Medline]
15 Singh-Manoux A, Adler NE, Marmot MG. Subjective social status: its determinants and its association with measures of ill-health in the Whitehall II study. Soc Sci Med (2003) 56:1321–33.[CrossRef][Web of Science][Medline]
16 Taylor HL, Jacobs DR, Schucker B, Knudsen J, Leon AS, Debacker G. A questionnaire for the assessment of leisure time physical activities. J Chron Dis (1978) 31:741–55.[CrossRef][Web of Science][Medline]
17 Hosmer D, Lemeshow S. Applied Logistic Regression (1989) New York: Wiley & Sons.
18 Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med (1991) 32:705–14.[CrossRef][Web of Science][Medline]
19 Janevic MR, Janz NK, Dodge JA, Wang Y, Lin X, Clark NM. Longitudinal effects of social support on the health and functioning of older women with heart disease. Int J Aging Hum Dev (2004) 59:153–75.[CrossRef][Web of Science][Medline]
20 Orth-Gomer K, Rosengren A, Wilhelmsen L. Lack of social support an incidence of coronary heart disease in middle-aged Swedish men. Psychosom Med (1993) 55:37–43.
21 Barefoot JC, Gronbaek M, Jensen G, Schnohr P, Prescott E. Social network diversity and risks of ischemic heart disease and total mortality: findings from the Copenhagen City Heart Study. Am J Epidemiol (2005) 161:960–67.
22 Kawachi I, Colditz GA, Ascherio A, et al. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Commun H (1996) 50:245–51.
23 Kaplan GA, Salonen JT, Cohen RD, et al. Social connections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland. Am J Epidemiol (1988) 128:370–80.
24 Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction: a prospective, population-based study of the elderly. Ann Intern Med (1992) 117:1003–09.
25 Case RB, Moss AJ, Case N, McDermott M, Eberly S. Living alone after myocardial infarction. JAMA (1992) 267:515–19.
26 Trager L. Migration and remittances: urban income and rural households in the Philippines. J Dev Areas (1984) 13:317–40.[Medline]
27 Seeman T, Berkman LF, Blazer D, Rowe JW. Social ties and support and neuroendocrine function. The McArthur studies of successful aging. Ann Behav Med (1994) 16:95–106.
28 Bobak M, Pikhart H, Rose R, Hertzman C, Marmot M. Socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries. Soc Sci Med (2000) 51:1343–50.[CrossRef][Web of Science][Medline]
29 Murphy M, Bobak M, Nicholson A, Rose R, Marmot M. The widening gap in mortality by educational level in the Russian Federation, 1980-2001. Am J Public Health (2006) 96:1293–99.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  G. Borges, J. Breslau, M. Su, M. Miller, M. E. Medina-Mora, and S. Aguilar-Gaxiola Immigration and Suicidal Behavior Among Mexicans and Mexican Americans Am J Public Health, April 1, 2009; 99(4): 728 - 733. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Burazeri, A. Goda, E. Roshi, and J. D. Kark Religious affiliation and acute coronary syndrome: a population-based case-control study in Tirana, Albania Eur J Public Health, June 1, 2008; 18(3): 329 - 334. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Ebrahim Uses of epidemiology, ways of living and dying. Int. J. Epidemiol., December 1, 2007; 36(6): 1159 - 1160. [Full Text] [PDF]
|
|
|
|
|
|
M. Bobak and A. Gjonca Commentary: Migration and health what about those who stay at home? Int. J. Epidemiol., December 1, 2007; 36(6): 1272 - 1273. [Full Text] [PDF]
|
|
|
|
|
|
O. Razum Commentary: Kisses or money for Penelope? Int. J. Epidemiol., December 1, 2007; 36(6): 1273 - 1274. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||