The Turkish Journal of Pediatrics
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Characteristics of relevance for health in Turkish and Middle Eastern adolescent immigrants compared to Finnish immigrants and ethnic Swedish teenagers
Lars I Holmberg1,2, Dan Hellberg2,3
1Child Health Unit, Falun Hospital
2Center for Clinical Research Dalarna, Falun
3Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
|Holmberg LI, Hellberg D. Characteristics of relevance for health
in Turkish and Middle Eastern adolescent immigrants compared to Finnish
immigrants and ethnic Swedish teenagers. Turk J Pediatr 2008; 50: 418-425.
Our objective was to compare sociodemographic conditions and risky/health
behaviors affecting Turkish or Middle Eastern versus ethnic Swedes and
Finnish immigrant adolescents, respectively.
All eligible adolescents 13-18 years old (3,216 pupils) in a medium-sized
town in Sweden completed a validated in-depth questionnaire (Q90), with
One hundred and one adolescents were Turkish or Middle Eastern immigrants,
while 73 were immigrants from Finland, a neighboring country to Sweden.
Turkish/Middle Eastern immigrants were more likely to attend a theoretical
program in school, were rarely bullied, as compared to ethnic Swedes and
Finns. Turkish/Middle Eastern girls used alcohol at a lower frequency, and
reported less depression and sexual experiences than ethnic Swedish girls
and Finns. A higher frequency of Finnish adolescents had been bullied and
had vandalized, and Finnish adolescents were also determined to have used
tobacco and cannabis and to be heavy drinkers more frequently than boys
from Turkey/the Middle East.
We concluded that adolescent immigrants from Turkey and the Middle East
seem to be well adapted to Sweden and also have ambitions for a higher
education. Differences in risky behaviors were particularly pronounced in
comparisons with immigrants from Finland for both boys and girls.
adolescents, Turkey, Middle East, Finland, Sweden, risk behavior.
|Immigrants are exposed to considerable changes
in their social and cultural environment,
including the fact that they have to learn
a new language and conform to new moral
values and standards. They must deal with
influences from the host culture, including
possible discrimination and low socioeconomic
status, which exposes immigrant adolescents
to considerable stress.
Berry et al. found that immigration to a new
country is often accompanied by acculturation,
“a process that individuals undergo in response
to a changing cultural context”. Acculturative
stress is dependent on a variety of factors,
such as integration, in opposition to rejection
and alienation, time since migration, social
support networks, and acceptance of the new
culture. For children and adolescents, the
parents' level of integration in the new culture
is of particular importance. Second-generation
adolescent immigrants and those who migrated
at an early age are thus more likely to integrate
in the new country.
Sweden, with a population of 9 million, is
considered to welcome “new Swedes”. During
the 1990s, approximately 15% of adolescents
in Sweden were first-generation immigrants
or had at least one parent who was born
abroad. During the last 20 years, a large
part of immigrants, in general refugees, have originated from Turkey and the Middle East.
The proportion of immigrants from Finland
has traditionally been high, but has decreased
during the last decades.
In Sweden, there are unique possibilities to
conduct register studies. Linked through each
individual's personal identification number,
it is possible to compare such registers as
the Swedish Population and Housing Census
(sociodemographic variables), National Board
of Health and Welfare (hospital admissions
and diagnoses), the Birth Registry, and the
Cancer Registry. All registers cover almost 100%
of events they are meant to record. Register
studies have analyzed hospitalization for several
conditions among immigrants, e.g. for alcoholrelated
disorders and attempted suicide.
Such studies, however, can only make a rough
analysis of the end-points reflecting immigrantrelated
problems. The present study used an indepth
questionnaire in a cohort of adolescents,
covering a wide spectrum of aspects of daily
life, and using the adolescent-specific Q90
instrument. The aim was to compare in detail
conditions affecting life and behaviors of
relevance for health in Turkish/Middle Eastern
immigrants with those of ethnic Swedish and
Finnish immigrant adolescents.
|Material and Methods |
|The study was conducted in a medium-sized
town, with a population of 60,000, situated
in central Sweden, 200 kilometers west of the
capital Stockholm. The eligible population for
this study was all pupils in 7th to 9th grades
(13 to 15 years of age) of compulsory school and
in 1st to 3rd years (16-18 years of age) of high
school. Altogether, 10 schools were involved.
The project, of which this study is one part,
was conducted from April 2004 to May 2005.
All questionnaires were distributed during
the autumn 2004. In addition to ethical
approval, the local political school authorities,
headmasters, and all teachers were informed
about the purpose and methods. Written
information was given to the parents. All
parties accepted the study.
The “Q90” questionnaire, tailored and validated
for teenagers, was used. The Q90 has been
proven successful in some previous Swedish
studies[7-9]. Q90 includes 165 questions and
covers sociodemographic characteristics,
school program, satisfaction and achievements,
self-image, dietary habits, sports activities,
psychological and physical conditions, medication,
medical care, friends, relations to family and
other adults, use of tobacco, alcohol and drugs,
criminality status, immigrant status, religion,
body development, sexuality, and expectations
for the immediate future.
All pupils completed the questionnaire during
one lesson. There were no personal details, and
thus no possibility to identify specific persons.
The adolescents completed the questionnaire
anonymously, and left it in a sealed envelope
before it was given to one of the authors (LIH).
There were multiple-choice questions ranging
from two to five alternatives. A question
such as “have you had sexual intercourse?”
was answered yes-or-no. For other questions,
such as “have you shoplifted?”, there were
five possible answers, ranging from “never”
to “more than 10 times”.
In total, there were 3,812 pupils registered at
the time the study was performed. Because of
occupational practice, sports events, leisure,
etc., 3,216 pupils (84.4%) were eligible for the
study. A small part of non-responders would
be expected to be truant from school, but it
was not possible to register the exact number.
Considerable effort was made to ensure the
reliability of the answers. In the classroom,
nearly all participants worked seriously and
in silence. As would be expected, not all
questions were answered by all participants
(2.2% to 7.4% missing data). In these cases,
however, there were often marks in-between
the alternatives, indicating that the individual
was unsure how to respond and found no
When responses to the questionnaires were
computerized, a careful check for consistency
was made. In the case of inconsequent answers
not due to obvious mistakes, the participant
was excluded. Such cases could include an
extremely early age at first intercourse or an
unreasonable amount of alcohol consumption.
In other cases, such as boys who answered
“have not had menstruation yet”, only that
variable was excluded. In all, 10 participants
did not complete the questionnaire at all
and 9 were excluded due to inconsequent or
unreasonable answers. A further 11 students
could not be identified by gender leaving 3186
(99.1%) students available for analyses.
When both parents were born abroad the
adolescent was defined as an immigrant. The
participants were initially divided into firstor
second-generation immigrants, not born
or born in Sweden. For simplicity, first- and
second-generation (Middle Eastern or Finnish)
immigrants will be joined and only termed as
immigrants below. Data was missing regarding
country of birth for 25 (0.8%) of the students,
and for 235 (7.4%) of the fathers and 231 (7.3%)
of the mothers. Altogether, 365 participants had
to be excluded as country of origin could not be
identified and 71 adolescents were excluded as
they originated from countries outside Turkey/
Middle East and Finland. This left a total of
2750 students eligible for analyses. Of these,
73 (2.7%) originated from the neighboring
country Finland, while 101 (3.7%) adolescents
were immigrants from Turkey/ Middle East,
and 2576 students were ethnic Swedes. Among
Middle Eastern immigrants, Islam was the
dominant religion (n=75, 78.1%). There was a
similar distribution of adolescents originating
from Turkey, Iraq, Iran and Lebanon.
The JMP statistical program was used for analyses.
T-test was used for continuous variables,
such as age. For nominal variables, odds ratios
(OR), 95% confidence intervals (95% CI) and
adjustments for possible confounding variables
were estimated by logistic regression. Nominal
variables were dichotomized. Fisher's test was
used when the number of positive or negative
answers for a variable was less than six. The
sociodemographic variables that differed most
between ethnic Swedes and immigrants were
having one's own house and employment
status of parents. These were therefore chosen
for adjustments in multifactorial analyses, in
addition to age when appropriate.
|Initially, all variables that were included in the
analyses were compared for Turkish/Middle
Eastern immigrants of Muslim religion with those
of other religions. The differences were very small
with the exception of regular alcohol use (11%
vs. 31%, respectively, p=0.02). Therefore, the
Turkish/Middle Eastern immigrant adolescents
are analyzed in the following as a unit.
Middle East were second-generation immigrants,
while the corresponding figure for the Finns was
66 (76.7%). Sociodemographic characteristics
and nutritional habits for Turkish/Middle
Eastern immigrants, ethnic Swedes, and Finns
that differed only marginally by gender are
given in Table I. More Turkish/Middle Eastern
adolescents lived in a family with both a mother
and father than the other two groups studied.
It was significantly more common for Turkish/
Middle Eastern immigrants to participate in a
theoretical program in school but not to have
at least one parent with university education,
as compared to ethnic Swedes and Finnish
adolescents. Living in their own house and
having at least one working parent was less
common among immigrants from Turkey/
Middle East than for Finns and ethnic Swedes.
Segregated schools were a minor problem, as
none of the 10 schools had a proportion of
immigrants higher than 17%.
| ||Table I: Sociodemographic and Some Nutritional Differences in First- or Second-Generation Turkish or Middle Eastern Adolescent Immigrants
Compared to Ethnic Swedes and Finnish Immigrant Adolescents of Both Genders|
Seventy-six percent of all adolescents whose
parents had a university education attended a
theoretical program, as compared to 48% of
those who were less likely to have working
parents, to live in their own house and to have
breakfast daily. The data in Tables I-IV were
therefore adjusted for age, housing conditions
and employment status of parents.
| ||Table II. Risk Factors for Well-Being in First- or Second-Generation Adolescent Turkish or Middle Eastern Immigrants Compared to
Ethnic Swedes and Finnish Immigrant Adolescents of Both Genders|
| ||Table III. Factors of Relevance for Health in First- or Second-Generation Adolescent Turkish or Middle Eastern Immigrants Compared to
Ethnic Swedes and Finnish Immigrant Adolescent Girls.|
| ||Table IV. Factors of Relevance for Health in First- or Second-Generation Adolescent Turkish or Middle Eastern Immigrant Boys Compared to
Ethnic Swedes and Finnish Immigrant Adolescent Boys|
Finnish teenagers had sleeping problems at a
higher frequency, were not satisfied with their
school achievements, had been bullied, and
had more frequent experience of vandalizing
compared to Turkish/Middle Eastern adolescents
(Table II). Involvement in fighting and having
bullied someone was more common among
Turkish/Middle Eastern adolescents, compared
with the other two groups. Eleven and a half
percent of ethnic Swedes reported allergies as
compared to 15.9% of the Finns (p=0.28),
but allergies were very uncommon (2.3%,
p=0.002) in Middle Eastern immigrants (not
shown in Table).
The Turkish/Middle Eastern girls were less
likely to feel depressed (although of borderline
significance) and to have experience of alcohol
and intimate relations with boys than the
ethnic Swedish and Finnish girls (Table III).
No Muslim girl admitted to having had sexual
intercourse. The Turkish/Middle Eastern girls
reported experience of being on a diet more
often than the Swedish girls. Ninety-three
(20.8%) and 2 (11.8%) of the sexually active
ethnic Swedish and Finnish girls, respectively,
reporting having had more than five sexual
partners (not shown in Table).
Boys from Turkey/Middle East practiced team
sports. They sometimes felt depressed at a
higher frequency than Swedish and Finnish
boys (Table IV). Less alcohol use among
Middle Eastern boys and fewer parents who
accepted alcohol use (40.9% vs. 61.6% in
Swedish boys, age adjusted OR 0.17, 95% CI
0.06-0.47) reflected the high proportion of
Muslim boys. There were no other significant
differences between these two groups. None
of the boys originating from Turkey/Middle
East was a smoker. The Finnish boys reported
smoking, heavier drinking habits and ever use
of cannabis at higher frequencies compared
to Turkish/Middle Eastern boys. No other
significant differences were found between
|Some of the f indings of this study were
that despite less favorable sociodemographic
conditions, Turkish/Middle Eastern immigrants
more often chose theoretical programs in
high school and were satisfied with their
achievements. They were less likely to use
tobacco, alcohol and drugs than ethnic Swedish
adolescents. The sociodemographic conditions
of Finnish immigrants were more similar to
those of ethnic Swedes, as would be expected
by their higher proportion of second-generation
adolescents, but they nevertheless were more
likely to have social problems and risky
behaviors. Turkish/Middle Eastern immigrants
had more in common in many aspects with
the ethnic Swedes.
Some strengths of this study were the design
that allowed inclusion of all teenagers attending
school in a medium-sized town. As the
questionnaire was personally distributed to
all classes, there was a very high response
rate and an opportunity to include a large
number of questions that covered numerous
aspects of adolescent life. Despite the inclusion
of more than 3000 adolescents, however, the
number of individuals in some immigrant
subgroups was rather small. Only relatively
large differences between these groups reached
statistical significance and the 95% confidence
intervals were sometimes wide. In this context,
we must stress that it was impossible to report
all results. One must remember that a large
number of the variables did not differ between
the compared groups.
When immigrant behaviors are compared to
those of ethnic Swedes, social and cultural
differences must be considered, as well as
those that are caused by migration as such.
Socioeconomic conditions must thus be
adjusted for. Hjern et al. found a considerable
decrease in the apparent increased risk ratio
for schizophrenia in immigrants when social
conditions were included in the analyses. Family
factors were closely associated with problematic
behavior among Turkish adolescents and in
children. On the other hand, this is true for
all families, irrespective of ethnic background.
In the present study, employment status of
parents and living in one's own house were
used for adjustments, as both variables differed
significantly between adolescent immigrants
from Turkey/Middle East as compared to
Finnish and ethnic Swedish adolescents. These
variables probably reflect that the former are
relative newcomers to Sweden. The levels of
university education were similar in all three
The low prevalence of allergic disorders among
adolescents from Turkey and the Middle East
has been reported previously. The etiology
is not fully clarified, but is thought to be a
combination of a variety of factors, such as diet,
heredity, and exposure to furry pets. This study
found different food habits, i.e. Turkish/Middle
Eastern immigrants more rarely had breakfast,
but more often had fruits or vegetables, as
compared to Swedish and Finnish adolescents.
These findings are probably important for
adolescent well-being and health both in the
short- and in the long run.
Some variables that could indicate personal
problems of importance for mental health were
observed at a higher frequency in Turkish/
Middle Eastern teenagers. The latter reported
a higher rate of experience in physical fighting.
Boys reported depression significantly more
often, while girls reported depression at a lower
frequency, compared to ethnic Swedes and Finns.
A correlation between increased exposure to
violence before migration and mental problems
among refugees were found in a previous study.
Initial psychosomatic problems, such as sleeping
problems and abdominal pain, had improved
considerably six years after settlement. The
main determinants in the latter study were
stress in the family sphere and exposure to
violence before migration.
There were no significant differences in scoring
with respect to school achievements or reported
delinquent behavior between immigrants from
Turkey/Middle East and ethnic Swedes, while
the Finns reported less satisfaction with school
results, but the difference was non-significant. A
Dutch study on Turkish adolescents found they
reported even less delinquent behavior than
ethnic Dutch adolescents. Teachers, however,
reported no more problems among these pupils
as compared to the Dutch pupils. It was,
however, speculated that Turkish adolescents
deliberately reported less antisocial behavior
for fear of being caught by authorities. In
the present study, Turkish/Middle Eastern
adolescents reported having been bullied
at a low frequency, but of having bullied
others relatively often. It has been shown that
among their classmates, bullies enjoy a high
social status, while their victims are socially
marginalized. Bullying may represent one
means of gaining respect.
There were fewer differences in sociodemographic
characteristics between Finnish and
Swedish adolescents, compared to Turkish/
Middle Eastern immigrants. An increased rate
of sleeping problems and having been bullied
and more frequent experience of vandalizing
indicate social problems in the Finnish group.
Among boys, tobacco and cannabis use and
heavy drinking stand out when compared to
Turkish/Middle Eastern boys. These findings
in Finnish immigrants, in particular for the
boys, seem to form a social pattern. In register
studies, Hjern and Allebeck found high relative
risks for adult Finnish immigrants to have
been hospitalized because of alcohol-related
disorders as compared to Swedes. Immigrants
from Turkey and the Middle East, on the
contrary, had low relative risks. In another
study, alcohol-related damage on autopsy
was observed to be more common among
Finnish-born adult suicide victims. These
differences between Finnish immigrants and
Turkish/Middle Eastern and ethnic Swedes
are possibly caused by cultural factors, but
they are important for health-compromising
Similarly, tobacco use and illicit drug use
seem to be more common in Finnish than in
Swedish adolescents. Finnish adults also had
the highest suicide rate when different groups
of immigrants were compared.
This study has shown similarities between
Turkish/Middle Eastern immigrant adolescents
and ethnic Swedes in many areas of life.
Differences in risk behaviors were, if any,
more prevalent in the Swedish adolescents. On
the other hand, there were a large number of
differences between Turkish/Middle Eastern and
Finnish immigrants. The differences covered
wide areas of life, such as socioeconomic
conditions and family, self-image, school, dietary
habits, sport activities, bullying, delinquent
behavior, self perceived mental health, tobacco,
alcohol and drug use, and sexual behavior. It
is important to realize that many, maybe most,
of these differences are not only caused by
immigration as such, but by cultural and social
differences among the different ethnic groups.
Some possible cultural differences are traditional
heavy drinking among Finnish adolescents and
differences in sexual behaviors between Muslim
boys and girls.
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