Abstract
Introduction
Migration is an increasing phenomenon and associated with a physical and psychosocial burden on individuals. Little is known about migration and skin health. The objective of this study was to describe the characteristics of patients regarding migration background and dermatological morbidity among adults seen in a dermatological out-patient clinic in Malmö, Sweden.
Methods
An observational cross-sectional study was performed in 2017. Dermatological out-patients completed questionnaires and were examined by a dermatologist. Sociodemographic variables including ethnicity and migration status were assessed by self-report. Ethnicity was assessed with country of birth. General and physical health and details about skin disease were self-reported. Stress was assessed by the Perceived Stress Scale (PSS) and with items assessing stressful life events and economic difficulties. Depression and anxiety were assessed with the Patient Health Questionnaire-2 (PHQ-2) and the General Anxiety Disorder Assessment-2 (GAD-2).
Results
250 patients were included. 24% were foreign-born (FB) reporting 41 different countries of birth. Mean duration of living in Sweden was 24.4 years. Compared to non-foreign-born (NFB) patients, FB patients were more stressed (PSS mean 17.5 vs. 15.3, p = 0.044), had more economic difficulties (31.0% vs. 14.6%, p = 0.005) and more anxiety (39.7% vs. 24.9%, p = 0.03). There were significantly fewer patients with psoriasis in FB and more with connective tissue disease. FB rated skin disease severity significantly higher than NFB patients.
Conclusion
This study reports the multi-ethnic population in an out-patient dermatological clinic in Malmö, Sweden and the difference in distribution of dermatological conditions among FB patients and NFB patients as well as the burden of disease, with higher levels of stress and anxiety in FB patients. These issues will be investigated further by our group in a larger multicentre study.
Keywords: Dermatology, Ethnicity, Health inequities, Migrant, Migration, Skin health
Introduction
Migration is an increasing phenomenon due to factors as globalization, armed conflicts and climate change. The UN definition of an international migrant is a person who moves away from his or her country of usual residence, temporarily or permanently, and for a variety of reasons [1]. Between 2009 and 2017, approximately 480,000 people sought asylum in Sweden and in 2017 foreign-born (FB) persons constituted 18.5% of the total population. Malmö, the third largest city in Sweden and destination for a large proportion of migrants, had an FB population of 33.1% in 2017 [2].
Migration can have a negative impact on health as it can result in stress, different living conditions, and health habits. Migrants are vulnerable to information and language barriers as well as potential differences in health literacy and discrimination compared to non-migrants [3–5].
Despite a history of steadily increasing migration to Europe, research on dermatological conditions and migration is still scarce. Both communicable and non-communicable dermatological diseases are recognized as a significant problem for newly arrived migrants [6], but not much studied in Europe in migrants with a longer duration of stay and in ethnic minorities as well as research on relevant physical and psychosocial comorbidities in these groups. However, describing and identifying ethnic and racial health disparities in dermatology is currently raised as highly relevant in dermatological scientific and clinical contexts. Richard et al. [7] recently reported results from a multinational European study assessing prevalence of skin disease. People identifying as black or mixed reported highest prevalence of at least one skin disease; 58.3% vs. 48.7% in people identifying as white. They had a higher impact of their skin condition on quality of life, stigmatization and impact on professional life than the people identifying as white.
Overall, patients with common skin diseases have a higher prevalence of clinical depression, anxiety disorder, and suicidal ideation [8]. Patients with a migration background or belonging to an ethnic minority group might be an even more vulnerable group with increased risk for psychosocial associated symptoms which would be important to take in consideration ensuring equality in health care.
There is a lack of knowledge about the migration history and ethnicity of patients seen in a dermatological out-patient clinic, and new insight is crucial in the evaluation of possible needs for adapting and strengthening areas of dermatological services. The aim of this study was to describe the migration background and dermatological morbidity among adults seen in a dermatological out-patient clinic in Malmö, Southern Sweden.
Methods
This is an observational cross-sectional study which is part of a larger European multicentre study. Study methods and English versions of all questionnaires are available in the published study protocol and the first publication on the European dataset [9, 10].
Consecutive dermatological out-patients at Skane University Hospital, Malmö, were on random days between September and November 2017 invited to participate in the study. Drop-out rate and reasons why they did not wish to participate if these were stated were noted.
Inclusion criteria included being over 18 years of age and able to read and write the language of the questionnaires. Questionnaires were available in 12 languages. All patients were informed and given a written consent form by a research assistant and were handed questionnaires which they returned before consultation. Patients were examined by a dermatologist who recorded skin disease according to International Classification of Disease (ICD-10). Severity was rated as mild, moderate, or severe. Comorbidities (cardiovascular disease, chronic respiratory disease, rheumatologic disease, and diabetes) were recorded.
Variables
Sociodemographic variables were assessed by self-report including age, sex, education level, employment status, income level, and marital status. Ethnicity was assessed with the variable “country of birth” and categorized patients into FB and NFB. Migration status was assessed by country of birth and duration of stay in Sweden.
General and physical health was assessed by self-report including height, weight, and the dermatologist recorded comorbidities after clinical examination. BMI was calculated from weight and height. Details about skin disease were self-reported measures on severity (mild, moderate, severe), localization, and age of onset. Stress was assessed by the Perceived Stress Scale (PSS) [11] and the questions “Have you had any stressful life events during the last 6 months (serious illness, death of close friend or family member, accident, divorce, or other events)?”(yes/no) and “Did you experience serious economic difficulties in the last 5 years?” (yes/no).
Depression and anxiety were assessed with the Patient Health Questionnaire-2 (PHQ-2) and the General Anxiety Disorder Assessment-2 (GAD-2), which are validated 2-item questionnaires. Scores on each scale range from 0 to 6 and a cutoff of ≥3 points indicates a screened depression or anxiety disorder [12]. Suicidal ideation was assessed by the question “Did you ever have suicidal ideation?” (yes/no) and “Did you ever have suicidal ideation because of your skin?” (yes/no).
Statistical Analysis
For continuous variables, t tests were used for analysing differences in means comparing FB patients with NFB patients. For dichotomous variables differences between proportions were analysed using X2 test. Dermatological conditions were classified into broader categories prior used in ESDaP studies [10]. SPSS version 27 was used.
Ethics
The study protocol was approved by the Swedish Regional Ethical Review Board (registration number 2017/418) and conducted in accordance with the Declaration of Helsinki.
Results
Data were collected for 250 patients. The participation rate was 81.2%. Table 1 describes sociodemographic factors among FB patients and NFB patients. FB patients constituted 24.4% of participants. For FB patients, mean duration of living in Sweden was 24.4 years (1.0–80.0, SD 18.5), and they were from 41 countries. 57.4% of them were born in Europe, 19.7% in the Middle East and North Africa, 8.2% in Sub-Saharan Africa, 6.6% in Central and South America, 4.9% in North America, and 3.3% in East Asia.
Table 1.
Characteristics of the study population: sociodemographic factors among NFB patients (N = 189) and FB patients (N = 61) in the Malmö sample (N = 250)
| | NFB patients = 189 | FB patients = 61 | p values |
|---|---|---|---|
| Sex, n (%) MD = 3 | |||
| Female | 95 (50.5) | 35 (59.3) | NS |
| Male | 93 (49.5) | 24 (40.7) | |
| Age, mean (SD) [range], years | 49.1 (19.1) [18–91] | 46.2 (19.1) [18–99] | NS |
| Female | 49.0 (18.6) | 44.3 (18.6) | NS |
| Male | 49.3 (19.7) | 50.0 (20.3) | NS |
| Self-reported income level, n (%) MD = 2 | | | NS |
| Low | 47 (25.1) | 20 (32.8) | |
| Middle | 108 (57.8) | 37 (60.7) | |
| High | 32 (17.1) | 4 (6.6) | |
| Educational level, n (%) MD = 13 | | | NS |
| Without possibility to go to college | 22 (12.1) | 4 (7.3) | |
| Possibility to go to college | 81 (44.5) | 25 (45.5) | |
| University diploma | 79 (43.4) | 26 (47.3) | |
| Marital status, n (%) MD = 3 | | | NS |
| Single | 63 (33.9) | 21 (34.4) | |
| Married/partner | 123 (66.1) | 40 (65.6) | |
| Employment status, n (%) MD = 1 | | | NS |
| Employed | 107 (56.6) | 34 (56.7) | |
| School/student | 14 (7.4) | 4 (6.7) | |
| On sick leave | 14 (7.4) | 3 (5.0) | |
| Retired | 47 (24.9) | 11 (18.3) | |
| Unemployed | 7 (3.7) | 8 (13.3) | |
| Birthplace, n (%) MD = 1 | |||
| Central and South America | | 4 (6.6) | |
| East Asia | | 2 (3.3) | |
| Europe (except Sweden) | | 35 (57.4) | |
| Middle East and North Africa | | 12 (19.7) | |
| North America | | 3 (4.9) | |
| Sub-Saharan Africa | | 5 (8.2) | |
| Sweden | 189 (100) | | |
SD, standard deviation; MD, missing data; NS, non-significant.
In both groups, there were more females. Mean age was 49.1 years in NFB patients and 46.2 years in FB patients. There were non-significant sociodemographic differences between the groups; more FB patients reported a low income level, had a lower educational level and there was a higher rate of unemployment compared to NFB patients.
Table 2 describes stress and comorbidities among FB patients and NFB patients. 40.7% of NFB patients and 31.1% of FB patients had physical comorbidities. Mean PSS-10 in both groups indicate moderate stress with a significantly higher mean in FB patients (p = 0.044). There was no significant difference in reporting stressful life events during last 6 months between both groups. There were significantly more FB patients that reported economic difficulties last 6 months (p = 0.005). On PHQ-2, 23.6% of NFB patients and 36.2% of FB patients scored ≥3 indicating screened depression (non-significant difference). On GAD-2, 24.9% of NFB patients and 39.7% FB patients scored ≥3 indicating screened anxiety (p = 0.03).
Table 2.
Population characteristics: stress, physical and psychological comorbidities among NFB patients (N = 189) and FB patients (N = 61) in the Malmö sample (N = 250)
| | NFB patients = 189 | FB patients = 61 | p values |
|---|---|---|---|
| Physical comorbidities, n (%) | | | NS |
| Yes | 77 (40.7) | 19 (31.1) | |
| Cardiovascular | 23 (12.2) | 8 (13.1) | |
| Respiratory | 9 (4.8) | 1 (1.6) | |
| Diabetes | 14 (7.4) | 2 (3.3) | |
| Rheumatological | 17 (9.0) | 2 (3.3) | |
| Other comorbidities | 46 (24.3) | 12 (19.7) | |
| BMI, mean (SD) MD = 15 | 25.4 (5.0) | 26.0 (4.3) | NS |
| Perceived stress scale (PSS), mean (SD) MD = 13 | 15.3 (7.3) | 17.5 (6.8) | 0.044 |
| Stressful life events during last 6 months, n (%) MD = 17 | | | NS |
| Yes | 59 (33.5) | 21 (36.8) | |
| Economic difficulties during last 6 months, n (%) MD = 7 | | | 0.005 |
| Yes | 27 (14.6) | 18 (31.0) | |
| The Patient Health Questionnaire-2 (PHQ-2) ≥3, n (%) MD = 14 | 42 (23.6) | 21 (36.2) | NS |
| The General Anxiety Disorder Assessment-2 (GAD-2) ≥3, n (%) MD = 11 | 45 (24.9) | 23 (39.7) | 0.03 |
| Suicidal ideation (overall), n (%) MD = 9 | 30 (16.3) | 11 (19.3) | NS |
| Suicidal ideation (skin), n (%) MD = 7 | 11 (5.9) | 4 (7.0) | NS |
Table 3 describes the characteristics of skin diseases among FB patients and NFB patients. A detailed table of diagnoses is presented in S1. Dermatitis/eczema (not including atopic dermatitis, hand eczema, or seborrhoeic dermatitis) was the most common diagnosis in both groups followed by non-melanoma skin cancer. The diagnosis group skin diseases in general medicine were more common in FB than NFB (19.7% vs. 8.5%, p = 0.016). Diagnoses in this group classified as connective tissue diseases (online suppl. Table S1; for all online suppl. material, see https://doi.org/10.1159/000545938) were significantly more prevalent in FB (8.2% vs. 0.5%, p = 0.004).
Table 3.
Distribution of skin diseases and self-reported severity among NFB patients (N = 189) and FB patients (N = 61) in the Malmö sample (N = 250)
| | Non-foreign (n = 189) | Foreign (n = 61) | p values |
|---|---|---|---|
| Skin disease groups, n (%) | |||
| All eczemas | 56 (29.6) | 20 (32.8) | NS |
| Psoriasis | 19 (10.1) | 0 | 0.005 |
| Tumours | 63 (33.3) | 15 (24.6) | NS |
| Disease of pilosebaceous unita | 28 (14.8) | 11 (18.0) | NS |
| Skin disease in general medicineb | 16 (8.5) | 12 (19.7) | 0.016 |
| Otherc | 7 (3.7) | 3 (4.9) | NS |
| Self-rated severity now, n (%) MD = 18 | | | NS |
| Mild | 70 (40.0) | 20 (35.1) | |
| Moderate | 77 (44.0) | 20 (35.1) | |
| High | 28 (16.0) | 17 (29.8) | |
| Self-rated severity last year, n (%) MD = 19 | | | 0.01 |
| Mild | 62 (35.4) | 16 (28.6) | |
| Moderate | 74 (42.3) | 16 (28.6) | |
| High | 39 (22.3) | 24 (42.9) | |
| Clinician-rated severity, n (%) MD = 16 | | | NS |
| Mild | 82 (46.1) | 23 (41.1) | |
| Moderate | 66 (37.1) | 20 (35.7) | |
| High | 30 (16.9) | 13 (23.2) | |
| Age at onset of skin disease, years, mean (SD) MD = 32 | 36.5 (23.4) | 32.9 (20.1) | NS |
aSeborrhoea, seborrhoeic dermatitis, alopecia, acne, rosacea, hidradenitis suppurativa, folliculitis.
bImmunobullous diseases, lupus erythematosus, localized morphea, sarcoidosis, pyoderma gangrenosum, leg ulcer, various veins, erythema nodosum, Bechet’s disease, cutaneous vasculitis, verrucae vulgaris, impetigo, scabies, Lyme disease, and dermatophyte infections.
cHyperpigmentation, melasma, ulcer, leukoplakia.
The prevalence of psoriasis in NFB was significantly higher than in FB (10.1% vs. 0%, p = 0.005). 6.3% of NFB patients and 1.6% of FB patients had atopic dermatitis (no significant difference). A higher proportion of FB than NFB patients reported skin disease severity as high, both at the time of data collection and the year before.
Discussion
This study points out the ethnic diversity of the patient population at a dermatological out-patient clinic in an urban setting in Sweden. 24.4% of patients were FB, and the different countries of origin reflect the ethnically diverse population of Sweden.
In this study, FB patients reported more perceived stress and screened anxiety compared to the NFB. Richard et al. [7] reported similar findings where non-white individuals had higher DLQI, stigmatization, and impact on daily and professional life. This might reflect the vulnerability of ethnic minority groups and migrants with long-term stressors such as socioeconomic factors, adapting to the majority culture and discrimination [4, 5]. In this study, both NFB patients and FB patients reported moderate stress which confirms earlier studies that have shown the link between stress and skin disease, mainly of inflammatory type [13–15]. It is known that skin disease is associated with depression and anxiety [8]. Further investigating the link between skin disease and stress, depression, and anxiety in ethnic minority groups and migrants adjusting for relevant confounding factors have important implications for health care as it might affect disease progression and treatment outcomes. In this study, significantly more FB patients reporting disease severity as high compared to NFB patients which further emphasize the urgent need for future research to exploring associated factors.
Among FB patients compared to NFB patients, there were no cases of psoriasis, fewer with atopic dermatitis, and more with connective tissue disorders. This contrasts the study by Richard et al. [7] where more non-white compared to white individuals answered that they have psoriasis. If our results are confirmed in a greater study population, it is important to evaluate health care access as well as physicians’ competence and confidence in diagnosing skin conditions in skin of colour. [16–18]. Non-melanoma skin cancer was common in both groups in our study population, probably due to the dominance of patients with European origin in the FB patient group.
The strength of this study lies in the study design and the high participation rate. Patients were asked consecutively and questionnaires were available in 12 languages and only 3 patients were not asked to participate due to lack of questionnaires (one Chinese and two Bosnian).
There are however several limitations to this study. First, we report on country of birth as a proxy for ethnicity which excludes patients born in Sweden but belonging to ethnic minority groups with migration history. Due to legal national regulations, undocumented migrants and asylum seekers with non-acute health issues are not eligible for health care and thus those are not represented in our study.
The study has a relatively small sample size and cases are not matched. With a greater sample possible differences between the groups could better be evaluated. The migrant and ethnic minority groups in Sweden are a highly heterogenous and our sample size did not allow us to stratify beyond two groups (FB patients and NFB patients). This would be an important analysis since more than half of the FB patients were born in Europe and they might be a less vulnerable group compared to some patient populations born outside of Europe. Further, with the cross-sectional study design, we are not able to evaluate causality and directionality. Results are not generalizable to other populations and contexts.
In conclusion, this study reports the multi-ethnic population in an out-patient dermatological clinic in Malmö, Sweden, and the difference in distribution of dermatological conditions among FB and NFB patients as well as the burden of disease, with higher levels of stress and anxiety in the FB patient group. These issues will be investigated further in a European multicentre study on prevalence of skin disease in patients with a migration background and patients belonging to an ethnic minority group.
Acknowledgment
The authors thank Ewa Wallin, Department of Dermatology and Venereology, Skåne University Hospital, Sweden, in her assistance conducting the study.
Statement of Ethics
The study protocol was approved by the Swedish Regional Ethical Review Board (2017/418). Written informed consent was obtained from participants.
Conflict of Interest Statement
A.E. has received honoraria for lectures from Beiersdorf, LEO Pharma, and Perrigo and travel support from LEO Pharma, not dependent with this manuscript. The authors declare no other conflicts of interest regarding this manuscript.
Funding Sources
This study was supported by Swedish HudFonden.
Author Contributions
Amna Elyas: conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, and writing – review and editing; Åke Svensson: conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, and writing – review and editing; Francesca Sampogna: conceptualization, data curation, formal analysis, investigation, methodology, and writing – review and editing; Slobodan Zdravkovic: conceptualization, data curation, formal analysis, investigation, methodology, and writing – review and editing; Jörg Kupfer: conceptualization, data curation, formal analysis, investigation, methodology, and writing – review and editing; Florence Dalgard: conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, and writing – review and editing.
Funding Statement
This study was supported by Swedish HudFonden.
Data Availability Statement
All data generated or analysed during this study are included in this article and its supplementary material files. Further enquiries can be directed to the corresponding author.
Supplementary Material.
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Associated Data
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Supplementary Materials
Data Availability Statement
All data generated or analysed during this study are included in this article and its supplementary material files. Further enquiries can be directed to the corresponding author.