Effect of regional deprivation on mental and physical health: a longitudinal natural experiment among refugees in Germany

BackgroundExisting studies on contextual health effects struggle to account for selection bias, limiting causal interpretation. We use refugee dispersal in Germany as natural experiment to study the effect of small-area deprivation on mental and physical health, while considering the potential mediating role of housing and social context. MethodsRefugees subject to dispersal (n=1400) are selected from a nation-wide longitudinal refugee study (IAB-SOEP-BAMF Panel; 2016-2018). Multi-level linear regression models, adjusted for age, sex, education, region of origin, federal state, asylum status and length of residence in Germany, are fitted to the change in mental and physical health subscales of the SF-12 depending on quintiles (Q1 - Q5) of district-level socioeconomic deprivation (German Index of Socio-Economic Deprivation, GISD). This is followed by mediation analyses (for housing and social context) and sensitivity analyses. FindingsResidency in districts with moderate-high deprivation (Q4) has a negative impact on physical health (coef{middle dot}: -2{middle dot}2, 95%CI: -4{middle dot}1;-0{middle dot}2) compared to lowest deprivation (Q1). Moderate-high deprivation (Q4) also has a positive impact on mental health, but the effect is statistically insignificant following covariate adjustment (coef{middle dot}: 2{middle dot}5, 95%CI: -0{middle dot}7;5{middle dot}6). Comparisons with other deprivation quintiles are statistically insignificant. InterpretationThe results point to gaps in health and social service provision for refugees living in the most deprived regions. Further efforts should be made to support integration of refugees into health and social systems in resource-poor regions, including improved interpreting services, specifically trained social workers and diversity-sensitive information offerings. Further research using longer timeframes and larger sample sizes are required to confirm results. FundingGerman Science Foundation (FOR: 2928/ GZ: BO5233/1-1).