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Sex-specific long-term mortality inequities among North Korean refugees resettled in South Korea: a nationwide matched cohort study

Year: 2026

Type: article

Abstract: Background: Forced migration is associated with adverse health outcomes, but long-term mortality patterns remain unclear, particularly in populations with shared ancestry but different early-life environments. North Korean refugees resettled in South Korea provide a regional model to examine these effects. Methods: In this nationwide matched cohort study using the National Health Insurance Service database (2002–2022), 26,123 North Korean refugees aged ≥20 years were matched 1:50 by sex, birth year, and index year to 1,300,144 South Korean residents. The primary outcome was all-cause mortality; secondary outcomes included cause-specific mortality. Sex-stratified Cox models adjusted for age, comorbidities, and medication use were applied, with time-varying analyses. Findings: During 24.3 million person-years (median follow-up 10.0 years), 713 deaths occurred among refugees and 30,478 among residents. Male refugees had higher all-cause mortality than South Korean men (adjusted hazard ratio [aHR] 1.68, 95% CI 1.52–1.86), with excess deaths from infection, trauma, gastrointestinal disease, cancer, and cardiovascular disease. Female refugees had similar overall mortality (aHR 0.95, 0.85–1.06), although infection-related (aHR 1.70) and trauma-related mortality (aHR 1.44) were higher. Women showed an early survival advantage that attenuated over time, whereas excess mortality among men persisted. Interpretation: Mortality after forced migration differed by sex and changed over time in this regionally defined population. Persistently higher mortality in men and elevated infection- and trauma-related mortality in both sexes suggest gaps beyond initial resettlement care. These findings support sex-specific, long-term strategies within regional health systems.

Source: International Journal for Equity in Health

DOI: 10.1186/s12939-026-03077-6