Socioeconomic Factors and Health Disparities Among North Korean Refugee Populations.

IMPORTANCE

Conventional frameworks often attribute migrant health disparities to language barriers, legal exclusion, or socioeconomic deprivation. However, it remains unclear whether health inequities persist when these structural barriers are removed. Isolating the impact of historical and intergenerational trauma requires examining a unique minoritized population that shares full citizenship and linguistic heritage with the host society.

OBJECTIVE

To quantify the explanatory power of conventional demographic, socioeconomic, and family determinants on health disparities in a fully integrated refugee group and to estimate the magnitude of the unexplained residual disparity attributed to nonsocioeconomic factors.

DESIGN, SETTING AND

PARTICIPANTS

This cross-sectional study analyzed data from the Korea Youth Risk Behavior Survey (2011 to 2024), a nationally representative survey. The study used North Korean refugee-origin youths (NKRY) as a strategic case study of a population sharing ethnicity and citizenship with the host country (South Korean-origin youth, SKY), compared alongside international-origin youths (IOY).

MAIN OUTCOMES AND MEASURES: Self-reported mental health outcomes and health risk behaviors. Fairlie decomposition analysis was performed to calculate the percentage of the disparity explained by observed conventional determinants vs the unexplained residual component.

RESULTS

Among 876 693 participants, SKY (n = 785 462; 392 731 [51.0%] male; median age, 14.97 years), NKRY (n = 547; 317 [58.25%] male; 15.61 years), and IOY (n = 13 800; 6675 [49.45%] male; 14.55 years) were included. NKRY had substantially poorer outcomes compared with SKY. Adjusted odds ratios for suicide planning (aOR, 4.35; 95% CI, 2.97-6.35), suicide attempts (aOR, 4.27; 95% CI, 2.78-6.56), and drug use (aOR, 14.09; 95% CI, 7.48-26.51) remained high. Decomposition analyses revealed that conventional socioeconomic factors explained less than 10% of these disparities. For suicide-related outcomes, observed factors accounted for less than 5% of the gap, leaving more than 95% unexplained. Conversely, disparities in the IOY group were largely explained by these conventional factors.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study, substantial health inequities persisted even in a minoritized population granted full legal and linguistic integration, with the vast majority of disparities remaining unexplained by conventional socioeconomic metrics. These findings challenge the sufficiency of standard social determinant frameworks and suggest that for displaced populations worldwide, policies must address unmeasured structural drivers such as historical trauma and intergenerational instability.