New National Approaches to New National Approaches to Immigrant Health AssessmentImmigrant Health Assessment

M. DesMeules, J. Gold, B. Vissandjée,

J. Payne, A. Kazanjian, D. ManuelHealth Canada, University of Montréal, University of British

Columbia, Institute for Clinical Evaluative Studies

Supported by Health Canada and the Canadian Population Health Initiative (CIHI)

I. BackgroundI. Background

The Immigrant Population in Canada:• Is large and growing (~17% in 1996, ~18% in

2001)• Is diverse - e.g. immigrants land in Canada under

different programs, from various countries of origin, etc.

• Has unique socio-demographic characteristics• Has changing demographics over time (e.g., recent

immigrants are from Asia vs. Europe)

Immigrants in the Context of Population Health

• Research shows that Immigrants are generally healthy in Canada.

However:• Specific knowledge on their health (for example by

subgroups of immigrants)- especially long term health and chronic disease outcomes - is limited and

• Information on their utilization of health services is lacking.

Disparities in health determinants, health status, and health services utilization may exist between Immigrant and Canadian-born populations, and between subgroups of Immigrants

Immigrant Health Assessment and Surveillance

Purpose:

• To describe the patterns of health status and health outcomes of immigrants in the broader context of determinants of health and health services utilization.

• To monitor trends over time

• To identify potential health risks and or health disparities among immigrants

• To inform immigrant health policies and programs

II. Areas of ResearchII. Areas of Research Immigrant Health Initiatives

National and provincial collaborators:– Health Canada, CPHI/CIHI, Citizenship and Immigration

Canada, academic experts, Statistics Canada, provinces.

Goal:– Through health assessment and surveillance, produce policy-

relevant information on the health outcomes and health service utilization of immigrants.

Objective:– To examine patterns of mortality, cancer incidence,

hospitalizations, physician visits, medication use and socio-demographic factors among immigrants and subgroups of immigrants using secondary data.

Immigrant Health Initiatives 1st Phase: Health Outcomes

• Record linkages were used to obtain health data on immigrants – 20% (369,972) of landed immigrants from

1980-90

• Mortality and cancer incidence outcomes over 19-years (until 1998) were examined

• Examine health differentials among socio-demographic sub-populations

Immigrant Health Initiatives2nd Phase: Health Services

• Immigration data on immigrants from largest receiving provinces (BC, ON, and Que.) were linked to physician and drug claims, and hospital records

• Analysis will focus, in particular, on chronic diseases, mental health, injury, and preventive services utilization

• Currently at the final record linkage stage

III. Key Health IssuesIII. Key Health Issues

Highlights of Main Findings

•Mortality

•Cancer Incidence

•Determinants of health

•Partial/Preliminary Results Health Services Utilization

Healthy Migrant Effect

• The healthy migrant effect is seen for “all- cause mortality” and leading causes of death in Canada (cancer, CVD and accidents)

• Is less pronounced for infectious diseases 0

0.2

0.4

0.6

0.8

1

1.2

Imm. Ref.

AllCancerCVDAccidentInfection

Imm. = immigrant non-refugees, Ref. = refugees,SMR= standardised mortality ratio CVD=Cardio-vascular disease

SMR estimates for 1980-98

Specific Health Outcomes

• Immigrants have elevated mortality for certain diseases

• Some sub-populations are at higher risk of stroke, diabetes, AIDS mortality 0

0.5

1

1.5

2

2.5

3

3.5

4

Imm. Ref.

DiabetesStrokeMVASuicideHepatitis*AIDS

Imm. = immigrant non-refugees, Ref. = refugees, SMR = standardised mortality ratio*AIDS mortality risk is elevated for females

SMR estimates for 1980-98

*

Cancer Outcomes

• Immigrants have a higher mortality risk for certain cancers (stomach, liver)

• Naso-pharyngeal cancer is also elevated

0

1

2

3

4

5

6

Imm. Ref.

StomachColorect.LiverLungBreastGenital

Imm. = immigrant non-refugees, Ref. = refugees, SMR = standardised mortality ratio

SMR estimates for 1980-98

Health by Type of Immigrant and Region of Origin

• Although a healthy migrant effect is present for immigrants from most regions of the world, mortality rates vary by sub-population

0100200300400500600700800900

1000

IM RM IF RF

GeneralCanada Europe

Asia

ME-Afr

Amer-Carib

IM = immigrant males, IF = immigrant females, RM= refugee malesRM= refugee females, ASMR = age standardised mortality rate

All-cause ASMR for 1980-98

Determinants of Health

Region of origin:• e.g., female non-refugees from the Caribbean present an

elevated mortality risk for Cervical cancer (SMR=2.4)Marital status:• For example, non-refugees who are previously married

present an elevated overall mortality risk, compared to those who land married (RR=1.5)

Education:• Immigrants with elementary school of less education

present an elevated mortality risk, compared to those who land with higher education (RR >=1.22)

SMR = standardised mortality ratioRR = relative risk

Immigrant Health over Time

• The healthy migrant effect decreases over time in Canada

• Is still present after 10+ years in Canada.

0100200300400500600700800900

1000

IM RM IF RF

GeneralCanada<5 yrs

5-9 yrs

10+ yrs

IM = immigrant males, IF = immigrant females, RM= refugee males, RM= refugee females , ASMR = age standardised mortality rate

All-Cause ASMR for 1980-98

Physician Visits (in 1995/96)-BC Pilot

Type/Region Males RR Females RR

All 0.58 0.61

Family 0.77 0.85

Refugee 1.04 0.95

North Africa 1.05 1.12

NE Asia 0.41 0.44

RR: Physician visits Rate ratios adjusted for age, compared to general BC population

0

10

20

30

40

50

60

0 2 4 6

Time of first claim (years since landing date)

Nu

mb

er o

f p

eop

le(t

ho

usa

nd

s)

• Time between landing (>=1992) and first physician billing claim for ON immigrant

First physician billing claim, ON

IV.Directions for Research and IV.Directions for Research and PolicyPolicy

•Research needs – Methodology considerations

•Policy needs - beyond infectious diseases

New Approaches to Immigrant Health Assessment

• Record linkages optimize available data on immigrant health

• Provide essential migration data on immigrant sub-populations, e.g., on geographical region of origin, type of immigrant, etc

• Provide capacity for longitudinal / followup studies.

• Do not rely on self-report for health outcomes and health services or active participation of respondents

Future Research

• Expand on sub-population health and health care utilization assessment

• Examine longer term outcomes and study more systematically the reasons for health deterioration over time.

• Consider other key determinants of health at the individual (eg health behaviours) and community (eg. availability of special health services for immigrants) levels.

Future Policy

• Expand provincial and national health and health care policies to address long term health outcomes and non-communicable conditions / chronic disease among immigrant populations

• Expand policies aimed at social determinants of health