immigrant health in alberta, april 2011...country. this was followed in order by the united states...

Immigrant Health in Alberta April 2011

Acknowledgements This work was completed by the Community and Population Health Division, Alberta Health and Wellness. For more information contact: Alberta Health and Wellness Surveillance and Assessment Branch Community and Population Health Division P.O. Box 1360, Station Main Edmonton, AB T5J 2N3 CANADA Phone 780-422-4771 Fax 780-427-1470 Internet: www.health.alberta.ca ISBN: 978-0-7785-8271-7 (Print) ISBN: 978-0-7785-8272-4 (online)

http://www.health.alberta.ca/�

Alberta Health and Wellness, Surveillance & Assessment Branch April 2011

i Immigrant Health in Alberta © 2011 Government of Alberta

Table of Contents Executive Summary............................................................................................................................................................ 5

Demographics.................................................................................................................................................................. 5 Health Determinants ...................................................................................................................................................... 5 Mortality............................................................................................................................................................................ 5 Children’s Health............................................................................................................................................................. 6 Circulatory Disease ......................................................................................................................................................... 6 Diabetes ............................................................................................................................................................................ 6 Injury ................................................................................................................................................................................. 6

Chapter 1: Introduction ..................................................................................................................................................... 7 Chapter 2: Methods and Interpretation........................................................................................................................... 8

Data Sources .................................................................................................................................................................... 8 1. Immigrant Registry ................................................................................................................................................. 8 2. Other Data Sources ..............................................................................................................................................10

Methodology ..................................................................................................................................................................11 1. Aggregation of Data Across Years ..................................................................................................................... 11 2. Standard Errors .....................................................................................................................................................11 3. Age Standardization..............................................................................................................................................11 4. Smoothing ..............................................................................................................................................................11 5. Incidence Rates......................................................................................................................................................11 6. Determinants of Health .......................................................................................................................................11

Interpretation Considerations .....................................................................................................................................12 1. Non-Immigrants....................................................................................................................................................12 2. Immigration Type .................................................................................................................................................12 3. Incidence ................................................................................................................................................................12 4. Ethnicity .................................................................................................................................................................12 5. Origin of Immigration..........................................................................................................................................13

Chapter 3: Demographics................................................................................................................................................14 Population ......................................................................................................................................................................14 Fertility ............................................................................................................................................................................15 Fertility: Women aged 15 to 19 years.........................................................................................................................17 Fertility: Women aged 40 to 44 years.........................................................................................................................19

Chapter 4: Selected Determinants of Health................................................................................................................20 Chapter 5: Mortality..........................................................................................................................................................21 Chapter 6: Children’s Health...........................................................................................................................................23

Infant Mortality Rates...................................................................................................................................................23 Low Birth Weight..........................................................................................................................................................24 High Birth Weight.........................................................................................................................................................25 Preterm Birth .................................................................................................................................................................26

Chapter 7: Ischemic Heart Disease................................................................................................................................29 Incidence of Ischemic Heart Disease ........................................................................................................................29 Hospital Separations .....................................................................................................................................................31

Chapter 8: Hypertension..................................................................................................................................................33 Chapter 9: Stroke ..............................................................................................................................................................35 Chapter 10: Diabetes and Related Co-morbidities ...................................................................................................... 37

Incidence of Diabetes...................................................................................................................................................37 Foot Disease ..................................................................................................................................................................39 Lower Limb Amputations ...........................................................................................................................................40 End-Stage Renal Disease .............................................................................................................................................41


ii Immigrant Health in Alberta © 2011 Government of Alberta

Chapter 11: Injury .............................................................................................................................................................43 Motor Vehicle Traffic Incidents .................................................................................................................................43

Chapter 12: Conclusion....................................................................................................................................................46 References ..........................................................................................................................................................................47 Appendix 1: Country Groupings....................................................................................................................................49 Appendix 2: Age-Standardization and Standard Errors ............................................................................................. 54

Age-Standardization:.....................................................................................................................................................54 Standard Errors: ............................................................................................................................................................54

1. Standard Errors for Age-Standardized Rates ................................................................................................... 54 2. Standard Errors for Crude Rates ........................................................................................................................54 3. Standard Errors for Fertility Rates .....................................................................................................................55

Appendix 3: Case Definitions .........................................................................................................................................56 Ischemic Heart Disease................................................................................................................................................56 Hypertension..................................................................................................................................................................56 Stroke ..............................................................................................................................................................................56 Diabetes ..........................................................................................................................................................................57 Foot Disease and Lower Limb Amputations ........................................................................................................... 57 End-Stage Renal Disease .............................................................................................................................................57 Motor Vehicle Traffic Incidents .................................................................................................................................58


iii Immigrant Health in Alberta © 2011 Government of Alberta

Tables and Figures Table 1: Immigrant Registry, Migration Counts by Year ............................................................................................. 8 Table 2: Immigrant Registry, Counts by Origin of Immigration (2006 to 2008) ..................................................... 9 Figure 1: Immigrants to Alberta, Immigrant Registry versus Citizenship and Immigration Canada.................10 Figure 2: World Map ........................................................................................................................................................13 Figure 3: Population in 2008: Immigrants versus Non-Immigrants......................................................................... 14 Figure 4: Fertility: Years Since Immigration: 1995 to 2006........................................................................................ 15 Figure 5: Fertility: Origin of Immigration: 1995 to 2006............................................................................................ 15 Table 3: Fertility: Origin of Immigration: 1995 to 2006............................................................................................. 16 Figure 6: Teen Fertility: Years Since Immigration: 1995 to 2006 ............................................................................. 17 Figure 7: Teen Fertility: Years Since Immigration: 1995 to 2006 ............................................................................. 17 Figure 8: Teen Fertility: Origin of Immigration: 1995 to 2006 ................................................................................. 18 Figure 9: Fertility Aged 40 to 44 years: Years Since Immigration: 1995 to 2006 ................................................... 19 Figure 10: Fertility Aged 40 to 44 years: Origin of Immigration: 1995 to 2006 ..................................................... 19 Table 4: Selected Indicators for Alberta, 2007 to 2008, Immigrants versus Non-Immigrants ............................20 Figure 11: Mortality: Years Since Immigration: 2000 to 2008................................................................................... 21 Figure 12: Mortality: Age Effects: 2000 to 2008..........................................................................................................21 Figure 13: Mortality: Origin of Immigration: 2000 to 2008....................................................................................... 22 Figure 14: Infant Mortality: Years Since Immigration: 2000 to 2006....................................................................... 23 Figure 15: Infant Mortality: Origin of Immigration: 2000 to 2006........................................................................... 23 Figure 16: Low Birth Weight: Years Since Immigration: 1995 to 2006 ................................................................... 24 Figure 17: Low Birth Weight: Origin of Immigration ................................................................................................ 24 Table 5: Low Birth Weight: Origin of Immigration.................................................................................................... 25 Figure 18: High Birth Weight: Years Since Immigration: 1995 to 2006 .................................................................. 25 Figure 19: High Birth Weight: Origin of Immigration: 1995 to 2006 ...................................................................... 26 Table 6: High Birth Weight: Origin of Immigration: 1995 to 2006.......................................................................... 26 Figure 20: Preterm Births: Years Since Immigration: 1995 to 2006 ......................................................................... 27 Figure 21: Preterm Births: Origin of Immigration: 1995 to 2006............................................................................. 27 Table 7: Preterm Births: Origin of Immigration: 1995 to 2006 ................................................................................ 28 Figure 22: Incidence of Ischemic Heart Disease: Years Since Immigration, 1995 to 2008.................................29 Figure 23: Incidence of Ischemic Heart Disease: Age Effects, 1995 to 2008......................................................... 29 Figure 24: Incidence of Ischemic Heart Disease: Origin of Migration, 1995 to 2008...........................................30 Table 8: Incidence of Ischemic Heart Disease: Origin of Immigration, 1995 to 2008 .........................................30 Figure 25: Separations due to Ischemic Heart Disease: Years Since Migration, 1994 to 2008 ............................31 Figure 26: Separations due to Ischemic Heart Disease: Age Effects, 1994 to 2008 ..............................................31 Figure 27: Separations due to Ischemic Heart Disease: Origin of Migration, 1994 to 2008 ................................32 Table 9: Separations due to Ischemic Heart Disease: Origin of Immigration, 1994 to 2008...............................32 Figure 28: Hypertension: Years Since Immigration: 1995 to 2008 ........................................................................... 33 Figure 29: Hypertension: Age Effects: 1995 to 2008.................................................................................................. 33 Figure 30: Hypertension: Origin of Immigration: 1995 to 2008 ............................................................................... 34 Table 10: Hypertension: Origin of Immigration: 1995 to 2008 ................................................................................ 34 Figure 31: Ischemic Stroke: Years Since Immigration: 1995 to 2008....................................................................... 35 Figure 32: Ischemic Stroke: Age Effects: 1995 to 2008.............................................................................................. 35 Figure 33: Ischemic Stroke: Origin of Migration: 1995 to 2008 ............................................................................... 36 Figure 34: Incidence of Diabetes: Years Since Immigration: 1995 to 2008 ........................................................... 37 Figure 35: Incidence of Diabetes: Age Effects: 1995 to 2008 ................................................................................... 38 Figure 36: Incidence of Diabetes: Origin of Migration: 1995 to 2008 ..................................................................... 38 Table 11: Incidence of Diabetes: Origin of Immigration: 1995 to 2008.................................................................. 38 Figure 37: Treated Prevalence of Foot Disease: Years since Immigration: 1995 to 2008 ....................................39


iv Immigrant Health in Alberta © 2011 Government of Alberta

Figure 38: Treated Prevalence of Foot Disease: Age Effects: 1995 to 2008........................................................... 39 Figure 39: Treated Prevalence of Foot Disease: Years Since Immigration: 1995 to 2008....................................40 Figure 40: Treated Prevalence of Limb Amputations: Age Effects: 1995 to 2008 ................................................40 Figure 41: Incidence of End-Stage Renal Disease: Years Since Immigration: 1995 to 2008 ...............................41 Figure 42: Incidence of End-Stage Renal Disease: Age Effects: 1995 to 2008 ...................................................... 41 Figure 43: Incidence of End-Stage Renal Disease: Origin of Immigration: 1995 to 2008 ...................................42 Figure 44: Emergency Visits due to Motor Vehicle Traffic Incidents: Years Since Immigration: 1998 to 2008..............................................................................................................................................................................................43 Figure 45: Emergency Visits due to Motor Vehicle Traffic Incidents: Age Effects: 1998 to 2008.....................44 Figure 46: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to 2008..44 Table 12: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to 2008 ...45 Figure 47: Emergency Visits due to Motor Vehicle – Drivers Only Traffic Incidents: Years Since Immigration, Male vs. Female: 1998 to 2008 ...............................................................................................................45


5 Immigrant Health in Alberta © 2011 Government of Alberta

Executive Summary Immigrants in Alberta are in many respects healthier than non-immigrants. Compared to non-immigrants, they have lower mortality, lower rates for many diseases, and show signs of better health behaviors. There are, however, health conditions for which immigrants are worse off than non-immigrants. In addition, immigrant’s health status can vary significantly depending on the part of the world from which they arrive. The purpose of this report is to provide a snapshot of the health status, and a detailed look at health issues associated with immigrants to Alberta between 1994 and 2008. The results will drive further analysis and provide a basis for sound evidence to direct public health policies for improving the health of immigrants in Alberta.

Demographics For the years 2006 to 2008, more immigrants arrived in Alberta from the Philippines than any other

country. This was followed in order by the United States (U.S.), India, United Kingdom (U.K.) and China. Immigrants in Alberta are younger than the general population. The median age at which people immigrate

to Alberta is about 29 years, while in 2009 the median population age in Alberta was about 36 years. Fertility among immigrant women is very high immediately following immigration (total fertility rate above

2.5), but declines steadily and falls below the fertility of non-immigrants as the number of years since immigrating increases.

Fertility is highest among immigrant women from Sudan, Lebanon, Iraq, Syria and Algeria. Compared to non-immigrants of similar age, fertility is typically lower among teen immigrants and higher

among immigrant women above the age of 40.

Health Determinants Immigrants in Alberta are less likely to smoke than non-immigrants, with about 15.7 per cent of

immigrants age 12 and over smoking in 2007 to 2008 compared to 23.3 per cent for non immigrants age 12 and over. The prevalence of smoking is significantly higher in immigrants who’ve been in Canada 10 or more years, compared to fewer than 10 years.

In 2007 to 2008, immigrants were less likely to binge drink (4.5 per cent vs. 14.1 per cent) or have a Body

Mass Index (BMI) considered overweight or obese (43.5 per cent vs. 56.5 per cent). Immigrants, however, were more likely to be physically inactive (53.0 per cent vs. 43.8 per cent);

Mortality Mortality is significantly lower among immigrants than non-immigrants, across all ages, origins of

migration, and time since migration (in this study limited to 15 years).



Children’s Health Infant mortality is somewhat lower in children born to immigrant women compared with non-immigrant

women.

The rates of Low birth weight were higher among births of immigrant women, particularly in southern and southeast Asian countries. High birth weight rates are significantly lower among immigrant women, with the exception of women from Europe, where rates are typically similar or higher than non-immigrant women.

Preterm birth rates are higher among immigrant women than non-immigrant women, especially for women

from southern and southeast Asia, as well as western Africa.

Circulatory Disease Overall, rates of ischemic heart disease, stroke, and hypertension are lower among immigrants. There are

exceptions however. Incidence rates for ischemic heart disease are elevated in immigrants from Israel, Bangladesh, Egypt, Malaysia and New Zealand, although no country showed statistically higher incidence than non-immigrants.

The incidence rates of hypertension are highest in immigrants from Brunei and Ghana. South Asian

immigrants from India, Sri Lanka, and Pakistan are also high. Incidence of hypertension was higher among immigrants in younger ages (under 65 years)

Diabetes Incidence of diabetes is elevated in immigrants. Most notably, south Asian immigrants had by far the

highest rates. Rates were also high in immigrants from the northeast section of Africa (Somalia, Ethiopia, Egypt, and Libya).

Rates for many of the co-morbidities related to diabetes, such as lower limb amputation, end-stage renal

disease, and foot disease were lower among immigrants.

Injury The rates of emergency visits due to a driver or passenger being injured in a motor vehicle traffic incident

were significantly higher among immigrants, particularly for males. The rates were highest among immigrants from Iraq, Ghana, Somalia, Turkey, Ethiopia and Fiji. Additional analysis is required to understand the underlying reasons for this finding.



Chapter 1: Introduction The number of international immigrants moving to Alberta in recent years has been substantial. In 2008, 3.5 per cent of the population of Alberta had immigrated into the province within the previous five years. Between 2006 and 2008, almost 140,000 immigrants arrived in Alberta, with slightly more than half of these coming from Asia. Statistics Canada reported from the 2006 census, that 16.2 per cent of the Alberta population was comprised of immigrants, compared to 14.9 per cent in 2001. The proportion of new immigrants to Alberta is closely in line with its population proportion. From 2005 to 2009, Alberta comprised approximately 10.6 per cent of the Canadian population. During that time about 9 per cent of permanent residents and 12.1 per cent of temporary residents opted to reside in Alberta. By comparison from 2005 to 2009, Ontario and British Columbia were the most likely destinations for new immigrants. Ontario, with approximately 38 per cent of the Canadian population, absorbed 59 and 39 per cent respectively of permanent and temporary residents. British Columbia had 13 percent of the population, and took in 17 per cent of permanent residents and 24 percent of temporary residents. Immigrants come from countries with widely differing economic, political, social, and environmental realities. Some have been exposed to war and extreme poverty that, while others are from upper socioeconomic classes with significant education. Given the substantial size and ever-growing numbers of immigrant populations in Alberta, as well as variations in their health behaviors and lifetime of exposure to risk factors in other parts of the world, it is important to ensure effective and ongoing monitoring of the health of immigrants in Alberta. This report provides an overview of health outcome measures associated with recent immigrants to Alberta. In addition to comparing immigrants with the non-immigrant Alberta population, the report examines, where possible: i) whether increasing length of residency in Alberta affects health, and ii) the effect of country/region of origin on a health measure. The surveillance information in the report, with the exception of the discussion of determinants of health (Chapter 4), focuses primarily on health status and is intended to direct further investigation and research. There is little attempt to link the underlying health determinants with the identified trends or variations. Links to related findings and research are provided where possible. The appendix provides an overview of the case definitions used throughout the report along with methodological approaches and formulas.



Chapter 2: Methods and Interpretation

Data Sources

1. Immigrant Registry Most analysis in this report relied on the creation of an Alberta Immigrant Registry. This registry uses the Alberta Health Care Insurance Plan Central Stakeholder Registry (CSR) to identify people who have migrated into Alberta since 1984. Immigration information, such as country or province of origin and date of arrival is typically provided when people register for health care coverage under the Alberta Health Care Insurance Plan (AHCIP). The CSR does not capture secondary migration. This means that if someone immigrates to Canada and stays in another province for a period of time prior to moving to Alberta, they will be considered an interprovincial migrant. People at less than one year of age, with either a newborn status or no origin information are considered births, and are excluded from the registry. Table 1 summarizes the immigrant registry, which contains 2,274,455 registrants migrating to Alberta between 1984 and 2008. The registry contains more accurate and complete information in recent years. International immigrants will be the focus of this report.

Table 1: Immigrant Registry, Migration Counts by Year

Migration Type Year of

Migration International Inter-Provincial Unknown

1984 5,935 (6.0%) 13,071 (13.3%) 79,275 (80.7%)1985 6,619 (7.2%) 12,448 (13.5%) 73,253 (79.4%)1986 6,382 (6.6%) 11,737 (12.1%) 78,815 (81.3%)1987 6,931 (8.8%) 10,233 (13.0%) 61,554 (78.2%)1988 9,454 (10.2%) 21,019 (22.8%) 61,810 (67.0%)1989 14,227 (14.2%) 31,668 (31.5%) 54,509 (54.3%)1990 17,019 (17.0%) 36,185 (36.2%) 46,743 (46.8%)1991 14,436 (17.0%) 33,020 (39.0%) 37,281 (44.0%)1992 15,111 (19.8%) 32,346 (42.4%) 28,821 (37.8%)1993 19,988 (24.5%) 39,858 (48.8%) 21,814 (26.7%)1994 18,745 (28.3%) 37,412 (56.4%) 10,135 (15.3%)1995 16,391 (23.8%) 42,332 (61.4%) 10,182 (14.8%)1996 16,543 (23.7%) 48,049 (68.7%) 5,338 (7.6%)1997 17,037 (19.4%) 64,465 (73.5%) 6,267 (7.1%)1998 16,616 (18.4%) 67,217 (74.6%) 6,293 (7.0%)1999 17,975 (24.8%) 50,087 (70.2%) 3,625 (5.0%)2000 20,255 (26.2%) 53,692 (69.5%) 3,260 (4.2%)2001 24,282 (27.2%) 62,052 (69.5%) 2,945 (3.3%)2002 24,067 (30.0%) 54,480 (68.0%) 1,622 (2.0%)2003 24,247 (33.2%) 47,088 (64.4%) 1,749 (2.4%)2004 23,947 (31.9%) 49,712 (66.2%) 1,394 (1.9%)2005 28,396 (30.5%) 63,626 (68.4%) 1,034 (1.1%)2006 37,084 (28.5%) 92,372 (70.9%) 780 (0.6%)2007 45,797 (39.3%) 70,380 (60.4%) 438 (0.4%)2008 55,367 (46.3%) 63,966 (53.5%) 301 (0.3%)



Table 2 summarizes the number of international immigrants on the immigrant registry by country of origin arriving in the three year span from 2006 to 2008. The Philippines is by far the largest source country for immigrants arriving in Alberta in recent years.

Table 2: Immigrant Registry, Counts by Origin of Immigration (2006 to 2008)

Immigrant Registry Counts

Country of Origin Number of Immigrants

Philippines 24,360U.S.A. 11,450India 11,347United Kingdom* 9,101China 8,552Mexico 7,582Pakistan 4,319South Korea 4,099Germany 3,147Australia 2,195Colombia 1,734Venezuela 1,533Hong Kong 1,465Romania 1,430Lebanon 1,398Vietnam 1,327Iran 1,322United Arab Emirates 1,275Poland 1,254Sri Lanka 1,232Nigeria 1,166Japan 1,133*Selecting country codes of England, United Kingdom and Scotland

Counts of migrants to Alberta compare well with other sources of migration data. Figure 1 shows international migration gains into Alberta, comparing the counts from the immigrant registry versus data received from Citizenship and Immigration Canada (CIC).



Figure 1: Immigrants to Alberta, Immigrant Registry versus Citizenship and Immigration Canada

Year

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Inte

rnat

ion

al M

igra

nts

(000

's)

10

20

30

40

50

60

70

AHCIP CIC

Counts of immigrants to Alberta from AHCIP

and CIC compare closely The numbers for CIC include the total number

of Albertans granted permanent residence in addition to the total first-time arrivals of humanitarian population (most of whom are refugee claimants along with some foreign nationals allowed to stay in Canada on compassionate grounds), temporary workers and students.

CIC counts are higher mainly because permanent

residents will include some people who are already physically present in Alberta. The counts from the immigrant registry will include individuals applying for health care coverage for the first time (i.e. just moving to Alberta).

2. Other Data Sources The indicators created for analysis in this report use population estimates derived from the Alberta Health Care Insurance Plan Population Registry, which contains all Alberta residents eligible for medical coverage of physician and hospital services through the Alberta Health Care Insurance Plan. The coverage does not include members of the Canadian Armed Forces, Royal Canadian Mounted Police (RCMP), or inmates of federal penitentiaries, whose medical coverage is from the federal government. It also excludes individuals who have decided not to register with the AHCIP. Registration with the AHCIP is required by law for all residents, even if they opt out of coverage. Approximately 200 individuals opt out of the AHCIP on an annual basis. The analysis of fertility patterns of immigrant women uses birth records from Alberta Vital Statistics. Birth records from 1995 to 2006 were linked with CSR to obtain Personal Health Numbers (PHNs) which were then used to capture immigration information for each mother from the CSR. The analysis of mortality uses death records from Alberta Vital Statistics. Death records from 1999 to 2008 were also linked to the CSR to obtain PHNs to enable the assignment of immigration information to each deceased resident of Alberta. Certain indicators, such as incidence of diabetes and ischemic heart disease, use Alberta Physician Claims data for case ascertainment. Physician Claims data from 1983 to 2008 were used. The 9th Revision of the International Classification of Diseases, Clinical Modification (ICD-9-CM) was used for coding of diseases and disorders. Emergency department visits data is available for all years since 1997 (and Hospitalizations since 1993) and are both used throughout the report. Both sources utilize ICD-9-CM diagnostic coding from 1997 to 2002 and ICD-10-CA (International Classification of Diseases, 10th Revision, Canadian Adaptation) thereafter.



Methodology

1. Aggregation of Data Across Years Each indicator was aggregated across all years for which the indicator was available, with 1994 as the earliest year if available, and 2008 as the most recent year if available. Comparisons were made across age (at event date), years since immigration (years from immigration to event), and origin of immigration.

2. Standard Errors All measures throughout the report are provided along with standard errors to ensure appropriate interpretations are made. Graphics are typically shown with the measure along with error bars with plus and minus two standard errors. Standard error calculation details are provided in Appendix 2.

3. Age Standardization Where possible, to ensure comparability, measures were age-standardized using the direct method, and using the Statistics Canada 1991 population.

4. Smoothing Graphics showing trends across time and age are frequently displayed using a smoothed line which is intended to display the underlying trends in the data with the noise removed. The loess smoothing technique was applied.

5. Incidence Rates Incidence rates were calculated by dividing new cases (over a year), by the at-risk population, where the at-risk population is derived from the non-prevalent cases in each year’s mid-year population file. An aggregated incidence rate over many years would involve summing the new cases across years and dividing by the at-risk population across years.

6. Determinants of Health Information on health determinants is available from the Canadian Community Health Survey (CCHS), a national survey covering health behaviors and outcomes. This survey covers approximately 10,000 Albertan youth and adults (age 12 and over) in each two-year cycle. The methods used in analyzing survey data will differ from the methods used with the administrative data used elsewhere in this report. Data from the CCHS cycle 4.1 provincial share file, covering 2007 and 2008, were analyzed. Cycle 4.1 has 11,129 respondents in the Alberta sample. Proportions were estimated utilizing the provincial share file survey weights to account for survey design effects. Comparisons between immigrants and non-immigrants were carried out using weighted logistic regression with a group indicator and controlling for age and sex. Significant differences between groups are reported for indicator estimates with p-values <.05. All analyses use a statistical re-sampling procedure called the bootstrap1 for standard error estimation and were carried out in SAS 9.2.



Interpretation Considerations There a variety of considerations requiring attention to help with interpreting the results in the report, some of which are discussed as follows.

1. Non-Immigrants Non-immigrants are compared to immigrants throughout the report. For purposes of analysis, an immigrant is defined as and individual on the immigrant registry with international migration type and a migration date on or after 1994. The non-immigrant group will contain everyone else, including immigrants prior to 1994 and inter-provincial migrants. Given that prior to 1994, a higher percentage of new residents have unknown origin, this was chosen as the cutoff.

2. Immigration Type Immigrants are classified into two types; permanent and temporary. Temporary residents are typically humanitarian populations (mostly refugee claimants with a few foreign nationals allowed to remain in Canada on compassionate grounds), students, and temporary workers. There is no way, from the data available on the immigrant registry, to distinguish, and thereby make comparisons across immigrant types.

3. Incidence Incidence rates for immigrants of several chronic diseases are examined in the report. Incidence is the measure most often of interest since it is desirable to know if certain groups such as immigrants are at higher risk of developing certain diseases. The information is used to inform policies and programs applied to prevention efforts. A new case is typically identified from information in administrative data records. Since new cases are more likely to be identified in people who are newer in administrative data records than people who’ve been residents a longer period of time, it becomes problematic to accurately capture incidence for immigrants. Many of the newly identified cases would have been identified previously had records been available for them, particularly in the period immediately after immigration. Throughout the report, chronic disease incidence is often trimmed to remove new cases identified in people who have an onset date within one year of immigrating. This is reasonable since the comparison group, the non-immigrants, contains a mix of new people as well (interprovincial migrants and immigrants prior to 1994).

4. Ethnicity The immigrant registry captures the country of origin of immigration, which should not be interpreted as a perfect representation of ethnicity. In many situations, particularly in source countries that are themselves not immigrant nations, it would be reasonable to assume that most immigrants from that nation are of the same ethnic composition as that country. For other source countries, especially the U.S. and some European countries that are themselves immigrant nations, immigrants are more likely to be composed of a variety of ethnicities.



5. Origin of Immigration The countries of the world have been grouped into 17 subcontinents by Statistics Canada. The country to subcontinent grouping is provided in Appendix 1. Figure 2 shows the subcontinents on a world map. In some cases due to small immigration counts (i.e. South America and Australia/Oceania), continents are not broken further into subcontinents. Indicators are frequently reported at the country level in addition to the subcontinent level. Several countries with very low immigration counts to Alberta were grouped into a small category, and would never be included in the list of countries, even if the actual value of the indicator for that country should have been in the list. The information for these countries would be of no use in any case because of the high variability associated with a country with such a low population count.

Figure 2: World Map

Source: Alberta Health and Wellness The following notation is throughout the report to label Subcontinents. AUSOCE: Australia and Oceania NOAFRI: Northern Africa USANOR: U.S.A. and other North America SCAFRI: South-Central Africa STHAME: South America WEAFRI: Western Africa CTRAME: Central America EAAFRI: Eastern Africa CRBNBE: Caribbean and Bermuda WCASIA: West-Central Asia NOEURO: Northern Europe SOASIA: Southern Asia SOEURO: Southern Europe SEASIA: Southeast Asia EAEURO: Eastern Europe EAASIA: Eastern Asia WEEURO: Western Europe



Chapter 3: Demographics

Population As of mid-year (i.e. June 30) 2008, a total of 215,211 people in Alberta (6.2 per cent of the population) had immigrated to Alberta in the previous 10 years. According to the 2006 Statistics Canada Census, over 16 per cent of Albertans were born outside of Canada. Immigrants to Alberta are typically young. From 1995 to 2005, the median age at immigration into Alberta fluctuated from 27.4 to 28.3 years. The median age at immigration has spiked upwards in recent years, and has been over 29 years of age since 2006.

Figure 3: Population in 2008: Immigrants versus Non-Immigrants

Percentage of Population

8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8

Age

Gro

up

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-89

90+ Male: Immigrant (last 10 yrs) Female: Immigrant (last 10 yrs) Male: Not immigrant (last 10 yrs )Female: Not immigrant (last 10 yrs)

Figure 3 compares the age structure in 2008 of

the recent immigrants from the previous 10 years versus those who are not immigrants in the past 10 years.

A significantly greater proportion of the non-

immigrant population is in the older age groups compared to the immigrant population. A sizeable proportion of the immigrant population in the 25 to 44 age range.

The young age structure of the immigrant population poses some challenges for analysis. Young immigrants, where events such as chronic disease onset rarely occur, are plentiful. Similarly, older immigrants, where these events are more likely to occur, are rare. Age-standardization is used to make the comparisons throughout the report meaningful. The standard populations used (1991 population from Canadian census) are structured different than the immigrant population, meaning the crude and age-standardized rates in the immigrant population will be different.



Fertility The total fertility rate (TFR) is interpreted as the number of children a woman would have throughout her child bearing years if the current age-specific fertility rates prevailed. The TFR is calculated by summing the age-specific rates across all child-bearing years, 15 to 49. In this section, the TFR is compared across years since migration as well as origin of immigration.

Figure 4: Fertility: Years Since Immigration: 1995 to 2006

Years Since Migrating

1 3 5 7 9 11 13

Bir

ths

per

wom

an (

Age

d 1

5 to

49)

0.5

1.0

1.5

2.0

2.5

3.0

Non-Immigrants

Fertility rates for immigrant women are high

immediately following migration, and decline as the time since immigration increases, eventually falling below rates for non-immigrant women.

Figure 5: Fertility: Origin of Immigration: 1995 to 2006

Origin of Immigration

EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Bir

ths

per

Wom

an a

ged

15

to 4

9

0

1

2

3

4

5

Non Immigrants

Immigrants from most sub-continental regions

show significantly higher fertility than non-immigrants.

Immigrants from Northern Africa, Central

America and West-Central Asia have the highest fertility rates.



Table 3: Fertility: Origin of Immigration: 1995 to 2006


Sub-Continent Births Females 15 to 49

Total Fertility Rate

Stand. Error

Sudan North Africa 500 2,145 5.96 0.14 Lebanon West-Central Asia 1,427 6,450 5.58 0.08 Iraq West-Central Asia 547 2,820 5.52 0.11 Syria West-Central Asia 181 959 5.15 0.18 Algeria North Africa 78 427 5.13 0.30 Somalia East Africa 155 800 5.03 0.20 Congo Sth.-Central Africa 49 325 4.79 0.33 Libya North Africa 103 758 4.60 0.21 Mexico Central America 1,216 7,603 4.28 0.06 Bolivia South America 117 726 4.26 0.18 Jordan West-Central Asia 151 1,044 4.02 0.15 Pakistan South Asia 1,892 12,994 3.96 0.04

Immigrant women with the highest fertility rates are from countries such as Sudan, Algeria, Somalia, Congo, and Libya from Africa as well as Lebanon, Iraq and Syria from West-Central Asia.

The results for fertility of immigrants in Alberta coincide closely with results of other Canadian studies. There is usually a carry over of fertility patterns from the source countries, whereby, if the fertility is high in the country of origin, it will typically remain high after arriving in Canada, at least for a while.1 The United Nations (UN) list of reported fertility rates around the world2 confirms this for the source countries listed in table 3, with the exception of perhaps Lebanon, where the TFR in 2001 was only 1.9. Furthermore, as Figure 4 suggests, fertility converges to, and falls below, non-immigrant levels as immigrants integrate into Canadian society.



Fertility: Women aged 15 to 19 years The teen fertility rate is the rate at which live births occur in women aged 15 to 19. Childbearing in early teen years can result in adverse outcomes for the baby and the mother. Teen mothers are more likely to smoke than older mothers, and have higher rates of low birth weight and pre-term babies3. In addition, teen mothers are more likely to be subject to poor economic conditions4.

Figure 6: Teen Fertility: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Bir

ths

per

1,0

00 W

omen

age

d 1

5 to

19

0

10

20

30

40

Non-Immigrants

Teen fertility rates decline over the first four years since immigration and then level off.

Figure 7: Teen Fertility: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Bir

ths

per

1,0

00 W

omen

age

d 15

to

19

0

20

40

60

80

100

120

140

NOAFRI, WCASIA, and CTRAME All Other Subcontinents

Non-Immigrants

The sharp decline shortly after immigrating is most profound with immigrant women from West Central Asia, North Africa and Central America.



Figure 8: Teen Fertility: Origin of Immigration: 1995 to 2006


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Bir

ths

per

1,0

00 W

omen

age

d 1

5 to

19

0

20

40

60

80

Non Immigrants

Immigrant women from most North Africa,

West-Central Asia, and Central America show significantly higher fertility at ages 15 to 19 years than non-immigrants.

Fertility rates for immigrant women aged 15 to 19 year were high for those from the following countries: Lebanon, Syria, Turkey, Iraq, and Jordan from West-Central Asia. The highest teen fertility rates for Central American countries were Mexico, Nicaragua, Guatemala, and El Salvador. For immigrant women from North Africa, the teen fertility rates were highest in women from Sudan, Morocco, and Egypt. There is evidence to suggest that exposure to Canadian culture, education system, and other factors in the early teen years will have an impact on the eventual fertility pattern of a 15 to 19 year old (for example, a 17 year old female just moving to Alberta is more likely to have a child, than a 17 year old female having migrated to Alberta as a 13 year old).



Fertility: Women aged 40 to 44 years Fertility for women 40 to 44 years is derived by dividing live births born to women aged 40 to 44 years, by the number of women aged 40 to 44 years. High maternal age has been linked to negative birth outcomes such as higher rates of small- and large- for gestational age, low birth weight, preterm births, stillbirths, as well as congenital anomalies such as Down’s Syndrome. Maternal mortality has also been associated with older mothers, particularly over 40 years of age5.

Figure 9: Fertility Aged 40 to 44 years: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Bir

ths

per

1,0

00 W

omen

age

d 4

0 to

44

0

5

10

15

20

25

Non-Immigrants

Immigrant women aged 40 to 44 years have higher fertility rates than non-immigrant women.

The number of years since immigrating has no impact on fertility of women aged 40 to 44 years.

Figure 10: Fertility Aged 40 to 44 years: Origin of Immigration: 1995 to 2006


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Bir

ths

per

1,0

00 W

omen

age

d 4

0 to

44

0

10

20

30

40

50

Non Immigrants

Immigrant women from most sub-continental

regions show significantly higher fertility at ages 40 to 44 years than non-immigrants.

Women from Europe had fertility rates for 40

to 44 year old women the closest to non-immigrant women. Only South-Central Africa and Southern Europe have rates not significantly higher than for non-immigrants



Chapter 4: Selected Determinants of Health Data for the years 2007 and 2008, from the Canadian Community Health Survey (CCHS) cycle 4.1 was used to compare selected health determinant indicators between immigrant and non-immigrant Albertans. Table 4 shows the estimated prevalence of immigrants and non-immigrants for a variety of indicators collected from CCHS and indicates whether they are significantly different after adjusting for age and sex. Immigrants are less likely to smoke or engage in binge drinking, but are more likely to be physically inactive. Immigrants are less likely to be overweight or obese. The results for the Alberta Risk Factor Index (ARFI) are also shown. The calculation of the ARFI involves each of the six indicators listed below being dichotomized as zero or one (zero for healthy or one for unhealthy) and totaling; meaning a six would be most unhealthy and zero would be most healthy. 1. Stress 2. BMI Category 3. Fruit and Vegetable Consumption 4. Physical Activity Category derived from reported physical activities 5. Smoking Status 6. Heavy Drinking frequency

A higher proportion of immigrants have only 0 or 1 of the risk factors present (i.e. a lower ARFI).

Table 4: Selected Indicators for Alberta, 2007 to 2008, Immigrants versus Non-Immigrants

CCHS Measure Immigrants Non-Immigrants

Significantly Different

Body Mass Index = overweight or obese (Ages 18+)

43.5% 56.5% Yes

Life Stress = a bit, not very, not at all (Ages 15+)

23.8% 26.3% No

Fruit and Vegetable Consumption = fewer than 5 servings daily (Ages 12+)

57.3% 57.1% No

Physical Activity = Inactive (Ages 12+)

53.0% 43.8% Yes

Smoking = daily or occasional (Ages 12+)

15.7% 23.3% Yes

Binge Drinking = Having 5 or more drinks, 2 or more times per month (Ages 12+)

4.5% 14.1% Yes

Seat Belt Use = always or mostly as a driver or passenger (Ages 12+)

97.9% 97.5% No

Alberta Risk Factor Index = 0 or 1 risk factor present (Ages 20 to 64)

36.0% 29.3% Yes

The indicators for the immigrants were also analyzed to determine if any of the risk factors changed based on years since migrating. In all cases, time since immigration is not a significant factor; the exception was smoking, where immigrants who had been in Canada longer than 10 years had significantly higher smoking rates than those in Canada fewer than 10 years.



Chapter 5: Mortality As described in the demographics section, immigrants are highly weighted towards younger ages. As a result, death events are rare in the immigrant population, making detailed analysis challenging. In 2008, more than 7.7 per cent of the population was comprised of immigrants who had migrated since 1994, but they accounted for only 1.7 per cent of the deaths in 2008 (i.e. 372 of the total 20,733 deaths). Given the small numbers of deaths, it is only possible to reliably analyze all-cause mortality. Mortality rates were aggregated across all years, selecting deaths occurring from 2000 to 2008. All analysis was based on individuals 20 years of age and older, and for combined sexes.

Figure 11: Mortality: Years Since Immigration: 2000 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nd

ard

ized

Mor

talit

y R

ate

(Per

100

,000

)

200

300

400

500

600

700

800

Non-Immigrants

There is no evidence to suggest the mortality of

immigrants is changing the longer they are in Alberta. Age-standardized mortality rates for the immigrant population remain well below the rates seen in the non-immigrant Alberta population.

Regardless of the time since migrating, mortality

rates for immigrants remain significantly lower than non-immigrants.

Figure 12: Mortality: Age Effects: 2000 to 2008

Age

20 to

24

25 to

29

30 to

34

35 to

39

40 to

44

45 to

49

50 to

54

55 to

59

60 to

64

65 to

69

70 to

74

75 to

79

80 to

84 85+

Dea

ths

per

100

,000

pop

ula

tion

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Immigrants Non Immigrants

Age-specific mortality rates of immigrants

remain lower than the non-immigrants across all ages



Figure 13: Mortality: Origin of Immigration: 2000 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Dea

ths

per

100

,000

pop

ula

tion

0

200

400

600

800

1000

1200

Non Immigrants

Immigrants from most sub-continental regions

show significantly lower or similar rates of mortality as do non-immigrants.

Immigrants from Australia (12 deaths), New

Zealand (nine deaths) and Fiji (22 deaths) had the highest mortality rates among all countries, but with the high standard error associated with each, no conclusions should be drawn.

Mortality is significantly lower among immigrants than non-immigrants. This is seen to be the case across all age groups and number of years since immigrating. As a measure of overall health status, mortality in immigrants is significantly lower than non-immigrants. There is no evidence to show that mortality converges to non-immigrant levels as the years since immigration increases. Given that mortality is rare among recent immigrants to Alberta who are young, no conclusions can be drawn for any given origin of migration at the country level or individual causes of death. Mortality patterns of immigrants from the U.S. and Australia and Oceania are most similar to the non-immigrant population.



Chapter 6: Children’s Health

Infant Mortality Rates The infant mortality rate is defined as the number of infant (age < 1 year) deaths per 1,000 live births. Rates are combined for the years 2000 to 2006.

Figure 14: Infant Mortality: Years Since Immigration: 2000 to 2006


1 3 5 7 9 11

Infa

nt

Mor

talit

y R

ate

(Per

1,0

00 L

ive

Bir

ths)

0

2

4

6

8

10

12

14

Non-Immigrants

Time since immigrating to Alberta has no effect

on infant mortality. The rates for immigrants, subject to significant

random error, are not significantly different from non-immigrants.

Figure 15: Infant Mortality: Origin of Immigration: 2000 to 2006


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Infa

nt

Mor

talit

y R

ate

(per

1,0

00 L

ive

Bir

ths)

0

5

10

15

20

25

30

35

Non Immigrants

There is no significant difference in infant

mortality for immigrants from most subcontinents compared with non-immigrants.

The infant mortality rate for Caribbean and

Bermuda was notably higher than any other region, but is not considered to be a reason for concern, given the small number of immigrant women from this region and sizeable standard error.

Infant mortality rates for immigrants do not suggest any areas for concern, with no subcontinent regions showing significantly higher infant mortality rates than the non-immigrant population. Little variation exists in the rates across years since immigration, as well as across the different origins of immigration.



Low Birth Weight Low birth weight is a measure of the proportion of live births that are below 2,500 grams. The proportions are combined for the years 1995 to 2006.

Figure 16: Low Birth Weight: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Low

Bir

th W

eigh

t P

erce

nt

(<2,

500

gram

s)

0

2

4

6

8

10

12

14

Non-Immigrants

Time since immigrating to Alberta is not a

significant factor in low birth weight increasing or decreasing.

Low birth weight rates among immigrant women

are consistently higher than rates for non-immigrants.

Figure 17: Low Birth Weight: Origin of Immigration


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Low

Bir

thW

eigh

t P

erce

nt

(< 2

500

gram

s)

0

2

4

6

8

10

12

Non Immigrants

Rates of low birth weight are statistically highest

for women from Southern and Southeast Asia. This may, in part, be due to these women being of small stature which results in lower birth weight, but not generally at the expense of the health of the newborn.



Table 5: Low Birth Weight: Origin of Immigration Origin of Immigration

Sub-Continent LBW Births

Live Births Percent Std. Error

France Western Europe 18 132 13.6 3.0 Fiji Australia-Oceania 44 371 11.9 1.7 Bangladesh South Asia 16 141 11.3 2.7 Bosnia Southern Europe 11 97 11.3 3.2 Kenya East Africa 17 152 11.2 2.6 Tanzania East Africa 5 52 9.6 4.1 Taiwan Southeast Asia 15 157 9.6 2.3 India South Asia 462 4,943 9.3 0.4 Philippines Southeast Asia 306 3,372 9.1 0.5 Scotland Northern Europe 10 112 8.9 2.6 S. Arabia West-Central Asia 14 158 8.9 2.3 Pakistan West-Central Asia 169 1,910 8.8 0.6

The higher rates of low birth weight in immigrants from the Philippines and Taiwan are contributing the most to the higher rates seen in Southeast Asia, while Pakistan, Bangladesh, and India are contributing significantly to the higher rates in women from South Asia.

Countries with low live birth counts are not

included in this list.

High Birth Weight High birth weight is the measure of the proportion of live births weighing more than 4,000 grams. The rates are combined for the years 1995 to 2006.

Figure 18: High Birth Weight: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Hig

h B

irth

Wei

ght

Per

cen

t (>

4,00

0 gr

ams)

4

6

8

10

12

14

Non-Immigrants

Rates of high birth weight are considerably lower

among immigrants than non-immigrants regardless of the number of years since immigration.



Figure 19: High Birth Weight: Origin of Immigration: 1995 to 2006


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Hig

h B

irth

Wei

ght

Per

cen

t (>

4,0

00 g

ram

s)

0

5

10

15

20

Non Immigrants

Only immigrants from Western Europe have

rates significantly higher than non-immigrants. This is likely, in part, due to the larger stature of women from European countries.

Rates for high birth weight are by far the lowest

in immigrants from Asian countries.

Table 6: High Birth Weight: Origin of Immigration: 1995 to 2006


Sub-Continent HBW Births

Live Births

Percent Std. Error

Bolivia South America 28 120 23.3 3.9 Netherlands Western Europe 109 521 20.9 1.8 Croatia Sothern Europe 10 52 19.2 5.5 Bosnia Sothern Europe 18 97 18.6 3.9 Sweden Northern Europe 9 51 17.6 5.3 Scotland Northern Europe 18 112 16.1 3.5 Cuba Caribbean/Berm 13 86 15.1 3.9 Yugoslavia Sothern Europe 79 565 14.0 1.5 Germany Western Europe 65 474 13.7 1.6

The immigrants with highest rates for high birth weight are primarily from Europe.



Preterm Birth Preterm birth is a measure of the proportion of live births that are born prior to 37 weeks gestation5. Many risk factors (i.e. smoking, substance abuse, stress, and high maternal age) and outcomes (i.e. respiratory problems, motor and sensory complication) for preterm births are presented in the Alberta Health and Wellness report; “Alberta Reproductive Health, Pregnancies and Births 2009”5.



Figure 20: Preterm Births: Years Since Immigration: 1995 to 2006


1 3 5 7 9 11 13

Pre

term

Bir

th R

ate

2

4

6

8

10

12

14

16

Non-Immigrants

The trend in preterm birth rates for immigrants

across years since immigration is not very different from the rates for low birth weights. This is not surprising since 72.5 per cent of low birth weight babies are preterm5.

For most years since immigrating the preterm

birth rates for immigrants are somewhat or significantly higher than the rate for non-immigrants

Figure 21: Preterm Births: Origin of Immigration: 1995 to 2006


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Pre

term

Bir

th R

ate

0

2

4

6

8

10

12

14

16

As is the case for low birth weights, preterm

birth rates are significantly higher in immigrants from Southeast and Southern Asia, as well as West Africa.



Table 7: Preterm Births: Origin of Immigration: 1995 to 2006


Sub-Continent Preterm Births

Live Births

Percent Std. Error

Thailand Southeast Asia 11 76 14.5 4.1 Banglad. Southern Asia 19 141 13.5 2.9 Argentina South America 13 97 13.4 3.5 France Western Europe 17 132 12.9 2.9 Kenya East Africa 19 152 12.5 2.7 Fiji Australia-Oceania 45 371 12.1 1.7 Nigeria West Africa 27 227 11.9 2.1 Philippines Southeast Asia 395 3372 11.7 0.6 Bosnia Southern Europe 11 97 11.3 3.2 Cambodia Southeast Asia 10 92 10.9 3.2 Guyana South America 7 65 10.8 3.8 Ireland Northern Europe 9 84 10.7 3.4 Pakistan Southern Asia 198 1910 10.4 0.7 India Southern Asia 508 4943 10.3 0.4

Immigrants from Thailand, Philippines, and Cambodia from the subcontinent of Southeast Asia, along with those from Bangladesh, Pakistan, and India from the subcontinent of Southern Asia have among the highest preterm birth rates. Immigrants from Liberia, Mauritania (not on list due to small live birth counts), and Nigeria from the subcontinent of West Africa are also among the highest rates of preterm births.





Chapter 7: Ischemic Heart Disease This section looks at incidence of ischemic heart disease (IHD) in the Alberta immigrant population. Incidence of ischemic heart disease measures the rate at which new cases of IHD occur in the population. The incidence measure in this section utilizes the case definition used in past publications for Alberta Health and Wellness8. Hospital inpatient separations (defined as a person leaving an inpatient facility due to death, discharge, or against medical advice) related to IHD are also examined. All analysis is for the years 1995 to 2008, based on individuals 20 years of age and older, and for combined sexes.

Incidence of Ischemic Heart Disease

Figure 22: Incidence of Ischemic Heart Disease: Years Since Immigration, 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

ndar

dize

d R

ate

(Per

100

,000

)

0

200

400

600

800

1,000

Non-Immigrants

As is explained in Chapter 2 under “Interpretation Considerations’ incidence is challenging to measure accurately for individuals with short length of residency (i.e. new immigrants) since many of the new cases would have been identified earlier given previous health information.

In summary, the period immediately following

immigration is measuring prevalent cases as well as incident cases. Therefore incidence is elevated shortly after migration.

Incidence of IHD is lower for immigrants, and it

appears the rate may actually decline as the number of years since immigrating increases.

Figure 23: Incidence of Ischemic Heart Disease: Age Effects, 1995 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84 85

+

Inci

denc

e R

ate

(Per

100

,000

pop

ula

tion

)

0

1,000

2,000

3,000

4,000

All Immigrants Immigrants (excl. within 1 yr.) Non Immigrants

Immigrants have lower incidence of IHD

across all ages compared to non-immigrants. Removing immigrants who have immigrated

within one year of incidence date lowers the rates.



Figure 24: Incidence of Ischemic Heart Disease: Origin of Migration, 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Inci

den

ce R

ate

per

100

,000

pop

ula

tion

0

200

400

600

800

1,000

1,200

1,400

Non Immigrants

Immigrants having migrated within one year of

the incidence date are removed. Incidence rates of ischemic heart disease are

higher in immigrant populations from Australia and Oceania and West Central Asia.

Immigrants from Eastern and Southeastern

Asia have significantly lower incidence rates of ischemic heart disease than non immigrants, while most areas of Europe and Africa are similar to the non-immigrant population.

Table 8: Incidence of Ischemic Heart Disease: Origin of Immigration, 1995 to 2008


Sub-Continent New Cases

Person yrs. at Risk

A.S. Rate

Std. Error

Israel West-Central Asia

25 5,926 1,119 486

Bangladesh South Asia 20 3,562 1,104 436 Egypt North Africa 27 7,134 1,070 319 Malaysia Southeast Asia 16 3,933 1,057 476 N. Zealand Australia-

Oceania 9 3,782 1,038 460

Guyana South America 7 1,618 936 471 Iran West-Central

Asia 45 10,440 887 253

Fiji Australia-Oceania

50 8,506 868 225

Russia Eastern Europe

40 16,214 836 199

Pakistan South Asia 143 33,577 835 109

Immigrants from Israel, Bangladesh, and Egypt show the highest incidence of IHD.

Immigrants from New Zealand and Fiji are

contributing to the high rates seen in the sub-continent of Australia and Oceania.



Hospital Separations

Figure 25: Separations due to Ischemic Heart Disease: Years Since Migration, 1994 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

ndar

diz

ed S

epar

atio

ns

(Per

100

,000

pop

n)

0

100

200

300

400

500

600

700

Non-Immigrants

Hospital separations due to IHD are significantly

lower among immigrants. There is a moderate decline in rates for

immigrants who have been in Alberta longer.

Figure 26: Separations due to Ischemic Heart Disease: Age Effects, 1994 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89 90

+

Sep

arat

ions

per

100

,000

pop

ulat

ion

0

500

1,000

1,500

2,000

2,500

3,000


Immigrants have significantly lower separation

rates due to IHD across all ages compared to non-immigrants.



Figure 27: Separations due to Ischemic Heart Disease: Origin of Migration, 1994 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Age

-Sta

nd

ard

ized

Sep

arat

ion

s (p

er 1

00,0

00 p

opn

)

0

200

400

600

800

1,000

1,200

Non Immigrants

Separation rates for IHD are higher in

immigrant populations from Australia and Oceania.

Immigrants from Eastern and Southeastern

Asia have significantly lower separation rates of IHD than non immigrants.

Table 9: Separations due to Ischemic Heart Disease: Origin of Immigration, 1994 to 2008


Sub-Continent Sepn’s Population A.S. Rate

Std. Error

Fiji Australia-Oceania

85 10,232 1,344 151

Bangladesh South Asia 23 4,661 1,290 n/a Sri Lanka South Asia 13 4,256 896 358 Pakistan South Asia 140 41,041 842 104 Chile South America 7 3,238 840 288 Guatemala Central America 6 1,582 766 401 United Arab Eremites

West-Central Asia

17 4,245 749 147

Immigrants from Fiji, along with the South Asian countries of Bangladesh, Sri Lanka, and Pakistan have the highest hospital separation rates for IHD.

Incidence rates of IHD for immigrants are lower than non-immigrants, supporting what would be expected given the lower rates of obesity and smoking for immigrants as shown in Chapter 4. There is evidence to suggest that the rates are declining the longer they are in Alberta. Several individual countries show elevated incidence of IHD. The countries vary, but are more concentrated in areas such as West-Central and Southern Asia, and Australia/Oceania. Hospital separations rates for IHD show a similar pattern for immigrants based on the number of years since immigrating, declining over time. Several of the countries that have high incidence rates, such as Bangladesh, Fiji, and Pakistan are also among the countries with the highest hospital separation rates. Rates of emergency department visits (no graphics shown here) across years since immigration are almost identical to hospital separations, showing a declining trend. Australia and Oceania stood out as the only sub-continent with significantly higher emergency visit rate due to IHD, where immigrants from Fiji had the highest rates of any country.



Chapter 8: Hypertension This chapter looks at the incidence of hypertension in Alberta immigrants. Incidence of hypertension measures the rate at which new cases of hypertension occur in the population. The incidence measure in this section utilizes the case definition as defined in Appendix 3. All analysis is for the years 1995 to 2008, based on individuals 20 years of age and older, and for combined sexes.

Figure 28: Hypertension: Years Since Immigration: 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nda

rdiz

ed R

ate

(Per

100

,000

)

0

2,000

4,000

6,000

8,000

Non-Immigrants

Due to the short clearance period for new

immigrants, incidence is greatly elevated shortly after migration.

Incidence of hypertension for recent immigrants

within about five years is lower than for non-immigrants. The rate for immigrants then appears to slightly decline as the number of years since migrating increases.

Figure 29: Hypertension: Age Effects: 1995 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84 85

+

Inci

den

ce R

ate

(Per

100

,000

pop

ula

tion

)

0

2,000

4,000

6,000

8,000

10,000

12,000

All Immigrants Immigrants (excl. within 1 yr.) Non Immigrants

Removing immigrants migrating within one

year of incidence date lowers the incidence rates.

With the first year after migrating removed, the

incidence rates of hypertension among immigrants remain just slightly higher than for non-immigrants for ages under 65, while the rates of immigrants over the age of 70 are lower.



Figure 30: Hypertension: Origin of Immigration: 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Inci

den

ce R

ate

per

100

,000

pop

ula

tion

0

1,000

2,000

3,000

4,000

5,000

Non Immigrants


the incidence date are removed. Incidence rates of hypertension are significantly

higher in immigrant populations from South and Southeast Asia, as well as Western Africa, although the standard error associated with West Africa is very large

Immigrants from most regions have rates

similar to non-immigrants.

Table 10: Hypertension: Origin of Immigration: 1995 to 2008



Person yrs. at Risk

A.S. Rate

Stand. Error

Brunei Southeast Asia 30 1,236 4,763 1,196 Ghana West Africa 59 2,316 3,983 1,174 India South Asia 2,257 96,823 3,622 179 Sri Lanka South Asia 54 2,750 3,473 867 Guyana South America 32 1,441 3.359 1,003 Philippines Southeast Asia 2,317 104,881 3,346 143 Israel West-Central Asia 107 5,399 3,187 573 Pakistan South Asia 609 31,017 3,175 217 Poland Eastern Europe 172 9,831 3,004 358 Egypt North Africa 117 6,509 2,981 484

Immigrants from Brunei, Ghana, and India show the highest incidence of hypertension.

Hypertension is being diagnosed at a greater rate in younger immigrants, which is a concern given it is a major risk factor for heart disease. Incidence rates are seen to be high in parts of Southern and Southeast Asia and parts of Africa. A recent study in Ontario showed hypertension having elevated prevalence for people with South Asian and Black ethnicity6.



Chapter 9: Stroke This section looks at incidence of acute ischemic stroke (AIS), which measures the rate at which first time occurrences of AIS occur in the population. The incidence measure in this section utilizes the case definition as defined in Appendix 3. All analysis is for the years 1995 to 2008, based on individuals 20 years of age and older, and for combined sexes.

Figure 31: Ischemic Stroke: Years Since Immigration: 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nda

rdiz

ed R

ate

(Per

100

,000

)

0

2,000

4,000

6,000

8,000

Non-Immigrants

There is a declining trend in the incidence rate of

AIS among immigrants, as the number of years since immigrating increases.

Figure 32: Ischemic Stroke: Age Effects: 1995 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84 85

+

Inci

den

ce R

ate

(Per

100

,000

pop

ula

tion

)

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

All Immigrants Non Immigrants

Incidence of AIS among immigrants is lower

than non-immigrants at all ages.



Figure 33: Ischemic Stroke: Origin of Migration: 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Inci

den

ce R

ate

per

100

,000

pop

ula

tion

0

1,000

2,000

3,000

4,000

Non Immigrants

At the subcontinent level, there is no origin of

immigration for which the incidence of AIS is significantly higher than for non-immigrants. (Note that immigrants within one year of migration are included here)

Counts of new occurrences of AIS by

individual country are quite small for many of the countries of origin, and are not included here.

As is the case with IHD, AIS rates are generally lower among immigrants and there is no origin of immigration for which immigrants are showing elevated rates. The low obesity and smoking rates of immigrants, as shown in Chapter 4 support this finding.



Chapter 10: Diabetes and Related Co-morbidities This section looks at incidence of diabetes in the Alberta immigrant population. Incidence of diabetes is a measure of the rate at which new cases of diabetes occur in the population. The incidence measure in this sections utilizes the case definition developed for the National Diabetes Surveillance System (NDSS)7. The diabetes case definition, which is assumed to encompass both type 1 and type 2 diabetes, is outlined in Appendix 3. All analysis is for the years 1995 to 2008, based on individuals 20 years of age and older, and for combined sexes. Incidence rates are aggregated across all years, selecting new cases occurring from 1995 to 2008. Health records from 1983 to current are used for case ascertainment. Some complications of diabetes, such as foot disease, lower limb amputations, and end-stage renal disease (ESRD) are examined to provide additional context of the burden of diabetes in immigrant populations. Case definitions for these complications are taken from the Alberta Diabetes Atlas and are outlined in Appendix 3.

Incidence of Diabetes

Figure 34: Incidence of Diabetes: Years Since Immigration: 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nda

rdiz

ed R

ate

(Per

100

,000

)

0

500

1,000

1,500

2,000

2,500

Non-Immigrants

Due to the short clearance period (i.e. time within Alberta for which administrative data is available to determine a new case), incidence is very high shortly after immigration.

Incidence rates of diabetes for immigrants

remain higher than non-immigrants, regardless of duration in Alberta.



Figure 35: Incidence of Diabetes: Age Effects: 1995 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89 90

+

Inci

denc

e R

ate

(Per

100

,000

pop

ula

tion

)

0

1,000

2,000

3,000

4,000

5,000

Immigrants Immigrants (excl. within 1 yr.) Non Immigrants

Immigrants have increased incidence of

diabetes across all ages compared to non-immigrants.

Removing immigrants migrating within one

year of incidence date lowers the rates, but the immigrant rates remain higher than non-immigrants.

Figure 36: Incidence of Diabetes: Origin of Migration: 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Inci

den

ce R

ate

per

100,

000

pop

ula

tion

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Non Immigrants


the incidence date are removed. Incidence rates of diabetes are significantly

higher in immigrant populations from Southern Asia, as well as many parts of Africa.

Immigrants from European countries, as well

as the U.S. have rates closest to non-immigrants.

High rates in several subcontinents call for

investigation at a more detailed (country) level.

Table 11: Incidence of Diabetes: Origin of Immigration: 1995 to 2008



Person yrs. at Risk

A.S. Rate

Stand. Error

Sri Lanka South Asia 44 2,850 1,962 449 Brunei Southeast Asia 20 1,370 1,853 497 Bangladesh South Asia 44 3,393 1,829 441 Somalia East Africa 15 1,631 1,825 457 Egypt North Africa 50 6,985 1,805 379 Pakistan South Asia 383 32,174 1,774 162 Fiji Australia-Oceania 112 8,019 1,671 205 Ethiopia East Africa 36 7,937 1,619 669 Portugal South Europe 15 1,467 1,492 482 Libya North Africa 17 1,976 1,450 849 El Salvador Central America 19 3,661 1,323 598 India South Asia 1087 105,341 1,283 142

Immigrants from the South Asian countries of Sri Lanka, Bangladesh, Pakistan, and India have among the highest incidence of diabetes.

Immigrants from four countries from the

northeast section of the African continent (Somalia, Ethiopia, Egypt, and Libya) also have among the highest incidence of diabetes.



Foot Disease

Figure 37: Treated Prevalence of Foot Disease: Years since Immigration: 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

ndar

dize

d R

ate

(Per

100

,000

)

1,800

2,000

2,200

2,400

2,600

2,800

3,000

Non-Immigrants

There is no apparent trend in rates of foot

disease, based on years since immigrating. Age-standardized treated prevalence rates of foot

disease are consistently lower in immigrants.

Figure 38: Treated Prevalence of Foot Disease: Age Effects: 1995 to 2008

Age

20 to

24

25 to

29

30 to

34

35 to

39

40 to

44

45 to

49

50 to

54

55 to

59

60 to

64

65 to

69

70 to

74

75 to

79

80 to

84

85 to

89 90+

Rat

e p

er 1

00,0

00 p

opul

atio

n

0

2,000

4,000

6,000

8,000

10,000


Age-specific treated prevalence rates of foot

disease for immigrants are lower across all age groups.



Figure 39: Treated Prevalence of Foot Disease: Years Since Immigration: 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Rat

e p

er 1

00,0

00 p

opul

atio

n

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Non Immigrants

Age-standardized treated prevalence rates of foot

disease for immigrants are lower across all origins of immigration.

Rates of foot disease for immigrants from

Southern Asia are closest to the non-immigrant population.

Lower Limb Amputations

Figure 40: Treated Prevalence of Limb Amputations: Age Effects: 1995 to 2008

Age

20 to

24

25 to

29

30 to

34

35 to

39

40 to

44

45 to

49

50 to

54

55 to

59

60 to

64

65 to

69

70 to

74

75 to

79

80 to

84

85 to

89 90+

Rat

e p

er 1

00,0

00 p

opu

lati

on

0

50

100

150

200


Age-specific treated prevalence rates for lower

limb amputations for immigrants are lower across all age groups.

Age-standardized rates by years since migration

or by origin of migration are not presented here due to small counts.



End-Stage Renal Disease

Figure 41: Incidence of End-Stage Renal Disease: Years Since Immigration: 1995 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nd

ard

ized

In

cid

ence

Rat

e (P

er 1

00,0

00)

0

10

20

30

40

50

60

70

Non-Immigrants

There is no apparent trend in incidence of end-

stage renal disease (ESRD), based on years since immigrating.

Age-standardized incidence rates of ESRD are

seen to be moderately, but not significantly lower in immigrant populations for most years since immigrating. The rates are highly variable given the low counts of new cases seen for ESRD.

Figure 42: Incidence of End-Stage Renal Disease: Age Effects: 1995 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89 90

+

Inci

den

ce R

ate

(Per

100

,000

pop

ula

tion

)

0

50

100

150

200


Age-specific incidence rates of ESRD for

immigrants are consistently lower across most age groups.



Figure 43: Incidence of End-Stage Renal Disease: Origin of Immigration: 1995 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

AFRICA

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CSAM

ER

USANOR

Inci

den

ce R

ate

per

100

,000

pop

ula

tion

0

20

40

60

80

Non Immigrants

Because of small counts of ESRD in several

subcontinents, the regions of Africa (using all African subcontinents) and Central/South America (Using South and Central America along with Caribbean/Bermuda) were combined.

There is no origin of immigration that stands out

with significantly higher rates of ESRD.

Immigrants from many areas of the world show high incidence of rates of diabetes, including many parts of Asia, Africa, and Oceania. Immigrants from Europe and the U.S. have rates similar to or lower than the Alberta population. Immigrants from the four South Asian countries of Bangladesh, Pakistan, Sri Lanka, and India stand out as having among the highest rates of developing diabetes. These results, showing higher levels of diabetes, particularly in South Asian immigrants, compare closely with an Ontario study that examined the prevalence of diabetes in recent immigrants to Ontario8. People (such as South Asians) with high levels of central adiposity (more body fat around the waist) are believed to be at greater risk of insulin resistance which leads one to be more likely to develop diabetes.9,15 Complications from diabetes, such as lower limb amputations and foot disease have lower rates from immigrants than non-immigrants, suggesting that immigrants have been effective in managing their diabetes. In the general population, patients with diabetes are 13 times more likely to develop ESRD than those without10. Incidence of ESRD is, however, slightly lower among the general immigrant population. Further assessment of the risks attributing to high incidence of diabetes in these immigrant subpopulations is required.



Chapter 11: Injury

Motor Vehicle Traffic Incidents This section examines the rates of emergency department visits as a result of a driver or passenger being injured in motor vehicle traffic incidents. Rates for motor vehicle related injuries are known to be higher in rural areas, specifically outside of Calgary and Edmonton11. Most immigrants settle in Calgary and Edmonton, and for the purpose of making a meaningful comparison of immigrants with non-immigrants, only those people residing in the municipalities of Calgary and Edmonton are selected for analysis. Emergency department visits are aggregated across the years 1998 to 2008. The ICD-9 and ICD-10 codes used are outlined in Appendix 3. All analysis is based on individuals 20 years of age and older.

Figure 44: Emergency Visits due to Motor Vehicle Traffic Incidents: Years Since Immigration: 1998 to 2008


1 3 5 7 9 11 13 15

Age

-Sta

nd

ardi

zed

Em

erg.

Vis

its

per

100

,000

pop

n

0

100

200

300

400

500

600

700

Non-Immigrants

The rate for immigrants is rapidly increasing the

first couple years after immigration, most likely due to the time lag involved for new immigrants to purchase a vehicle, and obtain a valid drivers license.

The rate for immigrants is significantly higher

than for non-immigrants. Most visits (approximately 73 per cent) are from

the driver of the motor vehicle as opposed to the passenger.



Figure 45: Emergency Visits due to Motor Vehicle Traffic Incidents: Age Effects: 1998 to 2008

Age

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89 90

+

Inci

den

ce R

ate

(Per

100

,000

pop

ula

tion

)

-200

0

200

400

600

800


Age-specific emergency department visits rates

for motor vehicle traffic incidents are consistently higher for immigrants up to about the age of 65 years.

Figure 46: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to 2008


EAEURO

NOEURO

SOEURO

WEEURO

EAAFRI

NOAFRI

SCAFRI

WEAFRI

AUSOCE

EAASIA

SEASI

A

SOASI

A

WCASI

A

CRBNBE

CTRAME

STHAM

E

USANOR

Age

-Sta

nd

ardi

zed

Em

erg.

Vis

its

per

100

,000

pop

n

0

200

400

600

800

Non Immigrants

Rates are elevated in immigrants from many

parts of the world, most notably in immigrants from East and West Africa, Caribbean/Bermuda, and West-Central Asia.

Immigrants from Western and Northern Europe,

as well as the U.S. show rates equivalent to or lower than non-immigrants.



Table 12: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to 2008


Sub-Continent ER Visits

Person Yrs. At Risk

A.S. Rate

Stand. Error

Iraq West-Central Asia

173 8,053 2,160 211

Ghana West Africa 42 2,857 1,344 252 Somalia East Africa 33 1,835 1,193 223 Turkey West-Central

Asia 33 3,162 1,185 332

Ethiopia East Africa 107 8,885 1,114 254 Fiji Australia-

Oceania 94 9,075 944 136

Afghanistan West-Central Asia

58 6,435 926 223

Jamaica Crbn./Bermuda 47 4,747 916 161 Sudan North Africa 91 8,091 916 220 Syria West-Central

Asia 21 2,683 856 266

Lebanon West-Central Asia

147 15,573 819 105

Kenya East Africa 70 7,660 781 115 Pakistan South Asia 285 38,748 778 61

Countries with high rates, but low numbers of immigrants, and hence very high standard errors, are not included on the list.

Immigrants from Iraq show the highest rates of

emergency visits, followed by Ghana, Somalia, Turkey, and Ethiopia.

Figure 47: Emergency Visits due to Motor Vehicle – Drivers Only Traffic Incidents: Years Since Immigration, Male vs. Female: 1998 to 2008

Years Since Migrating1 3 5 7 9 11 13 15

Age

-Sta

nd

ard

ized

Em

erg.

Vis

its

per

100

,000

pop

n

0

200

400

600

Male ImmigrantsFemale Immigrants

Male Non-Immigrants

Female Non-Immigrants

Rates of emergency department visits due to

motor vehicle traffic incidents for drivers only shows the rate for immigrant males significantly higher than immigrant females

The rates of emergency department visits (drivers only) for males and females separately, shown in figure 47, shows significantly higher rates for male immigrants than for females. An important consideration to be made when interpreting emergency department visit rates due to motor vehicle traffic incidents is the time at risk of being injured while driving. Some groups of people, such as those in driving related occupations, are more likely to suffer injury in a motor vehicle by virtue of the fact they are on the roads for longer periods of time. Additional investigation is required to determine if this occupational factor may be contributing to the elevated rates seen among male immigrants, along with other possible reasons such as seatbelt use or adjusting to different driving conditions from the source country.



Chapter 12: Conclusion The report identifies five primary areas of concern pertaining to immigrant health in Alberta. These are: Preterm births: Rates of preterm birth are significantly higher among children born to women from

Southern and Southeastern Asia Hypertension: Incidence of hypertension was found to be high among younger immigrants under 65

years of age, and specifically higher among South Asian immigrants. Diabetes: Incidence of diabetes was higher among immigrants, most notably, those from South Asia. Motor vehicle traffic incidents: Rates of emergency department visits due to motor vehicle traffic

incidents were significantly higher among immigrants under 65 years of age, particularly for males. Further analysis is required to determine some of the underlying causes.

Physical activity: Data fro the CCHS show lower physical activity levels among immigrants in Alberta. Additional research and analysis is required to more clearly understand the factors negatively influencing immigrant health. The Surveillance and Assessment Branch will need to conduct continuous and expanded surveillance of Alberta immigrants in the future, updating the immigrant registry annually. As new case definitions and data become available for surveillance purposes, applying new or updated health indicators to immigrant subpopulations will be required. Dissemination of immigrant health surveillance data through mechanisms such as the Interactive Health Data Application of the Alberta Health and Wellness website in addition to surveillance reports or briefings will ensure policy makers continue to be made aware of health issues related to immigrant populations.



References

1. Bélanger, A. and Gilbert, S. (2002). The Fertility of Immigrant Women and Their Canadian Born Daughters, Report on the Demographic Situation in Canada, 2002, Statistics Canada, Catalogue 91-209-XIE, Ottawa.

2. United Nations, Department of Economic and Social Affairs, Population Division, World Fertility

Patterns 2009 (Wall Chart). Available: http://www.un.org/esa/population/publications/worldfertility2009/worldfertility2009.htm [2010, March 8].

3. Alberta Health and Wellness (1999), Maternal Risk Factors in Relationship to Birth Outcome,

Edmonton, AB. Available: http://www.health.alberta.ca/documents/Maternal-Risk-Factor-1999.pdf [2010, March 8].

4. Roterman, M. (2007). Second or Subsequent Births to Teenagers, Health Reports (Vol. 18, No. 1,

February 2007, p. 39-42), Statistics Canada, Catalogue 82-003-XIE, Ottawa. Available: http://www.statcan.gc.ca/pub/82-003-x/82-003-x2006003-eng.pdf [2010, March 8].

5. Reproductive Health Working Group (2009), Alberta Reproductive Health; Pregnancies and Births

2009. Edmonton, AB: Alberta Health and Wellness. Available: http://www.health.alberta.ca/documents/Reproductive-Health-2009-Update.pdf [2010, March 8].

6. Maria Chiu, MSc, Peter C. Austin, PhD, Douglas G. Manuel, MD MSc and Jack V. Tu, MD PhD.

Comparison of Cardiovascular Risk Profiles among Ethnic Groups using Population health Surveys between 1996 and 2007.CMAJ, 2010 May 18;182(8):E301-10. Epub 2010 Apr 19.

7. Johnson, J. A., Balko, S. U., Hugel, G. Chapter 1: Background and Methods. In Johnson, J. A.,

editor; Alberta Diabetes Atlas 2009. Edmonton: Institute of Health Economics; 2009: 1-10.

8. Creator, M. I., Moineddin, R., Booth, G., Manuel, D.H., DesMeules, M., McDermott, S., Glazier, R.H. Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. CMAJ 2010 182: 781-789.

9. T.M. Knight, Z. Smith, A. Whittles. P. Sahota, J.A. Lockton, G. Hogg, A. Bedford, M. Toop, E.E.M.

Kernohan, M.R. Baker. Insulin resistance, diabetes, and risk markers for ischaemic heart disease in Asian men and non-Asian in Bradford. Br Heart J 1992;67:343-350

10. Klarenbach, S., Hemmelgarn, B.R., Jindal, K.K., Tonelli, M. Chapter 7: Diabetes and Kidney Disease

in Alberta. In Johnson, J. A., editor; Alberta Diabetes Atlas 2009. Edmonton: Institute of Health Economics; 2009: 141-152.

11. Alberta Centre for Injury Control & Research. Alberta “Injury Data: Comparison of Injuries in

Alberta’s Health Regions, 2006”. Edmonton: Alberta Centre for Injury Control & Research.

12. Alberta Health and Wellness (2008), Chronic Disease Projections 2006 to 2035, Ischemic Heart Disease, Edmonton, AB: Available: http://www.health.alberta.ca/documents/Chronic-Disease-Projections-2008.pdf [2010, March 9].

http://www.un.org/esa/population/publications/worldfertility2009/worldfertility2009.htm�

http://www.health.alberta.ca/documents/Maternal-Risk-Factor-1999.pdf�

http://www.statcan.gc.ca/pub/82-003-x/82-003-x2006003-eng.pdf�

http://www.health.alberta.ca/documents/Reproductive-Health-2009-Update.pdf�

http://www.health.alberta.ca/documents/Chronic-Disease-Projections-2008.pdf�



13. Kokotailo, R.A., Hill M.D. (2005). Coding of Stroke and Stroke Risk Factors Using International Classification of Diseases, Revisions 9 and 10. Stroke. 2005:1776-1781.

14. Haverstock, B.D., Senior, P.A., Bowker, S.L., McMurty, M.S., Bowering, C.K., Tsuyuki, R.T.

Chapeter 6: Diabetes, Foot Disease and Lower Limb amputations in Alberta. In Johnson, J.A., editor; Alberta Diabetes Atlas 2009. Edmonton: Institute of Health Economics; 2009: 127-140.

15. Benoit J., Arsenault PhD, Isabelle Lemieux PhD, Jean-Pierre Despres PhD, Nicholas J. Wareham

MBBS PhD, John J.P. Kastelein PhD, Kay-Tee Khaw MBBChir, S. Matthijs Boekholdt MD PhD. The hypertriglyceridemic-waist phenotype and the risk of coronary artery disease: results from the EPIC-Norfolk Prospective Population Health Study. Published online ahead of print July 19, 2010 CMAJ 10.1503/cmaj.091276.



Appendix 1: Country Groupings

Country Subcontinent Subcontinent Code (Used in Report)

Australia Australia and Oceania AUSOCE Cook Islands Australia and Oceania AUSOCE Fiji Australia and Oceania AUSOCE French Pacific Islands Australia and Oceania AUSOCE Guam Australia and Oceania AUSOCE Kiribati Australia and Oceania AUSOCE Marshall Islands Australia and Oceania AUSOCE Nauru Australia and Oceania AUSOCE New Caledonia Australia and Oceania AUSOCE New Zealand Australia and Oceania AUSOCE Northern Mariana Islands Australia and Oceania AUSOCE Palau Australia and Oceania AUSOCE Papua New Guinea Australia and Oceania AUSOCE Samoa Australia and Oceania AUSOCE Solomon Islands Australia and Oceania AUSOCE Tahiti Australia and Oceania AUSOCE Tonga Australia and Oceania AUSOCE United States Minor Outlying Islands Australia and Oceania AUSOCE Vanuatu Australia and Oceania AUSOCE Belize Central America CTRAME Costa Rica Central America CTRAME El Salvador Central America CTRAME Guatemala Central America CTRAME Honduras Central America CTRAME Mexico Central America CTRAME Nicaragua Central America CTRAME Panama Central America CTRAME Anguilla Caribbean and Bermuda CRBNBE Antigua and Barbuda Caribbean and Bermuda CRBNBE Aruba Caribbean and Bermuda CRBNBE Bahamas Caribbean and Bermuda CRBNBE Barbados Caribbean and Bermuda CRBNBE Bermuda Caribbean and Bermuda CRBNBE Cayman Islands Caribbean and Bermuda CRBNBE Cuba Caribbean and Bermuda CRBNBE Dominican Republic Caribbean and Bermuda CRBNBE Dominican Republic Caribbean and Bermuda CRBNBE Grenada Caribbean and Bermuda CRBNBE Guadeloupe Caribbean and Bermuda CRBNBE Haiti Caribbean and Bermuda CRBNBE Jamaica Caribbean and Bermuda CRBNBE Martinique Caribbean and Bermuda CRBNBE Montserrat Caribbean and Bermuda CRBNBE Netherlands Antilles Caribbean and Bermuda CRBNBE Puerto Rico Caribbean and Bermuda CRBNBE



Saint Kitts and Nevis Caribbean and Bermuda CRBNBE Saint Lucia Caribbean and Bermuda CRBNBE Saint Vincent and The Grenadines Caribbean and Bermuda CRBNBE St. Christopher Caribbean and Bermuda CRBNBE Trinidad and Tobago Caribbean and Bermuda CRBNBE Turks and Caicos Islands Caribbean and Bermuda CRBNBE Virgin Islands, British Caribbean and Bermuda CRBNBE Virgin Islands, US Caribbean and Bermuda CRBNBE West Indies Caribbean and Bermuda CRBNBE Burundi East Africa EAAFRI Djibouti East Africa EAAFRI Eritrea East Africa EAAFRI Ethiopia East Africa EAAFRI Kenya East Africa EAAFRI Madagascar East Africa EAAFRI Malawi East Africa EAAFRI Mauritius East Africa EAAFRI Mozambique East Africa EAAFRI Reunion East Africa EAAFRI Rwanda East Africa EAAFRI Seychelles East Africa EAAFRI Somalia East Africa EAAFRI Tanzania, United Republic of East Africa EAAFRI Uganda East Africa EAAFRI Zambia East Africa EAAFRI Zimbabwe East Africa EAAFRI China East Asia EAASIA Hong Kong East Asia EAASIA Japan East Asia EAASIA Korea East Asia EAASIA Korea, Democratic Peoples Republic of (North Korea) East Asia EAASIA Korea, Republic of (South Korea) East Asia EAASIA Macau East Asia EAASIA Mongolia East Asia EAASIA Taiwan, Province of China East Asia EAASIA Belarus East Europe EAEURO Bulgaria East Europe EAEURO Czech Republic East Europe EAEURO Estonia East Europe EAEURO Hungary East Europe EAEURO Latvia East Europe EAEURO Lithuania East Europe EAEURO Moldova, Republic of East Europe EAEURO Poland East Europe EAEURO Romania East Europe EAEURO Russia East Europe EAEURO Slovakia East Europe EAEURO Ukraine East Europe EAEURO Algeria North Africa NOAFRI Egypt North Africa NOAFRI



Libya North Africa NOAFRI Morocco North Africa NOAFRI Sudan North Africa NOAFRI Tunisia North Africa NOAFRI Denmark North Europe NOEURO England North Europe NOEURO Finland North Europe NOEURO Iceland North Europe NOEURO Ireland North Europe NOEURO Norway North Europe NOEURO Scotland North Europe NOEURO Sweden North Europe NOEURO United Kingdom North Europe NOEURO Wales North Europe NOEURO Angola South-Central Africa SCAFRI Botswana South-Central Africa SCAFRI Cameroon South-Central Africa SCAFRI Central African Republic South-Central Africa SCAFRI Chad South-Central Africa SCAFRI Congo South-Central Africa SCAFRI Congo, The Democratic Republic of the (Zaire) South-Central Africa SCAFRI Equatorial Guinea South-Central Africa SCAFRI Gabon South-Central Africa SCAFRI Lesotho South-Central Africa SCAFRI Liberia South-Central Africa SCAFRI Namibia South-Central Africa SCAFRI South Africa South-Central Africa SCAFRI Swaziland South-Central Africa SCAFRI Zaire South-Central Africa SCAFRI Brunei Darussalam Southeast Asia SEASIA Burma Southeast Asia SEASIA Cambodia Southeast Asia SEASIA East Timor Southeast Asia SEASIA Indonesia Southeast Asia SEASIA Kampuchea Southeast Asia SEASIA Laos Southeast Asia SEASIA Malaysia Southeast Asia SEASIA Myanmar (Burma) Southeast Asia SEASIA Philippines Southeast Asia SEASIA Singapore Southeast Asia SEASIA Thailand Southeast Asia SEASIA Viet Nam Southeast Asia SEASIA Bangladesh South Asia SOASIA Bhutan South Asia SOASIA India South Asia SOASIA Maldives South Asia SOASIA Nepal South Asia SOASIA Pakistan South Asia SOASIA Sri Lanka South Asia SOASIA Albania South Europe SOEURO



Azores South Europe SOEURO Balearic Islands South Europe SOEURO Bosnia and Herzegovina South Europe SOEURO Corsica South Europe SOEURO Croatia South Europe SOEURO Greece South Europe SOEURO Italy South Europe SOEURO Macedonia, The Former Yugoslav Republic of South Europe SOEURO Malta South Europe SOEURO Portugal South Europe SOEURO San Marino South Europe SOEURO Slovenia South Europe SOEURO Spain South Europe SOEURO Yugoslavia South Europe SOEURO Argentina South America STHAME Bolivia South America STHAME Brazil South America STHAME Chile South America STHAME Colombia South America STHAME Ecuador South America STHAME French Guiana South America STHAME Guyana South America STHAME Paraguay South America STHAME Peru South America STHAME South America South America STHAME Suriname South America STHAME Uruguay South America STHAME Venezuela South America STHAME Greenland U.S.A./Other North America USANOR Saint Pierre and Miquelon U.S.A./Other North America USANOR USA U.S.A./Other North America USANOR Afghanistan West-Central Asia WCASIA Armenia West-Central Asia WCASIA Azerbaijan West-Central Asia WCASIA Bahrain West-Central Asia WCASIA Cyprus West-Central Asia WCASIA Georgia West-Central Asia WCASIA Iran West-Central Asia WCASIA Iraq West-Central Asia WCASIA Israel West-Central Asia WCASIA Jordan West-Central Asia WCASIA Kazakstan West-Central Asia WCASIA Kuwait West-Central Asia WCASIA Kyrgyzstan West-Central Asia WCASIA Lebanon West-Central Asia WCASIA Oman West-Central Asia WCASIA Palestinian Territory, Occupied West-Central Asia WCASIA Qatar West-Central Asia WCASIA Republic of Kazakstan West-Central Asia WCASIA Saudi Arabia West-Central Asia WCASIA



South Yemen West-Central Asia WCASIA Syria West-Central Asia WCASIA Tajikistan West-Central Asia WCASIA Turkey West-Central Asia WCASIA Turkmenistan West-Central Asia WCASIA United Arab Emirates West-Central Asia WCASIA Uzbekistan West-Central Asia WCASIA Yemen West-Central Asia WCASIA Ascension West Africa WEAFRI Benin West Africa WEAFRI British Indian Ocean Territory West Africa WEAFRI Burkina Faso West Africa WEAFRI Cape Verde West Africa WEAFRI Cote D'Ivoire (Ivory Coast) West Africa WEAFRI Gambia West Africa WEAFRI Ghana West Africa WEAFRI Guinea West Africa WEAFRI Mali West Africa WEAFRI Mauritania West Africa WEAFRI Niger West Africa WEAFRI Nigeria West Africa WEAFRI Senegal West Africa WEAFRI Sierra Leone West Africa WEAFRI Togo West Africa WEAFRI Austria West Europe WEEURO Belgium West Europe WEEURO Channel Island West Europe WEEURO France West Europe WEEURO Germany West Europe WEEURO Luxembourg West Europe WEEURO Monaco West Europe WEEURO Netherlands Antilles West Europe WEEURO Switzerland West Europe WEEURO



Appendix 2: Age-Standardization and Standard Errors

Age-Standardization: The estimate of the standardized rate R, standardized over a variable (such as age) with J strata is given as:

/R w e nj

j

j j

where ej represents the number of events in the Jth stratum, nj represents the number of individuals in the Jth stratum, and the standardization weights wj are given by

w n nj j j / j

* *

where nj* represent the number of people in the Jth stratum in the standard population. The same weights are applied to the crude rates for males, females, and combined sexes.

Standard Errors:

1. Standard Errors for Age-Standardized Rates Age-standardized incidence, hospitalization, or emergency department visit rates throughout the report use the following formulae to derive the standard error, taken from Carriere and Roos (1994). The notation is adopted from that source. The variance of the number of events in the Jth stratum is given as:

)var (e n sj j j 2

where

s e e n nj ij j j j

n

i

j2 2

11

( / ) / ( )

2. Standard Errors for Crude Rates The standard error for the crude rates (or proportions) is calculated as follows:

p p

n

( )1



Where p is the incidence rate (estimate of probability) and n is the number of people at risk of developing the disease.

3. Standard Errors for Fertility Rates Assuming a poison distribution, the standard error for the age-specific fertility rate is calculated as the square root of the number of births (for the given mothers age) divided by the number of women of the given age. Letting ASFRi denote the age-specific fertility rate at each mothers age i = 15 to 49 and letting Pi denote the number of women of age i (i=15 to 49). Then the standard error of the total fertility rate is the square root of

i

)Pi/ASFRi(



Appendix 3: Case Definitions

Ischemic Heart Disease The case definition for ischemic heart disease (IHD) has been used previously12. Alberta Health Care Insurance Claims data is used to identify historical cases of IHD from 1983 to 2008. A person is said to have IHD is any of the following are met: Had 3 encounters with a physician with and ICD-9 diagnosis code between 410 to 414 Was hospitalized with a diagnosis code for IHD Had a heart attack (ICD-9 code equal to 410)

Hypertension In order to identify a case of hypertension, the algorithm established by the National Diabetes Surveillance System (NDSS) is used. The current NDSS case definition requires that an individual must have either One hospitalization with and ICD-9 code of 401.x – 405.x, selected from all available diagnostic codes

on the Hospital Discharge Abstract for the years 1993 to 2001, or equivalent ICD-10 codes (I10.x, I11.x, I12.x, I13.x, I15.x) for years after 2001/2002.

Two physician claims with an ICD-9 code of 401.x-405.x within three years. Physician Claims files going back to 1993 are used for case ascertainment.

Patients with pregnancy induced hypertension are excluded (codes 650.x-669.x, O13, O14, O29, O47, O48, O60-O75, O80-O84) defined as females with a hypertension diagnostic code and a physician service claim or hospital discharge record within 5 months indicating an obstetrical event.

Stroke In order to identify a case of acute ischemic stroke (AIS), the algorithm developed by Kokotailo and Hill13 is used. The algorithm uses hospital inpatient and emergency records to define AIS using the ICD-9 and ICD-10 codes as shown below. The incidence date is defined as the first of the hospital discharge date or emergency visit date, and only the primary diagnosis position is used. Prior to April 1, 2002, ICD-0 codes used are: 362.3 (Retinal Vascular Occlusion) 433.x1: (Occlusion and stenosis of precerebral arteries) 434.x1: (Occlusion of cerebral arteries) 436: (Acute, but ill-defined cerebrovascular disease)



After April1, 2002, ICD-10 coding is used: H34.1 (Central retina artery occlusion) I63.X: (Cerebral Infarction) I64.X (Stroke, not specified as hemorrhage or infarction) For case ascertainment, emergency visits data from 1997 to 2008 and hospital inpatient records from 1993 to 2008 are used.

Diabetes In order to identify a case of diabetes, the National Diabetes Surveillance System (NDSS) case definition is used7. The current NDSS case definition identifies a person as having diabetes if One hospitalization with and ICD-9 code of 250 (diabetes mellitus), selected from all available diagnostic

codes on the Hospital Discharge Abstract for the years 1995 to 2001, or equivalent ICD-10 codes (E10 to E14) for years after 2001.

OR Two physician claims with an ICD-9 code of 250 within two years Physician Claims files going back to the early 1980’s and hospital records since 1995 are used for case ascertainment. The incidence date (date at which the person is said to have developed the disease) is defined as the latest date of hospitalization, or the later of the two physician claims that contribute to the case definition.

Foot Disease and Lower Limb Amputations In order to identify a case of foot disease and lower limb amputations, the definitions used in Chapter 6 of the most recent Alberta Diabetes Atlas, 2009, is used14.

End-Stage Renal Disease In order to identify a case of end stage renal disease, the definition used in Chapter 7 of the most recent Alberta Diabetes Atlas, 2009, is used10.



Motor Vehicle Traffic Incidents Motor vehicle traffic incidents for drivers and passenger are indentified using ICD-9 codes for 1997 to March 31, 2002, and ICD-10 codes for April 1, 2002 to 2008. ICD-9: E810-E816 or E818-E819 (Fourth digit = 0 or 1) ICD-10: V30.5, V31.5, V32.5, V33.5, V34.5, V35.5, V36.5, V37.5, V38.5, V39.4, V40.5, V41.5, V42.5, V43.5, V44.5, V45.5, V46.5, V47.5, V48.5, V49.4, V50.5, V51.5, V52.5, V53.5, V54.5, V55.5, V56.5, V57.5, V58.5, V59.4, V60.5, V61.5, V62.5, V63.5, V64.5, V65.5, V66.5, V67.5, V68.5, V69.4, V70.5, V71.5, V72.5, V73.5, V74.5, V75.5, V76.5, V77.5, V78.5, V79.4, V83.0, V84.0, V85.0, V86.00, V86.08, or V30.6, V31.6, V32.6, V33.6, V34.6, V35.6, V36.6, V37.6, V38.6, V39.5, V40.6, V41.6, V42.6, V43.6, V44.6, V45.6, V46.6, V47.6, V48.6, V49.5, V50.6, V51.6, V52.6, V53.6, V54.6, V55.6, V56.6, V57.6, V58.6, V59.5, V60.6, V61.6, V62.6, V63.6, V64.6, V65.6, V66.6, V67.6, V68.6, V69.5, V70.6, V71.6, V72.6, V73.6, V74.6, V75.6, V76.6, V77.6, V78.6, V79.5, V83.1, V84.1, V85.1, V86.10, V86.18.

immigrant health in alberta, april 2011...country. this was followed in order by the united states...

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