Immigrant Health in Alberta

Transcription

1 Immigrant Health in Alberta April 211

2 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 136, Station Main Edmonton, AB T5J 2N3 CANADA Phone Fax Internet: ISBN: (Print) ISBN: (online)

3 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 Immigrant Registry Other Data Sources...1 Methodology Aggregation of Data Across Years Standard Errors Age Standardization Smoothing Incidence Rates Determinants of Health...11 Interpretation Considerations Non-Immigrants Immigration Type Incidence Ethnicity Origin of Immigration...13 Chapter 3: Demographics...14 Population...14 Fertility...15 Fertility: Women aged 15 to 19 years...17 Fertility: Women aged 4 to 44 years...19 Chapter 4: Selected Determinants of Health...2 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 1: Diabetes and Related Co-morbidities...37 Incidence of Diabetes...37 Foot Disease...39 Lower Limb Amputations...4 End-Stage Renal Disease...41 i Immigrant Health in Alberta 211 Government of Alberta

4 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: Standard Errors for Age-Standardized Rates Standard Errors for Crude Rates 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 ii Immigrant Health in Alberta 211 Government of Alberta

5 Tables and Figures Table 1: Immigrant Registry, Migration Counts by Year... 8 Table 2: Immigrant Registry, Counts by Origin of Immigration (26 to 28)... 9 Figure 1: Immigrants to Alberta, Immigrant Registry versus Citizenship and Immigration Canada...1 Figure 2: World Map...13 Figure 3: Population in 28: Immigrants versus Non-Immigrants...14 Figure 4: Fertility: Years Since Immigration: 1995 to Figure 5: Fertility: Origin of Immigration: 1995 to Table 3: Fertility: Origin of Immigration: 1995 to Figure 6: Teen Fertility: Years Since Immigration: 1995 to Figure 7: Teen Fertility: Years Since Immigration: 1995 to Figure 8: Teen Fertility: Origin of Immigration: 1995 to Figure 9: Fertility Aged 4 to 44 years: Years Since Immigration: 1995 to Figure 1: Fertility Aged 4 to 44 years: Origin of Immigration: 1995 to Table 4: Selected Indicators for Alberta, 27 to 28, Immigrants versus Non-Immigrants...2 Figure 11: Mortality: Years Since Immigration: 2 to Figure 12: Mortality: Age Effects: 2 to Figure 13: Mortality: Origin of Immigration: 2 to Figure 14: Infant Mortality: Years Since Immigration: 2 to Figure 15: Infant Mortality: Origin of Immigration: 2 to Figure 16: Low Birth Weight: Years Since Immigration: 1995 to 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 Figure 19: High Birth Weight: Origin of Immigration: 1995 to Table 6: High Birth Weight: Origin of Immigration: 1995 to Figure 2: Preterm Births: Years Since Immigration: 1995 to Figure 21: Preterm Births: Origin of Immigration: 1995 to Table 7: Preterm Births: Origin of Immigration: 1995 to Figure 22: Incidence of Ischemic Heart Disease: Years Since Immigration, 1995 to Figure 23: Incidence of Ischemic Heart Disease: Age Effects, 1995 to Figure 24: Incidence of Ischemic Heart Disease: Origin of Migration, 1995 to Table 8: Incidence of Ischemic Heart Disease: Origin of Immigration, 1995 to Figure 25: Separations due to Ischemic Heart Disease: Years Since Migration, 1994 to Figure 26: Separations due to Ischemic Heart Disease: Age Effects, 1994 to Figure 27: Separations due to Ischemic Heart Disease: Origin of Migration, 1994 to Table 9: Separations due to Ischemic Heart Disease: Origin of Immigration, 1994 to Figure 28: Hypertension: Years Since Immigration: 1995 to Figure 29: Hypertension: Age Effects: 1995 to Figure 3: Hypertension: Origin of Immigration: 1995 to Table 1: Hypertension: Origin of Immigration: 1995 to Figure 31: Ischemic Stroke: Years Since Immigration: 1995 to Figure 32: Ischemic Stroke: Age Effects: 1995 to Figure 33: Ischemic Stroke: Origin of Migration: 1995 to Figure 34: Incidence of Diabetes: Years Since Immigration: 1995 to Figure 35: Incidence of Diabetes: Age Effects: 1995 to Figure 36: Incidence of Diabetes: Origin of Migration: 1995 to Table 11: Incidence of Diabetes: Origin of Immigration: 1995 to Figure 37: Treated Prevalence of Foot Disease: Years since Immigration: 1995 to iii Immigrant Health in Alberta 211 Government of Alberta

6 Figure 38: Treated Prevalence of Foot Disease: Age Effects: 1995 to Figure 39: Treated Prevalence of Foot Disease: Years Since Immigration: 1995 to Figure 4: Treated Prevalence of Limb Amputations: Age Effects: 1995 to Figure 41: Incidence of End-Stage Renal Disease: Years Since Immigration: 1995 to Figure 42: Incidence of End-Stage Renal Disease: Age Effects: 1995 to Figure 43: Incidence of End-Stage Renal Disease: Origin of Immigration: 1995 to Figure 44: Emergency Visits due to Motor Vehicle Traffic Incidents: Years Since Immigration: 1998 to Figure 45: Emergency Visits due to Motor Vehicle Traffic Incidents: Age Effects: 1998 to Figure 46: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to Table 12: Emergency Visits due to Motor Vehicle Traffic Incidents: Origin of Immigration: 1998 to Figure 47: Emergency Visits due to Motor Vehicle Drivers Only Traffic Incidents: Years Since Immigration, Male vs. Female: 1998 to iv Immigrant Health in Alberta 211 Government of Alberta

7 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 28. 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 26 to 28, 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 29 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 4. 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 27 to 28 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 1 or more years, compared to fewer than 1 years. In 27 to 28, immigrants were less likely to binge drink (4.5 per cent vs per cent) or have a Body Mass Index (BMI) considered overweight or obese (43.5 per cent vs per cent). Immigrants, however, were more likely to be physically inactive (53. per cent vs 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). 5 Immigrant Health in Alberta 211 Government of Alberta

8 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. 6 Immigrant Health in Alberta 211 Government of Alberta

9 Chapter 1: Introduction The number of international immigrants moving to Alberta in recent years has been substantial. In 28, 3.5 per cent of the population of Alberta had immigrated into the province within the previous five years. Between 26 and 28, almost 14, immigrants arrived in Alberta, with slightly more than half of these coming from Asia. Statistics Canada reported from the 26 census, that 16.2 per cent of the Alberta population was comprised of immigrants, compared to 14.9 per cent in 21. The proportion of new immigrants to Alberta is closely in line with its population proportion. From 25 to 29, Alberta comprised approximately 1.6 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 25 to 29, 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. 7 Immigrant Health in Alberta 211 Government of Alberta

10 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 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 28. 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 International Inter-Provincial Unknown Migration ,935 (6.%) 13,71 (13.3%) 79,275 (8.7%) ,619 (7.2%) 12,448 (13.5%) 73,253 (79.4%) ,382 (6.6%) 11,737 (12.1%) 78,815 (81.3%) ,931 (8.8%) 1,233 (13.%) 61,554 (78.2%) ,454 (1.2%) 21,19 (22.8%) 61,81 (67.%) ,227 (14.2%) 31,668 (31.5%) 54,59 (54.3%) ,19 (17.%) 36,185 (36.2%) 46,743 (46.8%) ,436 (17.%) 33,2 (39.%) 37,281 (44.%) ,111 (19.8%) 32,346 (42.4%) 28,821 (37.8%) ,988 (24.5%) 39,858 (48.8%) 21,814 (26.7%) ,745 (28.3%) 37,412 (56.4%) 1,135 (15.3%) ,391 (23.8%) 42,332 (61.4%) 1,182 (14.8%) ,543 (23.7%) 48,49 (68.7%) 5,338 (7.6%) ,37 (19.4%) 64,465 (73.5%) 6,267 (7.1%) ,616 (18.4%) 67,217 (74.6%) 6,293 (7.%) ,975 (24.8%) 5,87 (7.2%) 3,625 (5.%) 2 2,255 (26.2%) 53,692 (69.5%) 3,26 (4.2%) 21 24,282 (27.2%) 62,52 (69.5%) 2,945 (3.3%) 22 24,67 (3.%) 54,48 (68.%) 1,622 (2.%) 23 24,247 (33.2%) 47,88 (64.4%) 1,749 (2.4%) 24 23,947 (31.9%) 49,712 (66.2%) 1,394 (1.9%) 25 28,396 (3.5%) 63,626 (68.4%) 1,34 (1.1%) 26 37,84 (28.5%) 92,372 (7.9%) 78 (.6%) 27 45,797 (39.3%) 7,38 (6.4%) 438 (.4%) 28 55,367 (46.3%) 63,966 (53.5%) 31 (.3%) 8 Immigrant Health in Alberta 211 Government of Alberta

11 Table 2 summarizes the number of international immigrants on the immigrant registry by country of origin arriving in the three year span from 26 to 28. 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 (26 to 28) Immigrant Registry Counts Number of Country of Origin Immigrants Philippines 24,36 U.S.A. 11,45 India 11,347 United Kingdom* 9,11 China 8,552 Mexico 7,582 Pakistan 4,319 South Korea 4,99 Germany 3,147 Australia 2,195 Colombia 1,734 Venezuela 1,533 Hong Kong 1,465 Romania 1,43 Lebanon 1,398 Vietnam 1,327 Iran 1,322 United Arab Emirates 1,275 Poland 1,254 Sri Lanka 1,232 Nigeria 1,166 Japan 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). 9 Immigrant Health in Alberta 211 Government of Alberta

12 Figure 1: Immigrants to Alberta, Immigrant Registry versus Citizenship and Immigration Canada International Migrants ('s) 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 Year 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 2 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 26 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 28 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 28 were used. The 9 th 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 22 and ICD-1-CA (International Classification of Diseases, 1 th Revision, Canadian Adaptation) thereafter. 1 Immigrant Health in Alberta 211 Government of Alberta

13 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 28 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 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 1, 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 27 and 28, 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 <.5. All analyses use a statistical re-sampling procedure called the bootstrap 1 for standard error estimation and were carried out in SAS Immigrant Health in Alberta 211 Government of Alberta

14 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 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. 12 Immigrant Health in Alberta 211 Government of Alberta

15 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 USANOR: U.S.A. and other North America STHAME: South America CTRAME: Central America CRBNBE: Caribbean and Bermuda NOEURO: Northern Europe SOEURO: Southern Europe EAEURO: Eastern Europe WEEURO: Western Europe NOAFRI: Northern Africa SCAFRI: South-Central Africa WEAFRI: Western Africa EAAFRI: Eastern Africa WCASIA: West-Central Asia SOASIA: Southern Asia SEASIA: Southeast Asia EAASIA: Eastern Asia 13 Immigrant Health in Alberta 211 Government of Alberta

16 Chapter 3: Demographics Population As of mid-year (i.e. June 3) 28, a total of 215,211 people in Alberta (6.2 per cent of the population) had immigrated to Alberta in the previous 1 years. According to the 26 Statistics Canada Census, over 16 per cent of Albertans were born outside of Canada. Immigrants to Alberta are typically young. From 1995 to 25, 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 26. Figure 3: Population in 28: Immigrants versus Non-Immigrants Age Group Male: Immigrant (last 1 yrs) Female: Immigrant (last 1 yrs) Male: Not immigrant (last 1 yrs ) Female: Not immigrant (last 1 yrs) Figure 3 compares the age structure in 28 of the recent immigrants from the previous 1 years versus those who are not immigrants in the past 1 years. A significantly greater proportion of the nonimmigrant 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 Percentage of Population 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. 14 Immigrant Health in Alberta 211 Government of Alberta

17 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 26 Births per woman (Aged 15 to 49) 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 Years Since Migrating Figure 5: Fertility: Origin of Immigration: 1995 to 26 Births per Woman aged 15 to EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI AUSOCE EAASIA SEASIA Origin of Immigration SOASIA WCASIA CRBNBE CTRAME STHAME USANOR Non Immigrants Immigrants from most sub-continental regions show significantly higher fertility than nonimmigrants. Immigrants from Northern Africa, Central America and West-Central Asia have the highest fertility rates. 15 Immigrant Health in Alberta 211 Government of Alberta

18 Table 3: Fertility: Origin of Immigration: 1995 to 26 Origin of Immigration Sub-Continent Births Females 15 to 49 Total Fertility Rate Stand. Error Sudan North Africa 5 2, Lebanon West-Central Asia 1,427 6, Iraq West-Central Asia 547 2, Syria West-Central Asia Algeria North Africa Somalia East Africa Congo Sth.-Central Africa Libya North Africa Mexico Central America 1,216 7, Bolivia South America Jordan West-Central Asia 151 1, Pakistan South Asia 1,892 12, 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 world 2 confirms this for the source countries listed in table 3, with the exception of perhaps Lebanon, where the TFR in 21 was only 1.9. Furthermore, as Figure 4 suggests, fertility converges to, and falls below, non-immigrant levels as immigrants integrate into Canadian society. 16 Immigrant Health in Alberta 211 Government of Alberta

19 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 babies 3. In addition, teen mothers are more likely to be subject to poor economic conditions 4. Figure 6: Teen Fertility: Years Since Immigration: 1995 to 26 4 Teen fertility rates decline over the first four years since immigration and then level off. Births per 1, Women aged 15 to Non-Immigrants Years Since Migrating Births per 1, Women aged 15 to 19 Figure 7: Teen Fertility: Years Since Immigration: 1995 to Non-Immigrants NOAFRI, WCASIA, and CTRAME All Other Subcontinents The sharp decline shortly after immigrating is most profound with immigrant women from West Central Asia, North Africa and Central America Years Since Migrating 17 Immigrant Health in Alberta 211 Government of Alberta

20 Figure 8: Teen Fertility: Origin of Immigration: 1995 to 26 Births per 1, Women aged 15 to Non Immigrants EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI AUSOCE EAASIA SEASIA Origin of Immigration SOASIA WCASIA CRBNBE CTRAME STHAME USANOR 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). 18 Immigrant Health in Alberta 211 Government of Alberta

21 Fertility: Women aged 4 to 44 years Fertility for women 4 to 44 years is derived by dividing live births born to women aged 4 to 44 years, by the number of women aged 4 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 4 years of age 5. Births per 1, Women aged 4 to 44 Figure 9: Fertility Aged 4 to 44 years: Years Since Immigration: 1995 to Non-Immigrants Immigrant women aged 4 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 4 to 44 years Years Since Migrating Figure 1: Fertility Aged 4 to 44 years: Origin of Immigration: 1995 to 26 Births per 1, Women aged 4 to EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI AUSOCE EAASIA SEASIA Origin of Immigration SOASIA WCASIA CRBNBE CTRAME STHAME USANOR Non Immigrants Immigrant women from most sub-continental regions show significantly higher fertility at ages 4 to 44 years than non-immigrants. Women from Europe had fertility rates for 4 to 44 year old women the closest to nonimmigrant women. Only South-Central Africa and Southern Europe have rates not significantly higher than for non-immigrants 19 Immigrant Health in Alberta 211 Government of Alberta

22 Chapter 4: Selected Determinants of Health Data for the years 27 and 28, 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 or 1 of the risk factors present (i.e. a lower ARFI). Table 4: Selected Indicators for Alberta, 27 to 28, Immigrants versus Non-Immigrants CCHS Measure Immigrants Non- Immigrants Significantly Different Body Mass Index = overweight or 43.5% 56.5% Yes obese (Ages 18+) Life Stress = a bit, not very, not at 23.8% 26.3% No all (Ages 15+) Fruit and Vegetable Consumption 57.3% 57.1% No = fewer than 5 servings daily (Ages 12+) Physical Activity = Inactive 53.% 43.8% Yes (Ages 12+) Smoking = daily or occasional 15.7% 23.3% Yes (Ages 12+) Binge Drinking = Having 5 or 4.5% 14.1% Yes more drinks, 2 or more times per month (Ages 12+) Seat Belt Use = always or mostly as 97.9% 97.5% No a driver or passenger (Ages 12+) Alberta Risk Factor Index = or 1 risk factor present (Ages 2 to 64) 36.% 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 1 years had significantly higher smoking rates than those in Canada fewer than 1 years. 2 Immigrant Health in Alberta 211 Government of Alberta

23 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 28, 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 28 (i.e. 372 of the total 2,733 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 2 to 28. All analysis was based on individuals 2 years of age and older, and for combined sexes. Figure 11: Mortality: Years Since Immigration: 2 to 28 Age-Standardized Mortality Rate (Per 1,) 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 Years Since Migrating Figure 12: Mortality: Age Effects: 2 to 28 Deaths per 1, population 16, 14, 12, 1, 8, 6, 4, 2, Immigrants Non Immigrants 2 to to 29 3 to to 39 4 to to 49 5 to to 59 Age 6 to to 69 7 to to 79 8 to Age-specific mortality rates of immigrants remain lower than the non-immigrants across all ages 21 Immigrant Health in Alberta 211 Government of Alberta

24 Figure 13: Mortality: Origin of Immigration: 2 to 28 Deaths per 1, population Non Immigrants EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI Origin of Immigration AUSOCE EAASIA SEASIA SOASIA WCASIA CRBNBE CTRAME STHAME USANOR 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. 22 Immigrant Health in Alberta 211 Government of Alberta

25 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, live births. Rates are combined for the years 2 to 26. Figure 14: Infant Mortality: Years Since Immigration: 2 to 26 Infant Mortality Rate (Per 1, Live Births) 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 Years Since Migrating Figure 15: Infant Mortality: Origin of Immigration: 2 to 26 Infant Mortality Rate (per 1, Live Births) EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI Origin of Immigration Non Immigrants AUSOCE EAASIA SEASIA SOASIA WCASIA CRBNBE CTRAME STHAME USANOR 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. 23 Immigrant Health in Alberta 211 Government of Alberta

26 Low Birth Weight Low birth weight is a measure of the proportion of live births that are below 2,5 grams. The proportions are combined for the years 1995 to 26. Figure 16: Low Birth Weight: Years Since Immigration: 1995 to 26 Low Birth Weight Percent (<2,5 grams) 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 nonimmigrants Years Since Migrating Figure 17: Low Birth Weight: Origin of Immigration Low BirthWeight Percent (< 25 grams) EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI Origin of Immigration AUSOCE EAASIA SEASIA SOASIA WCASIA CRBNBE CTRAME STHAME USANOR 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. 24 Immigrant Health in Alberta 211 Government of Alberta

27 Table 5: Low Birth Weight: Origin of Immigration Sub-Continent LBW Origin of Live Births Percent Std. Immigration Births Error France Western Europe Fiji Australia-Oceania Bangladesh South Asia Bosnia Southern Europe Kenya East Africa Tanzania East Africa Taiwan Southeast Asia India South Asia 462 4, Philippines Southeast Asia 36 3, Scotland Northern Europe S. Arabia West-Central Asia Pakistan West-Central Asia 169 1, 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, grams. The rates are combined for the years 1995 to 26. Figure 18: High Birth Weight: Years Since Immigration: 1995 to 26 High Birth Weight Percent (>4, grams) Non-Immigrants Rates of high birth weight are considerably lower among immigrants than non-immigrants regardless of the number of years since immigration Years Since Migrating 25 Immigrant Health in Alberta 211 Government of Alberta

28 Figure 19: High Birth Weight: Origin of Immigration: 1995 to 26 High Birth Weight Percent (> 4, grams) EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI Origin of Immigration Non Immigrants AUSOCE EAASIA SEASIA SOASIA WCASIA CRBNBE CTRAME STHAME USANOR Table 6: High Birth Weight: Origin of Immigration: 1995 to 26 Origin of Immigration Sub-Continent HBW Births Live Births Percent Std. Error Bolivia South America Netherlands Western Europe Croatia Sothern Europe Bosnia Sothern Europe Sweden Northern Europe Scotland Northern Europe Cuba Caribbean/Berm Yugoslavia Sothern Europe Germany Western Europe 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. The immigrants with highest rates for high birth weight are primarily from Europe. Countries with low live birth counts are not included in this list. Preterm Birth Preterm birth is a measure of the proportion of live births that are born prior to 37 weeks gestation 5. 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 Immigrant Health in Alberta 211 Government of Alberta

29 Figure 2: Preterm Births: Years Since Immigration: 1995 to 26 Preterm Birth Rate 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 preterm 5. For most years since immigrating the preterm birth rates for immigrants are somewhat or significantly higher than the rate for nonimmigrants Years Since Migrating Figure 21: Preterm Births: Origin of Immigration: 1995 to 26 Preterm Birth Rate 16 As is the case for low birth weights, preterm 14 birth rates are significantly higher in immigrants from Southeast and Southern Asia, as well as 12 West Africa EAEURO NOEURO SOEURO WEEURO EAAFRI NOAFRI SCAFRI WEAFRI Origin of Immigration AUSOCE EAASIA SEASIA SOASIA WCASIA CRBNBE CTRAME STHAME USANOR 27 Immigrant Health in Alberta 211 Government of Alberta

30 Table 7: Preterm Births: Origin of Immigration: 1995 to 26 Origin of Immigration Sub-Continent Preterm Births Live Births Percent Std. Error Thailand Southeast Asia Banglad. Southern Asia Argentina South America France Western Europe Kenya East Africa Fiji Australia-Oceania Nigeria West Africa Philippines Southeast Asia Bosnia Southern Europe Cambodia Southeast Asia Guyana South America Ireland Northern Europe Pakistan Southern Asia India Southern Asia 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. Countries with low live birth counts are not included in this list. 28 Immigrant Health in Alberta 211 Government of Alberta

31 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 Wellness 8. 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 28, based on individuals 2 years of age and older, and for combined sexes. Incidence of Ischemic Heart Disease Age-Standardized Rate (Per 1,) Figure 22: Incidence of Ischemic Heart Disease: Years Since Immigration, 1995 to 28 1, Years Since Migrating Non-Immigrants Figure 23: Incidence of Ischemic Heart Disease: Age Effects, 1995 to 28 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. Incidence Rate (Per 1, population) 4, 3, 2, 1, All Immigrants Immigrants (excl. within 1 yr.) Non Immigrants Age 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. 29 Immigrant Health in Alberta 211 Government of Alberta