Increased risk of heart disease and stroke among foreign-born females residing in the United States

International Migration and Cardiovascular Health: Unraveling the Disease Burden Among Migrants to North America and Europe

Europe and North America are the 2 largest recipients of international migrants from low-resource regions in the world. Here, large differences in cardiovascular disease (CVD) morbidity and death exist between migrants and the host populations. This review discusses the CVD burden and its most important contributors among the largest migrant groups in Europe and North America as well as the consequences of migration to high-income countries on CVD diagnosis and therapy. The available evidence indicates that migrants in Europe and North America generally have a higher CVD risk compared with the host populations. Cardiometabolic, behavioral, and psychosocial factors are important contributors to their increased CVD risk. However, despite these common denominators, there are important ethnic differences in the propensity to develop CVD that relate to pre- and postmigration factors, such as socioeconomic status, cultural factors, lifestyle, psychosocial stress, access to health care and health care usage. Some of these pre- and postmigration environmental factors may interact with genetic (epigenetics) and microbial factors, which further influence their CVD risk. The limited number of prospective cohorts and clinical trials in migrant populations remains an important culprit for better understanding pathophysiological mechanism driving health differences and for developing ethnic-specific CVD risk prediction and care. Only by improved understanding of the complex interaction among human biology, migration-related factors, and sociocultural determinants of health influencing CVD risk will we be able to mitigate these differences and truly make inclusive personalized treatment possible.

Predictive association between immigration status and chronic pain in the general population: results from the SwePain cohort

Background

Previous studies suggest that immigration may influence the experience of pain.

Objective

This population-based study examines whether immigration status is associated with chronic pain (CP), chronic widespread pain (CWSP), and severe CP at a two-year follow-up. We also tested mediation by mood status (i.e., anxiety and depression).

Methods

15, 563 participants from a representative stratified random sample of 34,000 individuals living in south-eastern Sweden completed a postal survey, during 2013–2015, that included the following data: immigration status; presence of CP (pain lasting at least 3 months) and CWSP (a modified classification of widespread pain for use in epidemiological studies); severity of CP based on a numeric rating scale; and depression, anxiety, economic situation, and sociodemographic information. We applied logistic regressions using the generalized estimating equations (GEE), with Swedish-born as the reference group and path analyses models.

Results

Compared to the Swedish-born participants (n = 14,093;90%), the immigrants (n = 1470;10%) had an elevated risk of all pain outcomes (CP: odds ratio [OR] = 1.18; 95% confidence interval [CI = 1.04–1.33, CWSP: OR = 1.39; 95% CI: 1.15–1.69 and severe CP: 1.51; 95% CI: 1.23–1.87) after adjustments. Path analyses showed that baseline age, immigrant status, and financial hardship had a significant influence on chronic pain outcomes at follow-up with baseline mood status as the mediator. Immigration status was also associated with age and financial hardship.

Conclusion

Immigrants may have increased risk of chronic pain, widespread pain, and severe pain and this risk is mediated by mood status. Targeted interventions better tailored to the socio-economic and psychological status of immigrants with chronic pain are warranted.

Internal migration and child health in Malawi

A strong and consistent association between migration and health has been found in many settings, but the overwhelming focus of this research has been on adults. In addition, identifying the effect of migration on health largely remains an unresolved challenge, due in part to the inability to distinguish between the effect of migration on health and the selection of children of differing health status into migration streams. In this research we examine the relationship between internal migration and child health in Malawi. We use longitudinal panel data with pre- and post-migration health measures for children and their mothers, which permits us to measure both migration health selection and the effect of migration on health. We also examine if child health changes over time in post-migration destinations. We do not find evidence of migration health selection: children who move have similar pre-migration health status to non-migrant children. We find that the impact of migration on child health is mediated by mothers' characteristics. Before controlling for mothers' health status, we find a strong negative impact of migration on health, particularly for children moving to rural areas or cities, and children moving due to changes in mothers' marital status. After controlling for mothers' health status, however, the negative impact of migration on child health disappears. We also find that child health is worse with longer durations spent in post-migration residence, compared to children who don't move.

Non-communicable diseases in migrants: an expert review

BACKGROUND

Non-communicable diseases (NCDs) remain a major challenge in the 21st century. High-income countries (HICs) populations are ethnically and culturally diverse due to international migration. Evidence suggests that NCDs rates differ between migrants and the host populations in HICs. This paper presents a review of NCDs burden among migrant groups in HICs in Europe, North America and Australia with a major focus on cardiovascular diseases (CVDs), cancer and diabetes.

METHODS

We performed a narrative review consisting of scholarly papers published between 1960 until 2018.

RESULTS

CVD risk differs by country of origin, country of destination and duration of residence. For example, stroke is more common in sub-Sahara African and South-Asian migrants, but lower in North African and Chinese migrants. Chinese migrants, however, have a higher risk of haemorrhagic stroke despite the lower rate of overall stroke. Coronary heart disease (CHD) is more common in South-Asian migrants, but less common in sub-Saharan and north African migrants although the lower risk of CHD in these population is waning. Diabetes risk is higher in all migrants and migrants seem to develop diabetes at an earlier age than the host populations. Migrants in general have lower rates of overall cancer morbidity and mortality than the host populations in Europe. However, migrants have a higher infectious disease-related cancers than the host populations in Europe. In North America, the picture is more complex. Data from cross-national comparisons indicate that migration-related lifestyle changes associated with the lifestyle of the host population in the country of settlement may influence NCDs risk among migrants in a very significant way.

CONCLUSION

With exception of diabetes, which is consistently higher in all migrant groups than in the host populations, the burden of NCDs among migrants seems to depend on the migrant group, country of settlement and NCD type. This suggests that more work is needed to disentangle the key migration-related lifestyle changes and contextual factors that may be driving the differential risk of NCDs among migrants in order to assist prevention and clinical management of NCDs in these populations.

Cohort profile: internal migration in sub-Saharan Africa-The Migration and Health in Malawi (MHM) study

PURPOSE

The Migration and Health in Malawi (MHM) study focuses on a key challenge in migration research: although it has long been established that migration and health are closely linked, identifying the effect of migration on various health outcomes is complicated by methodological challenges. The MHM study uses a longitudinal panel premigration and postmigration study design (with a non-migrant comparison group) to measure and/or control for important characteristics that affect both migration and health outcomes.

PARTICIPANTS

Data are available for two waves. The MHM interviewed 398 of 715 migrants in 2007 (55.7%) and 722 of 1013 in 2013 (71.3%); as well as 604 of 751 (80.4%) for a non-migrant reference group in 2013. The total interviewed sample size for the MHM in both waves is 1809. These data include extensive information on lifetime migration, socioeconomic and demographic characteristics, sexual behaviours, marriage, household/family structure, social networks and social capital, HIV/AIDS biomarkers and other dimensions of health.

FINDINGS TO DATE

Our result for the relationship between migration and health differs by health measure and analytic approach. Migrants in Malawi have a significantly higher HIV prevalence than non-migrants, which is primarily due to the selection of HIV-positive individuals into migration. We find evidence for health selection; physically healthier men and women are more likely to move, partly because migration selects younger individuals. However, we do not find differences in physical or mental health between migrants and non-migrants after moving.

FUTURE PLANS

We are preparing a third round of data collection for these (and any new) migrants, which will take place in 2018. This cohort will be used to examine the effect of migration on various health measures and behaviours, including general mental and physical health, smoking and alcohol use, access to and use of health services and use of antiretroviral therapy.

Nativity and Health Disparities: Predictors of Immigrant Health

This study examines the differences in the social determinants of health and chronic health conditions of immigrants and nonimmigrants. The logistic regression results indicate that employment, education, poverty, residential status, and neighborhood safety have strong influence on the health of immigrants and native-born Americans; however, gender and place of residence are significant to only nonimmigrant health. For chronic health conditions, age and employment status are significant predictors for immigrants whereas race/ethnicity, age, gender, insurance coverage, and education are important predictors of chronic health conditions among nonimmigrants. Neighborhood safety, English proficiency, and marital status were not significant determinants of the health conditions of both subgroups. The study points to the importance of education, poverty/income, and neighborhood safety as essential determinants of immigrant and nonimmigrant health. However, there are variations in the health predictors for each group.

Adverse Trends in Ischemic Heart Disease Mortality among Young New Yorkers, Particularly Young Black Women

BACKGROUND

Ischemic heart disease (IHD) mortality has been on the decline in the United States for decades. However, declines in IHD mortality have been slower in certain groups, including young women and black individuals.

HYPOTHESIS

Trends in IHD vary by age, sex, and race in New York City (NYC). Young female minorities are a vulnerable group that may warrant renewed efforts to reduce IHD.

METHODS

IHD mortality trends were assessed in NYC 1980-2008. NYC Vital Statistics data were obtained for analysis. Age-specific IHD mortality rates and confidence bounds were estimated. Trends in IHD mortality were compared by age and race/ethnicity using linear regression of log-transformed mortality rates. Rates and trends in IHD mortality rates were compared between subgroups defined by age, sex and race/ethnicity.

RESULTS

The decline in IHD mortality rates slowed in 1999 among individuals aged 35-54 years but not ≥55. IHD mortality rates were higher among young men than women age 35-54, but annual declines in IHD mortality were slower for women. Black women age 35-54 had higher IHD mortality rates and slower declines in IHD mortality than women of other race/ethnicity groups. IHD mortality trends were similar in black and white men age 35-54.

CONCLUSIONS

The decline in IHD mortality rates has slowed in recent years among younger, but not older, individuals in NYC. There was an association between sex and race/ethnicity on IHD mortality rates and trends. Young black women may benefit from targeted medical and public health interventions to reduce IHD mortality.

Perceived discrimination and chronic health in adults from nine ethnic subgroups in the USA

OBJECTIVE

This comparative analysis examines the association between chronic cardiovascular, respiratory and pain conditions, race, ethnicity, nativity, length of residency, and perceived discrimination among three racial and nine ethnic subgroups of Asian Americans (Vietnamese, Filipino, and Chinese), Latino-American (Cuban, Portuguese, and Mexican), and Afro-Caribbean American (Haitian, Jamaican, and Trinidadian/Tobagonian) respondents.

DESIGN

Analysis used weighted Collaborative Psychiatric Epidemiology Surveys-merged data from the National Latino and Asian American Study and the National Survey of American Life. Logistic regression analysis was conducted to determine which groups within the model were more likely to report perceived discrimination effects.

RESULTS

Afro-Caribbean subgroups were more likely to report perceived discrimination than Asian American and Latino-American subgroups were. Logistic regression revealed a significant positive association with perceived discrimination and chronic pain only for Latino-American respondents.

CONCLUSION

Significant differences in reports of perceived discrimination emerged by race and ethnicity. Caribbean respondents were more likely to report high levels of perceived discrimination; however, they showed fewer significant associations related to chronic health conditions compared to Asian Americans and Latino-Americans. Examination of perceived discrimination across ethnic subgroups reveals large variations in the relationship between chronic health and discrimination by race and ethnicity. Examining perceived discrimination by ethnicity may reveal more complex chronic health patterns masked by broader racial groupings.

Stroke knowledge among diabetics: a cross-sectional study on the influence of age, gender, education, and migration status

Background

Stroke campaigns are educating about the need to immediately contact the emergency medical system if symptoms occur. Despite higher stroke rates among patients with diabetics and some migrant populations, there are few data about stroke knowledge in these groups.

Methods

We performed a cross-sectional questionnaire survey among 250 diabetes patients from Germany and Turkey in a primary care and diabetes practice center. The two-page questionnaire asked for stroke knowledge and socio-demographic data. Also, medical and communication data were obtained. Stroke knowledge was defined as good if a participant knew (1) at least two stroke symptoms (good symptom knowledge) and (2) that immediate hospital admission or an emergency call is necessary in case of stroke symptoms (good action knowledge).

Results

A total of 231 of 250 patients took part in the survey (participation rate 92.4%) with 134 natives (53.6%), 84 migrants from Turkey (33.6%) and 13 migrants (5.2%) from other countries. Comparing natives and migrants from Turkey good symptom knowledge was documented in 52.8% of the participants, good action knowledge in 67.9%, and good stroke knowledge in nearly forty percent (39.4%) of patients (n = 218). A logistic regression analysis showed better stroke knowledge if patients were younger than 61 years, had good language abilities and were living in an one-generation household (p < 0.05), while gender, years since migration and diabetes control did not play a role.

Conclusions

We documented stroke knowledge deficits among patients with diabetes, both natives and migrants. Additional information strategies for these high risk populations are needed.

Dyspnea coping strategies in Korean immigrants with asthma or chronic obstructive pulmonary disease

PURPOSE

Patients with lung disease develop coping strategies to relieve dyspnea. The coping strategies of Korean immigrants, however, are poorly understood. The purpose of this study was to describe the strategies that Korean immigrants with asthma or chronic obstructive pulmonary disease (COPD) use to cope with dyspnea and to compare similarities and differences in coping strategies between the two conditions.

DESIGN

Outpatients with asthma (n = 25) or COPD (n = 48) participated in a cross-sectional descriptive study.

METHOD

Open-ended questions and a structured instrument were used to describe coping strategies for dyspnea. Descriptive and inferential statistics were used to analyze the data.

RESULTS

The most prevalent strategy was "I keep still or rest." Korean immigrants also used traditional therapies to manage dyspnea.

CONCLUSIONS

Although the coping strategies of Korean immigrants were similar to those of other ethnic groups, they incorporated elements of Asian medical practice and herbs. This finding enables health care providers to better understand Korean immigrants' efforts to overcome dyspnea and to guide their patients' approach to coping.

Comparison of stroke mortality in Finnish-born migrants living in Sweden 1970-1999 and in Swedish-born individuals

A limited number of studies have been found on stroke mortality in migrants showing higher mortality for some groups. Influence of time of residence has been studied by one research group. An earlier study showed a significantly higher number of deaths in Diseases of the circulatory system in Finnish migrants compared with native Swedes. To test the hypothesis of a higher mortality in and a decrease in mortality over time in stroke among Finnish migrants in Sweden. The study was based on National Population data, the study population included 321,407 Swedish and 307,174 foreign born persons living in Sweden 1987-1999. Mean age was lower at time for death for Finnish migrants than native Swedes, men 5.1 years difference and women 2.3 years. The difference decreased over time. The risk of death by stroke was higher for migrants with short time of residence than with long time (≤10 years, OR 1.61-1.36 vs ≥11 year, OR 1.18). Migrants with short time of residence died 9.8-5.3 years earlier than native Swedes. The hypothesis was confirmed and an indication of adjustment to life in the new country was found. International studies show similar results for other migrant groups but further studies are needed to verify if the same pattern can be found in other migrants groups in Sweden and to generalise the findings.

Epidemiology of chronic obstructive pulmonary disease: a literature review

The aim of this study is to quantify the burden of chronic obstructive pulmonary disease (COPD) – incidence, prevalence, and mortality – and identify trends in Australia, Canada, France, Germany, Italy, Japan, The Netherlands, Spain, Sweden, the United Kingdom, and the United States of America. A structured literature search was performed (January 2000 to September 2010) of PubMed and EMBASE, identifying English-language articles reporting COPD prevalence, incidence, or mortality. Of 2838 articles identified, 299 full-text articles were reviewed, and data were extracted from 133 publications. Prevalence data were extracted from 80 articles, incidence data from 15 articles, and mortality data from 58 articles. Prevalence ranged from 0.2%–37%, but varied widely across countries and populations, and by COPD diagnosis and classification methods. Prevalence and incidence were greatest in men and those aged 75 years and older. Mortality ranged from 3–111 deaths per 100,000 population. Mortality increased in the last 30–40 years; more recently, mortality decreased in men in several countries, while increasing or stabilizing in women. Although COPD mortality increased over time, rates declined more recently, likely indicating improvements in COPD management. In many countries, COPD mortality has increased in women but decreased in men. This may be explained by differences in smoking patterns and a greater vulnerability in women to the adverse effects of smoking.

Avenues and barriers to access of services for immigrant elders: state and local policies for OAA units on aging

The diversification and aging of the US population has been at the root of many political and policy debates in recent years. Of particular interest has been the place of immigrants in an aging society, and what rights these immigrants are entitled to. The objective of this article is to describe the current avenues and barriers to access of services for immigrant elders and examine potential solutions for reform. The article begins with a historical overview of the policy issue, followed by the current status of the issue in the United States and suggestions for reform.

The impact of migration on the health of voluntary migrants in western societies

The authors reviewed literature on the health of voluntary migrants to Western societies and factors affecting their health. Health indicators include mortality rates and life expectancy, birth outcomes, risk of illness, patterns of deteriorating health, cardiovascular disease, body mass index, hypertension, and depression. Multiple factors explain variability, including length of residence and acculturation, disease exposure, life style and living conditions, risky behaviors, healthy habits, social support networks, cultural and linguistic barriers, experiences with racism, and levels of awareness of cultural health practices among health care providers. Evidence exists for superior health among many migrants to Western countries relative to native-born persons, but the differential disappears over time. Migration is a dynamic, extended process with effects occurring years after physical relocation. Systemic change is required, including health policies that ensure equity for migrants, culturally appropriate health promotion, and routine assessment of migration history, cultural health practices, and disease exposure.

Immigration presents a potential increased risk for atherosclerosis

OBJECTIVE

Immigrants in Western countries tend to have a greater risk for cardiovascular disease (CVD) than those in their home country, but it is unclear if immigrants are at increased risk for CVD compared to non-immigrants in their new country. The purpose of this study was to determine the independent association of time since immigration with sub-clinical atherosclerosis in immigrants of Chinese, European and South Asian origin.

METHODS

A total of 460 immigrants and 158 non-immigrants of Chinese, European and South Asian origin without pre-diagnosed CVD were assessed for sub-clinical atherosclerosis by carotid artery ultrasound scan, socio-demographics, CVD risk factors and lifestyle factors. Time since immigration in years was used as a measure of exposure.

RESULTS

Participants who immigrated > or =30 years ago had a greater intima-media thickness (IMT) of the carotid artery compared to non-immigrants, and immigrants of < or =20 years. Time since immigration was associated with IMT, plaque area and IMT+plaque area. After adjustment for age, sex, ethnicity, income, education, family history of CVD and diabetes, smoking, physical activity, body mass index, visceral adipose tissue, lipids, insulin, glucose and blood pressure, time since immigration was significantly associated with IMT. For every ten years since immigration there was a 2% increase in IMT in addition to the 7% increase for every 10 years of age.

CONCLUSIONS

Immigration was associated with an increased burden of sub-clinical atherosclerosis that surpassed that of non-immigrants. This burden increased over time independent of other risk factors. Immigrants represent a high-risk group for which targeted interventions are needed.

The contribution of a gender perspective to the understanding of migrants' health

In 2005 women represented approximately half of all 190 million international migrants worldwide. This paper addresses the need to integrate a gender perspective into epidemiological studies on migration and health, outlines conceptual gaps and discusses some methodological problems. We mainly consider the international voluntary migrant. Women may emigrate as wives or as workers in a labour market in which they face double segregation, both as migrants and as women. We highlight migrant women's heightened vulnerability to situations of violence, as well as important gaps in our knowledge of the possible differential health effects of factors such as poverty, unemployment, social networks and support, discrimination, health behaviours and use of services. We provide an overview of the problems of characterising migrant populations in the health information systems, and of possible biases in the health effects caused by failure to take the triple dimension of gender, social class and ethnicity into account.

Health of foreign-born people in the United States: a review

This paper identifies the overarching patterns of immigrant health in the US. Most studies indicate that foreign-born individuals are in better health than native-born Americans, including individuals of the same race/ethnicity. They tend to have lower mortality rates and are less likely to suffer from circulatory diseases, overweight/obesity, and some cancers. However, many foreign-born groups have higher rates of diabetes, some infections, and occupational injuries. There is heterogeneity in health among immigrants, whose health increasingly resembles that of natives with duration of US residence. Prospective studies are needed to better understand migrant health and inform interventions for migrant health maintenance.

Migration and its impact on adiposity and type 2 diabetes

In this review, we discuss the impact of migration on the incidence and prevalence of obesity and type 2 diabetes mellitus (T2DM) in different ethnic groups and populations. We also analyze the determinants of such phenomena in view of the global increase in the migration and escalating prevalence of obesity and T2DM. The risk escalation of the obesity and T2DM followed a gradient, as migrants (Blacks, Hispanics, Chinese, South Asians, etc.) became more affluent and urbanized, indicating an important role of environmental factors. A stepwise increase in the prevalence of obesity in Blacks along the path of migration (5% in Nigeria, 23% in Jamaica, and 39% in the United States) is a classic example. Furthermore, South Asian migrants, who are particularly predisposed to develop insulin resistance and T2DM, showed nearly four times prevalence rates of T2DM than rural sedentee populations. Similar observations were also reported in intracountry migrants and resettled indigenous populations. The determinants were found to include nutrition transition, physical inactivity, gene-environment interaction, stress, and other factors such as ethnic susceptibility. However, certain contradictory trends were also seen in some migrant communities and have been explained by various phenomena such as healthy migrant effect, "salmon bias", and adherence to traditional diets. A review of the evidence suggests a critical role of environmental factors in conferring an increased risk of obesity and T2DM. The important contributory factors to this phenomenon were urbanization, mechanization, and changes in nutrition and lifestyle behaviors, but the role of stress and as yet unknown factors remain to be determined.

The Effects of Years Lived in the United States on the General Health Status of California’s Foreign-Born Populations

The purpose of this study was to examine the effect of immigrant status and years lived in the United States on the general health status of California's foreign-born populations. Two models were constructed using California's aggregate adult population and the adult foreign-born population. A binary logistic regression was conducted using data from the 2003 California Health Interview Survey. California's immigrant populations were found to enjoy a self-assessed health advantage compared to California's US-born population. The results present evidence of a downward trend in self-assessed health amongst California's foreign-born population associated with increased years lived in country. The initial health advantage found among California's foreign-born appears to function mainly through socio-economic factors. These results suggest that the deterioration in health associated with increased years lived in the US may be an effect of immigrants' exposure to California's environmental determinants of human health rather that the loss of culture-specific protective factors.

Out of the mainstream: low-income, lone mothers' life experiences and perspectives on heart health

Cardiovascular disease remains a health issue in North America, particularly for marginalized citizens. Although lifestyle issues and behavioral risk reduction continue to dominate prevention initiatives, an emerging literature suggests that contextual factors such as poverty and social exclusion also influence health. Using group and personal interviews (N = 38), this research explored the social and economic contexts shaping heart health-related experiences from the perspectives of low-income, lone mothers. The transcripts were analyzed using McKinlay and Marceau's upstream-midstream-downstream framework. The overriding pattern characterizing lone mothers' discussions was that the women felt out of the mainstream of everyday life. They lacked the resources and power to effect change, particularly regarding heart health behaviors that were not perceived to be a priority compared to more pressing survival issues. Results are discussed in terms of concepts from the population health and social determinants literature, concluding with policy implications for enhancing health while living in poverty.

Hospitalization for heart disease, stroke, and diabetes mellitus among Indian-born persons: a small area analysis

BACKGROUND

We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City.

METHODS

We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin.

RESULTS

After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons.

CONCLUSIONS

South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.

Incidence of Stroke and Stroke Subtypes in Malmö, Sweden, 1990–2000

BACKGROUND AND PURPOSE

The proportion of immigrants has increased in Sweden markedly during the last decades, as in many other Western countries. Incidence of stroke has increased during this period. However, it is primarily unknown whether incidence of stroke and stroke subtypes in Sweden is related to country of birth.

METHODS

Incidence of first-ever stroke was followed during 10 years in a cohort consisting of all 40- to 89-year-old inhabitants in the city of Malmö, Sweden (n=118,134). Immigrants from 12 different countries were compared with native-born Swedes.

RESULTS

Adjusted for age, sex, marital status, and socioeconomic indicators, the incidence of stroke (all subtypes) was significantly higher among immigrants from former Yugoslavia (relative risk [RR], 1.31; 95% CI, 1.1 to 1.6) and Hungary (RR, 1.33; CI, 1.02 to 1.7). A significantly increased incidence of intracerebral hemorrhage was observed in immigrants from Peoples Republic of China or Vietnam (RR, 4.2; CI, 1.7 to 10.4) and the former Soviet Union (RR, 2.7; CI, 1.01 to 7.3). Immigrants from Finland had a significantly higher incidence of subarachnoid hemorrhage (RR, 2.8; CI, 1.1 to 6.8). A significantly lower incidence of stroke was observed in the group from Romania (RR, 0.14; CI, 0.04 to 0.6). Immigrants from Denmark, Norway, Germany, Chile, Czechoslovakia, and Poland had approximately the same risk as citizens born in Sweden.

CONCLUSIONS

In this urban population from Sweden, there are substantial differences in stroke incidence and stroke subtypes between immigrants from different countries. To what extent this could be accounted for by exposure to biological risk factors remains to be explored.

Cardiovascular Disease

Health Issue

Cardiovascular disease (CVD) is the leading cause of death in Canadian women and men. In general, women present with a wider range of symptoms, are more likely to delay seeking medial care and are less likely to be investigated and treated with evidence-based medications, angioplasty or coronary artery bypass graft than men.

Key Findings

In 1998, 78,964 Canadians died from CVD, almost half (39,197) were women. Acute myocardial infarction, which increases significantly after menopause, was the leading cause of death among women.

Cardiovascular disease accounted for 21% of all hospital admissions for Canadian women over age 50 in 1999. Admissions to hospital for ischemic heart disease were more frequent for men, but the mean length of hospital stay was longer for women.

Mean blood pressure increases with age in both men and women. After age 65, however, high blood pressure is more common among Canadian women. More than one-third of postmenopausal Canadian women have hypertension.

Diabetes increases the mortality and morbidity associated with CVD in women more than it does in men. Depression also contributes to the incidence and recovery from CVD, particularly for women who experience twice the rate of depression as men.

Data Gaps and Recommendations

CVD needs to be recognized as a woman's health issue given Canadian mortality projections (particularly heart failure). Health professionals should be trained to screen, track, and address CVD risk factors among women, including hypertension, elevated lipid levels, smoking, physical inactivity, depression, diabetes and low socio-economic status.

Assuring the health of immigrants: what the leading health indicators tell us

Over the past 20 years, the United States has experienced one of the largest waves of immigration in its history. Understanding the health status and needs of immigrants is important because of their growing numbers and their contribution to the health of the nation, but it is challenging because of gaps in national databases, the heterogeneity of immigrant populations, and uncertainty about how migration affects health. Healthy People 2010 outlines the nation's public health objectives for the current decade. It includes ten leading health indicators (LHIs) chosen because of their importance as public health issues, their ability to motivate action, and the availability of data to measure their progress. In this paper, we discuss the health of immigrants from the perspective of these LHIs, as they provide a framework for anticipating some of the future health needs of immigrants and help define priority areas for research and action.

Cervical cancer mortality among foreign-born women living in the United States, 1985 to 1996

PURPOSE OF STUDY

This study explored the potential influence of increasing immigration to the United States (US) on US cervical cancer mortality trends.

BASIC PROCEDURES

Mortality data were derived from the National Center for Health Statistics' Detailed Mortality File. Population estimates were obtained from the US Bureau of the Census. Age-adjusted cervical cancer mortality rates were calculated for women living in the US according to place of birth.

MAIN FINDINGS

From 1985 to 1996, deaths and death rates from cervical cancer increased for foreign-born women and decreased for US-born women. Increases in death rates among foreign-born women were highest in the South. Cervical cancer deaths and death rates for US-born women decreased uniformly in all regions.

PRINCIPLE CONCLUSIONS

Cervical cancer mortality rates have increased among foreign-born women in the United States, and have influenced overall US cervical cancer mortality trends. Cervical cancer control efforts should be intensified in areas of the United States with large foreign-born communities.