Myocardial infarction associated with recency of immigration to Ontario

Determinants, Prevention, and Incidence of Cardiovascular Disease Among Immigrant and Refugee Populations

Immigration policies shape the composition, socioeconomic characteristics, and health of migrant populations. The health of migrants is also influenced by a confluence of social, economic, environmental, and political factors. Immigrants and refugees often face various barriers to accessing health care because of factors such as lack of familiarity with navigating the health care system, language barriers, systemic racism, and gaps in health insurance. Social determinants of health and access to primary care health services likely influence the burden of cardiovascular risk factors among immigrants. The relatively low burden of many cardiovascular risk factors in many immigrant populations likely contributes to the generally lower incidence rates of acute myocardial infarction, heart failure, and stroke in immigrants compared with nonimmigrants, although cardiovascular disease incidence rates vary substantially by country of origin. The "healthy immigrant effect" is the hypothesis that immigrants to high-income countries, such as Canada, are healthier than nonimmigrants in the host population. However, this effect may not apply universally across all immigrants, including recent refugees, immigrants without formal education, and unmarried immigrants. As unfolding sociopolitical events generate new waves of global migration, policymakers and health care providers need to focus on addressing social and structural determinants of health to better manage cardiovascular risk factors and prevent cardiovascular disease, especially among the most marginalized immigrants and refugees.

Chronic disease and malnutrition biomarkers among unemployed immigrants and Canadian born adults

Background

Immigration status and unemployment may intersect on the health outcomes of men and women. This study aimed to identify intersections between unemployment and immigration in inflammatory, metabolic and nutritional blood markers and assess gender differences.

Methods

We used Canadian Health Measures Survey data on 2493 participants aged 18 to 65. Outcomes were chronic inflammation (high-sensitivity C-reactive protein (hsCRP) and fibrinogen), nutritional (albumin and hemoglobin), and metabolic blood markers (glycosylated hemoglobin, blood glucose, total and high density lipoprotein (HDL) cholesterol). Multivariate linear regressions were used to assess the associations between each biomarker, unemployment and immigrant status, controlling for age, education, province, smoking, physical inactivity and body mass index and testing for multiplicative interactions between unemployment, immigrant status and gender.

Results

Unemployment was associated with higher inflammation (hsCRP and fibrinogen) in Canadian born men; Canadian born employed women showed higher hsCRP values compared with corresponding employed men. Unemployed immigrant women presented the highest values of hsCRP while employed immigrant women had the lowest hsCRP. Unemployment was associated with higher glucose; immigrant status was associated with higher glucose and glycosylated hemoglobin. Unemployed immigrants had significantly lower levels of hemoglobin and albumin than employed immigrants, and Canadian-born citizens regardless of their employment status. Some of these associations were attenuated after adjustment by body mass index, physical inactivity and smoking.

Conclusion

Blood biomarkers unveil intersections among unemployment, immigration and gender. This study provides evidence on biological pathways of unemployment on the likelihood of common chronic diseases, inflammation and potential malnutrition with some increased vulnerabilities in unemployed immigrants, and particularly in unemployed immigrant women.

Double Burden of Rural Migration in Canada? Considering the Social Determinants of Health Related to Immigrant Settlement Outside the Cosmopolis

There is a large and growing body of research acknowledging the existence of health disparities between foreign-born and native-born populations in many high immigrant-receiving countries. Significant attention has been paid to the role of physical and social environments in the changing health status of immigrants over time. However, very limited attention has been given to these issues within the context of rural geographies, despite global evidence that immigrants are increasingly settling outside of traditional gateway cities and into rural communities. This paper presents the results of a scoping review aimed at assessing the state of knowledge on the health impacts of immigrant migration into rural communities in Canada. Guided by Arksey and O’Malley’s scoping protocol, we conduct a review of academic literature in Canada related to rural migration. A total of 25 articles met inclusion criteria which included access to the social determinants of health. Findings identified a paucity of research directly connecting rural settlement to health but the literature did emphasize five distinct social determinants of health for rural residing immigrants: social inclusion, culturally-appropriate services, gender, employment, and housing. This paper concludes with an identification of research gaps and opportunities for future research into whether rural-residing immigrants face a double burden with respect to health inequity.

Immigration, region of origin, and the epidemiology of venous thromboembolism: A population-based study

BACKGROUND

Venous thromboembolism (VTE) epidemiology has been mainly studied in populations largely of European ancestry.

OBJECTIVES

To assess the epidemiology of VTE in immigrants to Ontario, Canada.

PATIENTS/METHODS

We conducted a population-based retrospective cohort study using linked health-care and administrative databases. We included 1 195 791 immigrants to Ontario and 1 195 791 nonimmigrants, matched on age, sex, and place of residence. The main exposure was ethnicity according to world region of origin, using a previously validated algorithm. The main outcome was incident onset of VTE during the period of observation. Risk ratios (RR) were calculated using Poisson regression models.

RESULTS

The incidence rate (IR) of VTE was lower among immigrants (0.87 per 1000 PY; 95% confidence interval [CI] 0.85-0.89) than nonimmigrants (1.59 per 1000 PY; 95% CI 1.56-1.61). Age- and sex-standardized IR were lower among East and South Asian immigrants. Compared to immigrants for predominantly White regions, age- and sex-specific RRs were consistently lower for East Asian (0.18-0.30) and South Asian (0.29-0.75) immigrants. In contrast, the RRs of VTE among Black (0.38-1.50), Latin American (0.29-1.25), Arab/Middle Eastern (0.44-1.08) and West Asian (0.31-1.16) immigrants were not significantly different from White immigrants.

CONCLUSIONS

In Ontario, the incidence of VTE is lower among immigrants compared to nonimmigrants. East and South Asian immigrants have a lower risk of VTE compared to White immigrants.

Mortality outcomes for Chinese and Japanese immigrants in the USA and countries of origin (Hong Kong, Japan): a comparative analysis using national mortality records from 2003 to 2011

BACKGROUND

With immigration and minority populations rapidly growing in the USA, it is critical to assess how these populations fare after immigration, and in subsequent generations. Our aim is to compare death rates and cause of death across foreign-born, US-born and country of origin Chinese and Japanese populations.

METHODS

We analysed all-cause and cause-specific age-standardised mortality rates and trends using 2003-2011 US death record data for Chinese and Japanese decedents aged 25 or older by nativity status and sex, and used the WHO Mortality Database for Hong Kong and Japan decedents in the same years. Characteristics such as age at death, absolute number of deaths by cause and educational attainment were also reported.

RESULTS

We examined a total of 10 458 849 deaths. All-cause mortality was highest in Hong Kong and Japan, intermediate for foreign-born, and lowest for US-born decedents. Improved mortality outcomes and higher educational attainment among foreign-born were observed compared with developed Asia counterparts. Lower rates in US-born decedents were due to decreased cancer and communicable disease mortality rates in the US heart disease mortality was either similar or slightly higher among Chinese-Americans and Japanese-Americans compared with those in developed Asia counterparts.

CONCLUSIONS

Mortality advantages in the USA were largely due to improvements in cancer and communicable disease mortality outcomes. Mortality advantages and higher educational attainments for foreign-born populations compared with developed Asia counterparts may suggest selective migration. Findings add to our limited understanding of the racial and environmental contributions to immigrant health disparities.

Immigrant status and cardiovascular risk over time: results from the Multi-Ethnic Study of Atherosclerosis

PURPOSE

Despite cross-sectional evidence that foreign-born United States (US) residents often have better health than US-born residents of similar race and/or ethnicity, we know little about overall cardiovascular risk progression over time among immigrants as they age in the US.

METHODS

Using longitudinal data from the Multiethnic Study of Atherosclerosis on 6446 adults aged 45-84 years at baseline, we examined how nativity and length of US residence related to change in cardiovascular health (CVH) and cardiovascular event incidence over 11-year follow-up. CVH was measured using the American Heart Association's CVH measure (range, 0-14; higher is better).

RESULTS

Immigrants, particularly those with shorter US residence, had better baseline CVH and lower cardiovascular event incidence than the US born. Baseline CVH scores ranged from 8.67 (8.42-8.92) among immigrants living in the US less than 10 years to 7.86 (7.76-7.97) among the US born. However, recent immigrants experienced the largest CVH declines over time: 10-year declines ranged from -1.04 (-1.27 to -0.80) among immigrants living in the US less than 10 years at baseline to -0.47 (-0.52 to -0.42) among the US born.

CONCLUSIONS

Public health prevention efforts targeting new immigrants may help slow the deterioration of CVH and reduce future cardiovascular risk.

Disparities in lifestyle habits and health related factors of Montreal immigrants: is immigration an important exposure variable in public health?

Study disparities in lifestyle habits and health characteristics of Canadian born population and immigrants with different duration of residence. Data are extracted from 2009 to 2010 public use micro-data files of Canadian Community Health Survey representing about 1.5 million people. Sixty-one percent of the study sample was born in Canada; 49 % males and 59 % below age 50. Amongst lifestyle habits, recent immigrants were less likely to be regular smokers, RR (95 % CI) 0.56 (0.36-0.88) and frequent consumers of alcohol 0.49 (0.27-0.89), but more likely to consume less fruits and vegetables 1.26 (1.04-1.53) than those born in Canada. Amongst health related factors, recent immigrants were less likely to be overweight 0.79 (0.62-0.99) and suffer from chronic diseases 0.59 (0.44-0.80), but more likely to have limited access to family medicine 1.24 (1.04-1.47) than Canada-born population. Immigration status is an important population characteristic which influenced distribution of health indicators. Prevention and promotion strategies should consider immigration status as an exposure variable in the development and implementation of public health programs.

Risk of cardiovascular events and mortality among a population-based cohort of immigrants and long-term residents with diabetes: Are all immigrants healthier and if so, for how long?

BACKGROUND

Cardiovascular events are responsible for half of all deaths among individuals with diabetes. Immigrants to Western countries may experience an acceleration of cardiovascular risk in the first 10 years of arrival because of a sedentary lifestyle, poor diet, or barriers to accessing care, leading to higher levels of obesity and diabetes.

OBJECTIVES

To compare the risk of cardiovascular events and mortality between immigrants to Canada and long-term residents with diabetes and to assess whether immigrants experience acceleration in risk after arrival.

METHODS

We conducted a population-based retrospective cohort study using linked health and immigration data from Ontario, Canada, of 87,707 immigrants who immigrated to Canada between 1985 and 2005 matched to 87,707 long-term residents with diabetes (age ≥20 years). Individuals were followed up from April 1, 2005, until February 29, 2012, for the primary composite outcome of a cardiovascular event (acute myocardial infarction, unstable angina, congestive heart failure, transient ischemic attack, stroke) or all-cause mortality.

RESULTS

There was a lower adjusted risk of cardiovascular events or mortality among immigrants (adjusted hazard ratio [HR] 0.76, 95% CI 0.74-0.78) after accounting for differences in baseline age, gender, socioeconomic status, neighborhood, and health care utilization-which persisted beyond 10 years from immigration. However, this healthy immigrant advantage was not found among more recent refugees (HR 0.93, 95% CI 0.81-1.08), immigrants with no previous education (HR 1.08, 95% CI 0.84-1.40), and those who were unmarried (HR 0.80, 95% CI 0.62-1.03).

CONCLUSION

Immigrants with diabetes are at lower risk for cardiovascular events and mortality compared with long-term residents, an effect that persists more than 10 years after arrival. Not all immigrants demonstrate this health advantage.

Roadway crash risks in recent immigrants

Adult immigrants are sometimes characterized as unsafe drivers and responsible for excess road crashes. We analyzed Canada's largest and most ethnically diverse province to assess whether recent immigrants had an increased risk of involvement as drivers in serious motor vehicle crashes. Overall, the study included 4,238,222 individuals followed for a median duration of 8.0 years. In total, 10,975 individuals were subsequently admitted to hospital as drivers involved in a crash, with a rate per 100,000 significantly lower among recent immigrants compared to long-term residents (158 vs 289, p<0.001). This difference was equal to a 45% relative reduction in the incidence of a crash (odds ratio=0.55, 95% confidence interval 0.52-0.58), persisted after adjustment for baseline characteristics (hazard ratio=0.61, 95% confidence interval 0.58-0.65), extended to extremes of crash severity, and was accentuated during initial years following immigration. These findings suggest that, contrary to popular opinion, recent immigrants are less prone to be drivers in serious motor vehicle crashes.

Recruitment of immigrant and ethnic minorities in primary prevention trials of cardiovascular disease

BACKGROUND

The risk of cardiovascular disease (CVD) may differ across ethnic groups, including those who immigrate to Canada, USA and the UK. Accordingly, the absolute and relative benefits of CVD prevention strategies evaluated in randomized clinical trials (RCTs) may differ by the ethnic and immigrant composition of study participants.

METHODS

We searched MEDLINE, EMBASE and Cochrane databases for RCTs of primary prevention strategies for CVD, published between 1980 and December 2009. We only included RCTs of a CVD primary prevention strategy comprising at least 100 participants aged >19 years, and those published in English. We abstracted data on study and participant characteristics, interventions and outcomes, as well as a description of the immigrants and ethnic composition of the participants. We also recorded whether a study was stratified by immigrant and/or ethnic subgroups in evaluating the efficacy of the study intervention.

RESULTS

Out of 45 RCTs that met the selection criteria, 11 (24.4%, 95% CI: 14.3-38.8) included and/or reported on the ethnic status of the participants. There were 140,764 persons enrolled in these 11 RCTs, with CVD and/or CVD-related death as the primary outcome, evaluated over a median duration of 5 years. In all 11 trials, the weighted proportion of participants of non-White ethnicity was 10.3% (95% CI: 6.8-15.4). Asian or Asian Pacific ancestry comprised 2.0% (95% CI: 1.1-3.9) of all participants in the five trials that reported details about this group. In no study was the therapeutic efficacy of the intervention was stratified by ethnicity, and none reported on the number of participants who were immigrants.

CONCLUSION

RCTs of CVD prevention strategies either rarely recruit or rarely report on the ethnic and immigrant status of their participants. Evaluation of the relative efficacy of CVD prevention strategies should also consider these criteria.

Immigration as pathogenic: a systematic review of the health of immigrants to Canada

This review investigates the health of immigrants to Canada by critically examining differences in health status between immigrants and the native-born population and by tracing how the health of immigrants changes after settling in the country. Fifty-one published empirical studies met the inclusion criteria for this review. The analysis focuses on four inter-related questions: (1) Which health conditions show transition effects and which do not? (2) Do health transitions vary by ethnicity/racialized identity? (3) How are health transitions influenced by socioeconomic status? and (4) How do compositional and contextual factors interact to affect the health of immigrants? Theoretical and methodological challenges facing this area of research are discussed and future directions are identified. This area of research has the potential to develop into a complex, nuanced, and useful account of the social determinants of health as experienced by different groups in different places.