Cross-cultural comparisons of health status in Canada using the Health Utilities Index

Later-life trajectories of cognitive functioning among immigrants of Mexican origin: implications of age at immigration and social resources

Objective. This study examines age-at-immigration disparities in later-life trajectories of cognitive functioning among immigrant men and women of Mexican descent. This study also considers the role of socioeconomic resources, family status, and church attendance in these disparities.Methods. This study draws on eight waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly and employs growth curve models. This study distinguished between immigrants who moved from Mexico to the U.S. in early life (before age 19), midlife (between ages 20 and 49; reference category), and late life (beyond age 50). The analyses were conducted separately for men and women. The final analytic sample consisted of 2,030 repeated observations from 639 men and 2,883 observations from 884 women.Results. Compared to midlife immigration, late-life immigration was associated with lower cognitive functioning at baseline among both men and women, whereas early- as well as late-life immigration was related to faster cognitive decline over time only among men. Adjusting for socioeconomic resources reduced cognitive disadvantages among late-life immigrants, regardless of gender. Family status also partially accounted for poorer cognitive functioning among late-life immigrant women.Conclusion. This study demonstrates that later-life cognitive functioning among immigrant men and women of Mexican descent might be contingent on age at immigration. By highlighting the importance of individuals' social resources for overall cognitive functioning and for age-at-immigration disparities, this study also suggests that social programs and interventions to improve cognitive health in this population group should address later-life disadvantages related to low educational attainment, being unmarried, and less frequent religious participation.

The long-term effect of intra-European migration on cognitive abilities in later life

The study raises the question about the long-term effect of intra-European migration on cognitive abilities in later life. In contrast to previous research that compares migrants to natives of the destination country, this study uses stayers in the European origin countries as reference group for migrants who moved to another European country earlier in life and are now growing old abroad. Selection into migration is addressed methodologically by applying an instrumental variable approach. Using the Global Bilateral Migration Database to generate the country- and time-specific share of emigrants as instrument for migration, the results indicate that intra-European migration turns out to have a negative long-term effect on the level of cognitive abilities.

Comparison of EQ-5D and SF-36 in untreated patients with symptoms of intermittent claudication

AIM

To compare health-related quality of life (HRQoL) descriptions and utility scores in newly diagnosed peripheral arterial disease (PAD) patients, using two most widely used instruments, EuroQol 5D (EQ-5D) and Medical Outcome Study 36-item Short-Form Health Status Survey (SF-36).

METHODS

Patients' self-assessment of HRQoL was measured by the Dutch versions of the EQ-5D and SF-36 in the 204 patients.

RESULTS

Mean utility scores ranged from 0.675 for Short-Form Six-Dimension, 0.648 for the EQ-5D UK tariff and 0.715 for the Dutch EQ-5D tariff. A moderate correlation between the utility scores was found due to different valuation techniques of these instruments.

CONCLUSION

Both instruments have clinical validity for use in the PAD and can be used alongside each other to provide a holistic assessment of the HRQoL. Before using these two instruments interchangeably for utility score calculations and healthcare resource allocation, a thorough sensitivity analysis is necessary to explore the robustness of the value argument based on these utility scores.

Are visible minorities “invisible” in Canadian health data and research? A scoping review

Purpose

Canada’s visible minority population is increasing rapidly, yet despite the demographic significance of this population, there is a surprising dearth of nationally representative health data on visible minorities. This is a major challenge to undertaking research on the health of this group, particularly in the context of investigating racial/ethnic disparities and health disadvantages that are rooted in racialization. The purpose of this paper is to summarize: mortality and morbidity patterns for visible minorities; determinants of visible minority health; health status and determinants of the health of visible minority older adults (VMOA); and promising data sources that may be used to examine visible minority health in future research.

Design/methodology/approach

A scoping review of 99 studies or publications published between 1978 and 2014 (abstracts of 72 and full articles of 27) was conducted to summarize data and research findings on visible minority health to answer four specific questions: what is known about the morbidity and mortality patterns of visible minorities relative to white Canadians? What is known about the determinants of visible minority health? What is known about the health status of VMOA, a growing segment of Canada’s aging population, and how does this compare with white older adults? And finally, what data sources have been used to study visible minority health?

Findings

There is indeed a major gap in health data and research on visible minorities in Canada. Further, many studies failed to distinguish between immigrants and Canadian-born visible minorities, thus conflating effects of racial status with those of immigrant status on health. The VMOA population is even more invisible in health data and research. The most promising data set appears to be the Canadian Community Health Survey (CCHS).

Originality/value

This paper makes an important contribution by providing a comprehensive overview of the nature, extent, and range of data and research available on the health of visible minorities in Canada. The authors make two key recommendations: first, over-sampling visible minorities in standard health surveys such as the CCHS, or conducting targeted health surveys of visible minorities. Surveys should collect information on key socio-demographic characteristics such as nativity, ethnic origin, socioeconomic status, and age-at-arrival for immigrants. Second, researchers should consider an intersectionality approach that takes into account the multiple factors that may affect a visible minority person’s health, including the role of discrimination based on racial status, immigrant characteristics for foreign-born visible minorities, age and the role of ageism for older adults, socioeconomic status, gender (for visible minority women), and geographic place or residence in their analyses.

Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?

BACKGROUND

Notwithstanding a general improvement in health status, the socioeconomic gradient in health remains a public health challenge worldwide.

OBJECTIVE

Using longitudinal data from the National Population Health Survey (NPHS, n=17,276), we examined trends in socioeconomic gradients in two health indicators, viz. the Health Utility Index (HUI) and the Frailty Index (FI), among Canadian adults (25 years and older) between 1998/9-2010/11.

METHODS

The relative and slope indices of inequality (RII and SII, respectively) were employed to summarize income- and education-based inequality in the FI and the HUI in Canada as whole, and in five regions: the Atlantic provinces, Quebec, Ontario, the Prairies and British Columbia.

RESULTS

We found that education- and income-related inequalities in health were present in all five regions of Canada. The estimated RIIs and SIIs suggested that education-related inequalities in the FI and the HUI increased among women. The results also revealed that relative and absolute income-related inequalities in the HUI increased in Canada, especially among women. Both absolute and relative inequalities indicated that income-related inequalities in the HUI increased in Quebec and in the Prairies over time.

CONCLUSION

Persistent and growing socioeconomic inequalities in health in Canada over the past one and half decades should warrant more attention. The mechanisms underlying socioeconomic-related inequalities in Canada are less clear. Therefore, further studies are required to identify effective polices to reduce the socioeconomic gradient in health in Canada.

Psychological Wellbeing in Three Groups of Skilled Immigrants to New Zealand

The present study sought to investigate the current levels of psychological wellbeing in three immigrant groups to New Zealand. In addition, we sought to determine whether aspects of the acculturation process were related to mental health outcomes. This is a cross–sectional study from the fifth wave of annual in-depth interviews with three groups of recently arrived skilled immigrants from India, the People's Republic of China and South Africa. Interviews focused on international contacts and the migration of relatives and friends, housing, language, qualifications and employment, and social participation. Participants were also asked about health difficulties, homesickness, and whether they felt settled in New Zealand. The SF-36 Health Status Questionnaire (Ware, 1997), assessed the respondent's functional status and wellbeing in relation to four health concepts: vitality, social functioning, role limitations due to emotional health, and general mental wellbeing. The immigrant group differed significantly from the New Zealand population on only one of the four mental health scales, Vitality, with immigrants reporting higher levels. Different acculturation factors were found to predict different mental health subscales in regression analyses. Gender, home contact and health difficulty explained 22% of the unique variance in Vitality; employment status and health difficulty explained 18% of the variance in Social Functioning; health difficulty significantly contributed to the explained variance (14%) in the Role limitations due to emotional health subscale; gender, home contact and health difficulty explained 27% of the variance in the Mental Health subscale. There was little evidence for lower levels of psychological wellbeing for the three immigrant groups compared to the general New Zealand population, nor for differences between the three groups. However, results highlight the importance of differential predictors in the understanding of psychological health in migrant groups.

Health-compromising behaviors among a multi-ethnic sample of Canadian high school students: risk-enhancing effects of discrimination and acculturation

This article examines whether acculturation and experiences of discrimination help to explain observed ethnic disparities in rates of three health-compromising behaviors: interpersonal violence, drinking, and cannabis use. Data were drawn from a cross-sectional survey of 3,400 high school students from Toronto, Canada, sampled in 1998-2000. Multivariate ordinary least squares and logistic regression models tested for baseline differences in the health-compromising behaviors by ethnic identity. Subsequent models adjusted for control measures and introduced acculturation and discrimination measures. Results confirm that experiences of discrimination and acculturation are risk enhancing, whereas active cultural retention appears to protect ethnic youth from participation in health-compromising activities.

Characterizing the relationship between health utility and renal function after kidney transplantation in UK and US: a cross-sectional study

BACKGROUND

Chronic allograft nephropathy (CAN) occurs in a large share of transplant recipients and it is the leading cause of graft loss despite the introduction of new and effective immunosuppressants. The reduction in renal function secondary to immunologic and non-immunologic CAN leads to several complications, including anemia and calcium-phosphorus metabolism imbalance and may be associated to worsening Health-Related Quality of Life. We sought to evaluate the relationship between kidney function and Euro-Qol 5 Dimension Index (EQ-5Dindex) scores after kidney transplantation and evaluate whether cross-cultural differences exist between UK and US.

METHODS

This study is a secondary analysis of existing data gathered from two cross-sectional studies. We enrolled 233 and 209 subjects aged 18-74 years who received a kidney transplant in US and UK respectively. For the present analysis we excluded recipients with multiple or multi-organ transplantation, creatinine kinase ≥200 U/L, acute renal failure, and without creatinine assessments in 3 months pre-enrollment leaving 281 subjects overall. The questionnaires were administered independently in the two centers. Both packets included the EQ-5Dindex and socio-demographic items. We augmented the analytical dataset with information abstracted from clinical charts and administrative records including selected comorbidities and biochemistry test results. We used ordinary least squares and quantile regression adjusted for socio-demographic and clinical characteristics to assess the association between EQ-5Dindex and severity of chronic kidney disease (CKD).

RESULTS

CKD severity was negatively associated with EQ-5Dindex in both samples (UK: ρ= -0.20, p=0.02; US: ρ= -0.21, p=0.02). The mean adjusted disutility associated to CKD stage 5 compared to CKD stage 1-2 was Δ= -0.38 in the UK sample, Δ= -0.11 in the US sample and Δ= -0.22 in the whole sample. The adjusted median disutility associated to CKD stage 5 compared to CKD stage 1-2 for the whole sample was 0.18 (p<0.01, quantile regression). Center effect was not statistically significant.

CONCLUSIONS

Impaired renal function is associated with reduced health-related quality of life independent of possible confounders, center-effect and analytic framework.

Immigrant status and cognitive functioning in late-life: an examination of gender variations in the healthy immigrant effect

Although some research suggests that the healthy immigrant effect extends to cognitive functioning, it is unclear whether this general pattern varies according to gender. We use six waves of data collected from the original cohort of the Hispanic Established Populations for the Epidemiologic Study of the Elderly to estimate a series of linear growth curve models to assess variations in cognitive functioning trajectories by nativity status and age at migration to the U.S.A. among women and men. Our results show, among women and men, no differences in baseline cognitive status (intercepts) between early- (before age 20) and late-life (50 and older) immigrants and U.S.-born individuals of Mexican-origin. We also find, among women and men, that middle-life (between the ages of 20 and 49) immigrants tend to exhibit higher levels of baseline cognitive functioning than the U.S.-born. Our growth curve analyses suggest that the cognitive functioning trajectories (slopes) of women do not vary according to nativity status and age at migration. The cognitive functioning trajectories of early- and late-life immigrant men are also similar to those of U.S.-born men; however, those men who migrated in middle-life tend to exhibit slower rates of cognitive decline. A statistically significant interaction term suggests that the pattern for middle-life migration is more pronounced for men (or attenuated for women). In other words, although women and men who migrated in middle-life exhibit higher levels of baseline cognitive functioning, immigrant men tend to maintain this advantage for a longer period of time. Taken together, these patterns confirm that gender is an important conditioning factor in the association between immigrant status and cognitive functioning.

Examining the gender, ethnicity, and age dimensions of the healthy immigrant effect: factors in the development of equitable health policy

This study expands on previous research on the healthy immigrant effect (HIE) in Canada by considering the effects of both immigrant and visible minority status on self-rated health for males and females in mid-(45-64) and later life (65+). The findings reveal a strong HIE among new immigrant middle-aged men, particularly non-Whites. For older men of color the reality is strikingly different: they are disadvantaged in health compared to their Canadian-born counterparts, even when a number of demographic, economic, and lifestyle factors are controlled. Health outcomes for immigrant women are in contrast to that of immigrant men. Among middle-aged women, immigrants, regardless of their ethnicity or number of years since immigration, are much more likely to report poor health compared to the Canadian-born. And, for older women, recent non-white immigrants are more likely to report better health compared to Canadian-born women, although this finding is explained by differences in demographic, economic, and lifestyle factors. Overall, the findings demonstrate the importance of considering the intersections of age, gender, and ethnicity for policymakers in assessing the health of immigrants.

Perceived health status of Francophones and Anglophones in an officially bilingual Canadian province

OBJECTIVE

It has been reported that being part of a minority group may be negatively associated with self-perceived health. The objective of this analysis was to determine whether there are differences in perceived health between the Francophone minority and Anglophone majority in New Brunswick, the only officially bilingual province in Canada.

METHODS

Data from the first four primary cycles of the Canadian Community Health Survey (2001 to 2007) were obtained for 17,729 New Brunswick residents. Odds of reporting good health among Francophones and Anglophones were compared using multivariate logistic regressions accounting for age, health-related behaviours, socio-demographic variables, and medical conditions.

RESULTS

In the final models, Francophone men and women were less likely than Anglophones to report their health as being good, although these differences were not statistically significant (Odds ratio, 95% confidence interval: 0.88, 0.61-1.26; 0.71, 0.49-1.04, in men and women, respectively).

CONCLUSION

This study suggests that being part of the linguistic minority in New Brunswick is not associated with statistically significant differences in self-perceived health.

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.

Palliative care symptom assessment for patients with cancer in the emergency department: validation of the Screen for Palliative and End-of-life care needs in the Emergency Department instrument

OBJECTIVE

We sought to develop and validate a novel palliative medicine needs assessment tool for patients with cancer in the emergency department.

METHODS

An expert panel trained in palliative medicine and emergency medicine reviewed and adapted a general palliative medicine symptom assessment tool, the Needs at the End-of-Life Screening Tool. From this adaptation a new 13-question instrument was derived, collectively referred to as the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED). A database of 86 validated symptom assessment tools available from the palliative medicine literature, totaling 3011 questions, were then reviewed to identify validated test items most similar to the 13 items of SPEED; a total of 107 related questions from the database were identified. Minor adaptations of questions were made for standardization to a uniform 10-point Likert scale. The 107 items, along with the 13 SPEED items were randomly ordered to create a single survey of 120 items. The 120-item survey was administered by trained staff to all patients with cancer who met inclusion criteria (age over 21 years, English-speaking, capacity to provide informed consent) who presented to a large urban academic emergency department between 8:00 am and 11:00 pm over a 10-week period. Data were analyzed to determine the degree of correlation between SPEED items and the related 107 selected items from previously validated tools.

RESULTS

A total of 53 subjects were enrolled, of which 49 (92%) completed the survey in its entirety. Fifty-three percent of subjects were male, age range was 24-88 years, and the most common cancer diagnoses were breast, colon, and lung. Cronbach coefficient α for the SPEED items ranged from 0.716 to 0.991, indicating their high scale reliability. Correlations between the SPEED scales and related assessment tools previously validated in other settings were high and statistically significant.

CONCLUSION

The SPEED instrument demonstrates reliability and validity for screening for palliative care needs of patients with cancer presenting to the emergency department.

Depression: Problem-solving appraisal and self-rated health among Hong Kong Chinese migrant women

This cross-sectional survey explored the depression status of new migrant women and its relationship with self-rated health in the Hong Kong Chinese context. A convenience sample of 68 migrant women volunteered to participate in the study. The data were collected by using the Problem Solving Inventory, the Center for Epidemiological Studies-Depression questionnaire, and a self-rated health scale. The respondents were found to have a lesser degree of problem-solving appraisal, compared with other populations, and almost half of the volunteers were found to be depressed. Approximately 50% of the women reported their general health as "excellent", "very good", or "good". The Pearson's correlation showed a positive significant correlation between problem-solving appraisal, depression, and self-rated health. The results of the regression analysis showed that family income, self-rated health, and problem-solving confidence are predictive factors of depression. Community nurses could consider using multidisciplinary interventions that focus on life-skills training in order to promote the psychological and general wellness of migrant women in addition to the use of counseling or medication interventions.

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.

Income-related health inequalities in Canada and the United States: a decomposition analysis

OBJECTIVES

We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics.

METHODS

We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada-US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors.

RESULTS

The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada.

CONCLUSIONS

Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada.

Mortality, cause of death and life expectancy of Chinese Canadians in Alberta

OBJECTIVE

To describe mortality, cause of death and life expectancy among Chinese (both immigrant and Canadian-born) and other Canadians in the Province of Alberta.

METHODS

A Chinese surname list was applied to the Alberta Health Insurance Plan and Vital Statistics Birth registry databases to define the Chinese population, and to the Vital Statistics Death registry to determine deaths among Chinese in Alberta from 1995 to 2003. Age- and sex-specific mortality, cause of death and life expectancy were calculated.

RESULTS

Of nearly 3 million Alberta residents, about 4% were Chinese in 2003. The age-adjusted mortality for Chinese was 4.2 per 1000 and for non-Chinese 6.2 per 1000 population. Infant mortality was lower for Chinese (4.9/1000 live births) than non-Chinese (6.2/1000 live births). Life expectancy at birth was 6.3 years longer for Chinese males compared to non-Chinese males (83.3 versus 77.0), and 5.4 years longer for Chinese females compared to non-Chinese females (87.9 versus 82.5). Cancer, heart disease and stroke were the leading causes of death for both Chinese and non-Chinese Albertans.

CONCLUSIONS

The Chinese ethnic population of Alberta had lower mortality and longer life expectancy than remaining Albertans, suggesting that the Chinese population has better health status than other Albertans. Reasons for the health gap between Chinese and non-Chinese populations should be further explored.

Comparing three measures of health status (perceived health with Likert-type scale, EQ-5D, and number of chronic conditions) in Chinese and white Canadians

BACKGROUND

Measures of perceived health status may be vulnerable to ethnic and sociodemographic characteristics. The purpose of this study was to compare self-reported health status in Chinese and whites using 3 measures: physical and mental health status with the 5-point Likert-type scale, the EQ-5D together with a modified health index scale (0-100), and number of chronic conditions.

METHODS

A cross-sectional telephone survey of Chinese and white Canadians was conducted in a large city in Alberta, Canada.

RESULTS

We analyzed 830 Chinese and 789 white respondents. Chinese, compared with whites, reported better health status using the EQ-5D health index (0.94 vs. 0.86) and had fewer chronic conditions surveyed (51.9% vs. 79.2% had one or more conditions). However, Chinese rated their health status fair or poor more often than whites (27.3% vs. 9.7% for physical health and 24.0% vs. 5.0% for mental health) and both groups rated similarly on the health index scale (80.0 for Chinese vs. 77.9 for white).

CONCLUSIONS

Health status measurements performed inconsistently across ethnic populations. The EQ-5D health index was consistent with the number of chronic conditions, whereas results from the 5-point Likert-type scale and the health index scale were not consistent with the number of chronic conditions. Perceived health status differed by the measures used and ethnicity.

Assessing differences in utility scores: a comparison of four widely used preference-based instruments

OBJECTIVES

To characterize the differences in utility scores (dUTY) among four commonly used preference-based Health-Related Quality of Life instruments, to evaluate the potential impact of these differences on cost-utility analyses (CUA), and to determine if sociodemographic/clinical factors influenced the magnitude of these differences.

METHODS

Consenting adult Chinese, Malay and Indian subjects in Singapore were interviewed using Singapore English, Chinese, Malay or Tamil versions of the EQ-5D, Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), and SF-6D. Agreement between instruments was assessed using Bland-Altman (BA) plots. Changes in incremental cost-utility ratio (ICUR) from dUTY were investigated using eight hypothetical decision trees. The influence of sociodemographic/clinical factors on dUTY between instrument pairs was studied using multiple linear regression (MLR) models for English-speaking subjects (circumventing structural zero issues).

RESULTS

In 667 subjects (median age 48 years, 59% female), median utility scores ranged from 0.80 (95% confidence interval [CI] 0.80, 0.85) for the EQ-5D to 0.89 (95% CI 0.88, 0.89) for the SF-6D. BA plots: Mean differences (95% CI) exceeded the clinically important difference (CID) of 0.04 for four of six pairwise comparisons, with the exception of the HUI2/EQ-5D (0.03, CI: 0.02, 0.04) and SF-6D/HUI2 (0.02, CI: 0.006, 0.02). Decision trees: The ICER ranged from $94,661/QALY (quality-adjusted life-year; 6.3% difference from base case) to 100,693 dollars/QALY (0.3% difference from base case). MLR: Chronic medical conditions, marital status, and Family Functioning Measures scores significantly (P-value < 0.05) influenced dUTY for several instrument pairs.

CONCLUSION

Although CIDs in utility measurements were present for different preference-based instruments, the impact of these differences on CUA appeared relatively minor. Chronic medical conditions, marital status, and family functioning influenced the magnitude of these differences.

Variation in health services utilization among ethnic populations

BACKGROUND

Although racial and ethnic disparities in health services utilization and outcomes have been extensively studied in several countries, this issue has received little attention in Canada. We therefore analyzed data from the 2001 Canadian Community Health Survey to compare the use of health services by members of visible minority groups and nonmembers (white people) in Canada.

METHODS

Logistic regression was used to compare physician contacts and hospital admissions during the 12 months before the survey and recent cancer screening tests. Explanatory variables recorded from the survey included visible minority status, sociodemographic factors and health measures.

RESULTS

Respondents included 7057 members of visible minorities and 114,255 white people for analysis. After adjustments for sociodemographic and health characteristics, we found that minority members were more likely than white people to have had contact with a general practitioner (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.42), but not specialist physicians (OR 1.01, 95% CI 0.93-1.10). Members of visible minorities were less likely to have been admitted to hospital (OR 0.83, 95% CI 0.70- 0.98), tested for prostate-specific antigen (OR 0.64, 95% CI 0.52-0.79), administered a mammogram (OR 0.68, 95% CI 0.59-0.80) or given a Pap test (OR 0.47, 95% CI 0.39-0.56).

INTERPRETATION

Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less.

Mental Health Comorbidity Patterns and Impact on Quality of Life Among Veterans Serving During the First Gulf War

PURPOSE

To examine the patterns of coexisting (comorbid) mental disorders and whether comorbidity influences quality of life ratings in a sample of U.S. veterans.

PATIENTS AND METHODS

The Iowa Gulf War Study Case Validation study evaluated 602 military personnel, two-thirds of whom had symptoms of depression, cognitive dysfunction, or chronic widespread pain, who were activated or on active duty sometime during the first Gulf War (GW). Mental health disorders were defined using the SCID-IV, and the Health Utilities Index Mark 3 (HUI3) was used to measure health-related quality of life (HRQoL). Comorbidity was defined as having two or more mental disorders that spanned across at least two separate categories (e.g., depressive disorders and anxiety disorders).

RESULTS

Over 35% of veterans with a current mental disorder had at least one other comorbid mental disorder. Those with mental disorder comorbidity had lower HUI scores than veterans with only one or less mental disorders (mean 0.41 +/- 0.30 vs. 0.72 +/- 0.25, p < 0.0001).

CONCLUSION

The co-occurrence of mental disorders that span at least two mental disorder categories is associated with impaired HRQoL in this veteran population. Early identification of mental health comorbidity may lead to interventions to enhance HRQoL among military personnel.

Meeting health need, accessing health care: the role of neighbourhood

Much of what we know about the determinants of access to health care comes from studies undertaken at a large scale, such as between cities, regions/counties/provinces/states and countries. This paper examines local level variations in access to and utilization of health care services across four distinct neighbourhoods in Hamilton, Ontario, Canada. Survey data (n = 1500) were analysed using logistic regression to explore the potential relationships between neighbourhood and health care utilization and unmet health care need. Results show some relationships between neighbourhood of residence and levels of reported utilization as well as unmet need, even when controlling for predisposing, enabling, and need factors (i.e. Age, gender, household composition, income, education, perceived gp visit time) as well as health status. Findings from this empirical study suggest a finer lens is required to examine the mechanisms through which place impacts access to and utilization of care, one that recognizes the roles of compositional, contextual and collective aspects of neighbourhood.

Proxy assessment of quality of life in pediatric clinical trials: application of the Health Utilities Index 3

BACKGROUND

With increased cure rates, pediatric oncology protocols increasingly seek to document the impact of treatment on patients' disease, symptoms, and functional capacity.

PROCEDURE

Nurses as proxy respondents used the Health Utilities Index 3 (HUI3) to assess the health-related quality of life (HRQL) in twenty-five patients (age 6 years or older) enrolled on a frontline protocol for leukemia. HRQL observations (n = 70) were made at three different time points to coincide with high-dose methotrexate therapy. Additionally, the proxy respondents evaluated the ease of use of the instrument and the data quality.

RESULTS

As patients' health status declined, the number of unassessable HRQL items increased. These missing data made scoring cumbersome and precluded calculation of the overall HRQL scores for nearly 50% of the patients.

CONCLUSIONS

Use of the provider proxy-assessed HUI3 in pediatric cancer trials may result in a high proportion of missing data. Trials may benefit more from the use of HRQL measures that consider the acuity of the child's illness, domains specific and sensitive to both disease and treatment, and items that can be proxy-assessed independent of input from parent or patient. Evaluations that combine child self-reports with both parent and provider reports may ultimately provide the most reliable and comprehensive perspective on children's quality of life.

Recent research on immigrant health from statistics Canada's population surveys

This paper reviews recent research using Statistics Canada data to compare immigrant health with that of the Canadian-born. A number of Statistics Canada studies have been used for such comparisons, including the National Population Health Survey and the Canadian Community Health Survey. Across the range of indicators studied, compared to the Canadian-born, immigrants are generally in as good or better health, have similar or better health behaviours, and similar or less frequent health service use (the "healthy immigrant effect"). These indications appear to be strongest among recent and non-European immigrants. These studies have established baseline patterns and identified that important distinctions exist among immigrant subgroups. Future research on more detailed subgroups that uses longitudinal data and cross-culturally validated instruments is needed.

National immigration health policy: existing policy, changing needs, and future directions

Canada has a long history of welcoming immigrants and a longstanding immigration policy framework. The historic principles that govern immigration selection and processing also include regulatory policies in the area of health. Based on historical principles that pre-date Confederation, Canadian immigration health policy has remained relatively constant. Policies are based on the identification of specific individuals and the exclusion, if appropriate, of the affected individuals - an approach that continues today. During the past three decades, however, evolutionary changes in the patterns, volume and demography of immigration have created situations that may necessitate changes to existing policy frameworks. This paper reviews current immigration health policies and practices in Canada, describes the nature and impact of existing challenges, and proposes some alternatives for future consideration.