Population Change and Lifecourse

Research Brief #24 - September 2015

(IN)Visible Minorities in Canadian Health Data and Research

Summary

This study examines the nature and extent of data and research on the role of race or visible minority status on health in Canada. Visible minorities represent a rapidly growing segment of Canada’s population. Approximately one in five Canadians is a member of a visible minority group. Policy makers and researchers are often unable to answer important questions related to visible minority health such as: Are visible minority Canadians healthier or less healthy than their white counterparts? Do risk factors for health conditions differ for visible minority and white Canadians? And how do different visible minority groups compare with one another on health outcomes and measures? Our review of the existing literature on visible minority health indicates that there is a paucity of data and research on the health of visible minorities in Canada, alone, and in comparison to ‘mainstream’ (white) Canadians. We recommend that there is a need for basic health data for visible minorities. Many current health surveys are severely limited by small sample sizes of visible minorities. We recommend oversampling visible minorities in standard health surveys such as the Canadian Community Health Survey, or conducting targeted health surveys of visible minorities. Surveys should collect information on key socio-demographic characteristics such as nativity, visible minority status, socioeconomic status, and age-at-arrival for immigrants.

We also recommend that if data were available, researchers consider an intersectionality approach in their analyses. Intersectionality is a flexible holistic 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 of residence.

Key Findings

  1. There is indeed a major gap in health data and research on visible minorities in Canada. We found just five studies that examined nationally representative data to compare visible minorities with whites on specific health conditions or behaviours.
  2. As a group, visible minorities appear to have a survival advantage over their white Canadian counterparts. However, most studies failed to distinguish between immigrants and Canadian-born visible minorities, thus conflating the effects of visible minority status with those of immigrant status on health. There were just two studies that compared the health of Canadian-born and foreign-born visible minorities.
  3. Visible minorities are often treated as a monolithic category, ignoring the diversity within this growing population, for example, differences by nativity, specific visible minority group, and other characteristics.
  4. The visible minority older adult (65+) population is even more invisible in health data and research.
  5. The most promising dataset appears to be the Canadian Community Health Survey (CCHS).

Background

In Canada, there is extensive documentation of health disparities between First Nations or Aboriginal populations and other Canadians. In contrast, there seems to be a lack of data and research on the role of race or visible minority status on health. Visible minorities, who represent approximately 19% of the Canadian population, include groups such as South Asians, Chinese, Latin Americans, and other groups other than Aboriginal peoples who are non-Caucasian in race or non-white in colour (Employment Equity Act). Much of what we do know about visible minority health comes from research on immigrants, many of whom are members of visible minority groups (Edge and Newbold, 2013). However, not all visible minorities are immigrants. The 2011 NHS reports that 30% of visible minority persons are Canadian-born. Drawing conclusions about visible minority health from research on immigrants conflates the role of race with immigration-related factors on health, as visible minority immigrants differ from Canadian-born visible minorities in important ways, including official language proficiency, cultural backgrounds, and familiarity with Canadian society and institutions. In addition, apparent health advantages for visible minorities, such as lower mortality rates reported in some studies (Wilkins et al., 2008), are strongly affected by the high foreign-born composition of the visible minority population. As such, the well-known “healthy immigrant effect” may obscure health differences between visible minority and white Canadians.

Questions and Objectives

Given what appears to be an important gap in data and research on visible minorities and health in Canada, the main question for this study was: Are visible minorities invisible in Canadian health data and research? Specifically, we wanted to know what data and research exist on visible minorities’ health. Such information would be necessary to provide an accurate and comprehensive profile of the health of Canadians, and to assist health policy makers and healthcare providers to ensure that all Canadians are as healthy as possible.

To answer the main question, we address four specific sub-questions:

  1. What do we know about the morbidity and mortality patterns of visible minorities, generally and in comparison with white Canadians?
  2. What do we know about the determinants of visible minority health?
  3. What do we know about the health status of visible minority older adults (VMOA), that is, those aged 65 and older? How does this compare with white older adults?
  4. What data sources have been used to study visible minority health?

Methodology

We chose the scoping review approach (Arksey et al., 2005; Armstrong et al., 2011) as the most appropriate and feasible method to achieve our objectives. The Canadian Institutes of Health Research (CIHR) defines scoping reviews as, “exploratory projects that systematically map the literature available on a topic” (CIHR, 2010). A total of 99 studies or publications from academic journals, as well as reports, press releases, and other documents from service, community, and research organizations, and government agencies (including Statistics Canada and Health Canada) were identified for review. Of these, we reviewed abstracts for 72 and the full article for 27. Information from the scoping review was collated and charted to address the four specific sub-questions listed above.

Results

While we reviewed a large number of publications, we note that only five examined nationally representative data to specifically compare visible minorities with white Canadians and just two distinguished between Canadian-born visible minorities and foreign-born visible minorities. In addition, due to data and methodological limitations and differences in topics examined, findings are not easily comparable, making it challenging to provide a clear picture of the health of visible minorities in Canada.

Table 1 provides a distribution of the studies included in our review.

Research Brief No 24 - Table 1

Synthesis of Main Findings

Mortality. As a group, visible minorities have a survival advantage over their white Canadian counterparts (Wilkins et al., 2008). Analysis of cause-specific mortality by ethnicity reveals, however, that South Asians are more susceptible to death from heart disease while Chinese have a moderate risk of death from cancer (Sheth et al., 1999). Visible minorities’ lower mortality risk has been documented more extensively in studies where country/region of origin for the foreign-born is used to proxy ethnicity or visible minority status (Payne et al., 2002; DesMeules, et al., 2004). However, racial/ethnic differences in mortality in these studies may be suppressed owing to the “healthy immigrant effect”.

Morbidity. Mental health appears to be better among visible minorities than white Canadians or the general Canadian population (Pahwa et al., 2012; Stafford et al., 2011; Wu et al., 2003). However, older visible minorities appear to have higher rates of depression (Lai, 2000) and are less likely to receive proper diagnosis for their mental health problems (McCleary et al., 2013). In terms of chronic diseases, national-level estimates indicate that visible minorities have a lower prevalence of diabetes, hypertension, smoking, and obesity than whites. But provincial-level analyses reveal that visible minorities are at greater risk for diabetes than white Canadians (Alangh et al., 2013; Chiu et al., 2010; Nijar et al., 2010; Shah, 2013; Zdravkovic et al., 2004). Moreover, blacks and South Asians are more susceptible to hypertension (Leenan et al., 2008) and stroke (Chui et al., 2010) than whites.

Table 2 presents a summary of the studies that examined visible minority mortality and morbidity patterns.

Research Brief No 24 - Table 2

Determinants of Visible Minority Health. The determinants of visible minority health include many well-known factors, such as socioeconomic status, culture (health-related norms, values, and beliefs), social support, immigrant status, health literacy, etc. The role of racialized identity and perceived discrimination has not been well examined, however, despite the fact that discrimination is a widely accepted social determinant of health (WHO, 2007). The few studies that have examined the role of discrimination in visible minority and/or immigrant health in some form suggest that discrimination is an important mechanism that warrants further investigation (Veenstra, 2009; Oxman-Martinez et al., 2012).

Visible Minority Older Adults. Research on the health of VMOA was scarce. Where data were available, it was generally shown that VMOA have worse mental and self-rated health than either their white counterparts or the general older adult population (Lai, 2004). Additionally, there are several barriers to accessing health and social care among VMOA, most notably language, cultural beliefs and practices, and immigrant status (Saldov and Chow, 1994; Ahmad et al., 2008; Weerasinghe and Numer, 2010).

Promising Datasets. Most of the data sources used in the studies we reviewed are cross-sectional surveys, some at the national level and others at the provincial or sub-provincial level. Among the datasets used by researchers to examine visible minority health, the Canadian Community Health Survey (CCHS) stands out as being the most promising.

Conclusion

There are four main conclusions.

  1. There is indeed a major gap in health data and research on visible minorities in Canada. We found just five studies (Fuller-Thomson & Brennenstuhl, 2000; Liu et al., 2010; Quan et al. 2006; Veenstra, 2009; Wu et al., 2004) that examined nationally representative data to compare visible minorities with whites on specific health conditions or behaviours.
  2. Many studies that reference visible minorities often failed to distinguish between immigrants and Canadian-born visible minorities, thus conflating the effects of visible minority status with those of immigrants on health outcomes. There were only two studies that distinguished between Canadian-born visible minorities and visible minority immigrants (Islam, 2014; Sheth, 1999).
  3. Visible minorities are often treated as a monolithic category, ignoring the diversity within this growing population.
  4. The particularly vulnerable visible minority older adult (65+) population (VMOA) is even more invisible in health data and research.

Recommendations

We propose two key recommendations:

Data Needs: There is a need for basic data on the health status of visible minorities. Such data should include important sociodemographic characteristics such as age, gender, visible minority status, marital status, nativity, age at immigration for the foreign-born, education, income, and geographic place of residence. Information on health status includes general health, mental health, specific health conditions, risk behaviours (e.g., smoking, alcohol and other drug use), diet, exercise, and other health-related behaviours. Such data could be obtained by oversampling visible minorities in standard health surveys such as the CCHS, or conducting targeted health surveys of visible minorities.

Research Needs: The main obstacle of research on the health of visible minorities is the lack of data. If data were available, we recommend that researchers consider an intersectionality approach in their analyses. Intersectionality is a flexible holistic approach that takes into account the multiple factors that may affect a visible minority individual’s health, including the role of visible minority status, immigrant characteristics for foreign-born visible minorities, age and the role of ageism for older adults, gender (for visible minority women), and geographic place of residence.

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Key References

  1. Arksey H., and O’Malley, L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 8 (1), 19–32.
  2. Chiu, M., Austin, P. C., Manuel, D. G., & Tu, J. V. (2010). Comparison of Cardiovascular Risk Profiles among Ethnic Groups using Population Health Surveys between 1996 and 2007. Canadian Medical Association Journal, 182, E301-E310.
  3. Quan, H., Fong, A., De Coster, C., Wang, J., Musto, R., Noseworthy, T.W., & Ghali, W.A. (2006.) Variation in Health Services Utilization among Ethnic Populations. Canadian Medical Association Journal, 174, 787-91.
  4. Wu, Z. and Schimmele, C.M. (2005). Racial/ethnic variation in functional and self-reported health. American Journal of Public Health 95(4), 710-716.
  5. Wilkins, R., Tjepkema, M. Mustard, C. and Choiniere, R. (2008). The Canadian census mortality follow-up study, 1991 through 2001. Health Reports 19(3, 25-43).

For cited references not listed here, please see PCLC Discussion Paper 3(1): 5.

About the Brief

This research brief is based on Mushira Khan, Karen Kobayashi, Sharon M. Lee, and Zoua M. Vang* (2015) (IN) Visible Minorities in Canadian Health Data and Research, PCLC Discussion Paper 3(1): 5.

The brief was written by the authors of this paper.

For more information, please contact Karen Kobayashi or Sharon Lee (University of Victoria) or Zoua Vang (McGill University)

*Note: The names of the authors are listed alphabetically.