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Integrating Ethnicity and Migration As Determinants of Canadian Women's Health Vissandjee, Bilkis; Desmeules, Marie; Cao, Zheynuan; Abdool, Shelly; Kazanjian, Arminée Aug 25, 2004

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ralssa, the Cana-BioMed CentBMC Women's HealthOpen AcceReportIntegrating Ethnicity and Migration As Determinants of Canadian Women's HealthBilkis Vissandjee*1, Marie Desmeules2, Zheynuan Cao3, Shelly Abdool4 and Arminée Kazanjian5Address: 1School of Nursing Sciences, University of Montreal, Montreal, Canada, 2Centre for Chronic Disease Prevention and Control, Health Canada, 120 Colonnade Rd, Ottawa, Canada, 3Centre for Chronic Disease Prevention and Control, Health Canada, 120 Colonnade Rd, Ottawa, Canada, 4School of Nursing Sciences, University of Montreal, Montreal, Canada and 5Faculty of Medicine, The University of British Columbia, 5804 Fairview Ave, Vancouver, CanadaEmail: Bilkis Vissandjee* - bilkis.vissandjee@umontreal.ca; Marie Desmeules - Marie_desmeules@hc-sc.gc.ca; Zheynuan Cao - Zhenyuan_cao@hc-sc.gc.ca; Shelly Abdool - shelly.n.abdool@umontreal.ca; Arminée Kazanjian - a.kazanjian@ubc.ca* Corresponding author    AbstractHealth Issue: This chapter investigates (1) the association between ethnicity and migration, asmeasured by length of residence in Canada, and two specific self-reported outcomes: (a) self-perceived health and (b) self-reports of chronic conditions; and (2) the extent to which theseselected determinants provide an adequate portrait of the differential outcomes on Canadianwomen's self-perceived health and self-reports of chronic conditions. The 2000 CanadianCommunity Health Survey was used to assess these associations while controlling for selecteddeterminants such as age, sex, family structure, highest level of education attained and householdincome.Key Findings: • Recent immigrant women (2 years or less in Canada) are more likely to reportpoor health than Canadian-born women (OR = 0.48 CI: 0.30–0.77). Immigrant women who havebeen in Canada 10 years and over are more likely to report poor health than Canadian-bornwomen (OR = 1.31 CI: 1.18–1.45).• Although immigrant women are less likely to report chronic conditions than Canadian-bornwomen, this health advantage decreased over time in Canada (OR from 0.35 to 0.87 for 0–2 yearsto 10 years and above compared with Canadian born women).Data Gaps and Recommendations: • Migration experience needs to be conceptualizedaccording to the results of past studies and included as a social determinant of health above andbeyond ethnicity and culture. It is expected that the upcoming longitudinal survey of immigrantswill help enhance surveillance capacity in this area.• Variables need to be constructed to allow women and men to best identify themselves appropriately according to ethnic identity and number of years in the host country; some of the proposed categories used as a cultural group may simply refer to skin colour without capturing from Women's Health Surveillance ReportA Multidimensional Look at the Health of Canadian Women. Published: 25 August 2004BMC Women's Health2004, 4(Suppl 1):S32 doi:10.1186/1472-6874-4-S1-S32<supplement> <title> <p>Women's Health Surveillance Report</p> </title> <editor>Marie DesMeules, Donna Stewart, Arminée Kazanjian, Heather McLean, Jennifer Payne, Bilkis Vissandjée</editor> <sponsor> <note>The Women's Health Surveillance Report was funded by Health Canaddian Institute for H alth Information (C nadian Population Health  Initiativ ) and the Canadian Instit tes of He lth Research</ ote> </spo sor> <note>R ports</note> <url>http://www.biom central.com/content/pdf/1472-6874-4-S1-info.pdf</ur > </supplement>This article is available from: http://www.biomedcentral.com/1472-6874/4/S1/S32Page 1 of 11(page number not for citation purposes)associated elements of culture, ethnicity and life experiences.BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32BackgroundGiven the increasing diversity of Canadian society, ethnic-ity and migration experiences are both important issues toconsider when examining the social determinants ofwomen's health. [1-7] Immigrants represent a large andincreasing segment of the Canadian population. In 2001,over 5 million Canadians (about 18% of the population)were born outside of the country, and each year approxi-mately 250,000 new immigrants are received. Immigrantwomen, women refugees and women of diverse ethnicbackgrounds form an increasingly large percentage of theCanadian "mosaic": up to 38% of Canadian women areneither French nor British in origin.[8,9] The body ofresearch on the relation between ethnic background andhealth suggests that immigrant subgroups may be vulner-able in terms of health status, health service use and deter-minants of health. [7-16] As well, it has been shown thatvarious mechanisms affect the relation between ethnicity,migration and health.[10,11,13]Health status research suggests that recent (less than 2years of residence in the host country) immigrants (partic-ularly from non-European countries) are, upon theirarrival, healthy overall, with notable exceptions for somehealth conditions, such as certain infectious diseases. [10-16] However, after 10 years of residence in Canada, theprevalence of a number of chronic conditions and long-term disability approaches the levels found in the Cana-dian-born population.[12,13] Explanations for this"healthy migrant effect" among recent immigrants mayinclude selection bias and healthy behaviours, such as lowrates of tobacco use, as well as spurious research findingsdue to methodological limitations.[1,2,14,15] However,comprehensive information that includes sex and genderdifferences in how migrants and ethnic groups experiencehealth is still lacking. More specifically, a number of stud-ies have shown that it is timely to assess the health ofwomen and men with respect to ethnicity and migrationexperiences, in order to contribute to the understandingof the complexity attached to these concepts.[10,13-15]Just as gender has been discussed in the various sectionsof this Report as an essential social determinant of health,diversity is as essential. Indeed, Health Canada, alongwith the Canadian Centres of Excellence on Migration andthe Centres of Excellence for Women's Health Program,strongly recommend a diversity analysis as a complementto the now widely accepted gender-based analysis. [15-17]Incorporating diversity based on ethnicity and migrationinto health analyses requires accounting for the subtletiesof distinction between women and men.[15-19,23].Diversity results in differential life experiences and oppor-tunities among the heterogeneous group of Canadiantry of origin, age at migration and experience with dis-crimination shape each person's unique identity and, inturn, will affect his or her health and well-being. [22-27]Evidence suggests that migration experiences – above andbeyond ethnicity – are as strongly correlated with migranthealth as are limited education and lack of access to mate-rial resources. While a number of studies have exploredethnicity and health, Cooper and Nazroo indicate thatethnicity has been a neglected dimension in comparativestudies of gender and health.[28,29] Similarly, Kinnon,on the basis of her review of the literature, stated thatmigration experiences have not been systematically inves-tigated in terms of their association with health along withgender and ethnicity.[15,16]Immigrants to CanadaIn Canada, immigrants are usually "classified" accordingto four major classes: independent immigrants (includingnominated relatives), business class immigrants, familyclass immigrants (who are sponsored by either independ-ent immigrants or family members who are already resid-ing in Canada) and refugees (who are further subdividedinto two classes).[30] China, India, Pakistan, the Philip-pines and the Republic of Korea were represented amongthe top 10 source countries for migration to Canada in2001. The top three regions of origin were Asia and thePacific (53%), Africa and the Middle East (19%), andEurope and the United Kingdom (17%). In 2001, 61% ofimmigrants fell into the independent class category, 27%into the family class category, 11% into the refugee cate-gory and 1% into a category labelled "other". The leadingfour source countries for refugees in 2001 were Afghani-stan, Sri-Lanka, Pakistan and Yugoslavia.[9,31,32]The Immigration Act establishes a multi-tiered system ofrights and privileges among immigrants based on a pointssystem to determine eligibility. Points need to be earnedin nine categories, such as education, language and occu-pation. Usually, when a two-parent family applies forlanded immigrant status, only one member in the familyis granted the independent status. In most cases, it is thehusband who is so designated, because he is perceived tobe the head of the household; the wife is categorized as afamily class immigrant along with the children. This clas-sification ignores the fact that the wife may have compa-rable education and work experience to her husband, andmay have made an essential contribution to the familyincome before immigration.[28,33-36]Migration experiences and their effects on health havereceived attention very recently.[10,15,29,37] Migratingrepresents a significant transition in the move from thehomeland to a new home, and brings with it many mate-Page 2 of 11(page number not for citation purposes)women and men. Studies have shown that determinantssuch as skin colour, immigration and refugee status, coun-rial and psychosocial losses.[22,23,37] This transition canproduce profound shifts in people's lives, involving short-BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32to long-term implications for health and well-being. [38-40] Immigrant women may experience increased vulnera-bility related to settlement, isolation and attainment ofthe basic needs of the family with limited knowledge ofresources in the host country. Such vulnerability poten-tially exposes them to differing structural, interpersonal,cultural and economic threats to their health and well-being.Migratory experiences are arbitrarily conceived in threeparts: pre-migratory includes those experiences that takeplace from the moment a decision is taken to emigrate(regardless of who in the family unit makes this decision);settlement experiences refer to those events after arrival inthe host country and up to 5 years after migration; and thepost-migratory experience refers to years 6 to 10 after migra-tion. Each phase represents different processes of progres-sive integration and thus should be considered as havingdifferential effects on health.The label "immigrant woman" does not simply refer to alegal status but encompasses a set of complex realities andexperiences. Midiema et al.[41] argue that "immigrantwoman" combines technical, legal and social criteria. It isof importance to note that the term "immigrant" oftenrefers to a person who has either acquired permanent res-ident status in Canada with the rights of Canadian citizensor has actually become a Canadian citizen. On the otherhand, when viewed as a social construct, the term "immi-grant woman" usually refers to women of colour, womenwho do not speak English (or French) very well or withoutan accent other than British or American (or French), andwomen who occupy lower positions in the occupationalhierarchy.[22,23,40]The Concept of EthnicityThere has been much debate surrounding the use of con-cepts such as "ethnicity", "race" and belongingness to aspecific group. Ethnic groups do not refer to homogene-ous populations; they include broad categories usuallybased on age at migration, length of residence, sourcecountry/ethnicity, knowledge of host country languages,health status and health behaviour.[10,17,28,36-38]These categories are a useful start in acknowledging diver-sity among groups of people. Yet these terms also havecertain limitations by way of capturing the interactionbetween biology and the socio-environmental circum-stances that are known to contribute to differential expe-riences in health. [22-24] As Davey Smith rightly pointsout, recognition of the need to analyze ethnicity andsocio-economic position as separate variables in healthstudies raises a number of issues, including the impor-tance of assessing whether conventional measures ofis that categories of "race" have often led to the under-counting of those who self-identify outside of the pre-scribed racial groups (e.g. White, Black, Asian).[39,40]These issues lead to the recognition that different ethnic/racial groups do experience discrimination based on sexand ethnic background. Discrimination can vary in form,depending on how it is expressed, by whom and againstwhom, and it can occur in all aspects of life. In turn, itaffects perceptions of health and health behav-iour.[17,22,24,28,35,38-45]Health is known to be influenced by socio-economic posi-tion, and it has also been argued that the socio-culturalcontext, which includes cultural and migratory experi-ences, of women and men shapes exposure to health-damaging agents as well as determining individualresources to promote health [17,28,42,46] (see also thechapter on Social Context in this Report). Aside from dis-crimination, as mentioned above, the literature attests tothe importance of cultural variations and migration expe-rience in perceptions of health and what makes one ill orhealthy.[17,21,47-53] A number of studies also show thatthe process of acculturation or progressive integrationproduces changes in health.[7,54-56] To investigate thesechanges in health and disease patterns during migration,research has traditionally relied on methods using at leasttwo groups: those born in the host country (a categorywithin which first, second and third generation could beassessed) and those born outside. The number of yearsspent in a specific country in lieu of assessing accultura-tion or progressive integration has recently been used toexplain determinants/variables of health and well-beingof women and men migrating to Canada. Research sug-gests that different dimensions of the progressive integra-tion process may be associated with different types ofoutcomes.[17,48,54] However, few studies have investi-gated health status or chronic conditions as perceived bya diversity of populations and according to the number ofyears since arrival in a host country.[13,28,29,55-58]In order to increase our understanding of the social deter-minants of health in ethnic groups undergoing migrationexperiences, this chapter seeks to investigate the differen-tial association between self-assessed ethnic affiliationand length of residence in Canada since migration, whilecontrolling for selected socio-economic determinants ofhealth such as age, smoking status and two specific out-comes among Canadian women and men, namely (a)self-perceived health and (b) self-reported chronic condi-tions.MethodsData Sources and MeasuresPage 3 of 11(page number not for citation purposes)health status and of socio-economic position are sensitiveenough for different ethnic groups.[10] Yet another issueCross-sectional data from the Canadian CommunityHealth Survey (CCHS) – Cycle 1.1 (2000) were analyzedBMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32for the purposes of this chapter. The CCHS is a repeated,cross-sectional household-level survey that effectivelyreplaces the cross-sectional component of the NationalPopulation Health Survey (NPHS). The sample com-prised 125,574 individuals aged 12 years and older at thetime of data collection, in 2000–2001. The sample usedfor the purpose of this chapter included women and menaged 18 to 65 years old and over. Accounting for the com-plex sample design, weighted methods were used accord-ing to CCHS integrated weighting strategies,[59] so thatthe final results could be generalized to the entire Cana-dian population.Dependent Variables1. Self-perceived health: respondents assessed their healthas excellent, very good, good, fair or poor; in order toassess the profile of the more vulnerable populations,excellent, very good, and good health ratings were com-bined into one group as well as fair and poor health rat-ings into one group, which is referred to hereafter as poor-rated health;2. Self-reported chronic conditions were assessed on adichotomous scale (yes, no)* (* The list of the reportedchronic conditions can be found in Appendix 1).Independent VariablesAcknowledging the fact that determinants of health arecomplex and that variables used for their understandingcannot be compartmentalized into completely independ-ent entities, the categories of sex, gender, ethnicity, migra-tion experience and socio-economic determinants, aslisted below, were used.The limited number of women and men who reportedbeing born outside Canada (21.28%, confidence interval[CI]: 20.84, 21.72) as compared with those who reportedbeing born in Canada (78.72%, CI: 78.28, 79.16) (Figure1) and the need to assess as accurately as possible the con-tribution of ethnicity and migration experiences as meas-ured by length of residence in Canada, most explanatoryvariables were reduced to a dichotomous scale for moreoptimal logistic regression analyses.1. Age – four age groups were selected to reflect differentperiods across the lifespan and workforce participation:18–34, 35–44, 45–64, 65+;2. Marital status – dichotomous variable: single; couple;3. Educational attainment – dichotomous variable: lessthan secondary graduation; some post-secondary school/postsecondary degree;4. Income adequacy – four original categories that weredichotomized: lowest income quartile and lower middleincome quartile combined in one category; and uppermiddle-income quartile and highest income quartile com-bined in another category;5. Food insecurity – a dichotomous variable asking whetherthe respondent had had some food insecurity in the pre-vious 12 months;6. Dwelling security – four original categories that weredichotomized: detached house, semi-detached/town-house and apartment were lumped together to create acategory indicating that the respondent did not have anysense of insecurity with respect to his/her dwelling at thetime of the survey; the second category referred to therespondent who reported that he/she experienced a senseof insecure dwelling at the time of the survey, namely liv-ing in an institution, a mobile home, or some form of col-lective dwelling;7. Employment status – a dichotomous variable askingwhether the respondent worked or not at the time of thesurvey;8. Ethnic affiliation – a categorical variable asking therespondent to self-identify on the basis of four broad cat-egories: Western European, Chinese, South Asian andBlack;9. Length of residence – a categorical variable asking arespondent to choose a category that corresponded to thenumbers of years since he/she migrated to Canada (0 to 2years, 3 to 9 years, and 10 years and more).Figure 1Proportion of women and men migrants in Canada in terms of length of residence in Canada Source: CCHS, 2000 0-2 years 7,75   3-9 years 20,25   10+ years 72,00         Proportion of women and men migrants in Canadain terms of country of birth Source: CCHS, 2000     Born in Canada 78,72             CI 78.28 - 79.16  Born outside Canada 21,28             CI 20.84 - 21.72 Page 4 of 11(page number not for citation purposes)BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32Statistical AnalysisFrequency procedures were used to create tables and cal-culate the prevalence estimates for each determinant. Inaccordance with Statistics Canada's guidelines, estimatesthat were based on a sample of fewer than 30 weredeemed unreliable and suppressed. Because socio-eco-nomic position has been shown to play a large role in dis-parities in health, logistic regression models were set upfor multivariate analysis to evaluate the effects of covari-ates on the assessment of self-perceived health and thereported presence of chronic conditions. Confidenceintervals for weighted estimates were calculated using thebootstrap method.ResultsAccording to the data from CCHS (2000), 20% of womenand men reported that they had been in Canada between3 and 9 years, and 72% of women and men indicated 10years or more of residence in Canada, leaving 8% ofwomen and men who would be categorized as recentimmigrants, that is, 0 to 2 years of residence in Canadasince migration (Figure 1).Regarding self-identification to some proposed ethnic cat-egories in the survey, approximately 64% of women andmen aged 18 to 34 reported being of Western origin, andthat proportion went up to approximately 75% in bothgroups aged 65 and over (Figure 2). The proportion indi-cating that they were of Chinese origin ranged from 2% to5% across the age groups for both sexes. The proportionof South Asian respondents ranged from 1% to 5%.Finally, those who identified themselves as Black wereunder-represented and made up from 0.3% to 2% ofrespondents. It is interesting to note that a range ofwomen and men (from 20% to 26%) decided not tochoose any of the proposed ethnic affiliation categories.Figure 3 shows that among women born outside Canadaand who reported both a lower and a higher income, theproportions reporting good to excellent health decreasedwith the number of years of residence in Canada; of thosereporting lower income, 93% of recent immigrants ratedtheir health as good to excellent, as compared, on the onehand, with 73% of those resident in Canada for 10 yearsand over and, on the other hand, with 79% of those whoreported being Canadian born. Of women with a higherreported income, the proportion of recent immigrantsreporting good to excellent health was similar to that ofCanadian-born individuals, at 95% and 93% respectively;in the higher income category, 87% of those who reportedresiding in Canada for 10 years or over rated their healthas good to excellent.proportions with self-reported chronic conditionsincreased along with the number of years of residence inCanada (Figure 4): of those reporting lower income, 44%of recent immigrants reported the presence of chronicconditions, a proportion that jumped to 75% amongwomen who had lived in Canada for 10 years or longer;this compares with 76% reporting chronic conditions inthe Canadian-born group. Of those with higher reportedincome, 45% of recent immigrants reported the presenceof chronic conditions, whereas once again the proportionof women who had lived in Canada for 10 years or moreProportion of self-reports of excellent to good health among women who report lower / higher income by length of residence Source: CCHS, 2000Lower income women  Reporting excellent to good health length of residence in Canada : 0-2 years 93,33 length of residence in Canada : 3-9 years 87,78 length of residence in Canada : 10+ years 72,93 Canadian born women 78,87   Higher income women  Reporting excellent to good health  length of residence in Canada : 0-2 years 94,66 length of residence in Canada : 3-9 years 92,12 length of residence in Canada : 10+ years 87,10 Canadian born women 92,63Figure 2Proportion of women and men migrants in Canada in terms of self-identification to an ethnic group Source: CCHS, 2000 WomenWestern Europe South Asian Chinese Blac k Other18-34 63,66 4,74 4,01 1,26 26,3335-44 66,90 3,16 4,33 1,00 24,6145-64 70,02 2,71 2,61 0,95 23,7265+ 74,86 0,84 2,10 1,67 23,68            Men Western Europe South Asian Chinese Blac k Other18-34 64,37 3,73 4,56 1,03 26,3135-44 66,82 3,14 4,46 1,23 24,3545-64 71,49 2,73 2,94 0,63 22,2165+ 74,91 1,54 2,70 0,29 20,56Page 5 of 11(page number not for citation purposes)With respect to the reports of chronic conditions, amongwomen who reported both a lower and higher income theFigure 3BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32and reported chronic conditions was similar to that ofCanadian-born individuals, at 72% and 70% respectively.The results of the logistic regression multivariate analysesare presented as odds ratios (OR) and their 95% CIs (Fig-ures 5 and 6). Logistic regression analyses are useful fordescribing the simultaneous relationship of a group ofcontinuous and/or categorical independent variables anda dichotomous outcome variable, namely self-perceivedhealth and reports of chronic conditions[57,59,61,64,66]. The relative odds express the amount ofincrease in the outcome that would be produced by oneunit increase in the independent variable. In order toavoid obscuring gender and ethnic differences, as canoccur when combining both sexes in multivariate modelsor age-adjusted health outcomes, the models in theseanalyses were set up separately for women andmen.[2,6,7,15,16,27,28] Since a large number of variableswere controlled for simultaneously (age and socio-eco-nomic position, including employment status, maritalstatus, educational attainment, income adequacy, dwell-ing security and food insecurity[17,35,38,42,43,46,57,60]), it was deemed important toassess the stability of the model in order to rule out biasedresults due to multicollinearity. Model fit statisticsshowed that the models are significant. Pearson correla-tions were also performed. Coefficients demonstratedweak to moderate associations between each two givenAnalyses show that immigrant women who have been inCanada for less than 2 years are less likely to report poorhealth than Canadian-born women (OR = 0.48, CI: 0.30,0.77).As discussed earlier as well as by a number ofauthors,[10,12-16,21,28,29,37,38,48,51,57-60] this"healthy immigrant effect" disappears over time. Womenwho have migrated to and resided in Canada for at least10 years and over are more likely to report poor healththan Canadian-born women (OR = 1.31, CI: 1.18,1.45).Among men, the protective effect of length of residencewears out from between 2 and 9 years of residence, but nosignificant differences are shown after 10 years and over ofresidence in Canada between the long-term migrant menand Canadian-born men.With respect to the association of ethnic affiliation andself-perceived health, controlling for confounders,women who indicated that they were of South Asian ori-gin were more likely than Canadian women to reportpoor health (OR = 1.42, CI: 1.06,1.91). Among men,those who identified themselves as Black were less likelythan their Canadian counterparts to report poor health,whereas the opposite was observed for men of WesternEuropean origin (OR = 1.16, CI: 1.03,1.31).Controlling for confounders as indicated above, clearerpatterns by length of residence in Canada were observedfor both women and men when self-reported chronic con-ditions were considered as an outcome variable. Womenand men were both less likely than Canadian-born indi-viduals to report chronic conditions. However, as theyears of residence in Canada increase, the protective effectbecomes progressively less for both groups. This gradientshows a gradual loss over time of the health advantagethat migrant women (for 0–2 years of residence, OR =0.35, CI:0.27, 0.46 and for 10+ years of residence, OR =0.87, CI:0.79, 0.95) and men (for 0–2 years of residence,OR = 0.42, CI:0.33,0.55 and for 10+ years of residence,OR = 0.82, CI:0.75, 0.90) are known to enjoy upon arrivalin the host country.With respect to the association between ethnic affiliationand self-report of chronic conditions, controlling for con-founders, women who indicated that they were of SouthAsian (OR = 0.60, CI: 0.48,0.75) as well as of Chinese (OR= 0.64, CI: 0.53,0.77) origin were less likely than Cana-dian women to report chronic conditions. On the otherhand, women self-assessing themselves as Western Euro-pean were more likely to report chronic conditions (OR =1.14, CI: 1.05,1.24). Interestingly, a similar patternbetween the same ethnic affiliation groups and CanadianFigure 4Proportion of self-reports of chronic conditions among women who report lower / higher income by length of residence Source: CCHS, 2000Lower income women            Reportin g chronic conditions length of residence in Canada : 0-2 years 43,68 length of residence in Canada : 3-9 years 45,65 length of residence in Canada : 10+ years 75,15 Canadian born women 76,25   Higher income women            Reporting chronic conditions   length of residence in Canada : 0-2 years 44,58 length of residence in Canada : 3-9 years 49,06 length of residence in Canada : 10+ years 71,70 Canadian born women 69,97Page 6 of 11(page number not for citation purposes)variables, indicating a fairly stable multivariate model. men was observed.BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32DiscussionOne limitation of our analysis is that the use of cross-sec-tional data makes it difficult to disentangle the directionof causality and thus limits the ability to exclude thepotential for reverse causation.[8,10-13] Nonetheless,controlling for determinants such as age and socio-eco-nomic position, complex variables such as ethnic affilia-tion and/or country of origin remain associated with self-reported measures of health known to be rather subjectiveand culturally bound measures ofhealth.[13,17,28,29,42,43,61] Women who had been inCanada for at least 10 years and over were significantlymore likely to report poor health than recent immigrantwomen; for men, being in Canada at least 10 years andover did not make a significant difference. This attests tothe differential needs and patterns of reporting unmetThese results are convergent with the study by Dunn andDyck[13] of the social determinants of health in Canada'simmigrant population using the NPHS (1994–1995).They found some consistent pattern for length of resi-dence in Canada and reports of chronic conditions bywomen and men. Their data also showed that as length ofresidence increased, women and men were more likelythan the Canadian-born population to report poor healthstatus. They explain these findings by the fact that age iscertainly associated with reports of poorer health statusamong the migrant population, as is the case with olderCanadians in general.With respect to self-reports of chronic conditions, womenwho had experienced migration were less likely to reportchronic conditions than Canadian-born women, and theFigure 5Figure 5. Adjusted ¥ odds ratios of self-reports of poor healthby length of residence and ethnic affiliationOdds ratios 95% Confidence interval Selected determinants Men Women Men Women Canadian bornx - - - - 0-2 years 0.55* 0.48* 0.31, 0.99 0.30, 0.77 3-9 years 0.63* 0.96 0.44, 0.88 0.74, 1.26 Length of residence in Canada since migration 10 years + 1.10 1.31* 0.98, 1.24 1.18, 1.45 Canadianx - - - - Chinese 1.14 1.01 0.82, 1.60 0.75, 1.36 South Asian 1.03 1.42* 0.70, 1.51 1.06, 1.91 Black 0.40* 1.27 0.19, 0.85 0.78, 2.06 Ethnic affiliation Western European 1.16* 1.02 1.03, 1.31 0.91, 1.13 ¥ determinants adjusted for are as follows: age, marital status, educational attainment,  income adequacy, dwelling security, food insecurity and employment status; xReference group*Significance level p < 0.05 Source: CCHS 2000Page 7 of 11(page number not for citation purposes)needs of care between women and men who experiencemigration.gradient among women according to their years of resi-dence in Canada was steeper than for men. Furthermore,BMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32women and men identifying themselves as having West-ern European origin were more likely to report chronicconditions. Similar results were obtained by Dunn andDyck using the NPHS.[13] Our descriptive data showedthat those who identified themselves as having WesternEuropean origin were older and more established immi-grants, and this may partly explain the likelihood ofreports of chronic conditions among women and menwho migrated to Canada a long time ago.These trends in research results raise the possibility thatsocio-economic inequalities cannot fully explain ethnicinequalities in health.[51,54] This very measure is cultur-ally bound. As Nazroo points out,[51] "It is important torecognize that the process of standardization for socio-economic position when making comparisons acrossgroups, particularly ethnic groups, may not be so straight-encing migration needs to be accounted for, not only withrespect to their country of birth, but also the country oforigin, the migratory trajectory and the actual experiencesof migration as they relate to health.Variables such as migration, as measured here by length ofresidence in Canada, as well as self-reports of ethnic affil-iation are indeed complex variables; they need to beexamined in conjunction with variables such as age atmigration, conditions of migration and socio-economicconditions across the life course.[22,25,27] The progres-sive integration process also needs to be examined with amore systematic gender perspective. Language spokeninside and outside the home, values and religious observ-ances may be associated with different aspects of the pro-gressive integration process; the latter may occurdifferentially between women and men. Indeed, the rela-Figure 6Figure 6. Adjusted ¥ odds ratios of self-reports of chronic conditions by length of residence and ethnic affiliationOdds ratios 95% Confidence interval Selected determinants Men Women Men Women Canadian bornx - - - - 0-2 years 0.42* 0.35* 0.33, 0.55 0.27, 0.46 3-9 years 0.47* 0.41* 0.38, 0.57 0.35, 0.48 Length of residence in Canada since migration 10 years + 0.82* 0.87* 0.75, 0.90 0.79, 0.95 Canadianx - - - - Chinese 0.74* 0.64* 0.59, 0.92 0.53, 0.77 South Asian 0.64* 0.60* 0.52, 0.80 0.48, 0.75 Black 0.66 1.00 0.44, 1.00 0.72, 1.40 Ethnic affiliation Western European 1.19* 1.14* 1.10, 1.28 1.05, 1.24 ¥ determinants adjusted for are as follows: age, marital status, educational attainment,  income adequacy, dwelling security, food insecurity and employment status; xReference group*Significance level p < 0.05 Source: CCHS 2000Page 8 of 11(page number not for citation purposes)forward." In cross-cultural research, the heterogeneity ofwomen and men who constitute the population experi-tion between taking on host country culture and relin-quishing the culture of origin is not reciprocal, as a strictBMC Women's Health 2004, 4:S32 http://www.biomedcentral.com/1472-6874/4/S1/S32assimilation model would imply; therefore, acculturationis not a linear process, simultaneously invoking healthrisk and protective environment.[14,17,61-67] Further-more, it has also been shown that ethnic differences inself-reported health cannot be assumed to be a conse-quence of cultural differences between immigrantgroups.[22-24,28,38,54,61]Examining migration as a determinant of health requiresmore research and debate on the methods of measuringethnicity and migration variables that would betteraccount for gender and diversity in the experiences ofmigration as time of residence in a host country increases.Some have argued that it is time to abandon the assess-ment of race/ethnicity in public health research.[68] Oth-ers, including a number of authors in this Report, insistthat collecting gender, ethnicity and migration data alongwith other social determinants of health is necessary tothe creation of gender sensitive and culturally appropriateinterventions of public health surveillance that contributeto the elimination of ethnic inequalities inhealth.[14,17,21-23,29,42,43,47,51,55]Data Gaps and Recommendations• Current surveillance methods need to continue andinclude representative samples of subgroups in the Cana-dian population; the heterogeneity of women and menexperiencing migration requires that large enough sam-ples of women and men from different countries of birthas well as countries of origin are selected so that culturallysensitive conclusions can be drawn and allow for a properanalysis of the health determinants of women fromdiverse ethnic backgrounds and/or experiences of migra-tion.• Migration experience needs to be conceptualizedaccording to the results of past studies and included as asocial determinant of health above and beyond ethnicityand culture. It is expected that the upcoming longitudinalsurvey of immigrants will help enhance surveillancecapacity in this area.• In order to account for the cultural differences in thepathways of experiencing health and chronic conditionsand because these experiences are relational and illustratethe underlying mechanisms for the differential distribu-tion of health by socio-economic position, it is importantto adopt not only a gender sensitive approach to thedevelopment of indicators but also a broader diversityinterpretation of the health effects of potential advanta-geous and disadvantageous conditions – for example, totry and account for the social capital of women and menwho undergo experiences of migration (network, resil-resources by women, men and other members of the fam-ily).• Issues such as accessibility (cultural, geographic, linguis-tic, financial), appropriateness and adequacy of healthservices are unlikely to be unique to women and menexperiencing migration and need to be systematicallyaccounted for.• There should be consideration of the underlying socio-economic and socio-political forces that shape the lifeconditions of women and men who are from a diversebackground and/or undergo migration.• Variables need to be constructed to allow women andmen to best identify themselves appropriately accordingto ethnic identity and number of years in the host country;some of the proposed categories used as a cultural groupmay simply refer to skin colour without capturing associ-ated elements of culture, ethnicity and life experiences.• Variables need to be constructed to reflect the ability tocope with a physically or psychologically hazardous workenvironment, which has been shown to be associatedwith a better trajectory of healthy life in a new countryand/or culture.• Research designs need to account for the fact that report-ing of perceived health and presence of chronic condi-tions is sensitive to gender, culture and ethnicity as well asmigration experience.• A variety of research strategies are needed that shouldinclude a diversity of women and men to collaborate inthe development, design, and implementation of nationalmonitoring.References1. 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