Prepared for 2008 CPHA Conference, June 1-4, 2008 Steve Kisely MD Mikiko Terashima MSc

1. Using administrative data to analyze the health experience of African Nova Scotians—An exploratory study Prepared for 2008 CPHA Conference, June 1-4, 2008 Steve Kisely MD Mikiko Terashima MSc Donald Langille MD Department of Community Health & Epidemiology Dalhousie University

2. Study objectives • Investigate differential health experiences by different groups of people— ethnicity/race, socioeconomic situations, immigration status etc.—in Nova Scotia. • Need to identify patterns of health experience by different groups for further, more in-depth study (hypothesis building) • Explore ways to use health administration data and geographic information to study health experiences of different groups. • Few studies on ethnicity/race based health experiences using health administrative data • GIS as a way to link geographic information with health data

3. Canada Nova Scotia 31,241,030 913,465 Population Immigrants (%) Total visible minority (%) Aboriginal individuals (%) Language (English vs French)(%) 20% 5% 4% (2.2% African Nova Scotian) 13.4% 4% 2.7% English only 66% French only 21% Both 0.3% English only 96% French only 2% Both 0.1% Census Canada 2006

4. Two questions • How does incidence in members of African Nova Scotian communities compare with comparison communities and the province as a whole? • Are health service utilization patterns different from those expected based on the incidences?

5. “African Nova Scotian” communities? • “Being African Nova Scotian” or “living in a community with high rates of African Nova Scotian residents”? • According to Nova Scotia Community Counts (NSCC) data (2001 census), 19,670 individuals identified themselves as “black” for visible minority status • Individual status data unavailable on health records or census • There is only one “community” (NSCC defined) comprised predominantly of African Nova Scotian individuals • Preston is one of the well established communities resided by generations of families since late 1700s (86% African Nova Scotian individuals) • Only 14 out of 278 communities that have more than 5% African Nova Scotian individuals—an analysis of ethnic density gradient is not possible  Limitation of the study  Hybrid of the two questions

6. Data • Population Health Research Unit (PHRU) database • Discharge Abstract Database • Physician Billings database • Mental Health Outpatient Information System (MHOIS) • NS Community Counts – Census data recalibrated to “community” units • Statistics Canada Postal Code Conversion File (PCCF+ Version 4G, 2006)

7. Process/methods • 1. Carcinoma, 2. Diabetes, 3. Vascular diseases and 4. Mental disorder—ICD-9 • Age-sex standardized event ratios for: 1) hospital admission; 2) specialist visits; 3) general practitioner visits (plus 4) registration in MHOIS for mental health); and 5) any visits—“incidence”: Province as standard • One community qualified as “African Nova Soctian community” and seven comparison communities matched for community level socioeoconomic characteristics • 8 communities are in the lower 30 percentile of a material based deprivation scoring—Preston the lowest (most deprived), Tatamagouche the highest (least deprived) of them • Geocoding was used to count community level sums of events

8. Community characteristics NS Community Counts 2001 census data

9. Results Overall GP Specialist Hospital Overall GP Specialist Hospital MHOIS Overall GP Specialist Hospital Overall GP Specialist Hospital

10. Results (cont.) • The case community generally shows higher incidences than both province and the comparison communities • Rates for most communities are somewhat higher than the province in CVD and diabetes, while this is not necessarily the case with mental health and cancer • Respective service use patterns follow incidences in CVD and diabetes, but not mental health and cancer —for both case and comparison communities

11. Discussion • For CVD and diabetes, considerable part of the higher incidence compared with the province may be explained by socioeconomic characteristics. • Some differences in specialist, gp, and hospital service rates in communities may reflect what services are available locally. • Flip side of “compositional effect” • Although our result cannot be attributed to the individuals, the “composition” of the community is probably driving the rates.

12. Discussion (cont.) • Maybe that health experiences of African Nova Scotians in other communities, where they are a small minority, are less favourable than members of Preston community. • In which contextual scale relevant psychosocial factors affect individuals the most—communities, neighbourhoods, regions or province—are still unclear. • Immigration and language are unlikely factors given the historical presence of the community and its families

13. More questions than answers • Are psychosocial stress playing a role through forms of unfavourable social relations (discrimination, exclusion, history)? • Gene-environment interaction? • Are comparisons between subgroups of African Nova Scotians (e.g. based on their ancestral location) meaningful? • Are comparisons with experiences in groups of African origins elsewhere meaningful? • How do we move forward research on ethnicity/race based inequality in health in Canada?

14. Future study needs • Qualitative studies — guidance from African Nova Scotian leaders and residents • Clear conceptualization of psychosocial, material, contextual (and genetic) risk pathways • More specific diagnoses (e.g. exclude benign tumour) • Other group experiences (e.g. Francophone group, aboriginal peoples)

15. Acknowledgement The authors wish to thank: • The Capital Health Research Fund for funding of this project • The Population Health Research Unit (PHRU) within Dalhousie University’s Department of Community Health and Epidemiology Although this research is based on data obtained from the unit, the observations and opinions expressed are those of the authors and do not represent those of the Population Health Research Unit.

16. Thank you!