Migration and Diabetes Self-management, health service use and information seeking for diabetes care among recent immi

1. Migration and Diabetes Self-management, health service use and information seeking for diabetes care among recent immigrants in Toronto Ilene Hyman, PhD Presentation to the MULTICULTURAL HEALTH AND CHRONIC ILLNESS: FROM HEALTH PROMOTION TO PALLIATION November 18, 2011

2. Prevalence 5% of the Canadian pop. is living with Type II diabetes and this will increase to 11% by 2020 (CDA, 2011). Prevalence of Type II diabetes is increasing among Canadian immigrants (PHAC, 2005) with variation by ethnicity and country of origin. Immigrants from South Asia, Latin America, the Caribbean and sub-Saharan Africa have a two –three times greater risk of developing diabetes than Western European or North American immigrant populations (Creatore et al., 2010). Elevated risk begins earlier in life (e.g. 20 – 40) and is equivalent or higher among women (e.g. 35-49) (Creatore et al., 2010).

3. Management and Control The effective control of diabetes depends on self-management. Recognition of the complexity of pathways that limit opportunities to engage in health enhancing behaviours, deter access to health care and information, contribute to psychosocial stress, which may impact on diabetes outcomes. Barriers to health care for immigrants are well documented: informational, financial, linguistic, cultural and systemic (Hyman, 2001; 2009).

4. Study Description Main Objective: To explore self-management, information seeking and access to health care among recent immigrants in the GTA. This research was part of an international collaborative study on migration and diabetes being coordinated by the International Centre for Migration and Health (ICMH) in Geneva, Switzerland. Two Canadian sites: Toronto and Montreal Funding: Public Health Agency of Canada (research) and Citizenship and Immigration Canada (KT).

5. Migration and Diabetes Project: Research Team Investigators: • Ilene Hyman, Yogendra Shakya, Anneke (Joanna) Rummens, Dianne Patychuk, Marisa Creatore • Qamar Zaidi, Research Coordinator (Urdu) • Sivajini Sivasamy, Assistant Research Coordinator/Peer Researcher (Tamil) • Khaleda Yesmin, Peer Researcher (Bengali) • Ying Zhou, Peer Researcher (Mandarin) • Dragan Kljujic, Data Manager, CAPI Programmer and Designer

6. Methods Exploratory study Adaptation of an international questionnaire Translation into 4 study languages CAPI development and training Ethics (U of T and collaborating hospitals) No sampling frame – use of community-based recruitment strategies

7. Measures Socio-demographic variables Self-management practices Use of health services Information seeking Barriers to accessing health care

8. Study Population – recent immigrants (O-9 years in Canada) Rationale for selection: High risk of developing diabetes post-migration and/or Current immigration trends in Canada and/or Major social, economic and linguistic barriers to care and/or Pre-existing relationships with newcomer organizations

9. Table 1 – Demographics, recent immigrants and Canadian-born

10. Figure 1 – Self-management practices: Recent immigrants and Canadian-born study groups *** p < 0.001; * p < 0.05 1 significant differences by gender 2 significant differences by country of origin

11. Diabetes Care • Family physicians usual source of care for both groups. • No difference in rates of eye exams (ever) and A1C (every 3 months). • Rates of ‘never’ having foot exam signif. higher for recent immigrants. • Fewer recent immigrants use specialists (24.6%, 40.7%) or dieticians (19.3%, 38.9%)

12. Sources of Information • Recent immigrants less likely to seek information from dieticians (24.6%, 40.7%), nurses (11.5%, 24.1%) and Diabetes Associations (2.3%, 24.1%). • Recent immigrants more likely to rely on friends (39.2%, 13%) and family (46.9%, 27.8%). • No difference between groups in use of the internet (28.5%, 29.6%).

13. Barriers to Care • Long waits to see MD/specialist • Lack of information on where to go • Language problems • Child care issues • Finding a doctor of the same gender • Costs not covered by insurance (p<.05)

14. STUDY LIMITATIONS • Small sample sizes • Limitations of sampling frame • Differences in severity of diabetes • Similar rates of participants reporting ‘diabetes under control’ (76.6%, 78.8%). • Similar rates of gestational diabetes. • Risk of obesity risk was higher in the Canadian-born group compared to recent immigrants. • Recent immigrants reported more problems associated with diabetes than Canadian-born group.

15. Implications for Practice and policy Address informational and systemic barriers to diabetes care. Positive health practices need to be encouraged and supported. Continue to address the SDOH, especially income, that contribute to diabetes inequities in newcomer communities Develop and support policies and strategies that recognize unique needs of newcomer communities as a priority population (e.g., language and other supports) Identify community information sharing networks and community-based support systems (informal and formal) as the foundation for prevention and health promotion strategies.

16. Next steps: Diabetes Prevention and Management in the Black Caribbean Communities in Toronto - Gucciardi, E. (co-PI) Objectives: • Compare risk factors associated with diabetes between Black Caribbean newcomers with and without diabetes. • Compare risk factors associated with diabetes between newcomer Caribbean and other newcomer communities with diabetes. • Compare access to diabetes education and care between newcomer and Canadian-born members of Black Caribbean communities with diabetes. • Compare access to diabetes education and care between Canadian-born Black Caribbean and non-Black Caribbean communities.

17. THANK YOU!QUESTIONS / COMMENTS?