Abstract
ObjectivesHealth region differences in immigration patterns and premature mortality rates exist in Ontario, Canada. This study used linked population-based databases to describe the regional proportion of immigrants in the context of provincial health region variation in premature mortality.MethodsWe analyzed all adult premature deaths in Ontario from 1992 to 2012 using linked population files, Canadian census, and death registry databases. Geographic boundaries were analyzed according to 14 health service regions, known as Local Health Integration Networks (LHINs). We assessed the role of immigrant status and regional proportion of immigrants in the context of these health region variations and assessed the contribution using sex-specific multilevel negative binomial models, accounting for age, individual- and area-level immigration, and area-level material deprivation.ResultsWe observed significant premature mortality variation among health service regions in Ontario between 1992 and 2012. Average annual rates ranged across LHINs from 3.03 to 6.40 per 1000 among males and 2.04 to 3.98 per 1000 among females. The median rate ratio (RR) decreased for men from 1.14 (95% CI 1.06, 1.19) to 1.07 (95% CI 1.00, 1.11) after adjusting for year, age, area-based material deprivation, and individual- and area-level immigration, and among females reduced from 1.13 (95% CI 1.05, 1.18) to 1.04 (95% CI 1.00, 1.05). These adjustments explained 84.1% and 94.4% of the LHIN-level variation in males and females respectively. Reduced premature mortality rates were associated with immigrants compared with those for long-term residents in the fully adjusted models for both males 0.43 (95% CI 0.42, 0.44) and females 0.45 (0.44, 0.46).ConclusionThe findings demonstrate that health region differences in premature mortality in Ontario are in part explained by individual-level effects associated with the health advantage of immigrants, as well as contextual area-level effects that are associated with regional differences in the immigrant population. These factors should be considered in addition to health system factors when looking at health region variation in premature deaths.
Highlights
In the 20-year period spanning 1992 and 2012, Ontario, Canada’s most populous province, achieved substantial declines in all-cause mortality rates by 40% in men and 30% in women (Rosella et al 2016)
Relative to neighbourhoods with the highest material deprivation (Q5), the proportions of premature deaths were higher in Toronto and Northern regions compared with those of similar neighbourhoods in the Greater Toronto and Hamilton (GTHA), Western, and Eastern regions
Using population-based linked mortality data, this study has demonstrated that the observed regional variation in premature mortality in Ontario, Canada, is patterned by regional differences in the immigrant population
Summary
In the 20-year period spanning 1992 and 2012, Ontario, Canada’s most populous province, achieved substantial declines in all-cause mortality rates by 40% in men and 30% in women (Rosella et al 2016). Despite the overall reductions in mortality, a geographic gradient in mortality exists in that the centrally located regions of Ontario generally have shown lower all-cause and premature mortality rates compared with those regions located in the eastern, northern, and western boundaries of the province (Buajitti et al 2018). Ontario exhibits a unique population structure with an estimated 29.1% of the total population comprised of immigrants as of 2016 (Statistics Canada 2017). The majority of immigrants to Ontario settle in major urban cities located centrally in the Greater Toronto census metropolitan area, which was home to 70.2% of Ontario’s immigrant population in 2016 (Statistics Canada 2019)
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