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
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).
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).

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).
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
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
MEASURES
 Socio-demographic
variables
 Self-management practices
 Use of health services
 Information seeking
 Barriers to accessing health
care
STUDY POPULATION – RECENT
IMMIGRANTS (O-9 YEARS IN CANADA)
Communities
Diabetes
+
Bangladeshi (Bengali-speaking)
35
Mainland Chinese (Mandarin-speaking)
30
Sri Lankan Tamils
30
Pakistani (Urdu-speaking)
35
Canadian Born
54
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
Table 1 – Demographics, recent immigrants and Canadian-born
Significant
differences
by gender
(p<.05)
Recent
immigrants
(N =130 )
Canadianborn adults
(N = 54)
P-value
Age
– Mean
51.15
52.28
ns
Marital status
- % Married
89.20
24.10
p < .001
52.30
35.20
ns
yes
33.80
29.60
ns
yes
60.00
94.40
p < .01
yes
41.30
0.00
p < .01
36.30
41.90
ns
---
75.90
Education
- or higher
Employment
- % Unemployed
Type of
employment
- % Permanent
Job reflects
credentials - % No
Income
- % Low income
Race
- % ‘White’
Significant
differences
by country
of origin
(p<.05)
yes
yes
Figure 1 – Self-management practices: Recent immigrants and
Canadian-born study groups
100
90
80
70
60
50
Immigrant
Non-Immigrant
40
30
20
10
0
% daily/weekly
% daily/weekly foot
glucose check***2
check***1,2
% smoking***2
*** p < 0.001; * p < 0.05
1 significant differences by gender
2 significant differences by country of origin
% regular physical % reducing dietary
activity*
fat moderately or a
lot***
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%)

80
66.2 75.9
60
60
Immigrant
33.3
40
17.1
20
24
NonImmigrant
0
% eye exam
(ever)
% foot exam
(never)***
% AIC (every 3
months)
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%).

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)

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.

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.
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 nonBlack Caribbean communities.
THANK YOU!
QUESTIONS / COMMENTS?