Major Research Initiative (MRI) Projects

1. New Canadian Children and Youth Study (NCCYS) - Pilot Project

Research team (lead researcher, partners):

Morton Beiser, Department of Psychiatry, Faculty of Medicine, University of Toronto and

Centre for Addiction and Mental Health, Clarke Division.

Jacqueline Oxman-Martinez, The Centre for Applied Family Studies, School of Social Work,

McGill University

Linda Ogilvie, Faculty of Nursing, University of Alberta

Frank Trovato, Department of Sociology, University of Alberta

Chuck Humphrey, Data Library, University of Alberta

David Este, Faculty of Social Work, University of Calgary

Elizabeth Lynn, Chinese Information and Community Services

Jagama Gobena, Ethiopian Association in Toronto

Rajko Seat, Family Service Association of Metropolitan Toronto

Start date: January 1999

Date of completion: March 2000

Amount awarded from CERIS: $20,000 from CERIS MRI

Amount awarded from other sources of funding: $20,000 from Health Canada

Abstract:

The experience of adapting to a new society poses challenges to immigrant and refugee children. Examples of such challenges include establishing identities, experience of discrimination, integration into the school system, or access to health care system. These challenges may create health and mental health risks, on the one hand, and opportunity on the other. Neglect of the needs of immigrant and refugee children amplifies health and mental health risks. Appropriate response to their unique needs will help immigrant children realize their potential. The aim of the NCCYS pilot project is to address the needs of immigrant and refugee children during the resettlement process. The key research question for the NCCYS is: What are the health and mental health needs of immigrant and refugee children and youth in order to achieve physical health and mental development? Objectives and proposed methods include: (1) to design and test the feasibility of recruiting samples in a variety of immigrant and refugee communities in Toronto, (2) to develop partnerships with community, ethnospecific and multicultural groups with an interest in pursuing this study, (3) to adapt the National Longitudinal Survey of Children (NLSC) instruments, develop new sections relevant for the immigrant and refugee experience, translate and pretest documents, and (4) to collect pilot data on health and mental health in at least two new settler communities. Aside from the topic’s intrinsic importance and its potential to ultimately attract large-scale funding, the project will also address the gap of much needed research on the needs of immigrant children and youth. Through collaboration with different ethno-specific communities and among Metropolis centres, findings from this study will ultimately serve to provide support for evidence-based policy decisions in the area of immigration and settlement.

Outcomes/results:

(1) A culturally sensitive and linguistically appropriate survey instrument will be developed for the NCCYS.

(2) This instrument will be pilot tested in the Ethiopian, Hong Kong Chinese, and Former Yugoslavian immigrant communities.

(3) Data from immigrant and refugee children will be collected from three age cohorts: 4-5 year olds; 8-9 year olds; and 12-13 year olds.

Contribution to training and/or professional development:

The NCCYS project coordinator, Angela Shik, who is completing her doctoral thesis on the experience of loneliness among immigrant youth from Hong Kong, is trained to coordinate and conduct community-based, policy-directed immigration research. Through her coordination work, she has gathered information on the health needs of immigrant and refugee children and youth from community agencies and also from researchers in academia.

Angela Shik, NCCYS Project Coordinator

Role: helping to write grant proposals; adapting and developing the questionnaires; initiating and maintaining contacts with the community, ethnospecific and multicultural groups; hiring and coordinating the activities of personnel involved in data collection; operating computerized databases and managing the administrative aspects of the study.

Monika Curyk, NCCYS Community Researcher, Polish Immigrant and Community Services (PICS)

Role: initiating and maintaining contacts with community, ethno-specific and multicultural groups; conducting literature searches on computerized databases; preparation of literature review on the health status of immigrant and refugee children and youth.

Policy implications of work:

Findings from this study will provide support for evidence-based policy decisions in the area of immigration and settlement.

As described elsewhere, this project has now developed into NCCYS, a six-city study of immigration and refugee children involving all four Metropolis Centres.

2. Accommodating Diversity: Toronto at the Millennium (AD)

Research team (lead researcher, partners):

Michael Lanphier, Department of Sociology, York University

Paul Anisef, Department of Sociology, York University

Barbara Burnaby, Modern Language Centre, Ontario Institute for Studies in Education,

University of Toronto

Robert A. Murdie, Department of Geography, York University

Myer Siemiatycki, Department of Politics and School of Public Administration,

Ryerson Polytechnic University

John Shields, Department of Politics and School of Public Administration,

Ryerson Polytechnic University

Samuel Noh, Department of Psychiatry, University of Toronto, and Culture, Community and Health Studies Section, Centre for Addiction and Mental Health, Clarke Division

Ontario Ministry of Citizenship, Culture, and Recreation

Start date: July 1998

Date of completion: November 1999

Amount awarded from CERIS: Initial start-up grant from CERIS was $20,000.00.

Amount awarded from other sources of funding: In-kind funding from the provincial Ministry of Citizenship, Culture and Recreation (in the form of access to database and similar sources, with the assistance of ministry personnel) has been estimated as a sum of $7,500.00 and a grant was received from Heritage Canada for $58,000.

Abstract:

The AD project framed the accommodation of diversity in the multicultural metropolis of the Greater Toronto Area (GTA), through the optic of immigration and settlement. The research for this project is a multi-disciplinary collaboration among researchers who offer convergent perspectives on the dynamics of the civic culture of Toronto as a metropolis. This work drew upon past research that has been conducted by academics, governmental planning offices and community agencies. Within this frame, the researchers addressed the reciprocal impact of successive waves of immigration from diverse origins since 1960 on the development of Toronto as a metropolis and correspondingly, the effects of metropolis as a social form on the collective lives of those newly arrived and their descendants. This social portrait is composed of institutional analysis and evidence from community agencies of the development and change in their orientations as a result of increase and change in settlement patterns throughout the GTA.

Outcomes/results anticipated:

The AD project was designed to produce a series of research monographs destined for the interested public and written in language accessible to that audience. An edited book entitled, World in a City, will be published by the University of Toronto Press in the summer of 2003. It explores challenges relating to the accommodation of immigrants in Toronto with respect to health, education, housing, employment and community, and to the capacity of Toronto to sustain a civic society. The book offers a template for comparative studies of cities both within Canada and across countries. To facilitate this process, Paul Anisef, one of the co-editors, and Khan Rahi, representing an NGO and one of the chapter co-authors, have organized a series of workshops for the upcoming (September 2003) international Metropolis conference in Vienna.

World in a City will be followed by a series of publications exploring issues raised in its various chapters in more depth and detail. The first of these publications, Managing Two Worlds (Paul Anisef and Kenise Murphy Kilbride co-editors), derives from their work in the education domain that has involved a number of mature and younger scholars, and will be published by Scholars Press in 2003.

Contribution to training and/or professional development:

The AD project provided graduate students with training opportunities in the areas of annotation of research studies; data analysis of Census public use sample tapes; and library search techniques. It is also envisioned that future research monographs will provide graduate students with the opportunity to develop skills in interviewing and policy analysis of documents.

Six graduate students were hired to assist them in reviewing pertinent literature, and in conducting new analyses on public use and other data sets.

Policy implications of work:

As noted, World in a City is organised according to CERIS research domain chapters and within each chapter authors will attempt to flag those research and policy questions which have not been addressed and which will loom as important in the next decade or so. One implicit question is: What are the existing research gaps? Questions concerning structural discrimination by gender, for example, might be signalled. A second analogous question also will be addressed: What are the existing policy gaps?

Thus, each chapter will provide readers not only with a synthetic analysis of available research in a given domain but also identify major settlement issues and the models employed to accommodate diversity in response to those issues. Finally, each domain chapter will identify those gaps in knowledge that researchers, social service organisations, and policy makers currently face and will continue to encounter as we move into the millennium.

3. Changes in the Democratic Composition and Health Status of Immigrant Populations in Toronto’s Inner City

Research team (lead researcher, partners):

Richard Glazier, Associate Professor, Faculty of Medicine, University of Toronto, Inner City Health Research Unit, St. Michael's Hospital

Carl Amrhein

Robin Badgley

Elizabeth Badley

David Buckeridge

Marsha Cohen

Stephen Hwang

Byron Muldofsky

Dianne Patychuk

Leah Steele

Rob Wright

Nita Chaudry

Start date: April 2000

Projected date of completion: September 2003

Amount awarded from CERIS: $40,000

Abstract:

Recent immigrant communities face hardships that may create special health needs and barriers. This study explored the risk of hospitalization in high recent-immigration areas in Toronto compared to other Toronto neighbourhoods. The study used 1996 hospitalization and census data. Regression was used to examine the effects of recent immigration on hospitalization. Average household income was almost 60% lower ($36,122) in the highest versus the lowest immigration areas ($82,641). Most hospitalization categories showed significantly higher rates of admission as the proportion of recent immigrants increased. Income was significantly associated with all categories of hospitalization except surgical admissions. Higher recent-immigration areas exhibited higher risks for hospitalizations in contrast to the “healthy migrant effect.” These findings have important implications for health care planning, delivery, and policy.

Collaboration:

Community collaboration with Southeast Toronto Project (SETO) has helped ensure access to community ideas and perceptions and community input into research design, conduct, analyses and interpretations. Among SETO members are South Riverdale Community Health Centre, Toronto Public Health, Regent Park Community Health Centre, St. Michael’s Hospital, and the University of Toronto. All of these partners are actively involved in the provision of care to immigrants and immigrant communities.

The 1999 MRI resulted in a book chapter that is going to press shortly and a submitted paper. The chapter will appear in Immigration, Health and Ethnicity to be published by University of Toronto Press. The editors are Joanna Rummens, Morton Beiser and Samuel Noh. Our chapter is entitled "Utilization of Hospital Services by Recent Immigrants in Toronto, Canada"
The authors are Richard Glazier, Maria Creatore, Andrea Cortinois and Mohammad Agha.

Introduction:

Half of all new immigrants to Canada, approximately 100,000-125,000 annually, settle in or near Toronto.^1,2 One in eight of Toronto’s residents are recent immigrants, having arrived in Canada in the last five years. Recent immigrants can face unique hardships associated with emigration, adjustment, and integration into society. Socioeconomic factors likely play a major role, but other aspects of migration may impact a newcomer’s health and create special needs for health services as well as barriers to accessing health care. The impact immigration has on health and the use of health services by both individuals and areas experiencing high levels of recent immigration are not fully understood.

Canadian studies have shown varying results regarding the health services utilization of recent immigrants – depending on the type of service used, circumstances of migration, country of origin, and socioeconomic status. Some report few differences between the health service utilization rates of immigrant and Canadian-born populations,^3-8 while others report lower rates by recent immigrants.^3,4,6-13 Most earlier studies, however, did not satisfactorily differentiate between recent and non-recent immigrants, and thus may not have captured the immediate health effects of recent immigration and resettlement. As well, many previous studies used self-reported use of the health care system which often makes use of proxy respondents.^9,10 Only one study looked at general hospital discharge data for immigrants in British Columbia and Manitoba.¹¹

It is not clear if the reduced utilization observed in previous studies is due to better health (“healthy immigrant effect”) or whether it is due to decreased access to services. Hospitalization data are able to give an objective measure of health care use that is not associated with self-reported information or discretionary use of services. The purpose of this study is to examine the use of hospital inpatient services in high recent-immigration areas in Toronto, to more fully understand the health care needs of these areas. The results are interpreted in the context of the sociodemographic characteristics of those neighbourhoods that may most influence health and health care utilization.

Area of Research:

Setting

The geographic area covered by this study consists of the central southern portion of the amalgamated city of Toronto, Ontario, including the city’s downtown core. In 1996, the study area had a population of just under 800,000.

Descriptive analysis

To conduct the descriptive analyses on geographic areas relevant to community agencies and hospitals, we adopted the neighbourhoods defined by the city of Toronto Public Health Department.¹⁴ 1996 Canada Census data at the census tract level were aggregated into a total of 62 neighbourhoods which were then grouped into quintiles according to the proportion of recent immigrants in their population. Recent immigrants were defined as having immigrated between 1991 and 1996. The top three immigrant groups for each neighbourhood were determined and illustrated spatially on a map. Quintile five represented the highest percent of recent immigrants and the neighbourhoods comprising this quintile were described in a separate table. Neighbourhood quintiles were compared by socioeconomic status, immigration, and other factors.

To assess whether the incomes of recent immigrants are reflective of the incomes of the rest of the neighbourhood, we generated the percent difference in average total income earned by recent immigrants compared to other residents in the same neighbourhood. This information on income disparity was obtained in custom cross-tabulations from Statistics Canada.

Multivariate analyses

Hospitalization for major medical conditions based on hospitalization discharge abstracts from the Canadian Institute for Health Information, obtained from the Ontario Ministry of Health and Long Term Care, was the main outcome for the analyses. All residents of the study area with a hospital admission in 1996 anywhere in Ontario were included in the study. Using the most responsible diagnosis at hospital separation and the Medical Surgical INDicator, hospitalizations were grouped into five main categories: medical, surgical, obstetrical, psychiatric, or ambulatory care sensitive (ACS) conditions. Uncomplicated births were excluded from the obstetrical admissions. ACS conditions include diseases, such as pneumonia, diabetes, and asthma, for which it is widely believed that timely access to a usual source of primary care should reduce the need for hospital admission.¹⁵

Multivariate analyses were based on the enumeration area (EA) of residence, which is the smallest geographical area for which Canada Census socioeconomic data are available.¹⁶ Postal codes from the hospitalization data were converted to EAs using the Postal Code Conversion File available from Statistics Canada. Within each EA, the expected number of hospitalizations for males and females during the 1996 fiscal year was derived by applying the population age distribution of each EA to the age-specific rate of hospitalization for the entire study area. The observed/expected ratio of hospitalizations for each EA was then modelled using Poisson regression and odds ratios (ORs) were generated along with 95% confidence intervals (CIs). The baseline level of risk was the one experienced by the lowest recent immigration quintile. Average individual income was modelled separately because it was highly collinear with recent immigration (Pearson correlation coefficient = - 0.66).

Key Findings:

Descriptive analysis

The study area included 88,440 recent immigrants. Recent immigrants comprised one-fifth of the highest recent-immigration quintile and only 3% of the lowest. In general, the neighbourhoods with the highest proportion of recent immigrants had lower incomes, higher proportions of visible minorities, higher proportions of people not speaking English at home, and the largest proportion of immigrants from all periods of immigration (Table 1). The range of values in the highest immigration neighbourhoods is described in Table 2. The top three source countries for recent immigrants are displayed by neighbourhood in Figure 1. The average household income for the highest recent-immigration quintile was almost 60% lower ($36,122) than the average household income of the lowest immigration quintile ($82,641). Recent immigrants earned 37.5% less than the rest of the neighbourhood population independent of neighbourhood income level. This difference was not affected by the immigrant/non-immigrant composition of the neighbourhood.

Statistical analysis

The findings of our regression analysis demonstrate that all of the categories of hospitalization, except for surgical and mental health conditions in males, show significantly higher rates of admission for both females and males as the proportion of recent immigrants increases (Table 3). The highest relative rates of hospital admission are seen for ACS conditions where the highest quintile of recent immigration has rates of admission 1.5 times (95% CI = 1.3-1.8 for females and 1.3-1.7 for males) greater than the lowest quintile.

Income was significantly associated with all categories of hospitalization except for surgical admissions. With income already in the model, income disparity was not associated with hospitalization.

Directions for Research

Insights for future analyses, health care planning, policy, and delivery

Our findings demonstrate considerably greater hospital use and potentially more serious morbidity in areas with high rates of recent immigration. Whether this reflects the actual utilization by recent immigrants or some other area-level risk factors such as low socioeconomic status is not known. If they do reflect use by recent immigrants, these findings then contradict the “healthy migrant effect” (i.e., self-selection of migrants who are healthier and younger) supported by previous Canadian research.^9,10,17 As discussed earlier, however, previous research did not focus on hospitalization and was mostly limited to self-reported health care. Our findings also may differ from those of previous studies due to our focus on recent immigrants rather than all immigrants. Recent immigrants may face increased morbidity during the stressful years of initial adjustment rather than over the long term. In addition, immigration in the early 1990s may have been qualitatively different with respect to health status from earlier waves of immigration. Immigrants to Toronto’s inner city may also be unique with respect to health status compared with immigrants to suburban areas or other provinces.

If recent immigrants are indeed experiencing higher rates of hospitalization than the general population, there are various possible explanations. The most obvious may be higher rates of morbidity in this population resulting from circumstances related to migration or their pre-immigration experiences. An alternative to the “higher morbidity” explanation may be differences in physician practice style.¹⁸ Providers may feel that recent immigrants are less able to manage their conditions as outpatients and therefore require hospital admission. Another possible explanation, as suggested by our results for ACS conditions, is that residents of high immigration neighbourhoods may not receive timely access to primary care and may not be aware of steps they can take to decrease the progression of an illness episode, thereby avoiding hospitalization. This may be a result of barriers to the appropriate use of health services.

Immigrants generally report significantly more barriers to health care than non-immigrants.^7,13,19 Available health information and services are often not sensitive to cultural, faith, language, or literacy needs of diverse communities.^7,20 Language barriers in particular may be affecting access to care for an increasing number of new immigrants. The most common countries of origin for recent immigrants in the past 10 years have been increasingly from non-English speaking countries. In 2001, 45.3% of new immigrants to Toronto reported no knowledge of English or French.²

Chen et al. found that immigrant status and length of time in Canada were not associated with unmet need, but that income was a significant predictor.³ In their research, poor immigrants reported double the unmet need than higher-income immigrant households, suggesting that socioeconomic status may be a significant driving force behind unmet need among immigrants. Socioeconomic gradients in hospital utilization may be based on similar explanations, and thus greater morbidity in low-income areas may explain the variation in rates.²¹ The results of our analyses support the conclusion that income is a significant predictor of hospitalization and should be considered in any analysis involving the health of recent immigrants. In previous work, we found significant socioeconomic gradients in the use of hospital services in Toronto’s inner city. Since many high recent-immigration areas in Toronto’s inner city are also low-income areas,²² it is extremely difficult to disentangle the effects of immigration and income. Our income disparity findings suggest that the relationship may be even more complex given that recent immigrants not only settle in low-income areas, but regardless of where they settle, they earn considerably less than their non-immigrant neighbours. Thus, not only are recent immigrants exposed to neighbourhood poverty, but they also experience greater personal levels of poverty than their neighbours.

With area-level analyses we cannot determine who is being hospitalized, only that they are more likely to be from a high recent-immigration, low-income area. Individual-level analyses, preferably using hierarchical models that include neighbourhood effects, would be an important next step in this work. These neighbourhood-level results, however, form an important basis for health planning and resource allocation.

We conclude that neighbourhoods in Toronto’s inner city with high proportions of recent immigrants make greater use of inpatient hospital services than other neighbourhoods. These results are in contrast with much of the Canadian literature which has found decreased use of health services by recent immigrants. Although the causes underlying these effects are complex, multiple, and heavily influenced by socioeconomic status, increased morbidity and barriers to accessing care are likely to be among the contributing factors. These findings of greater utilization in high recent-immigration areas have important implications for health care planning, delivery, and policy.

References

1. Siemiatycki M, Isin E. Immigration, diversity and urban citizenship in Toronto. Can J Regional Sci 1998;20:73-102.

2. Citizenship and Immigration Canada. Facts and Figures, 2001 – Immigration Overview. Ottawa ON: Policy, Planning and Research, Citizenship and Immigration Canada, 2002.

3. Chen J, Ng E, Wilkins R. The health of Canada's immigrants in 1994-95. Health Rep 1996;7:33-45.

4. Globerman S. Immigration and Health Care Utilization Patterns in Canada. Research on Immigration and Integration in the Metropolis Working Paper Series. Vancouver, BC: Vancouver Centre of Excellence, 1998.

5. Hyman I, Stewart DE, Cameron JI, Singh M. Physician-related determinants of cervical cancer screening among Chinese and Vietnamese women in Toronto (Poster). Harvey Stancer Research Day, Centre for Addiction and Mental Health, Toronto, 2000.

6. Wen SW, Goel V, Williams JI. Utilization of health care services by immigrants and other ethnic/cultural groups in Ontario. Ethn Health 1996;1:99-109.

7. Kirmayer L, Galbaud du Fort G, Young A, Weinfeld M, Lasry JC. Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study Report No. 6 (Part 1). Toronto ON: Culture and Mental Health Research Unit, Sir Mortimer B. Davis Jewish General Hospital, 1996.

8. Laroche M. Health status and health services utilization of Canada's immigrant andnon-immigrant populations. Can Public Policy 2000;26:51-73.

9. Perez, CE. Health status and health behaviour among immigrants. Health Rep 2002; 13(Suppl.):1-12.

10. Ali, J. Mental health of Canada’s immigrants. Health Rep 2002;13(Suppl.):1-11.

11. Kliewer EV. Benign prostatic hyperplasia morbidity and mortality among immigrants in Australia and Canada. Prostate 1996;28:211-18.

12. Roberts N, Crockford D. Psychiatric admissions of Asian Canadians to an adolescent inpatient unit. Can J Psychiatry 1997;42:847-51.

13. Matuk LC. Pap smear screening practices in newcomer women. Women’s Health Issues 1996;6:82-88.

14. McKeown DJ. Indicators and Information Sources for Community Health Planning: A Resource Guide. Toronto, ON: City of Toronto Public Health Department, 1995.

15. Institute of Medicine. Access to Health Care in America. Washington, DC: National Academy Press, 1993.

16. Statistics Canada. 1996 Census Dictionary. Ottawa, ON: Minister of Industry, 1996.

17. Parakulam G, Krishnan V, Odynak D. Health status of Canadian-born and foreign-born residents. Can J Public Health 1992;83:311-14.

18. Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, et al. Preventable hospitalizations and access to health care. JAMA 1995;274:305-11.

19. Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees. After the Door Has Opened: Mental Health Issues Affecting Immigrants and Refugees. Ottawa, ON: Minister of Supply and Services Canada, 1988.

20. Bird JA, McPhee SJ, Ha NT, Le B, Davis T, Jenkins CN. Opening pathways to cancer screening for Vietnamese-American women: Lay health workers hold a key. Prev Med 1998;27:821-29.

21. Blustein J, Hanson K, Shea S. Preventable hospitalizations and socioeconomic status. Health Aff 1998;17:77-89.

22. Glazier RH, Badley EM, Arnold J, Rothman L. The nature of increased hospital use in poor neighborhoods: findings from a Canadian inner city. Can J Public Health 2000;91:268-73.

TABLE I Recent Immigration to Toronto's Inner City: Characteristics of Neighbourhoods by Immigration Quintiles*

Variables		Recent-Immigration Quintiles
	1†	2	3	4	5	Total Study Area
Mean Age (years)	39.7	37.4	36.6	35.6	35.7	36.9
Mean Household Income (C$)	82,641	56,308	45,523	40,182	36,122	52,004
Recent Immigrants (%)	3.6	7.2	10.7	13.2	20.4	11.2
Total Immigrants (%)	28.2	37.7	46.9	51.2	53.3	43.8
Recent Immigrants/Total Immigrants (%)	12.8	19.2	22.9	25.8	38.3	25.7
Knowledge of neither English nor French (%)	1.8	5.6	10.2	11.2	7.6	7.4
Home Language not Usually English (%)‡	11.0	22.0	34.0	37.5	36.7	28.7
Visible Minority Population (%)	11.4	22.8	27.2	36.2	49.9	29.9
Unemployment (%)	5.8	9.1	11.0	12.6	13.1	10.3
Population without High School Education (%)	19.8	26.7	36.7	43.7	31.7	31.9
Rental Housing (%)	44.1	58.5	58.5	57.0	82.7	60.7
Male: Female Ratio	0.9	0.9	1.0	1.0	0.9	0.9
% Difference in Average Income between Recent Immigrants and Others	-36.2	-44.3	-37.4	-33.1	-36.6	-37.5
* Quintile 5 is highest % of recent immigration and quintile 1 is lowest %. † One neighbourhood in this quintile had no recent immigrants and therefore was excluded from the disparity analysis. ‡ Single and multiple responses were used for this calculation.

TABLE II Recent Immigration to Toronto's Inner City: Characteristics of Neighbourhoods in the Highest Recent-immigration Quintile
Neighbourhoods in the Highest Recent-immigration Quintile	Mean Age (years)	Mean Household Income ($C)	Mean Household Income Quintile	Recent Immigrants (%)	Total Immigrants (%)	Recent Immigration/Total Immigration (%)	Knowledge of neither English nor French (%)	Home language not usually English (%)	Visible Minority Population (%)	Percent Income Disparity *
A	36.2	32,712	1	27.7	56.7	48.9	6.4	41.7	58.8	-36.1
B	35.5	34,257	1	25.9	55.8	46.3	5.1	35.5

Abstract:

Introduction:

Setting

Descriptive analysis

Statistical analysis

Directions for Research

Insights for future analyses, health care planning, policy, and delivery

References

TABLE I

Variables

Recent-Immigration Quintiles