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Rate of Mental Health Service Utilization By Chinese Immigrants in British Columbia

Posted on: Tuesday, 25 January 2005, 03:00 CST

ABSTRACT

Objective: Reports suggest that immigrants are under-served by the mental health service system. The aim of this study is to examine the rates of mental health visits and hospitalization of Chinese immigrants in British Columbia using historic administrative databases.

Method: A total of more than 150,000 Chinese immigrants who landed in BC between 1985 and 2000 were identified from an immigration database which was linked to the province's administrative health records, as part of a national study on immigrant health. Controls were individually matched to immigrants by sex, age and region and randomly selected from the general BC population.

Results: Preliminary results confirm that, while Chinese immigrants use less overall health care than controls, the difference in utilization rates is particularly pronounced with regard to mental health problems, especially for visits to psychiatrists and psychiatric hospitalization.

Discussion: The under-utilization of mental health services may reflect better health status, ongoing barriers to access, or other factors. There are different implications for health policy-makers. Further research is necessary to determine the reasons for the low rates of utilization.

MeSH terms: mental health services; immigrants; utilization; Chinese; British Columbia

RSUM

Objectif : Selon plusieurs rapports, le systme des services de sant mentale desservirait mal les immigrants. Notre tude visait examiner les taux de consultation des services de sant mentale et les taux d'hospitalisation d'immigrants chinois en Colombie- Britannique partir de bases de donnes administratives historiques.

Mthode : Nous avons recens plus de 1 50 000 immigrants chinois tablis en ColombieBritannique entre 1985 et 2000 partir d'une base de donnes de l'immigration, relie aux dossiers de sant administratifs de la province dans le cadre d'une tude nationale sur la sant des immigrants. Nous avons jumel, selon le sexe, l'ge et la rgion, des immigrants et des tmoins choisis au hasard dans la population gnrale de la Colombie-Britannique.

Rsultats : Nos rsultats prliminaires confirment que mme si les immigrants chinois utilisent moins les soins de sant que les tmoins dans l'ensemble, l'cart dans les taux d'utilisation est particulirement marqu en ce qui a trait aux problmes de sant mentale, surtout pour les consultations de psychiatres et les hospitalisations dans des services de psychiatrie.

Discussion : La sous-utilisation des services de sant mentale peut reflter un meilleur tat de sant chez les immigrants, des obstacles continus l'accs ou d'autres facteurs, ce qui a des rpercussions diffrentes pour les responsables des politiques de sant. Une recherche plus pousse s'impose pour dterminer les causes des faibles taux d'utilisation.

In 2001, 26% of British Columbia's population was comprised of immigrants, 37% of whom arrived within the previous 10 years. Among these recent immigrants, 40% were of Chinese origin.1 Providing appropriate health services to such a culturally diverse population is a challenge to health policy-makers and service planners. There are reports that immigrants are less likely to use mental health services, but no comprehensive Canadian studies on this topic are available.2,3 The objective of this study, therefore, is to examine the rates of mental health visits and hospital discharges from 1991 to 2000 by recent Chinese immigrants to BC.

METHODS

As part of a national immigrant health project, a database of information on immigrants who landed in Canada between 1985 and 2000 and whose stated destination was BC was linked to the province's administrative health database by probabilistic linkage/1 Those immigrants whose place of birth and place of last permanent residence were either Hong Kong, China, Taiwan or Macau were identified as subjects for this study and their health care utilization records were extracted for analysis. Control subjects were individually matched to the immigrants by sex, age and health region, and randomly selected from the province's health plan registry, excluding those in the immigration database. This resulted in a study population of 154,728 Chinese immigrants and the same number of controls, with 51% being female and 49% male.

The number of mental health visits was derived from EC's database of fee-forservice payments to physicians. A mental health visit was defined as all inpatient and outpatient services provided to a patient in one day by a general practitioner for mental health problems or by a psychiatrist. Information on hospitalization was obtained from the hospital discharge database. Mental health hospitalizations include all hospital discharges where the most responsible diagnosis was a mental health problem or where the patient service was psychiatry or the most responsible physician was a psychiatrist. Only visits and hospitalizations that occurred between 1991 and 2000 and after the landing date of the respective immigrants were included in the analysis. Rates for both mental health visits and hospital discharges were estimated by negative binomial regression modelling, weighted by the length of time each subject was registered in the health plan during the study period. The rates of all physician visits and hospital discharges for the immigrants and controls, regardless of diagnosis, were also calculated for comparison purposes.

TABLE 1

Rate of Physician Visits per 100 Person Years in 1991-2000

TABLE II

Rate of Hospital Discharges per 1000 Person Years in 1991-2000

Ethics approval for the study was received from the University of British Columbia Clinical Research Ethics Board.

RESULTS

Table I shows the rates of physician visits in 1991-2000. While females in both the immigrant population and the control group had higher rates of visits than males, rates for the Chinese immigrants were significantly lower than controls for both sexes. The relative difference was larger for mental health visits than for all physician visits and particularly pronounced in psychiatry. Whereas Chinese immigrant women were 59% as likely as control women to consult physicians, their rate of visits to general practitioners for mental health reasons was only 20% that of control women and rate of visits to psychiatrists was 10%. Among men, Chinese immigrants were half as likely as controls to visit any physician while their rates of mental health visits to general practice and psychiatry compared to controls were 14% and 11% respectively.

A similar pattern was seen in hospital discharges. Table II shows that the overall rate of hospital discharges was much lower among Chinese immigrants than controls and the contrast was greater in mental health hospitalizations. While Chinese immigrant women were half as likely as controls to be hospitalized, they were only 15% as likely to be hospitalized for psychiatric reasons. The difference was more exaggerated among men, with controls having almost 3 times the rate of hospital discharges of Chinese immigrants but 12 times the rate of mental health hospital discharges. Sex difference was not observed in mental health discharges in the control group.

DISCUSSION

This is the first population-based Canadian study on immigrants' utilization of mental health services using administrative databases. The findings confirm earlier reports that immigrants are less likely to use mental health care, especially with respect to specialist and hospital care. A limitation of administrative database analysis is that the reason for the discrepancy cannot be immediately determined. Several explanations are possible. The first hypothesis that Chinese immigrants enjoy better mental health is supported by epidemiological studies which found lower prevalence rates of mental disorders in Hong Kong, Taiwan and China - the source regions of the study population in this paper.5-7 If this is the case, it behooves the population and public health community to identify the protective factors among these immigrants for maintaining their positive mental health status, as such knowledge would benefit the general Canadian population.

Several studies suggest that another explanation for the immigrants' reduced use of mental health services is cultural and language barriers.8-10 The particularly low rate of visits to psychiatry is consistent with evidence that use of specialists is associated with English skills.8 If this is the circumstance, it will be important to examine the health and social outcomes of untreated and under-treated mental illness. It is also crucial that vulnerable subgroups within this immigrant population be identified for targeted programs.

Other alternative explanations may elucidate the results of this study. For instance, the low rates may be an artefact of physician practice patterns. Immigrants tend to seek care from general practitioners who share their language background.8,11 It is plausible that these physicians are less disposed to diagnosing mental health problems or referring their patients to specialist care, resulting in fewer visits made by immigrants being identified as mental health visits. This scenario implies very di\fferent strategies to ensure that immigrants receive adequate mental health care. Further research is necessary to understand the factors that contribute to the low rates of mental health service utilization by Chinese immigrants in BC; such efforts are required to achieve the best health outcome for all Canadians.

REFERENCES

1. 2001 Census of Population. Statistics Canada.

2. Kirmayer LJ, Galbaud du Fort G, Young A, Weinteld M, Lasry J. Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study, Culture & Mental Health Research Unit Report No. 6. Montreal: McGill University, 1996.

3. Klimidis S, McKenzie DP, Lewis J, Minas IH. Continuity of contact with psychiatric services: Immigrant and Australian-born patients. ,Sor Psychiatry Psychiatr Epidemhl 2000;35:554-63.

4. DesMeules M, Gold J, Kazanjian A, Manuel D, Payne J, Vissandje B, et al. New approaches to immigrant health assessment. Can J Public Health 2004;95(3):I22-I26.

5. Chen C, Wong J, Lee N, Ghan-Ho M, Lau JT, Fung M. The Shatin Community Mental Health Survey in Hong Kong. Arch Gen Psychiatry 1993;50:125-33.

6. Hwu H, Yeh E, Chang L. Prevalence of psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatr Scand 1989;79:136-47.

7. WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291(21):2581-90.

8. Stuart GW, Minas IH, Klimidis S, O'Connell S. English language ability and mental health service utilization: A census. Amt N Z J Psychiatry 1996;30(2):270-77.

9. Tahora BL, Flaskerud JH. Mental health beliefs, practices, and knowledge of Chinese American immigrant women. Issues Ment Health Nurs 1997; 18:173-89.

10. Ying Y, Miller LS. Help-seeking behavior and attitude of Chinese Americans regarding psychological problems. Am J Community Psychol 1992;20(4):549-56.

11. Leduc N, Proulx M. Patterns of health services utilization by recent immigrants. J Immigrant Health 2004;6(1):15-27.

Alice W. Chen, PhD(Cand)

Armine Kazanjian, DrSoc

Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC

Correspondence and reprint requests: Alice W. Chen, Department of Health Care and Epidemiology, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC V6T 1Z3, Tel: 604-438-7405, Fax: 604- 822-4994, E-mail: alice.chen@canada.com

Acknowledgement: A.W. Chen is supported by training fellowships from: Institute of Health Services and Policy Research, Canadian Institutes of Health Research; Western Regional Training Centre, funded by Canadian Health Services Research Foundation, Alberta Heritage Foundation for Medical Research and Canadian Institutes of Health Research; and Research in Addictions and Mental Health Policy and Services Strategic Training Program, funded by Canadian Institutes of Health Research.

Copyright Canadian Public Health Association Jan/Feb 2005

Source: Canadian Journal of Public Health

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