Morbidity-Mortality Paradox Among South Asians Living in Britain

Matthew Wallace, Ined
Frances Darlington-Pollock, University of Liverpool

Background: immigrants from India, Pakistan, and Bangladesh are three of the largest and most important foreign-born populations in Britain. The morbidity-mortality literature on South Asians is fascinating because they report higher limiting long-term illness (LLTI) rates yet lower mortality than the UK-born. Such an inconsistency may be down to study design i.e. differing definitions, time periods, and age-ranges. However, given that LLTI has been proven to be an effective proxy for mortality, such an inconsistency remains striking. Aim: we would like to know whether the paradox is real: are South Asians living longer, but in worse health, than the UK-born (which would impact demand for health services and require culture-specific health policies) or whether it is generated by overestimation of LLTI, or underestimation of mortality. Our initial aim is to calculate LLTI and mortality ratios for Indians, Pakistanis and Bangladeshis, using a consistent definition (country of birth), age group (20-85+) and period (2010-2012) to determine whether we can observe this morbidity-mortality paradox among South Asians. Data and methods: we calculate age-adjusted and age-specific LLTI and mortality incidence rate ratios through Poisson regression by sex, using the age range 20-24 up to 85+. Death and population counts are taken from the 2011 Census and Office for National Statistics Mortality tables; LLTI and population counts are taken from a 5% sample of the 2011 Census. Results: we observe this morbidity-mortality paradox in all groups except Indian males. The paradox begins emerges around age 40. Future work: our next step is to use an individual-level, longitudinal dataset which allows us to track South Asians and UK-born by their linked LLTI-mortality status. In doing this we will be able to investigate differences in mortality (rates, time-to-death, and cause of death) among South Asians relative to the England and Wales-born according to their LLTI status.

Morbidity-mortality paradox amongSouth Asians in Britain

MatthewWallace

Ined

FranDarlington-Pollock

University of Liverpool

Introduction

Migration from SouthAsia (India, Pakistan, and Bangladesh) played a pivotal role in the rebuilding ofBritain after WWII, with individuals encouraged to move to fill severe laborshortages across Britain’s industries1. While the nature of these streams has changed (from labor, to familyreunification, to education), South Asians have continued moving to Britain. In2011, India became the largest non-UK country of birth in Britain, with Pakistan4th, and Bangladesh 8th. The morbidity-mortality literatureon South Asians is fascinating: they are found to report higher limitinglong-term illness (LLTI) rates2-4 while experiencing lower mortality than the UK-born5-7. Such an inconsistency may be down to study design i.e. differingdefinitions, time periods, and age-ranges. For example, some define migrants bycountry of birth5,6, ethnicity (which includes the G2+)3 or a combination thereof7. Regardless, LLTI is an effective proxy for mortality so such an inconsistencyremains striking. We question whether the paradox is real i.e. are South Asiansliving longer, but in worse health, than the UK-born (which would impact demandfor health services, requiring culture-specific policies) or, whether it isgenerated by either an overestimation of LLTI or an underestimation ofmortality. Initially, we aim to calculate LLTI and mortality ratios for SouthAsians, using a consistent definition (country of birth), age group (20-85+)and period (2010-2012), to determine whether we observe a morbidity-mortalityparadox. If so, we want to see if it differs according to the two most fundamentaldemographic characteristics: sex and age.

Data, Methods

We calculateage-adjusted and age-specific LLTI and mortality incidence rate ratios (IRR) viaPoisson regression by sex, using the age range 20-24 up to 85+. Death andpopulation counts are taken from the 2011 Census and Office for NationalStatistics Mortality tables; LLTI and population counts are taken from a 5% sampleof the 2011 Census. The age-adjusted results are displayed in Figure 1 whichfor the first time presents comparable LLTI and mortality estimates among SouthAsians. The age-specific results are displayed in Figure 2, illustrating at whatages the paradox (when it is observed) emerges.

Results

In Fig.1, wefind the paradox in all groups except Indian males who have an LLTI IRRconsistent with their mortality IRR. We observe a difference by sex in thescale of LLTI IRR, but not mortality, which is consistent.

Figure1. Age-adjusted mortality and LLTI ratios relativeto UK-born.

In Fig.2,mortality differences are pronounced at young adult ages but approximate fullytowards the reference line, usually around age 50. Interestingly, in four ofthe six groups, mortality decreases post-retirement (65+). For LLTI, a commonshape is shared in Pakistanis and Bangladeshis, in which LLTI is not differentfrom the reference at young ages, rises above the reference line at age 40,peaks at age 60 and declines thereafter. For Indians, the shape is different,with both males and females reporting lower levels of LLTI before age 40 (withmales attenuating to the reference, but females rising above). Thus the paradoxtaken in its definition of high illness-low mortality emerges from age 40.

Figure2. Age-specific mortality and LLTI ratios relativeto UK-born.

 

Next steps

We will use anindividual-level, longitudinal dataset which allows us to track South Asiansand UK-born by their linked LLTI-mortality status. In doing this, we will beable to investigate differences in mortality (rates, time-to-death, and causeof) among South Asians relative to the England and Wales-born by LLTI status.Additionally, we will also calculate emigration rates by country of birth andLLTI status.

Bibliography

1             Castles,S., De Haas, H. & Miller, M. J. The age of migration: Internationalpopulation movements in the modern world. 5th edn,  (Palgrave Macmillan,2013).

2             Smith, N.R. & Grundy, E. Time period trends in ethnic inequalities in limiting longterm illness in England and Wales. Ethnicity and inequalities in health andsocial care 40, 198-208 (2011).

3             Bécares,L. Which ethnic groups have the poorest health? Ethnic health inequalities 1991to 2011. (Joseph Rowntree Foundation, Manchester, 2013).

4             Evandrou,M., Falkingham, J., Feng, Z. & Vlachantoni, A. Ethnic inequalities inlimiting health and self-reported health in later life revisited. Journal ofepidemiology and community health 0, 1-10 (2016).

5             Wallace,M. & Kulu, H. Low immigrant mortality in England and Wales: a dataartefact? Soc Sci Med 120, 100-109,doi:10.1016/j.socscimed.2014.08.032 (2014).

6             Wallace,M. & Kulu, H. Mortality among immigrants in England and Wales by majorcauses of death, 1971-2012: A longitudinal analysis of register-based data. SocSci Med 147, 209-221, doi:10.1016/j.socscimed.2015.10.060 (2015).

7             Scott,A. P. & Timaeus, I. M. Mortality differentials 1991-2005 by self-reportedethnicity: findings from the ONS Longitudinal Study. Journal of epidemiologyand community health 67, 743-750, doi:10.1136/jech-2012-202265(2013).

 

 

Presented in Session 1122: International Migration and Migrant Populations