Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes | OPEN ACCESS
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People of Asian ethnicity are the third largest ethnic group in New Zealand,[[1]] and addressing their health is increasingly important. The Asian ethnic group in New Zealand comprises of people from a vast geographical area spanning from Afghanistan in the West, to Japan in the East, China in the North and Indonesia in the South.[[2]] This group currently makes up 15% of the New Zealand population (2018 census).[[1]] Population projections indicate that the size of the Asian ethnic group in New Zealand is already similar to that for Māori and nearly double the number of Pacific Peoples, and the numbers are increasing progressively (Table 1).[[3]]
Table 1: Projected population by ethnicity, median projection, 30 June 2020–2043.[[3]] View Table 1.
The proportion of the New Zealand population who are migrants (ie, born overseas) has steadily increased from 23% in 2006 to 25% in 2013 and 27% in the 2018 New Zealand census.[[4]] The majority of migrants are Asian.[[4]] Voluntary migration to New Zealand is permitted primarily for maintaining and sustaining economic vibrancy. Hence stringent health screening is imposed to ensure all migrants have a health advantage over the resident population on their arrival to enable economic gain and reduce any burden to the health system. However, it has been found that the health of some migrants declines more rapidly than expected following migration to New Zealand.[[5,6]]
Immigration is a recognised determinant of health.[[7]] This relates not only to expected factors, such as health status on arrival, age, gender, marital status, language skills and income, but also to the adoption of unhealthy lifestyle behaviours in the host country, which impacts negatively on the health of migrants.[[5,8,9]] For example, sibling studies among South Asians have found higher serum cholesterol levels and an increased prevalence of coronary heart disease among those who migrated to the UK compared with their siblings who remained in India.[[10]]
In New Zealand, the health of the Asian ethnic group is not well understood. Although much progress has been made since 2006 to address Asian health issues,[[11]] a number of challenges persist.[[12–14]] Current sources of data for monitoring Asian health in New Zealand include routinely collected population surveys and administrative data. Nevertheless, there are several important issues regarding how data are collected and reported for New Zealand Asians, which is the focus of this article. The arguments raised in this article are based on available health statistics for the South Asian people in New Zealand and use certain health indicators as examples, but the same arguments will hold for other health issues and for East and South East Asians who are at higher risk for other disorders, such as certain cancers.[[15]]
Asian health indicators from population surveys
The continued use of the single “Asian” category when reporting data from population health surveys, such as the New Zealand Health Survey (NZHS), obscures a true description of the health of this diverse population group. In fact, due to the effect of averaging, this practice grossly masks subgroup differences in health indicators, risk factors and disease prevalence.[[16]] For example, the prevalence of obesity was 16% for Asians in both the 2011–2013 [[17]] and 2019/20 [[18]] NZHSs. In addition to not using the World Health Organization (WHO) ethnic specific body mass index (BMI) categories to define obesity,[[19]] these surveys did not disaggregate the Asian ethnic group. A secondary analysis of the 2011–2013 data [[6]] clearly showed the effect of “masking.” When “Asian” was subdivided and ethnic specific BMI categories were used to define obesity, the prevalence of obesity among adults was 57% in South Asians, 25% in Chinese and 33% in the “Other” Asian group.[[6]]
In the 2008/09 Adult Nutrition Survey, data for Asians were not reported at all, but combined with the “European/Other” category.[[20]] However, secondary analysis of these data clearly showed subgroup differences in the prevalence of overweight/obesity and diagnosed diabetes within the Asian ethnic group.[[5]] Asians were sub-categorised as “South Asians” (people from India, Sri Lanka, Pakistan, Afghanistan, Nepal, Bangladesh, Fijian Indians) and “East and South East Asians” (people from China, Hong Kong, Malaysia, Singapore, Indonesia, Vietnam, Cambodia, Philippines, Thailand, Korea, Japan, Myanmar, Tibet). The prevalence of obesity was 66% and 56% in South Asian men and women, respectively, compared to 37% and 22% in East and South East Asian men and women.[[5]] The prevalence of diagnosed diabetes was 23% and 21% in South Asian men and women, respectively, in contrast to less than 1% in East and South East Asian men and women.[[5]]
Data from the NZHS series also show that the prevalence of “unmet need for primary health care” among Asians has increased over the last decade from 21.1% to 24.2%, with a significantly marked increase among Asian men (15.3% to 22.6%).[[17]] Disaggregated data from the 2011–12 and 2012–13 NZHSs (combined) for Asian subgroups indicate that a lower proportion of South Asians (88%), Chinese (87%) and Other Asian (82%) had a health practice or service to access, if unwell.[[6]] Poor access to healthcare was even more evident among new Asian migrants (those resident in New Zealand for less than five years), of whom only 62% reported being enrolled in a primary health organisation (PHO), in contrast to 91% of those who had lived in New Zealand for between 5 and 10 years and 93% of those who had lived in New Zealand for over 10 years.[[6]] These statistics suggest that new Asian migrants have a poor understanding of the New Zealand health system. This is compounded by cultural differences and poor English language proficiency, which in itself is a risk factor for the loss of the healthy migrant status enjoyed by new migrants. Hence understanding health issues using high-quality ethnicity data for Asians is imperative.
Asian health indicators from administrative data
As discussed above, grouping Asians together (level 1 ethnicity code) reduces prevalence estimates of disease for some groups. Using level 2 ethnicity codes can also mask disease prevalence in certain Asian subgroups. Healthcare administrative data usually record main ethnic groups only. For example, PHO enrolment forms include ethnicity but only provide options for the largest Asian subgroups, namely Indian, Chinese and “Other Asian.” The “Other Asian” category is a mixed group of South Asians, East Asians and South East Asians.[[3]] Indians make up 87% of South Asians,[[1]] and as noted above, South Asians have a high prevalence of obesity and diabetes.[[5]] This means that the high rates of obesity and diabetes among the other 13% of South Asians (Sri Lanka, Pakistan and Bangladesh) are obscured in PHO data, as they are captured as part of the “Other Asian” category.
Examples of studies using administrative data include the papers reporting cardiovascular disease incidence[[21]] and mortality rates[[22]] and publications from the PREDICT study. In a recent PREDICT publication,[[23]] Indians made up 8% of the 475,241 adults in the New Zealand primary care study population, and 10% were “Other Asians.” The prevalence of diabetes among Indians was higher (33% in women and 24% in men) than that of “Other Asians” (21% in women and 15% in men), which included South Asians from Sri Lanka, Pakistan and Bangladesh, who have a similar prevalence of diabetes to Indians, and people from Japan, Korea and other East and South East Asian countries, among whom diabetes is relatively uncommon.[[5]]
The use of the “Indian” group to make inferences for the South Asian group as a whole is an emerging practice, which has led to the inappropriate use of the category “South Asian” in making international comparisons. For instance, in 2017 Rabanal et al [[24]] used the data from the New Zealand PREDICT study, which has information on “Indians” only, to make comparisons with South Asians in Norway. Further, the ethnicity classification used in Norway for South Asian is not consistent with that used in New Zealand. For example, in Norway people from Myanmar are considered South Asian, whereas in New Zealand they are considered South East Asian.[[3]] Such inconsistent definitions of South Asian in New Zealand and other migrant-receiving countries pose a challenge for international comparisons. The use of the term “South Asian” to represent just one ethnicity, for example Indian, should be avoided to reduce ambiguity in interpreting research findings. Having a well-defined “South Asian” ethnic category to report health data in New Zealand will perhaps stimulate similar thinking and action in other migrant-receiving countries, such as the UK, Norway, USA and Canada, and improve international comparisons of health indicators.
The case for disaggregated Asian health statistics
By combining all Asians into one group, the overall poor metabolic health of South Asians is obscured. For example, in a secondary analysis of the NZHS data, South Asians were found to have a five- to six-fold increased risk of being on treatment for diabetes.[[6]] Similar findings have been observed in the USA,[[25]] Canada,[[26]] UK[[27]] and Norway,[[28]] where migrants from Sri Lanka and Pakistan (predominant South Asians in Norway) have a more than five-fold higher risk of diabetes and cardiovascular disease compared with the majority population and other migrant groups world-wide. International multi-ethnic studies have also found the prevalence of diabetes to be higher in younger (20–29-year-old) South Asians compared to other minority (Chinese, African American and Hispanic) and majority (European) ethnic groups.[[29]] In addition, national hospitalisation and mortality data in New Zealand suggest that Indians have a higher prevalence and incidence of cardiovascular disease when compared to NZ Europeans.[[21]] Cardiovascular disease mortality rates are significantly higher among people of Indian ethnicity compared to New Zealand Europeans[[22]] and other Asian subgroups in New Zealand, such as Chinese people.[[30]] Among New Zealand women who had been screened for gestational diabetes and birthed at National Women’s Health, the prevalence of gestational diabetes was reported to be the highest among Indian women (20%) compared to “Other Asian” (18%), Pacific (12%), Māori (8%) and European (4%) women.[[31]] Non-alcoholic fatty liver disease is also an emerging issue for the South Asian population.[[32]]
The examples provided in this discourse provide strong evidence that New Zealand is inadequately addressing Asian health by using a “broad-brush” approach via its level 1 and 2 ethnicity classifications. These high-level categories ignore the subtleties and nuances seen in different Asian cultures, which from a health perspective may under-recognise and under-address certain conditions in some groups leading to greater harm. One can argue ethnicity classifications are developed based on the size of the population groups in a country. South Asians currently make up 6% of the total New Zealand population, and East and South East Asians make up 9%.[[1]] These figures are similar for New Zealand Pacific Peoples, who currently make up 8% of the New Zealand population,[[1]] and provide the rationale for disaggregated level 1 ethnicity codes for the “Asian” group as “South Asians” and “East and South East Asians”.[[5]] This will enable unmasked reporting of health statistics, which will pave the way to equitable health outcomes for New Zealand Asians.
The health disparity observed for South Asians is a serious concern for New Zealand. While South Asian migrants are healthier than the resident population on arrival, their subsequent poor health lowers their overall wellbeing and productivity. An early loss of their healthy migrant status is therefore counterproductive towards the main objective of migration and poses an increased burden on individuals, families and the health system. Government and policy response to New Zealand Asians has been sporadic and limited at best. The current New Zealand Health Strategy (2017–2027) acknowledges this limitation[[33]] but has no road map to address it. This provides the impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asians are nearly the second largest ethnic group in New Zealand,[[3]] practical steps need to be taken to strengthen the New Zealand Health Strategy to enable equitable investment into Asian health. Developing appropriate level 1 and 2 ethnicity codes for Asians and reporting health statistics in a disaggregated form would be a pragmatic way forward. To improve the visibility of health issues, the collection of disaggregated health survey data for Asian subgroups will better enable policies and programmes to address unmet health needs. In addition, using more detailed ethnicity codes (level 3 or 4) for patient enrolment forms in primary and secondary healthcare would be critical for capturing health information to inform actions to address the health needs of Asians in New Zealand.
In conclusion, equitable health outcomes for New Zealand Asians are only possible by identifying and developing appropriate, cost-effective and ethnic-specific health-promoting approaches. Using revised ethnicity codes and disaggregated health statistics to understand post-migration health trajectories and associated risk factors of Asian subgroups would be critical to achieve this. It would also provide much needed information for informing policies and programmes both for research and health promotion initiatives to address Asian health in New Zealand in a pragmatic, translational manner and to reduce health disparity for this fast-growing population in New Zealand.
Summary
Abstract
Aim
People of Asian ethnicity in Aotearoa New Zealand currently constitute 15% of the population. The majority are migrants. The current sources of data to monitor Asian health in New Zealand are routine population surveys and administrative data. This article highlights the effect of “masking” due to the use of a single “Asian” category for reporting health indicators. Issues regarding the use of the “Other Asian” category in administrative data are also discussed. This discourse provides an impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asian population will become the second largest ethnic group in New Zealand, practical steps need to be taken to strengthen the New Zealand health strategy and enable equitable investment in Asian health.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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2) Statistics New Zealand [Internet]. Ethnicity New Zealand Standard Classification 2005V2.1.0. Available from: http://aria.stats.govt.nz/aria/#ClassificationView:uri=http://stats.govt.nz/cms/ClassificationVersion/YVqOcFHSlguKkT17
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4) Statistics New Zealand [Internet]. Birthplace (broad geographic areas) and years since arrival in New Zealand by age and sex, for the overseas born census usually resident population count, 2006, 2013, and 2018 Censuses (RC, TA, SA2, DHB) 2020. Available from: http://nzdotstat.stats.govt.nz/wbos/index.aspx?_ga=2.194604781.1109808399.1620695530-1637168086.1462318868&_gac=1.60112351.1620695602.Cj0KCQjws-OEBhCkARIsAPhOkIbTBbukLLTS5DisIpKbUKAqdKn2pLMnkSI2ypGHquWXEGMEjHOmqccaAsJUEALw_wcB#
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6) Scragg R. Asian Health in Aotearoa in 2011-2013: trends since 2002-2003 and 2006-2007. Auckland: Northern Regional Alliance Ltd, 2016.
7) Fuller-Thomson E, Noack AM, George U. Health decline among recent immigrants to Canada: findings from a nationally representative longitudinal survey. Can J Public Health. 2011;102(4):273-80. doi: 10.1007/BF03404048.
8) Montesi L, Caletti MT, Marchesini G. Diabetes in migrants and ethnic minorities in a changing World. World J Diabetes. 2016;7(3):34-44. doi: 10.4239/wjd.v7.i3.34.
9) Agyemang C, van den Born BJ. Non-communicable diseases in migrants: an expert review. J Travel Med. 2019;26(2):tay107. doi: 10.1093/jtm/tay107.
10) Bhatnagar D, Anand IS, Durrington PN, Patel DJ, Wander GS, Mackness MI, Creed F, Tomenson B, Chandrashekhar Y, Winterbotham M, et al. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet. 1995;345(8947):405-9. doi: 10.1016/s0140-6736(95)90398-4.
11) Ministry of Health [Internet]. Asian health chart book 2006. Wellington: Ministry of Health; 2006. Available from: http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006
12) Rasanathan K, Ameratunga S, Tse S. Asian health in New Zealand--progress and challenges. N Z Med J. 2006;119(1244):U2277. PMID: 17072352.
13) Wong A. Challenges for Asian health and Asian health promotion in New Zealand, Auckland: Health Promotion Forum of New Zealand; 2015. Available from: http://www.hauora.co.nz/~hpforum/assets/files/Occasional Papers/15128 FINAL Health promotion forum Asian promotion article.pdf
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Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes | OPEN ACCESS
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People of Asian ethnicity are the third largest ethnic group in New Zealand,[[1]] and addressing their health is increasingly important. The Asian ethnic group in New Zealand comprises of people from a vast geographical area spanning from Afghanistan in the West, to Japan in the East, China in the North and Indonesia in the South.[[2]] This group currently makes up 15% of the New Zealand population (2018 census).[[1]] Population projections indicate that the size of the Asian ethnic group in New Zealand is already similar to that for Māori and nearly double the number of Pacific Peoples, and the numbers are increasing progressively (Table 1).[[3]]
Table 1: Projected population by ethnicity, median projection, 30 June 2020–2043.[[3]] View Table 1.
The proportion of the New Zealand population who are migrants (ie, born overseas) has steadily increased from 23% in 2006 to 25% in 2013 and 27% in the 2018 New Zealand census.[[4]] The majority of migrants are Asian.[[4]] Voluntary migration to New Zealand is permitted primarily for maintaining and sustaining economic vibrancy. Hence stringent health screening is imposed to ensure all migrants have a health advantage over the resident population on their arrival to enable economic gain and reduce any burden to the health system. However, it has been found that the health of some migrants declines more rapidly than expected following migration to New Zealand.[[5,6]]
Immigration is a recognised determinant of health.[[7]] This relates not only to expected factors, such as health status on arrival, age, gender, marital status, language skills and income, but also to the adoption of unhealthy lifestyle behaviours in the host country, which impacts negatively on the health of migrants.[[5,8,9]] For example, sibling studies among South Asians have found higher serum cholesterol levels and an increased prevalence of coronary heart disease among those who migrated to the UK compared with their siblings who remained in India.[[10]]
In New Zealand, the health of the Asian ethnic group is not well understood. Although much progress has been made since 2006 to address Asian health issues,[[11]] a number of challenges persist.[[12–14]] Current sources of data for monitoring Asian health in New Zealand include routinely collected population surveys and administrative data. Nevertheless, there are several important issues regarding how data are collected and reported for New Zealand Asians, which is the focus of this article. The arguments raised in this article are based on available health statistics for the South Asian people in New Zealand and use certain health indicators as examples, but the same arguments will hold for other health issues and for East and South East Asians who are at higher risk for other disorders, such as certain cancers.[[15]]
Asian health indicators from population surveys
The continued use of the single “Asian” category when reporting data from population health surveys, such as the New Zealand Health Survey (NZHS), obscures a true description of the health of this diverse population group. In fact, due to the effect of averaging, this practice grossly masks subgroup differences in health indicators, risk factors and disease prevalence.[[16]] For example, the prevalence of obesity was 16% for Asians in both the 2011–2013 [[17]] and 2019/20 [[18]] NZHSs. In addition to not using the World Health Organization (WHO) ethnic specific body mass index (BMI) categories to define obesity,[[19]] these surveys did not disaggregate the Asian ethnic group. A secondary analysis of the 2011–2013 data [[6]] clearly showed the effect of “masking.” When “Asian” was subdivided and ethnic specific BMI categories were used to define obesity, the prevalence of obesity among adults was 57% in South Asians, 25% in Chinese and 33% in the “Other” Asian group.[[6]]
In the 2008/09 Adult Nutrition Survey, data for Asians were not reported at all, but combined with the “European/Other” category.[[20]] However, secondary analysis of these data clearly showed subgroup differences in the prevalence of overweight/obesity and diagnosed diabetes within the Asian ethnic group.[[5]] Asians were sub-categorised as “South Asians” (people from India, Sri Lanka, Pakistan, Afghanistan, Nepal, Bangladesh, Fijian Indians) and “East and South East Asians” (people from China, Hong Kong, Malaysia, Singapore, Indonesia, Vietnam, Cambodia, Philippines, Thailand, Korea, Japan, Myanmar, Tibet). The prevalence of obesity was 66% and 56% in South Asian men and women, respectively, compared to 37% and 22% in East and South East Asian men and women.[[5]] The prevalence of diagnosed diabetes was 23% and 21% in South Asian men and women, respectively, in contrast to less than 1% in East and South East Asian men and women.[[5]]
Data from the NZHS series also show that the prevalence of “unmet need for primary health care” among Asians has increased over the last decade from 21.1% to 24.2%, with a significantly marked increase among Asian men (15.3% to 22.6%).[[17]] Disaggregated data from the 2011–12 and 2012–13 NZHSs (combined) for Asian subgroups indicate that a lower proportion of South Asians (88%), Chinese (87%) and Other Asian (82%) had a health practice or service to access, if unwell.[[6]] Poor access to healthcare was even more evident among new Asian migrants (those resident in New Zealand for less than five years), of whom only 62% reported being enrolled in a primary health organisation (PHO), in contrast to 91% of those who had lived in New Zealand for between 5 and 10 years and 93% of those who had lived in New Zealand for over 10 years.[[6]] These statistics suggest that new Asian migrants have a poor understanding of the New Zealand health system. This is compounded by cultural differences and poor English language proficiency, which in itself is a risk factor for the loss of the healthy migrant status enjoyed by new migrants. Hence understanding health issues using high-quality ethnicity data for Asians is imperative.
Asian health indicators from administrative data
As discussed above, grouping Asians together (level 1 ethnicity code) reduces prevalence estimates of disease for some groups. Using level 2 ethnicity codes can also mask disease prevalence in certain Asian subgroups. Healthcare administrative data usually record main ethnic groups only. For example, PHO enrolment forms include ethnicity but only provide options for the largest Asian subgroups, namely Indian, Chinese and “Other Asian.” The “Other Asian” category is a mixed group of South Asians, East Asians and South East Asians.[[3]] Indians make up 87% of South Asians,[[1]] and as noted above, South Asians have a high prevalence of obesity and diabetes.[[5]] This means that the high rates of obesity and diabetes among the other 13% of South Asians (Sri Lanka, Pakistan and Bangladesh) are obscured in PHO data, as they are captured as part of the “Other Asian” category.
Examples of studies using administrative data include the papers reporting cardiovascular disease incidence[[21]] and mortality rates[[22]] and publications from the PREDICT study. In a recent PREDICT publication,[[23]] Indians made up 8% of the 475,241 adults in the New Zealand primary care study population, and 10% were “Other Asians.” The prevalence of diabetes among Indians was higher (33% in women and 24% in men) than that of “Other Asians” (21% in women and 15% in men), which included South Asians from Sri Lanka, Pakistan and Bangladesh, who have a similar prevalence of diabetes to Indians, and people from Japan, Korea and other East and South East Asian countries, among whom diabetes is relatively uncommon.[[5]]
The use of the “Indian” group to make inferences for the South Asian group as a whole is an emerging practice, which has led to the inappropriate use of the category “South Asian” in making international comparisons. For instance, in 2017 Rabanal et al [[24]] used the data from the New Zealand PREDICT study, which has information on “Indians” only, to make comparisons with South Asians in Norway. Further, the ethnicity classification used in Norway for South Asian is not consistent with that used in New Zealand. For example, in Norway people from Myanmar are considered South Asian, whereas in New Zealand they are considered South East Asian.[[3]] Such inconsistent definitions of South Asian in New Zealand and other migrant-receiving countries pose a challenge for international comparisons. The use of the term “South Asian” to represent just one ethnicity, for example Indian, should be avoided to reduce ambiguity in interpreting research findings. Having a well-defined “South Asian” ethnic category to report health data in New Zealand will perhaps stimulate similar thinking and action in other migrant-receiving countries, such as the UK, Norway, USA and Canada, and improve international comparisons of health indicators.
The case for disaggregated Asian health statistics
By combining all Asians into one group, the overall poor metabolic health of South Asians is obscured. For example, in a secondary analysis of the NZHS data, South Asians were found to have a five- to six-fold increased risk of being on treatment for diabetes.[[6]] Similar findings have been observed in the USA,[[25]] Canada,[[26]] UK[[27]] and Norway,[[28]] where migrants from Sri Lanka and Pakistan (predominant South Asians in Norway) have a more than five-fold higher risk of diabetes and cardiovascular disease compared with the majority population and other migrant groups world-wide. International multi-ethnic studies have also found the prevalence of diabetes to be higher in younger (20–29-year-old) South Asians compared to other minority (Chinese, African American and Hispanic) and majority (European) ethnic groups.[[29]] In addition, national hospitalisation and mortality data in New Zealand suggest that Indians have a higher prevalence and incidence of cardiovascular disease when compared to NZ Europeans.[[21]] Cardiovascular disease mortality rates are significantly higher among people of Indian ethnicity compared to New Zealand Europeans[[22]] and other Asian subgroups in New Zealand, such as Chinese people.[[30]] Among New Zealand women who had been screened for gestational diabetes and birthed at National Women’s Health, the prevalence of gestational diabetes was reported to be the highest among Indian women (20%) compared to “Other Asian” (18%), Pacific (12%), Māori (8%) and European (4%) women.[[31]] Non-alcoholic fatty liver disease is also an emerging issue for the South Asian population.[[32]]
The examples provided in this discourse provide strong evidence that New Zealand is inadequately addressing Asian health by using a “broad-brush” approach via its level 1 and 2 ethnicity classifications. These high-level categories ignore the subtleties and nuances seen in different Asian cultures, which from a health perspective may under-recognise and under-address certain conditions in some groups leading to greater harm. One can argue ethnicity classifications are developed based on the size of the population groups in a country. South Asians currently make up 6% of the total New Zealand population, and East and South East Asians make up 9%.[[1]] These figures are similar for New Zealand Pacific Peoples, who currently make up 8% of the New Zealand population,[[1]] and provide the rationale for disaggregated level 1 ethnicity codes for the “Asian” group as “South Asians” and “East and South East Asians”.[[5]] This will enable unmasked reporting of health statistics, which will pave the way to equitable health outcomes for New Zealand Asians.
The health disparity observed for South Asians is a serious concern for New Zealand. While South Asian migrants are healthier than the resident population on arrival, their subsequent poor health lowers their overall wellbeing and productivity. An early loss of their healthy migrant status is therefore counterproductive towards the main objective of migration and poses an increased burden on individuals, families and the health system. Government and policy response to New Zealand Asians has been sporadic and limited at best. The current New Zealand Health Strategy (2017–2027) acknowledges this limitation[[33]] but has no road map to address it. This provides the impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asians are nearly the second largest ethnic group in New Zealand,[[3]] practical steps need to be taken to strengthen the New Zealand Health Strategy to enable equitable investment into Asian health. Developing appropriate level 1 and 2 ethnicity codes for Asians and reporting health statistics in a disaggregated form would be a pragmatic way forward. To improve the visibility of health issues, the collection of disaggregated health survey data for Asian subgroups will better enable policies and programmes to address unmet health needs. In addition, using more detailed ethnicity codes (level 3 or 4) for patient enrolment forms in primary and secondary healthcare would be critical for capturing health information to inform actions to address the health needs of Asians in New Zealand.
In conclusion, equitable health outcomes for New Zealand Asians are only possible by identifying and developing appropriate, cost-effective and ethnic-specific health-promoting approaches. Using revised ethnicity codes and disaggregated health statistics to understand post-migration health trajectories and associated risk factors of Asian subgroups would be critical to achieve this. It would also provide much needed information for informing policies and programmes both for research and health promotion initiatives to address Asian health in New Zealand in a pragmatic, translational manner and to reduce health disparity for this fast-growing population in New Zealand.
Summary
Abstract
Aim
People of Asian ethnicity in Aotearoa New Zealand currently constitute 15% of the population. The majority are migrants. The current sources of data to monitor Asian health in New Zealand are routine population surveys and administrative data. This article highlights the effect of “masking” due to the use of a single “Asian” category for reporting health indicators. Issues regarding the use of the “Other Asian” category in administrative data are also discussed. This discourse provides an impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asian population will become the second largest ethnic group in New Zealand, practical steps need to be taken to strengthen the New Zealand health strategy and enable equitable investment in Asian health.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Statistics New Zealand [Internet]. Ethnic group (detailed total response - level 4), by age group and sex, for the census usually resident population count, 2006, 2013, and 2018 Censuses. 2019. Available from: http://nzdotstat.stats.govt.nz/wbos/Index.aspx?DataSetCode=TABLECODE8338
2) Statistics New Zealand [Internet]. Ethnicity New Zealand Standard Classification 2005V2.1.0. Available from: http://aria.stats.govt.nz/aria/#ClassificationView:uri=http://stats.govt.nz/cms/ClassificationVersion/YVqOcFHSlguKkT17
3) Statistics New Zealand [Internet]. Population projected to become more ethnically diverse. Available from: https://www.stats.govt.nz/news/population-projected-to-become-more-ethnically-diverse
4) Statistics New Zealand [Internet]. Birthplace (broad geographic areas) and years since arrival in New Zealand by age and sex, for the overseas born census usually resident population count, 2006, 2013, and 2018 Censuses (RC, TA, SA2, DHB) 2020. Available from: http://nzdotstat.stats.govt.nz/wbos/index.aspx?_ga=2.194604781.1109808399.1620695530-1637168086.1462318868&_gac=1.60112351.1620695602.Cj0KCQjws-OEBhCkARIsAPhOkIbTBbukLLTS5DisIpKbUKAqdKn2pLMnkSI2ypGHquWXEGMEjHOmqccaAsJUEALw_wcB#
5) Parackal S, Smith C, Parnell WR. A profile of New Zealand ‘Asian’ participants of the 2008/09 Adult National Nutrition Survey: focus on dietary habits, nutrient intakes and health outcomes. Public Health Nutr. 2015 18(05):893-904.
6) Scragg R. Asian Health in Aotearoa in 2011-2013: trends since 2002-2003 and 2006-2007. Auckland: Northern Regional Alliance Ltd, 2016.
7) Fuller-Thomson E, Noack AM, George U. Health decline among recent immigrants to Canada: findings from a nationally representative longitudinal survey. Can J Public Health. 2011;102(4):273-80. doi: 10.1007/BF03404048.
8) Montesi L, Caletti MT, Marchesini G. Diabetes in migrants and ethnic minorities in a changing World. World J Diabetes. 2016;7(3):34-44. doi: 10.4239/wjd.v7.i3.34.
9) Agyemang C, van den Born BJ. Non-communicable diseases in migrants: an expert review. J Travel Med. 2019;26(2):tay107. doi: 10.1093/jtm/tay107.
10) Bhatnagar D, Anand IS, Durrington PN, Patel DJ, Wander GS, Mackness MI, Creed F, Tomenson B, Chandrashekhar Y, Winterbotham M, et al. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet. 1995;345(8947):405-9. doi: 10.1016/s0140-6736(95)90398-4.
11) Ministry of Health [Internet]. Asian health chart book 2006. Wellington: Ministry of Health; 2006. Available from: http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006
12) Rasanathan K, Ameratunga S, Tse S. Asian health in New Zealand--progress and challenges. N Z Med J. 2006;119(1244):U2277. PMID: 17072352.
13) Wong A. Challenges for Asian health and Asian health promotion in New Zealand, Auckland: Health Promotion Forum of New Zealand; 2015. Available from: http://www.hauora.co.nz/~hpforum/assets/files/Occasional Papers/15128 FINAL Health promotion forum Asian promotion article.pdf
14) Liao R. In the shadow of exclusion: the state of New Zealand Asian health. N Z Med Stud J. 2019. 29:32-36.
15) Tran HN, Li Y, Udaltsova N, Armstrong MA, Friedman GD, Klatsky AL. Risk of cancer in Asian Americans: a Kaiser Permanente cohort study. Cancer Causes Control. 2016;27(10):1197-207. doi: 10.1007/s10552-016-0798-2.
16) Rasanathan K, Craig D, Perkins R. The novel use of 'Asian' as an ethnic category in the New Zealand health sector. Ethn Health. 2006;11(3):211-27. doi: 10.1080/13557850600565525.
17) Ministry of Health. The Health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey. Wellington: Ministry of Health, 2012.
18) Ministry of Health [Internet]. New Zealand Health Survey: Annual Data Explorer. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2019-20-annual-data-explorer/_w_1683f56e/#!/ Nov 2020.
19) WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157-63.
20) University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. 2011 Wellington: Ministry of Health.
21) Chan WC, Wright C, Riddel T, Wells S, Kerr A, Gala G et al. Ethnic and socio-economic disparities in the prevalence of cardiovascular disease in New Zealand. N Z Med J. 2008;12(1285):3341
22) Perumal L, Wells S, Ameratunga S, Pylypchuk D. Markedly different clustering of CVD risk factors in New Zealand Indian and European people but similar risk scores (PREDICT-14). Aust N Z J Public Health. 2012;36(2):141-4.
23) Selak V, Poppe K, Grey C, Mehta S, Winter-Smith J, Jackson R, Wells S, Exeter D, Kerr A, Riddell T, Harwood M. Ethnic differences in cardiovascular risk profiles among 475,241 adults in primary care in Aotearoa, New Zealand. N Z Med J. 2020;133(1521):14-27.
24) Rabanal KS, Meyer HE, Tell GS, et al Can traditional risk factors explain the higher risk of cardiovascular disease in South Asians compared to Europeans in Norway and New Zealand? Two cohort studies. BMJ Open 2017;7:e016819. doi:10.1136/bmjopen-2017-016819
25) Shah AD, Vittinghoff E, Kandula NR, Srivastava S, Kanaya AM. Correlates of prediabetes and type II diabetes in US South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Annals of Epidemiology. 2015;25(2):77-83.
26) Creatore MI, Moineddin R, Booth G, Manuel DH, DesMeules M, McDermott S, et al. Age-and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. Can Med Assoc J 2010; 182(8):781-9.
27) Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Primary Care Diabetes. 2011;5(1):45-56.
28) Jenum AK, Diep LM, Holmboe-Ottesen G, Holme IM, Kumar BN, Birkeland KI. Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with Norwegians-the association with adiposity is strongest for ethnic minority women. BMC Public Health. 2012;12(1):1.
29) C.Ke P, Sohal H, Qian H, Quan, Khan NA. Diabetes in the young: a population-based study of South Asian, Chinese and White people. Diabet. Med. 2015;32:487-96.
30) Jatrana S, Richardson K, Blakely T, Dayal S. Does mortality vary between Asian subgroups in New Zealand: an application of hierarchical Bayesian modelling? PloS One. 2014; 9(8):e105141
31) National Women’s Health Annual Clinical Report 2018 [Internet]. Available from: https://nationalwomenshealth.adhb.govt.nz/healthprofessionals/annual-clinical-report/national-womens-annual-clinical-report/
32) Singh S, Kuftinec GN, Sarkar S. Non-alcoholic fatty liver disease in South Asians: A review of literature. J Clin Transl Hepatol. 2017;5(1):76-81.
33) Ministry of Business, Innovation and Employment and Ministry of Health [Internet]. 2017. New Zealand Health Research Strategy 2017-2027. Wellington: Ministry of Business, Innovation and Employment and Ministry of Health. Available from: https://www.health.govt.nz/publication/new-zealand-health-research-strategy-2017-2027
For the PDF of this article,
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Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes | OPEN ACCESS
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People of Asian ethnicity are the third largest ethnic group in New Zealand,[[1]] and addressing their health is increasingly important. The Asian ethnic group in New Zealand comprises of people from a vast geographical area spanning from Afghanistan in the West, to Japan in the East, China in the North and Indonesia in the South.[[2]] This group currently makes up 15% of the New Zealand population (2018 census).[[1]] Population projections indicate that the size of the Asian ethnic group in New Zealand is already similar to that for Māori and nearly double the number of Pacific Peoples, and the numbers are increasing progressively (Table 1).[[3]]
Table 1: Projected population by ethnicity, median projection, 30 June 2020–2043.[[3]] View Table 1.
The proportion of the New Zealand population who are migrants (ie, born overseas) has steadily increased from 23% in 2006 to 25% in 2013 and 27% in the 2018 New Zealand census.[[4]] The majority of migrants are Asian.[[4]] Voluntary migration to New Zealand is permitted primarily for maintaining and sustaining economic vibrancy. Hence stringent health screening is imposed to ensure all migrants have a health advantage over the resident population on their arrival to enable economic gain and reduce any burden to the health system. However, it has been found that the health of some migrants declines more rapidly than expected following migration to New Zealand.[[5,6]]
Immigration is a recognised determinant of health.[[7]] This relates not only to expected factors, such as health status on arrival, age, gender, marital status, language skills and income, but also to the adoption of unhealthy lifestyle behaviours in the host country, which impacts negatively on the health of migrants.[[5,8,9]] For example, sibling studies among South Asians have found higher serum cholesterol levels and an increased prevalence of coronary heart disease among those who migrated to the UK compared with their siblings who remained in India.[[10]]
In New Zealand, the health of the Asian ethnic group is not well understood. Although much progress has been made since 2006 to address Asian health issues,[[11]] a number of challenges persist.[[12–14]] Current sources of data for monitoring Asian health in New Zealand include routinely collected population surveys and administrative data. Nevertheless, there are several important issues regarding how data are collected and reported for New Zealand Asians, which is the focus of this article. The arguments raised in this article are based on available health statistics for the South Asian people in New Zealand and use certain health indicators as examples, but the same arguments will hold for other health issues and for East and South East Asians who are at higher risk for other disorders, such as certain cancers.[[15]]
Asian health indicators from population surveys
The continued use of the single “Asian” category when reporting data from population health surveys, such as the New Zealand Health Survey (NZHS), obscures a true description of the health of this diverse population group. In fact, due to the effect of averaging, this practice grossly masks subgroup differences in health indicators, risk factors and disease prevalence.[[16]] For example, the prevalence of obesity was 16% for Asians in both the 2011–2013 [[17]] and 2019/20 [[18]] NZHSs. In addition to not using the World Health Organization (WHO) ethnic specific body mass index (BMI) categories to define obesity,[[19]] these surveys did not disaggregate the Asian ethnic group. A secondary analysis of the 2011–2013 data [[6]] clearly showed the effect of “masking.” When “Asian” was subdivided and ethnic specific BMI categories were used to define obesity, the prevalence of obesity among adults was 57% in South Asians, 25% in Chinese and 33% in the “Other” Asian group.[[6]]
In the 2008/09 Adult Nutrition Survey, data for Asians were not reported at all, but combined with the “European/Other” category.[[20]] However, secondary analysis of these data clearly showed subgroup differences in the prevalence of overweight/obesity and diagnosed diabetes within the Asian ethnic group.[[5]] Asians were sub-categorised as “South Asians” (people from India, Sri Lanka, Pakistan, Afghanistan, Nepal, Bangladesh, Fijian Indians) and “East and South East Asians” (people from China, Hong Kong, Malaysia, Singapore, Indonesia, Vietnam, Cambodia, Philippines, Thailand, Korea, Japan, Myanmar, Tibet). The prevalence of obesity was 66% and 56% in South Asian men and women, respectively, compared to 37% and 22% in East and South East Asian men and women.[[5]] The prevalence of diagnosed diabetes was 23% and 21% in South Asian men and women, respectively, in contrast to less than 1% in East and South East Asian men and women.[[5]]
Data from the NZHS series also show that the prevalence of “unmet need for primary health care” among Asians has increased over the last decade from 21.1% to 24.2%, with a significantly marked increase among Asian men (15.3% to 22.6%).[[17]] Disaggregated data from the 2011–12 and 2012–13 NZHSs (combined) for Asian subgroups indicate that a lower proportion of South Asians (88%), Chinese (87%) and Other Asian (82%) had a health practice or service to access, if unwell.[[6]] Poor access to healthcare was even more evident among new Asian migrants (those resident in New Zealand for less than five years), of whom only 62% reported being enrolled in a primary health organisation (PHO), in contrast to 91% of those who had lived in New Zealand for between 5 and 10 years and 93% of those who had lived in New Zealand for over 10 years.[[6]] These statistics suggest that new Asian migrants have a poor understanding of the New Zealand health system. This is compounded by cultural differences and poor English language proficiency, which in itself is a risk factor for the loss of the healthy migrant status enjoyed by new migrants. Hence understanding health issues using high-quality ethnicity data for Asians is imperative.
Asian health indicators from administrative data
As discussed above, grouping Asians together (level 1 ethnicity code) reduces prevalence estimates of disease for some groups. Using level 2 ethnicity codes can also mask disease prevalence in certain Asian subgroups. Healthcare administrative data usually record main ethnic groups only. For example, PHO enrolment forms include ethnicity but only provide options for the largest Asian subgroups, namely Indian, Chinese and “Other Asian.” The “Other Asian” category is a mixed group of South Asians, East Asians and South East Asians.[[3]] Indians make up 87% of South Asians,[[1]] and as noted above, South Asians have a high prevalence of obesity and diabetes.[[5]] This means that the high rates of obesity and diabetes among the other 13% of South Asians (Sri Lanka, Pakistan and Bangladesh) are obscured in PHO data, as they are captured as part of the “Other Asian” category.
Examples of studies using administrative data include the papers reporting cardiovascular disease incidence[[21]] and mortality rates[[22]] and publications from the PREDICT study. In a recent PREDICT publication,[[23]] Indians made up 8% of the 475,241 adults in the New Zealand primary care study population, and 10% were “Other Asians.” The prevalence of diabetes among Indians was higher (33% in women and 24% in men) than that of “Other Asians” (21% in women and 15% in men), which included South Asians from Sri Lanka, Pakistan and Bangladesh, who have a similar prevalence of diabetes to Indians, and people from Japan, Korea and other East and South East Asian countries, among whom diabetes is relatively uncommon.[[5]]
The use of the “Indian” group to make inferences for the South Asian group as a whole is an emerging practice, which has led to the inappropriate use of the category “South Asian” in making international comparisons. For instance, in 2017 Rabanal et al [[24]] used the data from the New Zealand PREDICT study, which has information on “Indians” only, to make comparisons with South Asians in Norway. Further, the ethnicity classification used in Norway for South Asian is not consistent with that used in New Zealand. For example, in Norway people from Myanmar are considered South Asian, whereas in New Zealand they are considered South East Asian.[[3]] Such inconsistent definitions of South Asian in New Zealand and other migrant-receiving countries pose a challenge for international comparisons. The use of the term “South Asian” to represent just one ethnicity, for example Indian, should be avoided to reduce ambiguity in interpreting research findings. Having a well-defined “South Asian” ethnic category to report health data in New Zealand will perhaps stimulate similar thinking and action in other migrant-receiving countries, such as the UK, Norway, USA and Canada, and improve international comparisons of health indicators.
The case for disaggregated Asian health statistics
By combining all Asians into one group, the overall poor metabolic health of South Asians is obscured. For example, in a secondary analysis of the NZHS data, South Asians were found to have a five- to six-fold increased risk of being on treatment for diabetes.[[6]] Similar findings have been observed in the USA,[[25]] Canada,[[26]] UK[[27]] and Norway,[[28]] where migrants from Sri Lanka and Pakistan (predominant South Asians in Norway) have a more than five-fold higher risk of diabetes and cardiovascular disease compared with the majority population and other migrant groups world-wide. International multi-ethnic studies have also found the prevalence of diabetes to be higher in younger (20–29-year-old) South Asians compared to other minority (Chinese, African American and Hispanic) and majority (European) ethnic groups.[[29]] In addition, national hospitalisation and mortality data in New Zealand suggest that Indians have a higher prevalence and incidence of cardiovascular disease when compared to NZ Europeans.[[21]] Cardiovascular disease mortality rates are significantly higher among people of Indian ethnicity compared to New Zealand Europeans[[22]] and other Asian subgroups in New Zealand, such as Chinese people.[[30]] Among New Zealand women who had been screened for gestational diabetes and birthed at National Women’s Health, the prevalence of gestational diabetes was reported to be the highest among Indian women (20%) compared to “Other Asian” (18%), Pacific (12%), Māori (8%) and European (4%) women.[[31]] Non-alcoholic fatty liver disease is also an emerging issue for the South Asian population.[[32]]
The examples provided in this discourse provide strong evidence that New Zealand is inadequately addressing Asian health by using a “broad-brush” approach via its level 1 and 2 ethnicity classifications. These high-level categories ignore the subtleties and nuances seen in different Asian cultures, which from a health perspective may under-recognise and under-address certain conditions in some groups leading to greater harm. One can argue ethnicity classifications are developed based on the size of the population groups in a country. South Asians currently make up 6% of the total New Zealand population, and East and South East Asians make up 9%.[[1]] These figures are similar for New Zealand Pacific Peoples, who currently make up 8% of the New Zealand population,[[1]] and provide the rationale for disaggregated level 1 ethnicity codes for the “Asian” group as “South Asians” and “East and South East Asians”.[[5]] This will enable unmasked reporting of health statistics, which will pave the way to equitable health outcomes for New Zealand Asians.
The health disparity observed for South Asians is a serious concern for New Zealand. While South Asian migrants are healthier than the resident population on arrival, their subsequent poor health lowers their overall wellbeing and productivity. An early loss of their healthy migrant status is therefore counterproductive towards the main objective of migration and poses an increased burden on individuals, families and the health system. Government and policy response to New Zealand Asians has been sporadic and limited at best. The current New Zealand Health Strategy (2017–2027) acknowledges this limitation[[33]] but has no road map to address it. This provides the impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asians are nearly the second largest ethnic group in New Zealand,[[3]] practical steps need to be taken to strengthen the New Zealand Health Strategy to enable equitable investment into Asian health. Developing appropriate level 1 and 2 ethnicity codes for Asians and reporting health statistics in a disaggregated form would be a pragmatic way forward. To improve the visibility of health issues, the collection of disaggregated health survey data for Asian subgroups will better enable policies and programmes to address unmet health needs. In addition, using more detailed ethnicity codes (level 3 or 4) for patient enrolment forms in primary and secondary healthcare would be critical for capturing health information to inform actions to address the health needs of Asians in New Zealand.
In conclusion, equitable health outcomes for New Zealand Asians are only possible by identifying and developing appropriate, cost-effective and ethnic-specific health-promoting approaches. Using revised ethnicity codes and disaggregated health statistics to understand post-migration health trajectories and associated risk factors of Asian subgroups would be critical to achieve this. It would also provide much needed information for informing policies and programmes both for research and health promotion initiatives to address Asian health in New Zealand in a pragmatic, translational manner and to reduce health disparity for this fast-growing population in New Zealand.
Summary
Abstract
Aim
People of Asian ethnicity in Aotearoa New Zealand currently constitute 15% of the population. The majority are migrants. The current sources of data to monitor Asian health in New Zealand are routine population surveys and administrative data. This article highlights the effect of “masking” due to the use of a single “Asian” category for reporting health indicators. Issues regarding the use of the “Other Asian” category in administrative data are also discussed. This discourse provides an impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asian population will become the second largest ethnic group in New Zealand, practical steps need to be taken to strengthen the New Zealand health strategy and enable equitable investment in Asian health.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Statistics New Zealand [Internet]. Ethnic group (detailed total response - level 4), by age group and sex, for the census usually resident population count, 2006, 2013, and 2018 Censuses. 2019. Available from: http://nzdotstat.stats.govt.nz/wbos/Index.aspx?DataSetCode=TABLECODE8338
2) Statistics New Zealand [Internet]. Ethnicity New Zealand Standard Classification 2005V2.1.0. Available from: http://aria.stats.govt.nz/aria/#ClassificationView:uri=http://stats.govt.nz/cms/ClassificationVersion/YVqOcFHSlguKkT17
3) Statistics New Zealand [Internet]. Population projected to become more ethnically diverse. Available from: https://www.stats.govt.nz/news/population-projected-to-become-more-ethnically-diverse
4) Statistics New Zealand [Internet]. Birthplace (broad geographic areas) and years since arrival in New Zealand by age and sex, for the overseas born census usually resident population count, 2006, 2013, and 2018 Censuses (RC, TA, SA2, DHB) 2020. Available from: http://nzdotstat.stats.govt.nz/wbos/index.aspx?_ga=2.194604781.1109808399.1620695530-1637168086.1462318868&_gac=1.60112351.1620695602.Cj0KCQjws-OEBhCkARIsAPhOkIbTBbukLLTS5DisIpKbUKAqdKn2pLMnkSI2ypGHquWXEGMEjHOmqccaAsJUEALw_wcB#
5) Parackal S, Smith C, Parnell WR. A profile of New Zealand ‘Asian’ participants of the 2008/09 Adult National Nutrition Survey: focus on dietary habits, nutrient intakes and health outcomes. Public Health Nutr. 2015 18(05):893-904.
6) Scragg R. Asian Health in Aotearoa in 2011-2013: trends since 2002-2003 and 2006-2007. Auckland: Northern Regional Alliance Ltd, 2016.
7) Fuller-Thomson E, Noack AM, George U. Health decline among recent immigrants to Canada: findings from a nationally representative longitudinal survey. Can J Public Health. 2011;102(4):273-80. doi: 10.1007/BF03404048.
8) Montesi L, Caletti MT, Marchesini G. Diabetes in migrants and ethnic minorities in a changing World. World J Diabetes. 2016;7(3):34-44. doi: 10.4239/wjd.v7.i3.34.
9) Agyemang C, van den Born BJ. Non-communicable diseases in migrants: an expert review. J Travel Med. 2019;26(2):tay107. doi: 10.1093/jtm/tay107.
10) Bhatnagar D, Anand IS, Durrington PN, Patel DJ, Wander GS, Mackness MI, Creed F, Tomenson B, Chandrashekhar Y, Winterbotham M, et al. Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet. 1995;345(8947):405-9. doi: 10.1016/s0140-6736(95)90398-4.
11) Ministry of Health [Internet]. Asian health chart book 2006. Wellington: Ministry of Health; 2006. Available from: http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006
12) Rasanathan K, Ameratunga S, Tse S. Asian health in New Zealand--progress and challenges. N Z Med J. 2006;119(1244):U2277. PMID: 17072352.
13) Wong A. Challenges for Asian health and Asian health promotion in New Zealand, Auckland: Health Promotion Forum of New Zealand; 2015. Available from: http://www.hauora.co.nz/~hpforum/assets/files/Occasional Papers/15128 FINAL Health promotion forum Asian promotion article.pdf
14) Liao R. In the shadow of exclusion: the state of New Zealand Asian health. N Z Med Stud J. 2019. 29:32-36.
15) Tran HN, Li Y, Udaltsova N, Armstrong MA, Friedman GD, Klatsky AL. Risk of cancer in Asian Americans: a Kaiser Permanente cohort study. Cancer Causes Control. 2016;27(10):1197-207. doi: 10.1007/s10552-016-0798-2.
16) Rasanathan K, Craig D, Perkins R. The novel use of 'Asian' as an ethnic category in the New Zealand health sector. Ethn Health. 2006;11(3):211-27. doi: 10.1080/13557850600565525.
17) Ministry of Health. The Health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey. Wellington: Ministry of Health, 2012.
18) Ministry of Health [Internet]. New Zealand Health Survey: Annual Data Explorer. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2019-20-annual-data-explorer/_w_1683f56e/#!/ Nov 2020.
19) WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157-63.
20) University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. 2011 Wellington: Ministry of Health.
21) Chan WC, Wright C, Riddel T, Wells S, Kerr A, Gala G et al. Ethnic and socio-economic disparities in the prevalence of cardiovascular disease in New Zealand. N Z Med J. 2008;12(1285):3341
22) Perumal L, Wells S, Ameratunga S, Pylypchuk D. Markedly different clustering of CVD risk factors in New Zealand Indian and European people but similar risk scores (PREDICT-14). Aust N Z J Public Health. 2012;36(2):141-4.
23) Selak V, Poppe K, Grey C, Mehta S, Winter-Smith J, Jackson R, Wells S, Exeter D, Kerr A, Riddell T, Harwood M. Ethnic differences in cardiovascular risk profiles among 475,241 adults in primary care in Aotearoa, New Zealand. N Z Med J. 2020;133(1521):14-27.
24) Rabanal KS, Meyer HE, Tell GS, et al Can traditional risk factors explain the higher risk of cardiovascular disease in South Asians compared to Europeans in Norway and New Zealand? Two cohort studies. BMJ Open 2017;7:e016819. doi:10.1136/bmjopen-2017-016819
25) Shah AD, Vittinghoff E, Kandula NR, Srivastava S, Kanaya AM. Correlates of prediabetes and type II diabetes in US South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Annals of Epidemiology. 2015;25(2):77-83.
26) Creatore MI, Moineddin R, Booth G, Manuel DH, DesMeules M, McDermott S, et al. Age-and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada. Can Med Assoc J 2010; 182(8):781-9.
27) Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Primary Care Diabetes. 2011;5(1):45-56.
28) Jenum AK, Diep LM, Holmboe-Ottesen G, Holme IM, Kumar BN, Birkeland KI. Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with Norwegians-the association with adiposity is strongest for ethnic minority women. BMC Public Health. 2012;12(1):1.
29) C.Ke P, Sohal H, Qian H, Quan, Khan NA. Diabetes in the young: a population-based study of South Asian, Chinese and White people. Diabet. Med. 2015;32:487-96.
30) Jatrana S, Richardson K, Blakely T, Dayal S. Does mortality vary between Asian subgroups in New Zealand: an application of hierarchical Bayesian modelling? PloS One. 2014; 9(8):e105141
31) National Women’s Health Annual Clinical Report 2018 [Internet]. Available from: https://nationalwomenshealth.adhb.govt.nz/healthprofessionals/annual-clinical-report/national-womens-annual-clinical-report/
32) Singh S, Kuftinec GN, Sarkar S. Non-alcoholic fatty liver disease in South Asians: A review of literature. J Clin Transl Hepatol. 2017;5(1):76-81.
33) Ministry of Business, Innovation and Employment and Ministry of Health [Internet]. 2017. New Zealand Health Research Strategy 2017-2027. Wellington: Ministry of Business, Innovation and Employment and Ministry of Health. Available from: https://www.health.govt.nz/publication/new-zealand-health-research-strategy-2017-2027
Contact diana@nzma.org.nz
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Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes | OPEN ACCESS
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People of Asian ethnicity are the third largest ethnic group in New Zealand,[[1]] and addressing their health is increasingly important. The Asian ethnic group in New Zealand comprises of people from a vast geographical area spanning from Afghanistan in the West, to Japan in the East, China in the North and Indonesia in the South.[[2]] This group currently makes up 15% of the New Zealand population (2018 census).[[1]] Population projections indicate that the size of the Asian ethnic group in New Zealand is already similar to that for Māori and nearly double the number of Pacific Peoples, and the numbers are increasing progressively (Table 1).[[3]]
Table 1: Projected population by ethnicity, median projection, 30 June 2020–2043.[[3]] View Table 1.
The proportion of the New Zealand population who are migrants (ie, born overseas) has steadily increased from 23% in 2006 to 25% in 2013 and 27% in the 2018 New Zealand census.[[4]] The majority of migrants are Asian.[[4]] Voluntary migration to New Zealand is permitted primarily for maintaining and sustaining economic vibrancy. Hence stringent health screening is imposed to ensure all migrants have a health advantage over the resident population on their arrival to enable economic gain and reduce any burden to the health system. However, it has been found that the health of some migrants declines more rapidly than expected following migration to New Zealand.[[5,6]]
Immigration is a recognised determinant of health.[[7]] This relates not only to expected factors, such as health status on arrival, age, gender, marital status, language skills and income, but also to the adoption of unhealthy lifestyle behaviours in the host country, which impacts negatively on the health of migrants.[[5,8,9]] For example, sibling studies among South Asians have found higher serum cholesterol levels and an increased prevalence of coronary heart disease among those who migrated to the UK compared with their siblings who remained in India.[[10]]
In New Zealand, the health of the Asian ethnic group is not well understood. Although much progress has been made since 2006 to address Asian health issues,[[11]] a number of challenges persist.[[12–14]] Current sources of data for monitoring Asian health in New Zealand include routinely collected population surveys and administrative data. Nevertheless, there are several important issues regarding how data are collected and reported for New Zealand Asians, which is the focus of this article. The arguments raised in this article are based on available health statistics for the South Asian people in New Zealand and use certain health indicators as examples, but the same arguments will hold for other health issues and for East and South East Asians who are at higher risk for other disorders, such as certain cancers.[[15]]
Asian health indicators from population surveys
The continued use of the single “Asian” category when reporting data from population health surveys, such as the New Zealand Health Survey (NZHS), obscures a true description of the health of this diverse population group. In fact, due to the effect of averaging, this practice grossly masks subgroup differences in health indicators, risk factors and disease prevalence.[[16]] For example, the prevalence of obesity was 16% for Asians in both the 2011–2013 [[17]] and 2019/20 [[18]] NZHSs. In addition to not using the World Health Organization (WHO) ethnic specific body mass index (BMI) categories to define obesity,[[19]] these surveys did not disaggregate the Asian ethnic group. A secondary analysis of the 2011–2013 data [[6]] clearly showed the effect of “masking.” When “Asian” was subdivided and ethnic specific BMI categories were used to define obesity, the prevalence of obesity among adults was 57% in South Asians, 25% in Chinese and 33% in the “Other” Asian group.[[6]]
In the 2008/09 Adult Nutrition Survey, data for Asians were not reported at all, but combined with the “European/Other” category.[[20]] However, secondary analysis of these data clearly showed subgroup differences in the prevalence of overweight/obesity and diagnosed diabetes within the Asian ethnic group.[[5]] Asians were sub-categorised as “South Asians” (people from India, Sri Lanka, Pakistan, Afghanistan, Nepal, Bangladesh, Fijian Indians) and “East and South East Asians” (people from China, Hong Kong, Malaysia, Singapore, Indonesia, Vietnam, Cambodia, Philippines, Thailand, Korea, Japan, Myanmar, Tibet). The prevalence of obesity was 66% and 56% in South Asian men and women, respectively, compared to 37% and 22% in East and South East Asian men and women.[[5]] The prevalence of diagnosed diabetes was 23% and 21% in South Asian men and women, respectively, in contrast to less than 1% in East and South East Asian men and women.[[5]]
Data from the NZHS series also show that the prevalence of “unmet need for primary health care” among Asians has increased over the last decade from 21.1% to 24.2%, with a significantly marked increase among Asian men (15.3% to 22.6%).[[17]] Disaggregated data from the 2011–12 and 2012–13 NZHSs (combined) for Asian subgroups indicate that a lower proportion of South Asians (88%), Chinese (87%) and Other Asian (82%) had a health practice or service to access, if unwell.[[6]] Poor access to healthcare was even more evident among new Asian migrants (those resident in New Zealand for less than five years), of whom only 62% reported being enrolled in a primary health organisation (PHO), in contrast to 91% of those who had lived in New Zealand for between 5 and 10 years and 93% of those who had lived in New Zealand for over 10 years.[[6]] These statistics suggest that new Asian migrants have a poor understanding of the New Zealand health system. This is compounded by cultural differences and poor English language proficiency, which in itself is a risk factor for the loss of the healthy migrant status enjoyed by new migrants. Hence understanding health issues using high-quality ethnicity data for Asians is imperative.
Asian health indicators from administrative data
As discussed above, grouping Asians together (level 1 ethnicity code) reduces prevalence estimates of disease for some groups. Using level 2 ethnicity codes can also mask disease prevalence in certain Asian subgroups. Healthcare administrative data usually record main ethnic groups only. For example, PHO enrolment forms include ethnicity but only provide options for the largest Asian subgroups, namely Indian, Chinese and “Other Asian.” The “Other Asian” category is a mixed group of South Asians, East Asians and South East Asians.[[3]] Indians make up 87% of South Asians,[[1]] and as noted above, South Asians have a high prevalence of obesity and diabetes.[[5]] This means that the high rates of obesity and diabetes among the other 13% of South Asians (Sri Lanka, Pakistan and Bangladesh) are obscured in PHO data, as they are captured as part of the “Other Asian” category.
Examples of studies using administrative data include the papers reporting cardiovascular disease incidence[[21]] and mortality rates[[22]] and publications from the PREDICT study. In a recent PREDICT publication,[[23]] Indians made up 8% of the 475,241 adults in the New Zealand primary care study population, and 10% were “Other Asians.” The prevalence of diabetes among Indians was higher (33% in women and 24% in men) than that of “Other Asians” (21% in women and 15% in men), which included South Asians from Sri Lanka, Pakistan and Bangladesh, who have a similar prevalence of diabetes to Indians, and people from Japan, Korea and other East and South East Asian countries, among whom diabetes is relatively uncommon.[[5]]
The use of the “Indian” group to make inferences for the South Asian group as a whole is an emerging practice, which has led to the inappropriate use of the category “South Asian” in making international comparisons. For instance, in 2017 Rabanal et al [[24]] used the data from the New Zealand PREDICT study, which has information on “Indians” only, to make comparisons with South Asians in Norway. Further, the ethnicity classification used in Norway for South Asian is not consistent with that used in New Zealand. For example, in Norway people from Myanmar are considered South Asian, whereas in New Zealand they are considered South East Asian.[[3]] Such inconsistent definitions of South Asian in New Zealand and other migrant-receiving countries pose a challenge for international comparisons. The use of the term “South Asian” to represent just one ethnicity, for example Indian, should be avoided to reduce ambiguity in interpreting research findings. Having a well-defined “South Asian” ethnic category to report health data in New Zealand will perhaps stimulate similar thinking and action in other migrant-receiving countries, such as the UK, Norway, USA and Canada, and improve international comparisons of health indicators.
The case for disaggregated Asian health statistics
By combining all Asians into one group, the overall poor metabolic health of South Asians is obscured. For example, in a secondary analysis of the NZHS data, South Asians were found to have a five- to six-fold increased risk of being on treatment for diabetes.[[6]] Similar findings have been observed in the USA,[[25]] Canada,[[26]] UK[[27]] and Norway,[[28]] where migrants from Sri Lanka and Pakistan (predominant South Asians in Norway) have a more than five-fold higher risk of diabetes and cardiovascular disease compared with the majority population and other migrant groups world-wide. International multi-ethnic studies have also found the prevalence of diabetes to be higher in younger (20–29-year-old) South Asians compared to other minority (Chinese, African American and Hispanic) and majority (European) ethnic groups.[[29]] In addition, national hospitalisation and mortality data in New Zealand suggest that Indians have a higher prevalence and incidence of cardiovascular disease when compared to NZ Europeans.[[21]] Cardiovascular disease mortality rates are significantly higher among people of Indian ethnicity compared to New Zealand Europeans[[22]] and other Asian subgroups in New Zealand, such as Chinese people.[[30]] Among New Zealand women who had been screened for gestational diabetes and birthed at National Women’s Health, the prevalence of gestational diabetes was reported to be the highest among Indian women (20%) compared to “Other Asian” (18%), Pacific (12%), Māori (8%) and European (4%) women.[[31]] Non-alcoholic fatty liver disease is also an emerging issue for the South Asian population.[[32]]
The examples provided in this discourse provide strong evidence that New Zealand is inadequately addressing Asian health by using a “broad-brush” approach via its level 1 and 2 ethnicity classifications. These high-level categories ignore the subtleties and nuances seen in different Asian cultures, which from a health perspective may under-recognise and under-address certain conditions in some groups leading to greater harm. One can argue ethnicity classifications are developed based on the size of the population groups in a country. South Asians currently make up 6% of the total New Zealand population, and East and South East Asians make up 9%.[[1]] These figures are similar for New Zealand Pacific Peoples, who currently make up 8% of the New Zealand population,[[1]] and provide the rationale for disaggregated level 1 ethnicity codes for the “Asian” group as “South Asians” and “East and South East Asians”.[[5]] This will enable unmasked reporting of health statistics, which will pave the way to equitable health outcomes for New Zealand Asians.
The health disparity observed for South Asians is a serious concern for New Zealand. While South Asian migrants are healthier than the resident population on arrival, their subsequent poor health lowers their overall wellbeing and productivity. An early loss of their healthy migrant status is therefore counterproductive towards the main objective of migration and poses an increased burden on individuals, families and the health system. Government and policy response to New Zealand Asians has been sporadic and limited at best. The current New Zealand Health Strategy (2017–2027) acknowledges this limitation[[33]] but has no road map to address it. This provides the impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asians are nearly the second largest ethnic group in New Zealand,[[3]] practical steps need to be taken to strengthen the New Zealand Health Strategy to enable equitable investment into Asian health. Developing appropriate level 1 and 2 ethnicity codes for Asians and reporting health statistics in a disaggregated form would be a pragmatic way forward. To improve the visibility of health issues, the collection of disaggregated health survey data for Asian subgroups will better enable policies and programmes to address unmet health needs. In addition, using more detailed ethnicity codes (level 3 or 4) for patient enrolment forms in primary and secondary healthcare would be critical for capturing health information to inform actions to address the health needs of Asians in New Zealand.
In conclusion, equitable health outcomes for New Zealand Asians are only possible by identifying and developing appropriate, cost-effective and ethnic-specific health-promoting approaches. Using revised ethnicity codes and disaggregated health statistics to understand post-migration health trajectories and associated risk factors of Asian subgroups would be critical to achieve this. It would also provide much needed information for informing policies and programmes both for research and health promotion initiatives to address Asian health in New Zealand in a pragmatic, translational manner and to reduce health disparity for this fast-growing population in New Zealand.
Summary
Abstract
Aim
People of Asian ethnicity in Aotearoa New Zealand currently constitute 15% of the population. The majority are migrants. The current sources of data to monitor Asian health in New Zealand are routine population surveys and administrative data. This article highlights the effect of “masking” due to the use of a single “Asian” category for reporting health indicators. Issues regarding the use of the “Other Asian” category in administrative data are also discussed. This discourse provides an impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asian population will become the second largest ethnic group in New Zealand, practical steps need to be taken to strengthen the New Zealand health strategy and enable equitable investment in Asian health.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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31) National Women’s Health Annual Clinical Report 2018 [Internet]. Available from: https://nationalwomenshealth.adhb.govt.nz/healthprofessionals/annual-clinical-report/national-womens-annual-clinical-report/
32) Singh S, Kuftinec GN, Sarkar S. Non-alcoholic fatty liver disease in South Asians: A review of literature. J Clin Transl Hepatol. 2017;5(1):76-81.
33) Ministry of Business, Innovation and Employment and Ministry of Health [Internet]. 2017. New Zealand Health Research Strategy 2017-2027. Wellington: Ministry of Business, Innovation and Employment and Ministry of Health. Available from: https://www.health.govt.nz/publication/new-zealand-health-research-strategy-2017-2027
Contact diana@nzma.org.nz
for the PDF of this article
Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes | OPEN ACCESS
People of Asian ethnicity are the third largest ethnic group in New Zealand, and addressing their health is increasingly important.
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