20‐Year Trajectories of Substance‐Use Service Utilization by Ontario's Muslim‐Majority Country Immigrants
Publication: Psychiatric Research and Clinical Practice
Abstract
Objective
The aim of this study is to conduct a population‐level study on substance use treatment utilization among immigrants from Muslim‐majority countries (MMC) and non‐MMC, compared with Canadian‐born individuals in Ontario.
Methods
A population‐based, repeated measures cross‐sectional study was conducted. Additionally, individuals with at least one contact with substance use services were followed. Negative binomial models were run to compare the rate ratio of the number of repeated healthcare visits per person per year of follow‐up by subpopulation group. This study included three separate populations (Canadian‐born, immigrants from MMC, and immigrants from non‐MMC) residing in Ontario, Canada. All individuals residing in Ontario on the first day of each calendar year from January 2003 to December 2022 were included. Data were collected from three major sources: outpatient visits, emergency department visits, and inpatient hospitalizations.
Results
In 2022, immigrants from MMC (n = 561,937) and non‐MMC (n = 2,138,307) groups had lower substance‐use service utilization across all service types compared with Canadian individuals (n = 12,178,607). Comparing 2022 to 2003, the most significant increase in utilizing hospitalization was for MMC immigrants (RR: 3.0; 95% CI: 2.1–4.4; p < 0.01) and the lowest increase in outpatient service utilization was in MMC immigrants (RR: 1.8; 95% CI: 1.5–2.0; p < 0.01). The rates of repeated service utilization among those who initiated contact with outpatient services in the MMC and non‐MMC groups were significantly less than Canadian‐born individuals.
Conclusions
Immigrants from MMC and non‐MMC with substance use disorders may utilize service only at critical stages, thereby jeopardizing treatment success.
Highlights
•
Immigrants from Muslim‐majority country (MMC) had low substance‐use service utilization rates.
•
MMC group had the highest rate increase of hospitalization over 20 years.
•
MMC group had the lowest rate increase of outpatient services use over 20 years.
•
In those with substance use, MMC group had low repeated use of outpatient services.
•
In those with substance use, MMC group had high repeated use of hospitalization.
Substance misuse is an urgent public health issue associated with the increasing global disease burden (1). According to the Canadian Substance Use Costs and Harms report, substance use expenditure in Canada was nearly $46 billion in 2017 (2).
Globally, immigrants report less substance use than natives in Western countries (3, 4). The Healthy Immigrant Effect, also known as the “Immigrant Paradox,” found that immigrants had higher levels of well‐being compared to natives (5, 6, 7). However, the Healthy Immigrant Effect was not supported by the sample of Canadian Muslim immigrants (8). A Canadian survey found that severely distressed Canadian Muslim immigrants underutilized psychological health services, with only 48.7% seeking professional help compared to the general Canadian population (8). Although Canadian Muslims population has more than doubled in 20 years (from 2% to 4.9%) (9), there is a lack of relevant research evaluating substance‐use–related health outcomes and health service utilization in this population.
Several factors may exacerbate substance use among Muslims, which can also affect service utilization (10). Many Muslims residing in Canada and Western countries have migrated from countries affected by war, poverty, famine, displacement, or instability, resulting in trauma, a known risk factor for substance use disorders (SUDs) (11). Compounding this, a large proportion of workers in Muslim‐majority countries (MMC), who often migrate to Western countries, experience SUD in their home countries (12). A study on the prevalence of SUDs among Muslims in the United States, using a nationally representative sample, indicated that 10.9% had alcohol/drug use disorders and 18.4% had tobacco dependence (11). However, Muslims with SUD had lower emotional functioning scores than non‐Muslims with SUD (11). In contrast, research conducted on MMC such as Afghanistan, Kazakhstan, and Kyrgyzstan indicate a lack of trust in the treatment system and community exclusion as significant barriers to accessing substance use treatment. For instance, Kazakhstan and Kyrgyzstan require registration with narcology services to access drug treatment, leading to stigmatizing consequences such as police registration and restrictions on employment, which deter service utilization (13). Therefore, Muslims in these non‐Western countries face increasing challenges to treat SUDs (14).
The presence of risk factors for SUDs in Muslim individuals, coupled with the alarming disparities in mental health and service utilization in Muslim individuals, as well as continued migration from MMC suggest the need to undertake an in‐depth trends analysis of service utilization in individuals from MMC. Therefore, the purpose of this study was to gain an understanding of the prevalence patterns and treatment utilization behaviors of substance use within Canadian Muslim populations overall and compared to the Canadian‐born population and other immigrant populations in Ontario.
METHODS
Model Description
This population‐based, repeated measures cross‐sectional study included three separate populations (Canadian‐born, immigrants from MMC, and immigrants from non‐MMC) residing in Ontario, Canada, on the first day of each calendar year from January 1, 2003, to December 31, 2022. Everyone received provincial health insurance through the Ontario Health Insurance Plan (OHIP), which was accessed using linked health administrative databases. De‐identified data were obtained through the Institute for Clinical Evaluation Sciences (ICES), which is an independent research institute under Ontario's health information privacy law. ICES's legal status under Ontario's health information privacy law permits it to analyze healthcare system data, without individual patient consent, to improve health care quality. These datasets were linked using unique encoded identifiers and analyzed at ICES. This study was approved by the Center for Addiction and Mental Health (CAMH) Research Ethics Board (REB# 2023/090).
The cohort inclusion criteria included every individual alive in Ontario on January 1 of each calendar year from 2003 to 2022. The cohort exclusion criteria included individuals with a death date on or before each yearly index date, those without a date of last contact with the healthcare system within 7 years of the index date, those not residing in Ontario, and those without OHIP eligibility on the index date.
Data on immigrants from MMC and non‐MMC were obtained from the Permanent Resident Database of Immigration, Refugees and Citizenship Canada (IRCC). The Ontario portion of the IRCC Permanent Resident Database includes immigration application records for people who have applied to land in Ontario since 1985. The dataset contains demographic information on permanent residents such as country of citizenship, level of education, mother tongue, and landing dates. New immigrants currently residing in Ontario originally landed in another province were not included in this dataset. Immigration status was defined as immigrant from an MMC, where the individual arrived in Canada from a country with a Muslim population of greater than 50%, and immigrant from a non‐MMC, where the individual arrived in Canada from a country with a Muslim population of less than 50%. All individuals born in Canada regardless of their parents' immigrant status were included in the Canadian‐born category. This definition is based on a previous study (15). This study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Outcome Measures and Exposure
Our primary outcome was substance use service utilization across all ages (0–81+) from three major sources in Ontario: outpatient visits, ED visits, and inpatient hospitalizations (i.e., acute care or psychiatric institutions for substance use).
Outpatient visits were obtained from the Claims Database of the OHIP. The OHIP claims database contains information on inpatient and outpatient services provided to Ontario residents eligible for the province's publicly funded health insurance system by fee‐for‐service healthcare practitioners (primarily physicians) and “shadow billings” for those paid through non‐fee‐for‐service payment plans. The main data elements included patient and physician identifiers (encrypted), code for the service provided, date of service, associated diagnosis, and fees paid.
Data on ED visits were obtained from the National Ambulatory Care Reporting System (NACRS). The NACRS is compiled by the Canadian Institute for Health Information and contains administrative, clinical (diagnoses and procedures), demographic, and administrative information for all patient visits to hospital‐ and community‐based ambulatory care centers (e.g., EDs). At the ICES, the NACRS records are linked to other data sources to identify transitions to other care settings, such as inpatient acute care or psychiatric care.
Hospitalization data were obtained from the Canadian Institute for Health Information Discharge Abstract Database (DAD) and the Ontario Mental Health Reporting System (OMHRS). The DAD was compiled by the Canadian Institute for Health Information and contained administrative, clinical (diagnoses and procedures/interventions), demographic, and administrative information for all admissions to acute care hospitals and rehabilitation, chronic care hospitals, and day surgery institutions in Ontario. The details of the OMHRS have been described elsewhere (16).
Statistical Analyses
Baseline information at the yearly index date for the first and final years of the study period was reported by subpopulation. To describe the demographics, we use frequencies and percentages to report the characteristics at the index date for both 2003 and 2022 and immigration groups were compared using chi‐square, and one‐way ANOVA. Subsequently, statistical differences between the three subpopulations were calculated. First, the rate ratio (RR) comparing the number of visits per person in each subpopulation group was determined in 2003 and 2022 after accounting for age and sex using negative binomial models. The crude rate of visits was defined as the number of visits per group/number of individuals in each group × 100,000 and the age‐ and sex‐standardized rates used the Ontario population in 2022 as the standard. Second, the rate ratios of each service‐type visit in 2022 compared to 2003 were calculated across the three subpopulation groups. Finally, negative binomial models were run to compare the RR of the number of repeated healthcare visits of each type per person per year of follow‐up by subpopulation group. Person‐years is the time from the index date of the first visit to the end of follow‐up (December 31, 2022) or death. Statistical analyses were performed using SAS (Statistical Analysis Software 9.4, SAS Institute Inc, Cary, North Carolina, USA).
RESULTS
Demographics
Table 1 presents the demographic details of each subpopulation in 2003 and 2022. Canadian‐born individuals were, on average, older than those from MMC and non‐MMC. Most individuals in all three subpopulations were between 31 and 46 years of age. Approximately half of the individuals were female. Most individuals in all three subpopulations lived in urban settings.
| Variable | Values | 2003 | 2022 | ||||||
|---|---|---|---|---|---|---|---|---|---|
| MMC > 50% | Non‐MMC < 50% | Individuals born in Canadab | p‐value | MMC > 50% | Non‐MMC < 50% | Individuals born in Canada | p‐value | ||
| Sample size | N = 243,756 | N = 1,243,023 | N = 10,723,613 | N = 561,937 | N = 2,138,307 | N = 12,178,607 | |||
| Age | Mean (SD) | 31.89 (16.44) | 36.82 (16.84) | 37.41 (22.55) | <0.0001 | 41.58 (17.61) | 46.42 (17.18) | 40.37 (24.12) | <0.0001 |
| Median (Q1–Q3) | 32 (19–42) | 36 (25–46) | 37 (18–54) | 41 (29–54) | 46 (34–58) | 39 (20–60) | |||
| Age category | 0–5 | 8319 (3.4%) | 18,039 (1.5%) | 818,290 (7.6%) | <0.0001 | 3258 (0.6%) | 7866 (0.4%) | 869,969 (7.1%) | <0.0001 |
| 6–10 | 16,813 (6.9%) | 40,576 (3.3%) | 754,959 (7.0%) | 14,984 (2.7%) | 25,559 (1.2%) | 758,808 (6.2%) | |||
| 11–15 | 21,014 (8.6%) | 68,578 (5.5%) | 739,735 (6.9%) | 23,751 (4.2%) | 40,004 (1.9%) | 747,273 (6.1%) | |||
| 16–20 | 22,189 (9.1%) | 93,288 (7.5%) | 686,912 (6.4%) | 27,689 (4.9%) | 59,467 (2.8%) | 718,053 (5.9%) | |||
| 21–25 | 19,142 (7.9%) | 97,724 (7.9%) | 646,322 (6.0%) | 36,712 (6.5%) | 89,024 (4.2%) | 790,156 (6.5%) | |||
| 26–30 | 23,677 (9.7%) | 122,163 (9.8%) | 665,906 (6.2%) | 47,945 (8.5%) | 148,779 (7.0%) | 886,142 (7.3%) | |||
| 31–35 | 32,020 (13.1%) | 158,682 (12.8%) | 728,473 (6.8%) | 61,674 (11.0%) | 228,430 (10.7%) | 795,496 (6.5%) | |||
| 36–40 | 31,391 (12.9%) | 172,063 (13.8%) | 862,443 (8.0%) | 62,650 (11.1%) | 239,380 (11.2%) | 721,934 (5.9%) | |||
| 41–45 | 24,452 (10.0%) | 143,975 (11.6%) | 876,827 (8.2%) | 54,680 (9.7%) | 219,061 (10.2%) | 670,070 (5.5%) | |||
| 46–50 | 17,078 (7.0%) | 104,199 (8.4%) | 797,977 (7.4%) | 52,111 (9.3%) | 214,504 (10.0%) | 675,429 (5.5%) | |||
| 51–55 | 8959 (3.7%) | 65,790 (5.3%) | 731,081 (6.8%) | 50,306 (9.0%) | 213,642 (10.0%) | 714,012 (5.9%) | |||
| 56–60 | 5389 (2.2%) | 39,997 (3.2%) | 588,207 (5.5%) | 42,040 (7.5%) | 200,163 (9.4%) | 831,664 (6.8%) | |||
| 61–65 | 4292 (1.8%) | 33,295 (2.7%) | 461,134 (4.3%) | 31,752 (5.7%) | 157,392 (7.4%) | 785,156 (6.4%) | |||
| 66–70 | 3645 (1.5%) | 30,672 (2.5%) | 402,045 (3.7%) | 21,812 (3.9%) | 110,941 (5.2%) | 680,344 (5.6%) | |||
| 71–75 | 2781 (1.1%) | 24,360 (2.0%) | 360,129 (3.4%) | 13,162 (2.3%) | 75,918 (3.6%) | 594,086 (4.9%) | |||
| 76–80 | 1596 (0.7%) | 16,392 (1.3%) | 290,812 (2.7%) | 8110 (1.4%) | 46,507 (2.2%) | 401,314 (3.3%) | |||
| 81+ | 999 (0.4%) | 13,230 (1.1%) | 312,361 (2.9%) | 9301 (1.7%) | 61,670 (2.9%) | 538,701 (4.4%) | |||
| Sex | Female | 112,730 (46.2%) | 641,665 (51.6%) | 5,433,104 (50.7%) | <0.0001 | 277,593 (49.4%) | 1,127,657 (52.7%) | 6,140,799 (50.4%) | |
| Male | 131,026 (53.8%) | 601,358 (48.4%) | 5,290,509 (49.3%) | 284,344 (50.6%) | 1,010,650 (47.3%) | 6,037,808 (49.6%) | |||
| Area income quintile | Missing | 93 (0.0%) | 711 (0.1%) | 41,859 (0.4%) | <0.0001 | 1185 (0.2%) | 4208 (0.2%) | 30,445 (0.2%) | |
| 1—Lowest | 86,982 (35.7%) | 372,177 (29.9%) | 1,884,978 (17.6%) | 136,206 (24.2%) | 487,525 (22.8%) | 2,240,770 (18.4%) | |||
| 2 | 50,682 (20.8%) | 285,377 (23.0%) | 2,080,294 (19.4%) | 101,480 (18.1%) | 457,622 (21.4%) | 2,370,970 (19.5%) | |||
| 3 | 42,525 (17.4%) | 235,169 (18.9%) | 2,174,852 (20.3%) | 117,603 (20.9%) | 457,619 (21.4%) | 2,435,692 (20.0%) | |||
| 4 | 38,342 (15.7%) | 204,811 (16.5%) | 2,252,129 (21.0%) | 118,042 (21.0%) | 412,194 (19.3%) | 2,499,431 (20.5%) | |||
| 5—Highest | 25,132 (10.3%) | 144,778 (11.6%) | 2,289,501 (21.4%) | 87,421 (15.6%) | 319,139 (14.9%) | 2,601,299 (21.4%) | |||
| Generation | First | 243,756 (100.0%) | 1,243,023 (100.0%) | 10,496,500 (97.9%) | <0.0001 | 561,937 (100.0%) | 2,138,307 (100.0%) | 11,318,106 (92.9%) | <0.0001 |
| Second | 0 (0.0%) | 0 (0.0%) | 227,113 (2.1%) | 0 (0.0%) | 0 (0.0%) | 860,501 (7.1%) | |||
| Immigra‐tion category | Category not stated/Invalid | 0 (0.0%) | ≤ 5 | 10,723,052 (100.0%) | <0.0001 | 6 (0.0%) | 10 (0.0%) | 12,178,063 (100.0%) | <0.0001 |
| Immigrants | 186,921 (76.7%) | 1,052,018 (84.6%) | 531 (0.0%) | 396,985 (70.6%) | 1,842,899 (86.2%) | 480 (0.0%) | |||
| Refugees | 56,835 (23.3%) | 191,003 (15.4%) | 30 (0.0%) | 164,946 (29.4%) | 295,398 (13.8%) | 64 (0.0%) | |||
| Material resources quintile | Missing | 5035 (2.1%) | 23,944 (1.9%) | 303,305 (2.8%) | <0.0001 | 1252 (0.2%) | 5141 (0.2%) | 114,688 (0.9%) | <0.0001 |
| 1—Lowest | 43,265 (17.7%) | 219,870 (17.7%) | 2,255,299 (21.0%) | 93,734 (16.7%) | 333,124 (15.6%) | 2,618,178 (21.5%) | |||
| 2 | 37,281 (15.3%) | 198,183 (15.9%) | 2,163,405 (20.2%) | 130,322 (23.2%) | 445,618 (20.8%) | 2,690,785 (22.1%) | |||
| 3 | 39,610 (16.2%) | 213,929 (17.2%) | 2,090,558 (19.5%) | 119,324 (21.2%) | 464,260 (21.7%) | 2,438,369 (20.0%) | |||
| 4 | 43,834 (18.0%) | 246,060 (19.8%) | 2,017,618 (18.8%) | 97,238 (17.3%) | 419,174 (19.6%) | 2,154,379 (17.7%) | |||
| 5—Highest | 74,731 (30.7%) | 341,037 (27.4%) | 1,893,428 (17.7%) | 120,067 (21.4%) | 470,990 (22.0%) | 2,162,208 (17.8%) | |||
| House‐holds and dwellings quintile | Missing | 5035 (2.1%) | 23,944 (1.9%) | 303,305 (2.8%) | <0.0001 | 1252 (0.2%) | 5141 (0.2%) | 114,688 (0.9%) | <0.0001 |
| 1—Lowest | 36,771 (15.1%) | 237,823 (19.1%) | 2,099,538 (19.6%) | 162,004 (28.8%) | 638,828 (29.9%) | 2,500,521 (20.5%) | |||
| 2 | 29,060 (11.9%) | 178,030 (14.3%) | 2,276,365 (21.2%) | 93,502 (16.6%) | 348,977 (16.3%) | 2,333,131 (19.2%) | |||
| 3 | 34,642 (14.2%) | 199,419 (16.0%) | 2,180,779 (20.3%) | 76,689 (13.6%) | 295,325 (13.8%) | 2,324,341 (19.1%) | |||
| 4 | 60,424 (24.8%) | 274,733 (22.1%) | 2,084,727 (19.4%) | 83,479 (14.9%) | 320,005 (15.0%) | 2,321,263 (19.1%) | |||
| 5—Highest | 77,824 (31.9%) | 329,074 (26.5%) | 1,778,899 (16.6%) | 145,011 (25.8%) | 530,031 (24.8%) | 2,584,663 (21.2%) | |||
| Age and labor force quintile | Missing | 5035 (2.1%) | 23,944 (1.9%) | 303,305 (2.8%) | <0.0001 | 1252 (0.2%) | 5141 (0.2%) | 114,688 (0.9%) | <0.0001 |
| 1—Lowest | 94,256 (38.7%) | 419,487 (33.7%) | 2,223,436 (20.7%) | 247,855 (44.1%) | 822,971 (38.5%) | 3,148,161 (25.8%) | |||
| 2 | 59,725 (24.5%) | 291,022 (23.4%) | 2,113,647 (19.7%) | 117,281 (20.9%) | 468,833 (21.9%) | 2,345,638 (19.3%) | |||
| 3 | 36,190 (14.8%) | 220,131 (17.7%) | 2,137,423 (19.9%) | 80,102 (14.3%) | 328,173 (15.3%) | 2,147,329 (17.6%) | |||
| 4 | 26,086 (10.7%) | 160,384 (12.9%) | 2,017,734 (18.8%) | 66,407 (11.8%) | 280,930 (13.1%) | 2,092,317 (17.2%) | |||
| 5—Highest | 22,464 (9.2%) | 128,055 (10.3%) | 1,928,068 (18.0%) | 49,040 (8.7%) | 232,259 (10.9%) | 2,330,474 (19.1%) | |||
| Racialized and newcomer populations quintile | Missing | 5035 (2.1%) | 23,944 (1.9%) | 303,305 (2.8%) | <0.0001 | 1252 (0.2%) | 5141 (0.2%) | 114,688 (0.9%) | <0.0001 |
| 1—Lowest | 4239 (1.7%) | 39,727 (3.2%) | 2,033,369 (19.0%) | 7010 (1.2%) | 62,392 (2.9%) | 2,199,187 (18.1%) | |||
| 2 | 7298 (3.0%) | 61,281 (4.9%) | 2,254,875 (21.0%) | 21,734 (3.9%) | 120,754 (5.6%) | 2,313,967 (19.0%) | |||
| 3 | 17,411 (7.1%) | 114,322 (9.2%) | 2,144,068 (20.0%) | 52,754 (9.4%) | 235,561 (11.0%) | 2,298,146 (18.9%) | |||
| 4 | 49,019 (20.1%) | 263,406 (21.2%) | 2,094,887 (19.5%) | 142,191 (25.3%) | 511,276 (23.9%) | 2,491,425 (20.5%) | |||
| 5—Highest | 160,754 (65.9%) | 740,343 (59.6%) | 1,893,109 (17.7%) | 336,996 (60.0%) | 1,203,183 (56.3%) | 2,761,194 (22.7%) | |||
| Rurality | Missing | 90 (0.0%) | 492 (0.0%) | 7597 (0.1%) | <0.0001 | 1178 (0.2%) | 4094 (0.2%) | 25,905 (0.2%) | <0.0001 |
| Urban | 243,049 (99.7%) | 1,225,511 (98.6%) | 9,166,167 (85.5%) | 557,380 (99.2%) | 2,096,010 (98.0%) | 10,683,911 (87.7%) | |||
| Rural | 617 (0.3%) | 17,020 (1.4%) | 1,549,849 (14.5%) | 3379 (0.6%) | 38,203 (1.8%) | 1,468,791 (12.1%) | |||
| LHIN of patient residence | 1—Erie St. Clair | 10,354 (4.2%) | 29,239 (2.4%) | 601,974 (5.6%) | 22,297 (4.0%) | 42,957 (2.0%) | 624,780 (5.1%) | <0.0001 | |
| 2—South West | 6251 (2.6%) | 32,755 (2.6%) | 861,410 (8.0%) | 20,757 (3.7%) | 67,377 (3.2%) | 984,441 (8.1%) | |||
| 3—Waterloo Welling‐ton | 6199 (2.5%) | 43,653 (3.5%) | 622,453 (5.8%) | 25,478 (4.5%) | 99,628 (4.7%) | 753,631 (6.2%) | |||
| 4—Hamilton niagara Haldimand Brant | 10,880 (4.5%) | 61,399 (4.9%) | 1,259,099 (11.7%) | 35,513 (6.3%) | 136,604 (6.4%) | 1,390,628 (11.4%) | |||
| 5—Central West | 19,944 (8.2%) | 133,625 (10.8%) | 527,832 (4.9%) | 45,279 (8.1%) | 295,827 (13.8%) | 698,878 (5.7%) | |||
| 6—Mississauga Halton | 42,863 (17.6%) | 161,070 (13.0%) | 794,362 (7.4%) | 112,299 (20.0%) | 274,680 (12.8%) | 897,335 (7.4%) | |||
| 7—Toronto Central | 36,258 (14.9%) | 203,750 (16.4%) | 907,447 (8.5%) | 51,620 (9.2%) | 235,602 (11.0%) | 1,006,884 (8.3%) | |||
| 8—Central | 57,663 (23.7%) | 292,556 (23.5%) | 1,168,845 (10.9%) | 123,830 (22.0%) | 501,559 (23.5%) | 1,369,575 (11.2%) | |||
| 9—Central East | 31,268 (12.8%) | 200,256 (16.1%) | 1,211,737 (11.3%) | 69,369 (12.3%) | 303,710 (14.2%) | 1,322,041 (10.9%) | |||
| 10—South East | 994 (0.4%) | 7146 (0.6%) | 466,598 (4.4%) | 2851 (0.5%) | 16,282 (0.8%) | 516,014 (4.2%) | |||
| 11—Champlain | 19,928 (8.2%) | 63,657 (5.1%) | 1,075,815 (10.0%) | 46,026 (8.2%) | 119,319 (5.6%) | 1,290,046 (10.6%) | |||
| 12—North Simcoe Muskoka | 620 (0.3%) | 7097 (0.6%) | 396,207 (3.7%) | 4802 (0.9%) | 30,360 (1.4%) | 503,009 (4.1%) | |||
| 13—North East | 342 (0.1%) | 4033 (0.3%) | 581,524 (5.4%) | 1171 (0.2%) | 9930 (0.5%) | 581,629 (4.8%) | |||
| 14—North West | 192 (0.1%) | 2787 (0.2%) | 248,303 (2.3%) | 645 (0.1%) | 4472 (0.2%) | 239,714 (2.0%) | |||
| Primary care physicianc (virtually rostered) | 195,558 (80.2%) | 1,012,162 (81.4%) | 9,335,115 (87.1%) | <0.0001 | 416,719 (74.2%) | 1,503,637 (70.3%) | 8,029,607 (65.9%) | <0.0001 | |
a
MMC, Muslim‐majority countries.
b
Immigrants are defined as individuals who landed in Ontario. Immigrants who landed in another province and then moved to Ontario would be included in the category titled “Individuals born in Canada”.
c
Individuals were virtually rostered to a family physician if they had at least one visit with a primary care fee code within 2‐year prior to index date. p‐values for mean continuous variables were calculated using the one‐way ANOVA, for medians and IQR values the p‐value was determined with the Kruskal–Wallis test, and the p‐values for categorical variables were calculated using the chi‐squared test.
Rate Ratios for Utilizing Substance Use Services in Ontario During 2003 and 2022
Table 2 presents the rate ratios for utilizing substance use services by individuals from the MMC and non‐MMC groups compared to Canadian‐born individuals, adjusted for age and sex. The rate of ED visits among individuals from MMC was 0.28 and 0.33 times (p < 0.001) that seen among those born in Canada in 2003 and 2022, respectively. The rate of hospitalization among individuals from MMC was 0.12 and 0.30 times (p < 0.001) that seen among those born in Canada in 2003 and 2022, respectively. The rate of outpatient visits among individuals from MMC was 0.66 and 0.32 times (p < 0.001) that seen among those born in Canada in 2003 and 2022, respectively.
| Parameter | 2003 | p Value | 2022 | p Value | ||
|---|---|---|---|---|---|---|
| Rate ratio (95% confidence interval) | Rate ratio (95% confidence interval) | |||||
| ED models | Immigration group | MMC versus Canadian born | 0.28 (0.24–0.332) | <0.0001 | 0.33 (0.306–0.358) | <0.0001 |
| Immigration group | Non‐MMC versus Canadian born | 0.51 (0.48–0.541) | <0.0001 | 0.54 (0.52–0.561) | <0.0001 | |
| Sex | Female versus Male | 0.44 (0.425–0.454) | <0.0001 | 0.488 (0.477–0.5) | <0.0001 | |
| Age | 1.003 (1.003–1.004) | <0.0001 | 0.99 (0.991–0.993) | <0.0001 | ||
| Hospital models | Immigration group | MMC versus Canadian born | 0.18 (0.122–0.254) | <0.0001 | 0.295 (0.254–0.343) | <0.0001 |
| Immigration group | Non‐MMC versus Canadian born | 0.341 (0.301–0.385) | <0.0001 | 0.477 (0.446–0.51) | <0.0001 | |
| Sex | Female versus Male | 0.461 (0.438–0.486) | <0.0001 | 0.459 (0.44–0.478) | <0.0001 | |
| Age | 1.01 (1.01–1.013) | <0.0001 | 1.0 (0.999–1) | 0.33 | ||
| Outpatient models | Immigration group | MMC versus Canadian born | 0.66 (0.599–0.718) | <0.0001 | 0.32 (0.31–0.34) | <0.0001 |
| Immigration group | Non‐MMC versus Canadian born | 0.23 (0.22–0.24) | <0.0001 | 0.24 (0.23–0.24) | <0.0001 | |
| Sex | Female versus Male | 0.49 (0.478–0.5) | <0.0001 | 0.501 (0.491–0.511) | <0.0001 | |
| Age | 0.963 (0.962–0.964) | <0.0001 | 1.006 (1.005–1.006) | <0.0001 |
a
MMC, Muslim‐majority countries.
The crude rate of healthcare visits for each substance use type per year (2003–2022) was stratified according to immigration category and sex in Table S1. The rate of healthcare use for substance use was consistently higher among males than females. Among all groups, visit types and sex groups the rate of healthcare use for substance use increased over time, and the rates in 2022 are larger than in 2003. The overall crude and standardized rate of outpatient visits for substance use among individuals from MMC is lower than individuals born in Canada and the overall population of Ontario but higher than the rate among individuals from non‐MMC. The overall crude and standardized rate of emergency department or inpatient visits for substance use among individuals from MMC is lower than all other groups.
Changes in Substance Use Services Utilization in 2022 Compared to 2003
Figure 1 shows the rates per 100,000 for outpatient visits, ED visits, and hospitalizations in the three subpopulations, respectively.
Table 3 presents the RR change from 2003 to 2022 for each subpopulation group. In all three subpopulation groups, the ED visit rate in 2022 is more than twice as large as that in 2003. The largest increase was observed in the MMC group (RR = 2.4). The rate of hospitalizations in 2022 was 1.52, 3.01, and 2.45 times that in 2003 among individuals born in Canada, from MMC, and non‐MMC, respectively. The rate of outpatient visits in 2022 was 3.26, 1.75, and 2.67 times that in 2003 among individuals born in Canada, from MMC, and non‐MMC, respectively.
| Canadian‐born | p‐value | MMC | p‐value | Non‐MMC | p‐value | ||
|---|---|---|---|---|---|---|---|
| Rate ratio (95% confidence interval) | Rate ratio (95% confidence interval) | Rate ratio (95% confidence interval) | |||||
| Emergency department visits | Year (2022 vs. 2003) | 2.008 (1.967–2.049) | <0.0001 | 2.404 (2.067–2.796) | <0.0001 | 2.093 (1.941–2.257) | <0.0001 |
| Hospitalization | Year (2022 vs. 2003) | 1.521 (1.482–1.562) | <0.0001 | 3.008 (2.064–4.384) | <0.0001 | 2.451 (2.117–2.838) | <0.0001 |
| Outpatient visits | Year (2022 vs. 2003) | 3.261 (3.209–3.312) | <0.0001 | 1.752 (1.528–2.01) | <0.0001 | 2.665 (2.506–2.835) | <0.0001 |
a
MMC, Muslim‐majority countries.
Ratio Rates of Repeated Visits for Substance Use Services Utilization in Ontario
Table 4 shows a multivariable model, adjusted for age and sex, for repeated visits to substance use services among individuals from the MMC and non‐MMC groups compared with Canadian individuals with at least one visit from the index date of the first visit to the end of the follow‐up period.
| Substance services | Person‐years of observation | Number of unique individuals with service visit | Parameter | Rate ratio (95% confidence interval) | p‐value | |
|---|---|---|---|---|---|---|
| Emergency department | Canadian‐born: 3,685,375.6 | Canadian‐born: 403,381 | Immigration group | MMC versus Canadian born | 0.793 (0.771–0.816) | <0.0001 |
| MMC: 63,475.8 | MMC: 7872 | Immigration group | Non‐MMC versus Canadian born | 1.008 (0.995–1.021) | 0.2345 | |
| Non‐MMC: 307,063.0 | Non‐MMC: 35,462 | |||||
| Outpatients' visits | Canadian‐born: 8,450,486.7 | Canadian‐born: 804,953 | Immigration group | MMC versus Canadian born | 0.84 (0.818–0.862) | <0.0001 |
| MMC: 159,188.5 | MMC: 15,631 | Immigration group | Non‐MMC versus Canadian born | 0.552 (0.545–0.559) | <0.0001 | |
| Non‐MMC: 692,767.3 | Non‐MMC: 67,367 | |||||
| Hospitalization | Canadian‐born: 1,081,268.2 | Canadian‐born: 128,938 | Immigration group | MMC versus Canadian born | 1.102 (1.038–1.169) | <0.0001 |
| MMC: 9083.4 | MMC: 1305 | Immigration group | Non‐MMC versus Canadian born | 1.166 (1.14–1.193) | <0.0001 | |
| Non‐MMC: 65,274.9 | Non‐MMC: 8531 |
a
MMC, Muslim‐majority countries.
Among individuals who had at least one visit to ED in the Canadian‐born (n = 403,381), MMC (n = 7872), and non‐MMC (n = 35,462), the rate of repeated ED visits among immigrants from MMC is approximately 0.793 times that among individuals born in Canada. There was no difference between non‐MMC and Canadian‐born individuals in the rate of repeated ED visits (p = 0.24).
There were 804,953 Canadian‐born, 15,631 from MMC, and 67,367 from non‐MMC who had at least one visit to outpatient services. The rate of repeat outpatient visits among immigrants from MMC and non‐MMC was approximately 0.84 times and 0.552 times, respectively, that among individuals born in Canada.
There were 128,938 Canadian‐born, 1305 from MMC, and 8531 from non‐MMC individuals with at least one hospitalization. The rate of repeat hospitalizations among immigrants from MMC and non‐MMC is approximately 1.102 and 1.166 times, respectively, that among individuals born in Canada.
DISCUSSION
To our knowledge, this is the first study to conduct a population‐level analysis of service utilization for substance use treatment among Canadian individuals who immigrated from MMC and non‐MMC compared with individuals born in Canada over the last 20 years.
Although medically insured, immigrants from MMC and non‐MMC in this study tended to have lower substance‐use service utilization across all types compared to Canadian‐born individuals in Ontario. This can be attributed to the Healthy Immigrant Effect reported earlier, which generally indicates a lower prevalence of SUDs among immigrants (3, 4). Furthermore, this study provides evidence specific to individuals migrating from MMC. This is salient for Muslim populations residing in Western countries, as previous research has indicated a lower prevalence of certain forms of substance use, such as alcohol, among Muslims than among other individuals in the US (11). Notably, the key domains of religiosity, including religious beliefs, practices, and social environments, correlate with low substance use (17, 18). A religious social environment is defined as the “level of religiosity of the environment in which an individual lives,” which can apply to both Muslims and non‐Muslims who have immigrated from MMC (17). Taken together, individuals from MMC may have lower service utilization than other populations, partly owing to lower substance use and religiosity.
Muslim individuals with SUDs may be highly vulnerable to delayed access to early treatment, leading to greater severity of illness. Our findings show that, while the most significant increase between 2003 and 2022 in utilizing high‐intensity services, such as hospitalization and ED visits, over 20 years was for immigrants from MMC, the lowest increase in outpatient service utilization was also for them. Similarly, the rates of repeated service utilization among those who initiated contact with outpatient services were significantly lower in individuals from the MMC and non‐MMC groups than those born in Canada. However, the rates of repeated service utilization for inpatient hospitalization were significantly higher in individuals from MMC and non‐MMC than in Canadian‐born individuals. These trends can be detrimental to an individual's health and family and can impact their community. Previous research has shown differences in service utilization among certain ethnicities, reporting a lower likelihood of accessing mental health care compared with Caucasians (19).
Various other factors could contribute to these trends. There may be a lack of knowledge about the availability and/or importance of these services to immigrants, especially the continuity of care services such as outpatient services. For instance, lower familiarity with professional mental health services was among the predictive factors for the rejection of mental health services among Muslim women in the US (20). However, a more probable cause is the effect of the stigma associated with utilizing substance‐use services in MMC, as mentioned earlier (21). While the stigma regarding addiction is universally prevalent, it is further compounded in individuals from MMC (22). Many individuals conceal their usage from community members to avoid stigma (23). This creates a social environment that leads to secrecy around substance use and ambivalence regarding seeking treatment when needed.
Stigma, whether it is self‐stigma, social stigma or structural stigma, toward SUD also exists in individuals from non‐MMC. A review of 20 studies, most of which were conducted in Europe, indicated that the public held a negative view of substance users and held them accountable for their substance use (24). An individual's culture can also influence the etiology of substance use, which is important in the case of Muslims who may attribute their substance use to a lack of religiosity. Fear of discrimination by healthcare providers is a potential contributing factor. Individuals' negative experiences can also delay them from seeking treatment (25), with research showing that clinicians provide different quality of care to minority populations (25) and that clinicians with a lack of appropriate “social resources” contribute to poor quality of mental health care (26).
A possible solution to improve early help‐seeking is to launch public campaigns and programs targeting immigrants to raise awareness of the availability and trust/safety of these services, especially comprehensive outpatient services, and include individuals with lived experiences. Faith‐based interventions may be an appropriate solution for immigrants of certain faiths, such as Muslims, to enhance their outreach for professional assistance (27). These programs must be linguistically variable. Facilitating timely access to addiction medicine outpatient services (within 2 days) has been shown to reduce future ED visits in randomized trials (28).
This study had some limitations. First, the administrative health records used lacked sociodemographic information, including religion. Thus, MMC has been used as a proxy for religious affiliation. However, not all individuals who hail from MMC countries are Muslim. Individuals from non‐MMC countries may be identified as Muslim, as can those born in Canada. Second, confounding variables—such as inherent distinctions between individuals migrating from MMC and non‐MMC countries compared with Canadian individuals—may affect the trends in substance use‐related service utilization. We also lack important information about those who needed substance use services but could not reach help due to systematic barriers or other types of barriers. Finally, although these findings offer an overview of service use trends in Ontario at the population level, this dataset does not incorporate additional support potentially accessed for substance use, including social services and care from spiritual, religious, or allied health professionals (15).
CONCLUSION
Our findings indicate that there has been a significantly lower utilization of various types of substance‐related services by immigrants from MMC and non‐MMC countries compared to Canadian‐born individuals over the last 20 years. Within each subpopulation, there was an increase in service use for all substance‐use services; however, immigrants from MMC showed the greatest surge in high‐intensity services, such as inpatient hospitalization. Among those who accessed services for SUDs, immigrants from MMC were more likely to have repeated hospitalizations than Canadian individuals, suggesting a delay in service use leading to high severity of illness. To elucidate whether these results apply to Muslim populations in other Canadian provinces or Western countries such as the United States, future studies may evaluate the rate of utilization of substance‐related services in immigrants from MMC. Interventions that facilitate the utilization of low‐intensity services, such as outpatient services, to prevent hospitalization or other unfavorable outcomes are needed. Finally, our findings underscore the need for culturally sensitive, accessible, and non‐discriminatory services to address the unique needs of the Muslim population.
Footnotes
Previous Presentation: None.
This study contracted ICES Data & Analytic Services (DAS) and used de‐identified data from the ICES Data Repository, which is managed by ICES with support from its funders and partners: Canada's Strategy for Patient‐Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research, and the Government of Ontario. The opinions, results, and conclusions reported are those of the authors. No endorsement by ICES or any of its funders or partners is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI, Ontario Health (OH), and the Ontario Ministry of Health. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts or whole of this material are based on data and/or information compiled and provided by Immigration, Refugees and Citizenship Canada (IRCC) current to May 2017. However, the analyses, conclusions, opinions, and statements expressed in the material are those of the author(s), and not necessarily those of IRCC. We thank the Toronto Community Health Profiles Partnership for providing access to the Ontario Marginalization Index. We would like to thank Ms. Amina Alizzi for her help with this paper. This work was supported by a grant from the Canadian Institute of Health Research (CIHR) (DC0190GP; application number 478912). This work was supported in part by an Academic Scholars Award from the Department of Psychiatry, University of Toronto.
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Received: 30 July 2024
Accepted: 25 August 2024
Published online: 15 October 2024
Authors
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the Canadian Institute of Health Research: DC0190GP; application number 478912
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