Health Status of Immigrants from Nepal in the United States: Preliminary Findings and

Methodological Issues

Health Status of Immigrants from Nepal in the United States: Preliminary Findings and

Methodological Issues

By Srijana M. Bajracharya, PhD, CHES and Mary K. Bentley, PhD

Ithaca College, Ithaca New York

Why study Nepalese Immigrants?

• 1951- Immigrants from Nepal first come to the US. Due to geographical isolation, poverty, low literacy rates, and autocratic rule, very little immigration happened.

• Early immigrants were mostly professionals educated in India or Europe, or students entering US Colleges and Universities

• Unique opportunity to document health status of an immigrant population coming into US culture that is first generation.

• To delineate the health effects of rapid acculturation into the US. from extreme poverty.

Why Nepalese? (continued)

• Relatively small population of people- >1% of total US population.

• Govt. data are fragmented or non-existent for this group of people

• Less able to maintain traditional lifestyle in US. There are no specific ghetto areas (such as Chinatown)

• Very close connections with family in Nepal and in US. – May make sampling non-immigrated and immigrated

easier.– Immigrants have a clear understanding of cultural

differences• Most Nepalese immigrants are bilingual.

Nepal, officially Kingdom of Nepal, constitutional monarchy in South Asia. Locked within the rugged ranges of the Himalayas, Nepal is bounded by the Tibet region of China on the north and India on the south, east, and west. It was cut off from the rest of the world until the early 1950s, when a palace revolution and the subsequent overthrow of the autocratic Rana dynasty marked the beginning of Nepal’s immergence into the modern world. Kathmandu is the largest city and capital.

The Himalayas, which comprise the highest mountain system in the world, extend through most of Nepal and help shape its northern border. Eight of the ten highest mountains in the world, including Mount Everest (8,850 m/29,035 ft), are located either wholly or partially in the country. The resulting geographic isolation has hindered development

The People of Nepal

• We know relatively little about the health status indicators for people living in Nepal. The Infrastructure for collecting data is beginning to take shape and in 2003 the first formal census was conducted.

• Most Nepalese in the US are first or second generation, and have family living in Nepal.

• Although this tiny country is very isolated, there is a rich ethnic and racial mix, that dates back thousands of years.

Quality of Life Indicators (WHO 2004) Nepal Vs US

• Statistics:Total population: 25,284,463

• GDP per capita (Intl $): 1,224

• Life expectancy at birth m/f (years): 58.6/57.9

• Healthy life expectancy at birth m/f (years): 48.7/49.1

• Child mortality m/f (per 1000): 100/115

• Adult mortality m/f (per 1000): 302/293

• Total health expenditure per capita (Intl $): 66

• Total health expenditure as % of GDP: 5.4

• Statistics:Total population: 285,925,000

• GDP per capita (Intl $): 34,637

• Life expectancy at birth m/f (years): 74.3/79.5

• Healthy life expectancy at birth m/f (years): 66.4/68.8

• Child mortality m/f (per 1000): 9/7

• Adult mortality m/f (per 1000): 144/83

• Total health expenditure per capita (Intl $): 4,499

• Total health expenditure as % of GDP: 13.0

Population Trends(age/total population)

Nepal US

Caste/Ethnicityover 100 represented in Nepal

Top 24 from first census data 2003CASTE/ETHNIC GROUP

TOTAL % CUMULATIVE %

NEPAL 22736934 100.00 100.00 11359378 11377556CHHETRI 3593496 15.80 15.80 1774709 1818787BRAHMAN - HILL 2896477 12.74 28.54 1426915 1469562MAGAR 1622421 7.14 35.68 784828 837593THARU 1533879 6.75 42.43 774924 758955TAMANG 1282304 5.64 48.07 641361 640943NEWAR 1245232 5.48 53.54 620213 625019MUSLIM 971056 4.27 57.81 501793 469263KAMI 895954 3.94 61.75 432937 463017YADAV 895423 3.94 65.69 473421 422002RAI 635151 2.79 68.49 312363 322788GURUNG 543571 2.39 70.88 259376 284195DAMAI/DHOLI 390305 1.72 72.59 188329 201976LIMBU 359379 1.58 74.17 174760 184619THAKURI 334120 1.47 75.64 164643 169477SARKI 318989 1.40 77.05 153681 165308TELI 304536 1.34 78.38 158647 145889CHAMAR, HARIJAN, RAM 269661 1.19 79.57 138878 130783KOIRI 251274 1.11 80.68 130424 120850KURMI 212842 0.94 81.61 111638 101204SANYASI 199127 0.88 82.49 98006 101121DHANUK 188150 0.83 83.32 97507 90643MUSAHAR 172434 0.76 84.07 88041 84393DUSADH/PASWAN/PASI 158525 0.70 84.77 82173 76352SHERPA 154622 0.68 85.45 77511 77111

MALE FEMALE

Ethnicity as Defined in the US Census

• Nepal is clustered with Other Asian or with all Asian ethnicities. Typically China, Taiwan, Filipino, Korean, East Indian, and Other Asian or just Asian are census options

• Within the Asian Clustering there are over 50 cultures represented in over 50 countries.

• Huge differences in etiological factors relative to Morbidity and Mortality exist within this Asian cluster.

• Current censes data presents a very ethnocentric view of Asian culture, that provides little if any data relevant for behavioral risk factors and quality of life indicators for these unique populations.

Federal Classification of Ethnic Groups in the United States

White 75.1%

African Americans 12.3%

Hispanics 12.5%

Pacific Islander 0.1%

Native Americans 0.9%

Asian 3.6%

U.S. Bureau of the Census, Population Division, (2001)

Proportion of Nepalese Among Other Asians

National Origin Population PercentTotal 11,898,828 100.0%

Asian Indian 189,959 16.0Bangladeshi 57,412 0.5Burmese 16,720 0.1Cambodian 206,052 1.7Chinese (except Tawainese) 2,734,841 23.0Filipino 2,364,815 19.9Hmong 186,310 1.6Indonesian 63,073 0.5Japanese 1,148,932 9.7Korean 1,228,427 10.3Laotian 198,203 1.7Malaysian 18,566 0.2

Nepalese 9,399 0.1Okinawan 10,599 0.1Pakistani 204,309 1.7Sri Lankan 24,587 0.2Tawainese 144,795 1.2Thai 150,283 1.3Vietnamese 1,223,736 10.3Other Asian 369,430 3.1

* Bhutan, Indo China, Maldivia and Singapore all have U.S. populations which are <0.1%

Our Preliminary Survey

• Modified version of the BRFS- looking at specific items we felt important based on literature review and available surveillance data

• Sample- convenient sample from various areas

Perceived Health Status and Health Behaviors of Nepalese Immigrants and Their Children: A Pilot Study

Research Questions:

• What were the perceived health status, quality of life, and values of Nepalese people?

• What was the status of their behavioral risk factors?

• What was the status of their health care? (insurance coverage)

• Was there a difference between the first generation Nepalese Immigrants and the younger generation in their health behaviors and perceived health status?

Methods• A convenience (nonrandom) sample of 110

Nepalese people completed the survey• The return rate for distributed surveys was 44%• Small incentive was offered to the people who

filled out the survey.• The BRFSS (Behavior Risk Factor Surveillance

System) from the CDC national health study was modified and pilot tested with local Nepalese people before the final distribution.

• The survey contained 69 items and the Cronbach’s alpha reliability for the relationship scale was 0.82.

• After the collection of the survey, SPSS PC version was used to analyze data.

Sample characteristics Number (%)Age group (18-34) 69 74Gender (females) 53 55Education (some college) 95 92Married 61 58Employed (full time) 53 51Income (>$25,000) 61 63

Table 1. Characteristics of the Nepalese Subjects (N=110).

Figure 1. Percent Nepalese participants and US population (BRFSS 2002) and their percieved health status (N=110)

29.9

10.5

3.96.4

1.8

33.8

21.426.4

43.6

21.8

0

5

10

15

20

25

30

35

40

45

50

Excellent Very Good Good Fair Poor

US (BRFSS2002)

Nepal

Yes No1. During the past month, other than your regular job, did you participate in any physical activites or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

U.S. (2002 BRFSS Survey) 75.6 24.4

Nepal (N=110) 83.5 13.8 X2 (1) = 5, p = <0.020

2. Are you currently a regular smoker?

U.S. (2002 BRFSS Survey) 23 77

Nepal (N==110) 26.8 73.2 X 2 (1) =1, p = 0.367

3. If you are above 40 years of age, have you ever had prostate test in last two years? (n=39)

U.S. (2002 BRFSS Survey) 53.9 46.1

Nepal (n=39) 23.1 74.4

X 2 (1)= 33, p = <0.000

4. Do you have any kind of health care coveraage, including health insurance, prepaid plans such as HMSs, or government plans such as Medicare?

U.S. (2002 BRFSS Survey) 85.9 14.1

Nepal (N=110) 80.9 17.3

X 2 (1)= 1, p = 0.313

Table 2. Comparison Between US and Nepalese Population on Selected Health Maintenance Behaviors

Figure 2. Percent Nepalese (n=54) and US women (BRFSS, 2000) who had had Pap smear test in the past

70.5

12.6

38.5

0

50

1.95.6

27.8

4.33.7

11.1

0

10

20

30

40

50

60

70

80

Past year Past twoyears

Past threeyears

Past fiveyears

5 or moreyears ago

Don't know

US

Nepal

Never Seldom Consistently Daily Missing value

1. Have you ever been the victim of physical abuse? 46.4 5.5 1.8 0.9 57.2

2. Have you ever been the victim of sexual abuse? 48.2 5.5 0.9 0 45.5

3. Have you ever been the victim of emotional abuse? 35.5 13.6 3.6 0.9 46.4

4. Have you ever been in a physical fight? 38.2 11.8 3.6 0 46.4

5. Do you see violence in your communities? 29.1 19.1 5.5 0.9 44.5

6. Do you see violence in the schools? 36.4 15.5 2.7 0 45.5

Table 3. Response to the Voilence Related Questions by Nepalese Subjects (N=110)

Items: Mareital N Mean SD t-test df Sig. (2-tailed)Family needs should come first married 53 4 1.127 1.449 93 0.151

single 42 3.67 1.097Always keep family values married 51 4.24 1.031 2.92 91 0.004**

single 42 3.48 1.469Arranged marriage is the best married 54 2.72 0.979 1.145 94 0.255

single 42 2.45 1.329Parents must stress children's married 54 3.78 1.127 1.181 93 0.241 academics single 41 3.51 1.028It is acceptable: 1.006 to marry outside your race married 56 3.43 1.024 -2.98 95 0.004**

single 41 4.05 1.177 to live together before marriage married 54 2.54 0.96 -5.08 93 0.000***

single 41 3.68 1.278 to divorce if needed married 52 2.88 1.245 -3.21 91 0.002**

single 41 3.73 0.786 for men to remarry after married 53 3.81 0.789 -3.09 92 0.003** divorce/death single 41 4.32 0.826 for women to remarry after married 55 3.95 0.852 -1.59 94 0.116 divorce/death single 41 4.22 1.073 for boys to date before 13 married 54 1.98 1.227 -2.35 93 0.021*

single 41 2.54 1.092 for boys to date fefore age 18 married 55 2.75 1.049 -4.45 94 0.000***

single 41 3.73 0.937 for boys to date after age 18 married 55 3.58 0.932 -2.55 94 0.012*

single 41 4.07 0.864 for boys to kiss a girl when married 53 3.06 1.005 -3.88 92 0.000*** dating single 41 3.8 12.829 for boys have sex fefore marriage married 57 4.23 1.121 0.359 94 0.72

single 39 3.49 13.224 for boys to be homosexuals married 54 3.94 1.525 0.56 93 0.577

single 41 2.78 1.036 for boys to have more than one married 54 2.28 1.241 -3.51 93 0.001** sex partner single 41 3.1 0.626 for men to share hoursework married 56 4.41 6.118 -1.45 94 0.151

single 40 5.6 1.132 for girls to date before 13 married 54 2.04 1.095 -2.37 93 0.020*

single 41 2.59 1.131 for girls to date fefore age 18 married 52 2.77 0.974 -3.67 91 0.000***

single 41 3.59 1.183 for girls to date after age 18 married 54 3.19 0.821 -3.89 93 0.000***

single 41 4.02 1.09 for girls to kiss when dating married 55 2.87 0.883 -3.95 93 0.000***

single 40 3.7 1.123 for girls have sex when dating married 55 2.33 1.235 -3.69 94 0.000***

single 41 3.22 1.135 for girls to be homosexuals married 54 2.35 1.196 -4.43 92 0.000***

single 40 3.43 1.1 for girls to have sex before married 54 2.13 1.476 -3.18 92 0.002** marriage single 40 2.98 1.043 for girls to have more than one married 53 2.09 1.273 -4.1 92 0.000*** sex partner single 41 3.07 0.985 for girls to be in the military married 55 3.75 0.818 -2.65 92 0.009**

single 39 4.26*p<.05; **p<.01; ***p<.001

Table 5. Difference in Family Value and Relationships among Nepalese Subjects by Marietal Status

Summary Results

• A was a big difference between actual health status of people living in Nepal and the Unites States.

• The perceived health status among Nepalese studied subjects was higher

• There was no difference in smoking and drinking behaviors, however,

exercise level was much higher among Nepalese people.

• Despite relatively high rate of having health insurance coverage the screening for cancer was significantly lower.

• Family’s needs and cultural values were perceived to be important

• Perceptions about arranged marriage was mostly negative to neutral

• The perceptions regarding dating relationship was different based on their marital status, single being more open to the dating activities.

• Regarding homosexual relationship, more single people had positive attitudes than married people.

Conclusions• The unrepresentative sample, bigger sample is needed to

get conclusive results • Although Nepalese immigrants seem to hold on to certain

cultural beliefs, they seemed to change their attitudes about other issues such as marriage and dating.

• Younger generation (single) were obviously more open than the older (married) people indicating some acculturation taking place among younger generation

• Some critical health behaviors such as smoking, drinking, and most importantly yearly screening need to be changed.

• Because of the item structure, the question about the prostate cancer screening could not be compared. – Education about health behaviors including smoking,

alcohol use, yearly screening seems to be as critical to this population as for other groups.

Methodological Issues

• Cultural Difference made the use of the same survey instrument (modified BRFS) difficult and often irrelevant (diet items, cast category, and violence).

• Gender differences/roles may be the reason for the ability and willingness to answer questions that are viewed as inappropriate.

• Sampling of convention attendees is skewed toward upper SES immigrants and specific ethnic/caste members.

• It is extremely hard to get a representative sample as the actual number of total population could be very different from the census record.

• Comparison between population living in Nepal and in the United States may show more clear picture about acculturation on family values

Next Steps/Modified qualitative methodology

• Focus on Nepalese women first, and may be race, ethnicity or the cast categories should be considered.

• With the focus groups- formulate questions that may illicit better information about lifestyle and health status.

• Conduct interviews with individual men and women using qualitative interview techniques and analysis especially on the topic like violence then design the actual survey questions.

• Conduct cross-checks with and among the focus groups after the data has been coded and analyzed.

Suggestions ?Suggestions ?

Sources:• CDC, (2002). Behavioral Risk Factor Surveillance System, Retrieved at June,

2003, http://www.cdc.gov/brfss/brfsques.htm

• Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. (1998) Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA; 279(21) :1703-8.

• PHS Task Force on Minority Health Data. (1992) Improving minority health statistics: report of the PHS Task Force on Minority Health Data. Washington, DC: Department of Health and Human Services, Public Health Service, Office of Minority Health.

• Kramer, E.J., Kwong, K., Lee. E., and Chung, H. (2002). Cultural factors influencing the mental health of Asian Americans. West J Med. 176:227-231

• United States Department of State (2000). Diversity Immigrant Visa Program, Bureau of Consular Affairs, Washington DC)

• http://www.nepalnews.com

• http://www.WHO

• http://www.census.gov

Population• Nepal

• Total population (000), 2001 23,592    

• Annual population growth rate (%), 1991 to 2001

2.4     • Dependency ratio (per 100), 2001

81     • Dependency ratio (per 100), 1991

81     • Percentage of population aged 60+ ye

ars, 20015.9    

• Percentage of population aged 60+ years, 1991

5.8     • Total fertility rate, 2001

4.6     • Total fertility rate, 1991

5.1

• United States of America

• Total population (000), 2001 285,925    

• Annual population growth rate (%), 1991 to 2001

1.1     • Dependency ratio (per 100) 2001

51    • Dependency ratio (per 100), 1991

53     • Percentage of population aged 60+ ye

ars, 200116.2    

• Percentage of population aged 60+ years, 1991

16.6     • Total fertility rate, 2001

2.0     • Total fertility rate, 1991

2.0