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Figure.  Rates of Assault by Country of Immigration
Rates of Assault by Country of Immigration

Rates were adjusted for age, sex, neighborhood income, and rurality.

Table 1.  Cohort of Immigrant and Nonimmigrant Youth in Ontario, Canada, 2008-2016
Cohort of Immigrant and Nonimmigrant Youth in Ontario, Canada, 2008-2016
Table 2.  Frequency and Age-Sex Standardized Assault Rates by Immigration Status and Sociodemographic Characteristics in Ontario, Canada, 2008-2016
Frequency and Age-Sex Standardized Assault Rates by Immigration Status and Sociodemographic Characteristics in Ontario, Canada, 2008-2016
Table 3.  Adjusted RRs of Assault-Related Injuries by Immigrant Status and Sociodemographic Characteristics, 2008-2016
Adjusted RRs of Assault-Related Injuries by Immigrant Status and Sociodemographic Characteristics, 2008-2016
Table 4.  Adjusted RRs of Assault-Related Injuries by Immigrant Characteristics, 2008-2016a
Adjusted RRs of Assault-Related Injuries by Immigrant Characteristics, 2008-2016a
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Betancourt  TS, Abdi  S, Ito  BS, Lilienthal  GM, Agalab  N, Ellis  H.  We left one war and came to another: resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families.  Cultur Divers Ethnic Minor Psychol. 2015;21(1):114-125. doi:10.1037/a0037538PubMedGoogle ScholarCrossref
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    Original Investigation
    Public Health
    March 4, 2020

    Association of Immigrant and Refugee Status With Risk Factors for Exposure to Violent Assault Among Youths and Young Adults in Canada

    Author Affiliations
    • 1Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
    • 2Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
    • 3ICES, Toronto, Ontario, Canada
    • 4Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
    • 5Institute of Health Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
    • 6York University, Toronto, Ontario, Canada
    JAMA Netw Open. 2020;3(3):e200375. doi:10.1001/jamanetworkopen.2020.0375
    Key Points español 中文 (chinese)

    Question  What is the risk of experiencing violent injury associated with immigrant and refugee status among youth and young adults in Canada?

    Findings  In this population-based cohort study including 22 969 443 person-years, the adjusted risk ratio of experiencing assault among immigrants was 0.41 and among refugees was 0.82 compared with nonimmigrant individuals. Risk of assault among immigrants was stable with time since immigration, and rates were lowest among immigrants from South and East Asia.

    Meaning  The low relative rates of assault among immigrants suggest that Canadian immigrant settlement supports and cultural factors may be protective against the risk of experiencing assault.

    Abstract

    Importance  Immigrant populations continue to grow across Western countries. Such populations may face vulnerabilities that contribute to the risk of experiencing violent injury. Youths are at disproportionate risk compared with other age groups, and such violence may be preventable with appropriately targeted injury prevention strategies.

    Objective  To examine the association of immigrant or refugee status and immigration-related factors with the experience of assault.

    Design, Setting, and Participants  This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal, single-payer health insurance plan. All youths and young adults aged 10 to 24 years (hereafter referred to as youths) residing in Ontario from January 1, 2008, to December 31, 2016, were eligible to participate. Data were analyzed from April 13, 2017, to January 6, 2020.

    Exposures  The main exposure was immigrant status. Secondary exposures were immigration-related factors, including visa class, time since immigration, and region and country of origin.

    Main Outcomes and Measures  The main outcome consisted of violent injuries requiring acute care (emergency department visit or hospitalization) or causing death. Poisson regression models were used to estimate rate ratios for injuries.

    Results  A total of 22 969 443 person-years were included in the analysis (51.3% male and 48.7% female participants). Compared with nonimmigrants, a greater proportion of immigrants lived in the lowest neighborhood income quintile (30.5% vs 18.2%) and urban areas (98.9% vs 87.7%). Among immigrants, 17.9% were refugees. Rates of violent injuries experienced were 549.0 (95% CI, 545.7-552.2) per 100 000 person-years in nonimmigrant youth, 225.0 (95% CI, 219.4-230.7) per 100 000 person-years in nonrefugee immigrant youth, and 525.4 (95% CI, 507.2-544.1) per 100 000 person-years in refugee immigrant youth. The rates of violent injury among nonrefugee and refugee immigrants were lower than among nonimmigrants (nonrefugee adjusted rate ratio [aRR], 0.41 [95% CI, 0.38-0.43]; refugee aRR, 0.82 [95% CI, 0.76-0.89]). Older age (oldest vs youngest aRR, 6.90 [95% CI, 6.53-7.29]), male sex (aRR, 2.60 [95% CI, 2.52-2.68]), and low neighborhood income (aRR, 2.42 [95% CI, 2.32-2.53]) were associated with violent injury risk. Rates of experiencing assault were lowest among South Asian (aRR, 0.33 [95% CI, 0.30-0.37]) and East Asian (aRR, 0.23 [95% CI, 0.19-0.26]) immigrants. Only Somali immigrants experienced higher assault rates (712.0 [95% CI, 639.3-805.3] per 100 000 person-years) compared with nonimmigrants. Most injuries (79.9%) were from being struck, followed by being cut (5.9%).

    Conclusions and Relevance  The low rates of assault experienced by immigrants, including refugees, compared with nonimmigrants suggests that Canadian immigrant settlement supports and cultural factors may be protective against the risk of experiencing assault.

    Introduction

    Violence against youth is a global phenomenon and a leading cause of death in high-income countries.1,2 Prevalence rates vary considerably depending on the country, culture, and socioeconomic climate. Youths, in particular, are a group who disproportionately experience violence, with reported rates approximately 4 times higher than for middle-aged adults (aged 35-64 years) and 15 times higher than for adults 65 years or older.3 Physical violence in youth, which is detrimental to physical and mental well-being,2 may stem from punishment from caregivers, assault from strangers, bullying, and criminal or gang involvement. Understanding the distribution of youth who die due to or who experience and survive physical violence by sociodemographic factors, including immigration factors, can guide interventions and policies for violence prevention efforts.

    Foreign-born individuals now constitute 21.9% of the Canadian population.4 Immigrants to Canada come from more than 150 source countries for 1 of 3 main reasons: family reunification (ie, family class immigrants), humanitarian or compassionate needs (ie, refugees), and the ability to contribute economically and fill labor market needs (ie, economic class immigrants).4 As the number of immigrants continues to rise in Canada and most high-income countries,5 public concern has increased about racism, marginalization, poverty, use of public resources, criminal gang involvement, and violence among immigrant youth.6-9 Increasing global migration with a simultaneous rise in urban violence has fueled anti-immigrant sentiment, and the role immigrants play in contributing to this violence has dominated discourse.10-12 Given the lack of public crime statistics by immigrant status, conclusions cannot be drawn regarding causal relationships between immigration and violence.

    Immigrant experiences before and after migration may affect the risk of experiencing violence after resettlement. Immigrant youth, in particular refugees (those who typically have undergone forced migration), are vulnerable, often facing social disadvantage and challenged to adapt to new cultural milieus, language, social structures, and peer relationships. Immigrant youth who migrate with their families or to join them may experience discrimination, racism, xenophobia, bullying, peer aggression, and family or gang violence. These experiences may limit social and educational opportunities and leave lasting physical and emotional injury, which in turn may limit a youth’s ability to realize his or her potential.13-15 Understanding how migration factors affect the risk of experiencing violent injury is critical for the development and implementation of targeted injury prevention and settlement strategies. However, objective data on violence experienced by immigrant youths that do not rely on self-report, globally and in a Canadian context, are notably absent from existing published work to date.

    Our objectives were to describe at a population level the rates of serious assault (ie, requiring a hospital visit) in immigrant and nonimmigrant youths and young adults (hereafter referred to as youths) in Ontario, Canada, and to test the association of immigrant status and immigration-related factors with the experience of violent injury. We hypothesized that rates of experiencing violence are lower among immigrant youths, but the distribution patterns of experiencing violence vary between regions and countries of origin as well as by refugee status and time since migration.

    Methods
    Study Design, Setting, and Population

    This population-based cohort study used health and administrative data sets linked at ICES, a not-for-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health data without consent in Toronto, Canada. This study was approved by the research ethics board at The Hospital for Sick Children, Toronto, Ontario, and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Reporting of Studies Conducted Using Observational Routinely Collected Data (RECORD) reporting guidelines.

    In Ontario, the single-payer, universal Ontario Health Insurance Plan provides publicly funded health care for most hospital and physician services at no personal cost to all Ontarians, including immigrants with permanent residency in Canada. We included all youths aged 10 to 24 years living in Ontario from January 1, 2008, to December 31, 2016, with a valid Ontario Health Insurance Plan number. Nine annual cohorts were created within the study period to assign sociodemographic characteristics based on data available on December 31 of each cohort year.

    Data Sources

    A unique, encoded identifier for each individual, derived from Ontario Health Insurance Plan numbers, was used to link several data sets. We extracted and linked data from the Registered Persons Database (Ontario’s health insurance registry), the National Ambulatory Care Reporting System (emergency department visit data), the Canadian Institute for Health Information Discharge Abstract Database (hospitalization data), the Ontario Registrar General Database (deaths data),16 and the Rurality Index of Ontario17 based on postal code (rural vs urban residence). Statistics Canada’s Postal Code Conversion File was used to determine neighborhood income quintiles at the dissemination area level using Canadian Census data from 2006. A detailed outline of the data linkage process has been published elsewhere.16

    To obtain immigration information, we used the Immigration, Refugees and Citizenship Canada Permanent Resident Database. The available portion of this database contains data for all permanent residents (immigrants granted permission to live and work in Canada without limitations on their stay) landing in Ontario since 1985. Deterministic and probabilistic linkage to the Registered Persons Database identifies 86% of permanent residents.16 Not included in this data set are undocumented or temporary residents (eg, foreign students) and prehearing asylum seekers (including those who have not yet obtained residency status but eventually do). Permanent residents, including refugees, linked in the database are typically eligible for provincial health insurance within 3 months of arrival in Canada.

    Outcome Measures

    The primary outcome measure was any serious assault-related injury. Serious assaults were defined as any emergency department visit, hospital admission, or in- and out-of-hospital death (eg, homicides) using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada, codes for external causes of injury with a discharge diagnosis of an intentional injury (X85-X99 and Y00-Y09). This coding system is the most widely used framework for categorizing the circumstances of an injury and includes the intent and mechanism of injury.18

    Risk Factors

    The main risk factor was immigrant status (nonimmigrant vs immigrant) determined based on the presence or absence of an Immigration, Refugees and Citizenship Canada Permanent Resident Database record. Within-immigrant risk factors included visa class (refugee vs nonrefugee), time in Canada since immigration (recent: 0-5 years; intermediate: 6-10 years;and long-term: >10 years), and region and country of origin (based on the country of birth). We included age, sex, neighborhood income quintile, and rurality as covariates.

    Statistical Analysis

    Data were analyzed from April 13, 2017, to January 6, 2020. We described baseline characteristics of the cohort using frequencies and percentages. We calculated the total number of assaults overall and by mechanism during the 9-year study period and annual injury rates per 100 000 person-years directly standardized by age and sex using 2006 census estimates.

    Multivariable modified Poisson regression models with generalized estimating equations to account for multiple events within the same individual were built to estimate the relative risk (RR) with 95% CI of assault-related injury by immigrant status. We produced an overall model including nonimmigrants and immigrants and stratified models separately with nonimmigrants and immigrants, adjusting for age, sex, neighborhood income, and rurality. We then conducted analyses to estimate the risk of experiencing assault for various immigration characteristics, with separate models run for visa class, time since immigration, and region of origin, adjusting for age, sex, neighborhood income, and rurality. Country-specific risk-adjusted rates were achieved by calculating the overall crude rate in nonimmigrants, country-specific crude rates, and estimated rates based on the modified Poisson model on the risk of assault in nonimmigrants; the 95% CIs of the risk-adjusted rates were then calculated using the bootstrapping method19 with unrestricted random sampling and replacement for 250 occurrences. Finally, we used the funnel plot method20 to compare country-level, risk-adjusted rates of assault with the observed nonimmigrant rate to identify outliers; the funnel plot control limits were calculated using a Poisson distribution. All analyses were conducted using SAS Enterprise Guide, version 6.1 (SAS Institute Inc).

    Results

    We included 22 969 443 person-years (20 012 091 nonimmigrant and 2 957 352 immigrant; 51.3% male and 48.7% female) in our analyses (eFigure in the Supplement and Table 1). Immigrants had the largest proportion (1 288 711 [43.6%] vs 6 794 537 [34.0%]) in the oldest group (20-24 years), and there were similar proportions of male and female individuals in the immigrant (51.4% male and 48.6% female) and nonimmigrant (51.2% male and 48.8% female) groups. Immigrants had the largest proportion living in the lowest income quintile (30.5% among immigrants vs 18.2% among nonimmigrants). Almost all immigrants (98.9%) lived in urban settings in contrast to 87.7% of nonimmigrants. Among immigrants, 17.9% were refugees, 29.0% had been in Canada for less than 6 years, and 37.1% had been in Canada for more than 10 years. The largest source regions included South Asia (25.4%), East Asia and the Pacific (22.6%), the Middle East (12.9%), and the United States, United Kingdom, and Western Europe (10.6%).

    During the 9-year study period, nonimmigrants experienced 110 936 assaults (549.0 [95% CI, 545.7-552.2] per 100 000 person-years), and immigrants experienced 9654 assaults (280.2 [95% CI, 305.4-321.0] per 100 000 person-years), including 225.0 (95% CI, 219.4-230.7) per 100 000 person-years in nonrefugee immigrant youth, and 525.4 (95% CI, 507.2-544.1) per 100 000 person-years in refugee immigrant youth (Table 2). In adjusted models, immigrants had less than half the risk of experiencing assault compared with nonimmigrants (adjusted RR [aRR], 0.49 [95% CI, 0.47-0.51]) (Table 3). Male nonimmigrants had higher rates of experiencing assault than female nonimmigrants (male: 779.1 [95% CI, 773.7-784.5] per 100 000 person-years; female: 309.1 [95% CI, 305.7-312.6] per 100 000 person-years; aRR, 2.54 [95% CI, 2.50-2.57]). Among immigrants, male youths had a higher rate of assault (436.9 [95% CI, 427.0-446.9] per 100 000 person-years) than female youths (117.1 [95% CI, 111.9-122.5] per 100 000 person-years) with risk of experiencing assault in male immigrants more than 4 times that of female immigrants (aRR, 3.78 [95% CI, 3.58-4.00]). Most assaults were experienced by the oldest youths, with rates as high as 863.9 (95% CI, 852.0-871.0) per 100 000 person-years in nonimmigrants aged 20 to 24 years and 488.2 (95% CI, 476.2-500.4) per 100 000 person-years in immigrants from that same age group. Risk of experiencing assault was higher in nonimmigrants from rural areas (aRR, 1.30 [95% CI, 1.28-1.32]) and not different between urban and rural immigrants.

    Table 4 shows the aRRs for assault by immigration characteristics. Compared with nonimmigrants, refugees (aRR, 0.82 [95% CI, 0.76-0.89]) and nonrefugees (aRR, 0.41 [95% CI, 0.38-0.43]) had a lower risk of experiencing assault. Risk of experiencing assault was not different with duration of time in Canada and was lower in immigrants across all regions of origin except for those from Central America, with lowest rates experienced by immigrants from East Asia (aRR, 0.23 [95% CI, 0.19-0.26]) and South Asia (aRR, 0.33 [95% CI, 0.30-0.37]) (Table 4). Of all the regions of origin, immigrants from Central America had the highest rates of experiencing assault (552.2 [95% CI, 521.0-584.8] per 100 000 person-years; aRR, 0.91 [95% CI, 0.80-1.03]) compared with nonimmigrants. Older age (oldest vs youngest aRR, 6.90 [95% CI, 6.53-7.29]), male sex (aRR, 2.60 [95% CI, 2.52-2.68]), and low income (aRR, 2.42 [95% CI, 2.32-2.53]) were associated with violent injury risk.

    The Figure shows the funnel plot of country-specific, risk-adjusted rates of experiencing assault. Only those countries of origin with at least 20 individuals assaulted are shown, and specific rates are in eTable 1 in the Supplement. Immigrants from every country had rates no different than or lower than the nonimmigrant rate except for immigrants from Somalia, where rates were 712.0 (95% CI, 639.3-805.3) per 100 000 person-years. Immigrants from all large-volume countries (>75 000 person-years) had rates lower than nonimmigrants, including immigrants from India, China, Pakistan, Philippines, Sri Lanka, and the United States, except for Jamaica and Iran, whose rates were not different than those of Canadian-born individuals.

    The mechanism of assault by immigrant status is shown in eTable 2 in the Supplement. Most assaults were from being struck (79.9%) followed by being cut (5.9%). Immigrants had lower or similar rates of assaults from all causes except for firearm assaults (5.2 [95% CI, 4.4-6.1] per 100 000 person-years vs 3.3 [95% CI, 3.1-3.6] per 100 000 person-years) and those caused by cutting or piercing (31.3 [95% CI, 29.4-33.4] per 100 000 person-years vs 30.6 [95% CI, 29.9-31.4] per 100 000 person-years), for which rates were higher among immigrants.

    Discussion

    In this population-based study, we demonstrated that the risk of experiencing assault among immigrant youth was 51% lower than in Canadian-born youth. Rates of assault were particularly low among youth from Canada’s largest intake countries, including Pakistan, China, India, Philippines, the United States, and Sri Lanka. We found an increased risk of experiencing assault in refugee compared with nonrefugee immigrants but no change in this risk with increasing time since migration to Canada. There was substantial variability in the risk of experiencing assault by region and country of origin, with the lowest rates among those from South and East Asia and the highest among those from Central America and Africa. Importantly, we demonstrated high rates of experiencing assault among Somali immigrant youth.

    Comparing rates of violence experienced by immigrants in the present study, which includes violence experienced from peers, friends, relations, and strangers, with rates in other jurisdictions is difficult given the paucity of published studies on those who experience and survive violence that do not rely on self-report or only focus on intimate partner violence or homicides. One Swiss study in adolescents who experienced child maltreatment, including physical assault,21 found that the prevalence of assault was lowest in native Swiss, higher in Western immigrants, and highest in non-Western immigrants. The investigators found that, after adjusting for other risk factors, a family background of migration was the strongest risk factor for physical abuse.21 In Italy, foreign-born youth were more likely to perpetrate and experience homicide compared with Italian-born youth22; in Spain, foreign-born women were more likely to report experiencing violence than nonimmigrants.23 In the Netherlands, immigrant children were overrepresented in families who had witnessed prior violence (child maltreatment, neglect, or domestic violence) or homicide in their home.24 In contrast to studies of immigrants in Europe, most reports on individuals who experience violence in North America suggest immigrants are at lower risk than nonimmigrants. In Canada, adult immigrants reported experience of violent assault at almost half the rate of nonimmigrants (68 vs 116 per 1000 population).25 Wheeler et al26 reported that foreign-born adults in the United States have self-reported rates of experiencing violence not different from those of US-born adults. However, they also reported that, for immigrants entering the United States as youth, the prevalence of experiencing violence declined with longer residency in the United States.26

    Rates of assault may be lower in immigrant youth to Canada for several reasons. Canada accepts relatively high proportions of immigrants in economic and family classes in which socioeconomic disadvantage, language proficiency, exposure to trauma, and forced migration may be lower than that among immigrants in other jurisdictions.4 However, refugees to Canada experienced relatively low rates of assault. This finding suggests that, although prior experiences, including violence, conflict, and forced migration, may contribute to some extent, other factors, such as family cohesion, hope, opportunity, settlement supports, and living in urban centers with high-density immigrant communities (associated with reduced crime and better health outcomes), may contribute to our findings.8,27-29

    We found that with increasing time since migration, there was no change in risk of experiencing violence. Other studies have found that time since migration is associated with increasing perpetration of violence, increasing substance use, and increasing intimate partner violence.10,30 Instead, our findings demonstrate that immigrants maintain their health advantage with time in Canada. Refugees also had higher rates of experiencing assault compared with nonrefugees. Alink et al31 have shown higher rates of child maltreatment in refugee compared with nonrefugee families. Recent immigrants and refugees may be vulnerable to relative poverty and intimate partner violence, may have limited support systems with changing family dynamics, and may have new gender roles.6,32 However, their rates of experiencing violence are lower than those of native-born youths.

    Country-specific rates of assault in immigrants to Canada show low rates from each of Canada’s major source countries. However, violence experienced by Somali youth, most of whom come as refugees (76%), was disproportionately high compared with violence experienced by other immigrant groups. This violence may undermine their capacity to rebuild their lives in Canada and has been shown to perpetuate through generations, in part due to barriers to equitable opportunities in education and participation in the labor market.33,34 Our findings highlight that policy makers, clinicians, and settlement support workers need to address the unique sources of risk specific to the Somali immigrant population, including but not limited to the compounding effects of racism and Islamophobia, and work to identify institutional barriers at the root of violence.33,35

    Our study included a large sample size with almost complete coverage of the population of youth. Our findings include only substantiated assaults that are complimentary to studies on self-report and may have reporting bias, especially among immigrants hesitant to report experiencing assault. We included a large number of immigrants from all regions of the globe with detailed immigration data that allowed better understanding of immigration-specific risk factors for violent injury.

    Limitations

    A limitation of this study is that some important factors are unknown. These factors include the circumstances contributing to injury events (eg, perpetrator, gang involvement vs family violence) and some demographic information (eg, family educational level and language proficiency), both of which may have helped to further understand injury risk. Care seeking between immigrants and nonimmigrants may differ; thus, injuries may be underestimated among immigrants, particularly for more minor physical injuries. Immigration data was limited to permanent residents and did not include temporary (eg, foreign students or workers) or undocumented immigrants.

    Conclusions

    The low relative rates of assault among immigrants, in particular the almost universally equal or lower rates by country of origin, suggest that the Canadian immigrant settlement support system and cultural factors may be protective against the risk of experiencing assault. Results highlight a need for increased attention to immigrants from Somalia for whom vulnerabilities may be inadequately addressed and for whom settlement supports and opportunities for success may be insufficient.

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    Article Information

    Accepted for Publication: January 11, 2020.

    Published: March 4, 2020. doi:10.1001/jamanetworkopen.2020.0375

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Saunders NR et al. JAMA Network Open.

    Corresponding Author: Natasha Ruth Saunders, MD, MSc, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada (natasha.saunders@sickkids.ca).

    Author Contributions: Ms Guan and Dr Lu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Saunders, Guan, Macpherson, Guttmann.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Saunders.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Saunders, Guan, Lu.

    Obtained funding: Guttmann.

    Administrative, technical, or material support: Saunders, Macpherson.

    Supervision: Saunders, Guttmann.

    Conflict of Interest Disclosures: Dr Saunders reported receiving grants from the Canadian Institutes of Health Research (CIHR) and SickKids Foundation outside the submitted work. Dr Macpherson reported receiving grants from the CIHR outside the submitted work. Dr Guttmann reported receiving grants from the CIHR during the conduct of the study. No other disclosures were reported.

    Funding/Support: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC); by Applied Chairs in Reproductive and Child Health Services and Policy Research from the CIHR (Drs Guttmann and Macpherson); and grant APR 126 377 from Dr Guttmann’s Applied Chair award (data analysis).

    Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The opinions, results, and conclusions reported in this paper are those of the authors and are independent of the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI) and Immigration, Refugees Citizenship Canada (IRCC). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of the CIHI or IRCC. Parts of this report are based on Ontario Registrar General Database information on deaths, the original source of which is Service Ontario. The views expressed herein are those of the authors and do not necessarily reflect those of the Ontario Registrar General Database or Ministry of Government Services.

    Additional Information: The data set from this study is held securely in coded form at ICES. Data-sharing agreements prohibit ICES from making the data set publicly available, but access may be granted to those who meet prespecified criteria for confidential access, available at https://www.ices.on.ca/DAS. The full data set creation plan and underlying analytic code are available from the authors upon request, understanding that the programs may rely upon coding templates or macros that are unique to ICES.

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