Prevalence of diabetes and characteristics associated with poor diabetes outcomes among different migrant groups in Australia

Introduction

Migration is central to Australia’s prosperity (The Migration Council Australia 2015). Approximately 30% of the Australian population is born overseas, with almost all countries in the world represented in its population. About 25% speak a language other than English at home (Australian Bureau of Statistics 2021a, 2023a). This diverse population has various socioeconomic statuses and experiences with the Australian health system (Australian Bureau of Statistics 2019). Migration policies and self-selection to migrate generally result in migrants possessing a better general health status compared to their destination countries’ populations at the early stage of resettlement (Kennedy et al. 2015; World Health Organization 2022a). However, over time, some groups of migrants experience poorer health outcomes due to factors that increase their risk of developing diseases and the challenges they face in managing their health conditions (Adhikari et al. 2021; World Health Organization 2022b; Queensland Health 2023).

Diabetes-associated morbidity and mortality are higher among some groups of migrants compared to the destination countries’ born populations. Based on the Australian National Health Survey in 2022, the estimated prevalence of diabetes among migrants was higher than that of the Australian-born population (6.7% vs 4.7%) (Australian Bureau of Statistics 2023b). Additionally, some migrant groups experience poorer diabetes outcomes compared to the general Australian population (Australian Bureau of Statistics 2023b; Queensland Health 2023). A combination of factors such as lifestyle, social power structures, experience of racism and discrimination (Viruell-Fuentes et al. 2012; Willen et al. 2021; Egede et al. 2023), accessibility of health information, health system literacy and socioeconomic status can affect migrants’ experience with diabetes (Wilson et al. 2012; Lau et al. 2013; Pasupuleti et al. 2016; Kearns et al. 2017; Slopen et al. 2018; Khatri and Assefa 2022).

Some migrant groups in Australia, particularly visible minorities, experience racism and discrimination, which can increase their risks of diabetes morbidity and mortality (Zimmerman et al. 2011; Markus 2021; Ben et al. 2024). Access to diabetes-related information and services, as well as the ability to take action to manage diabetes in Australia, is associated with migrants’ English language proficiency and digital literacy. Some groups of migrants, especially older migrants, may lack sufficient English proficiency or digital literacy to access health information and services (Temple et al. 2022; Fry et al. 2024). The low socioeconomic status of some migrant groups can limit their access to health information and services and their ability to self-care, leading to a higher risk of diabetes and poorer outcomes (Pasupuleti et al. 2016; Khatri and Assefa 2022). The length of stay in the destination country also affects migrants’ health in various ways. They may not have sufficient knowledge and skills to navigate the unfamiliar health system in the destination country (Pasupuleti et al. 2016; Khatri and Assefa 2022). Recent migrants often have competing priorities, including financial challenges, which may affect their ability to prioritise diabetes care (Pasupuleti et al. 2016; Khatri and Assefa 2022).

Understanding the prevalence of diabetes among various migrant groups and identifying those that may need more support to manage their diabetes effectively can improve health equity, social cohesion and development. As the age structure differs among different migrant populations and the population born in the destination countries, it is important to use age-standardised methods to have a better estimate of the differences among migrant groups and the population born in the destination countries. This study aimed to report the crude and age-standardised prevalence of diabetes in different migrant groups in Australia and describe the characteristics of those with diabetes that can affect the diabetes outcomes to guide health planning and delivery for health equity.

Methods

The whole population data from the 2021 Australian census was used for this study and accessed through TableBuilder (Australian Bureau of Statistics 2021c). Self-reported diabetes, comorbidities and sociodemographic data from people aged 30 years and older were analysed. Missing data were excluded from the analysis. The census asked participants if a doctor or nurse had ever told them they have diabetes, excluding gestational diabetes. Questions asked for the census and methods used are available on the Australian Bureau of Statistics website (Australian Bureau of Statistics 2021b). The inclusion of only people aged 30 years and older was based on the higher risk of diabetes in this age group and the aim to better assess the comorbidities and sociodemographic characteristics of the overseas-born population living with diabetes in Australia.

The author categorised the populations based on the country of birth into Australian-born and people born in 10 different regions or groups of countries. A category was created to include people born in the USA, Canada and New Zealand as their English language background can define their experiences with the Australian health system. Another category was created to include people born in South America, Central America and the Caribbean countries. Other regions or countries in America were not included due to small representation in the Australian population. Other categories were based on defined categories by Australian Bureau of Statistics and included North-West Europe, Southern and Eastern Europe, North Africa and the Middle East, South-East Asia, North-East Asia, Southern and Central Asia, Sub-Saharan Africa, Oceania and South and Central America and the Caribbean (Australian Bureau of Statistics 2021d). For the Oceania category, we excluded people born in Australia or New Zealand.

Direct standardisation using the age-specific prevalence and the World Health Organization (WHO) standard population was used to calculate age-standardised prevalence. For calculating the age-standardised prevalence ratio (ASPR), the Australian-born group was considered the reference group.

For people who had diabetes, the percentages of those who had other long-term health conditions, had three or more long-term health conditions, needed assistance with core activities, did not go to school, had a weekly income of less than A$500, had low proficiency in spoken English and arrived in Australia less than 10 years ago were reported. The long-term health conditions included in this study were arthritis, asthma, cancer (including remission), dementia (including Alzheimer’s), heart disease (including heart attack or angina), kidney disease, lung condition (including chronic obstructive pulmonary disease, COPD, or emphysema), mental health condition (including depression or anxiety) and stroke. An income of A$489 per week for a single adult was defined as the poverty line in 2020 (Davidson et al. 2022). Low proficiency in spoken English was defined as combined responses of ‘Not well’ and ‘Not at all’ to the question, ‘How well does the person speak English?’

Results

Data on diabetes from more than 9,500,000 Australian-born and 5,500,000 overseas-born individuals aged ≥30 years were included. Among the Australian-born population, 51.6% were female. Among the overseas-born population, this ranged from 46.8% for individuals born in Southern and Central Asia to 59.8% for those born in South-East Asia. Among Australian-born individuals, 42.6% were under 50 years old, and among overseas-born this ranged from 20% for individuals born in Southern and Eastern Europe to 75.7% for those born in Southern and Central Asia.

The crude prevalence of diabetes among the Australian-born population aged 30 years and older was 7.1%. Among the overseas-born population, it ranged from 5.3% among people born in North-East Asia to 14.4% among those born in Oceania. Forty-one percent of the population with diabetes was born overseas. Of those, 22.6% were born in North-West Europe; 17.8% in Southern and Eastern Europe; 14.2% in South-East Asia; 13.8% in Southern and Central Asia; 8.4% in North Africa and the Middle East; 7.3% in North-East Asia; 6.3% in the USA, Canada or New Zealand; 4% in Oceania; 3.8% in Sub-Saharan Africa and 1.8% in South and Central America and the Caribbean.

The prevalence of diabetes in all population groups was higher among males, with the male-to-female ratio of prevalence ranging from 1.1 among the Oceania-born population to 1.6 among those born in North-East Asia. For the regions of North-West Europe, Southern and Eastern Europe, South-East Asia, North-East Asia and South and Central America and the Caribbean, the prevalence was highest among people aged 80 years and older. For other groups, the prevalence was highest in the age group 70–79 years. (Table 1, Supplementary Table S1)

Age-standardised prevalence was higher than the Australian-born population among migrants from South-East Asia (ASPR: 1.4), North Africa and the Middle East (ASPR: 1.7), Southern and Central Asia (ASPR: 2.2) and Oceania (ASPR: 2.2). The highest ASPR was observed among females born in Oceania (2.4). For other regions, ASPR was 0.8 (among populations born in North-West Europe), 0.9 (among populations born in North-East Asia and USA, Canada and New Zealand) and 1.0 among populations born in Southern and Eastern Europe, Sub-Saharan Africa and South and Central America and the Caribbean. (Table 2, Supplementary Table S2).

Among people who had diabetes, more than 30% of populations born in Australia, North-West Europe and Southern and Eastern Europe had arthritis, over 21% had heart diseases and more than 9% had cancer. Asthma and mental health conditions were more prevalent among people born in Australia (15.1% and 19.4% respectively) and in the USA, Canada and New Zealand group (14.2% and 15% respectively). Stroke and dementia were more prevalent among people born in Southern and Eastern Europe (6.3%) and North-West Europe (5.7% and 3.8% respectively). The prevalence of kidney disease was around 7% among people born in Southern and Eastern Europe, Oceania, Australia, North-West Europe and North Africa and the Middle East. Lung condition was more prevalent among people born in North-West Europe (8.5%) and Australia (7.6%). (Table 3, Supplementary Table S3)

Among people who had diabetes, the percentage of those with three or more long-term health conditions was higher (>31%) among populations born in Australia, North-West Europe and Southern and Eastern Europe. More than 37% of people born in Southern and Eastern Europe and North Africa and the Middle East needed assistance with core activities, and more than 8% of populations born in Southern and Eastern Europe, North Africa and the Middle East and South-East Asia did not have school education. The percentage of people with a weekly income of less than $500 ranged from 38.5% (born in Sub-Saharan Africa) to 66.2% (born in Southern and Eastern Europe). The percentage of people with low English proficiency and those who arrived in Australia less than 10 years ago was higher among migrants from North-East Asia (55.2% and 14.9% respectively) and North Africa and the Middle East (36.2% and 12.5% respectively). (Table 4)

Discussion

Compared with the Australian-born population, the age-standardised prevalence of diabetes was higher among migrants from South-East Asia, North Africa and the Middle East, Southern and Central Asia and Oceania. Diabetes prevalence was higher among males and people aged 70 years and more. Most comorbidities were more prevalent among people born in Australia, Southern and Eastern Europe and North-West Europe. The prevalence of characteristics that can lead to poor diabetes outcomes varied among different groups of migrants. Migrants from Southern and Eastern Europe, North Africa and the Middle East, South-East Asia, Southern and Central Asia and North-East Asia were highlighted in most of these characteristics.

Similar to our findings, a previous study in Australia using diabetes data from the National Diabetes Services Scheme reported that migrants born in the Pacific Islands, Southern and Central Asia and North Africa and the Middle East had the highest prevalence of type 2 diabetes, and the prevalence was higher among males (Abouzeid et al. 2013). However, they reported that all migrant groups based on the region of birth had higher prevalence than the Australian-born population, which is not consistent with our findings. This could be related to the inclusion of people aged 30 and older in this study and different datasets used and methods implemented to adjust for age differences among groups. Using direct standardisation is a standard method when prevalence for age groups is available. The use of census data provided sufficient information for this study to apply this method, allowing for better comparisons among groups.

A systematic review also reported that the prevalence of type 2 diabetes among migrants in Europe is higher among migrants from South Asia, North Africa and the Middle East, Sub-Saharan Africa, Western Pacific and Southern and Central Asia compared to the population born in the destination countries (Meeks et al. 2016). In our study, a similar prevalence to the Australian-born population was observed among migrants from Sub-Saharan Africa and South and Central America. This could be due to the specific socioeconomic status of migrants from these regions living in Australia, their migration reasons and pathways. Most of the migrants from Sub-Saharan Africa in Australia are from South Africa (Australian Bureau of Statistics 2019–2020). A high percentage of migrants from South and Central America and Sub-Saharan Africa living in Australia are younger than 50 years old, highly educated, speak English well and work in well-remunerated jobs (Soontiens and Van Tonder 2014; Kath and Del Río 2022). However, further studies to are needed to better understand variations among countries in these groups.

Multiple factors likely contribute to the high prevalence of diabetes in some groups of migrants, including pre-migration diabetes and its risk factor status and post-migration unhealthy dietary changes, reduced physical activity and accumulated psychosocial stressors associated with migration, settlement and experience of racism and discrimination (Zimmerman et al. 2011; Egede et al. 2023). Given the highest prevalence of diabetes among migrants born in Southern and Central Asia and Oceania, it is important that these groups are prioritised in diabetes prevention programs. Designing programs to empower migrants from these regions to prevent diabetes with the consideration of the colonisation effects on their lifestyle is crucial (Dye et al. 2018).

A high percentage of migrants from North-West Europe who had diabetes also had other comorbidities and low income. However, they were in a better position than other migrant groups for other characteristics reported in this study. The majority of migrants from North-West Europe are people born in England (Australian Bureau of Statistics 2019–2020). Most of these migrants have a good social status in Australian society and may not experience difficulties that other migrant groups may experience in accessing services in Australia, including health services.

Although migrants from Southern and Eastern Europe had a similar prevalence to those born in Australia, they are at higher risk of diabetes complications. A high percentage of them had other comorbidities, had low English language proficiency, needed assistance with core activities, did not have school education and had low income. As the majority of migrants from these regions are Italians and Greeks (Australian Bureau of Statistics 2019–2020), they experience more challenges in accessing services in Australia compared with those born in North-West Europe. However, as more than 99.5% of them have been living in Australia for more than 10 years, they may have developed some of the skills needed to navigate Australian social support and health services (Pasupuleti et al. 2016; Khatri and Assefa 2022).

Migrants from North Africa and the Middle East who had diabetes are also at higher risk of diabetes complications. Although they are younger than those from Southern and Eastern Europe, they share many of the studied characteristics with migrants from Southern and Eastern Europe. Additionally, a high percentage of them arrived in Australia less than 10 years ago. Migrants from North-East Asia may also be at higher risk of poor diabetes outcomes. Although the prevalence of diabetes among this group was similar to the Australian-born population, more than half of them had low income and English language proficiency, and a high percentage of them arrived in Australia less than 10 years ago.

Migrants from South-East Asia and Southern and Central Asia had a higher prevalence of diabetes compared with Australian-born and had high percentages in some characteristics associated with poor diabetes outcomes. A high percentage of those born in South-East Asia did not have school education, had low income and low English language proficiency. A high percentage of those born in Southern and Central Asia arrived in Australia less than 10 years ago and had low English language proficiency. It is also important to note the diversity among countries and groups in these regions. In 2022–2023, Myanmar, a country in South-East Asia, and Afghanistan and Pakistan, in the Southern and Central Asia, were among the top three countries for humanitarian resettlement in Australia (Commonwealth of Australia Department of Home Affairs 2023). Refugees and asylum seekers experience more challenges in accessing services in Australia compared to other groups of migrants (Au et al. 2019).

A higher prevalence among male migrants should be considered in diabetes prevention and control programs. Males, in general, are less likely to engage in health promotion activities and use health services (Banks 2001). With the difficulties that public health experience in engaging men, many argue that targeting women partners to improve men’s health-seeking behaviours can be an effective strategy (Robertson et al. 2008). Although this may work for some groups of the population, in the context of migrants’ experience, this may not be an effective strategy for all migrant groups. In some migrant groups, men are usually the breadwinners and are responsible for shelter and security for the family (Pease 2009; Rung and Adamson 2022), which can affect the power dynamic in families and the time that they have available to access preventive health or even services for diabetes control. Considering these factors, it is important to design programs specific to male migrants to empower them to protect themselves from diabetes and its complications (Banks 2001).

Apart from the characteristics reported in this study, the social status of different migrant groups also affects their experience in society and with the health system. Migrants who are visible minorities experience more challenges in accessing resources and services in Australia, including employment, education and health services (Pedersen et al. 2012; Wilson et al. 2012). A mapping social cohesion study in 2021 reported that 34% of people born in non-English speaking countries experienced discrimination because of their skin colour, ethnic origin or religion (Markus 2021). In addition to the sociopolitical changes needed to improve migrants’ social status in Australian society, more attention from the health system is required to empower these groups of the Australian population to protect themselves from diabetes and manage their diabetes (Willen et al. 2021).

Conclusion

Diabetes was more prevalent among migrants from South-East Asia, Southern and Central Asia, North Africa and the Middle East and Oceania, particularly among males. A higher percentage of people born in Australia, Southern and Eastern Europe and North-West Europe had other comorbidities. The highest prevalence of diabetes among migrants from Oceania and Southern and Central Asia requires specific attention. Considering the prevalence of comorbidities and characteristics affecting poor diabetes outcomes among different groups of migrants, those born in Southern and Eastern Europe, North Africa and the Middle East, South-East Asia, Southern and Central Asia and North-East Asia are at higher risk of experiencing poorer diabetes outcomes.

Improving migrants’ diabetes outcomes requires primary, secondary and tertiary prevention strategies designed and implemented based on the needs and characteristics of specific migrant groups. Primary prevention, such as health promotion programs, should consider migrants’ characteristics that affect their abilities to access diabetes information and take actions to protect their health. Enhancing migrants’ knowledge and skills to navigate the Australian health system can improve their access to early diagnosis of pre-diabetes and diabetes services. Migrants’ access to health and social services to manage diabetes complications should be facilitated with the consideration of the various factors affecting their access, including socioeconomic factors.

To improve health equity, the characteristics reported in this study should be considered in the design and implementation of diabetes prevention and control strategies and healthcare provision. The findings of this study indicate that different approaches should be used for different migrant groups. The strategies should also be tailored based on the different characteristics of female and male migrants. Incorporating findings from this study into health workforce education can equip healthcare providers and the broader health workforce with the knowledge and skills needed to improve diabetes outcomes in multicultural Australia. Considering intersectionality can help in understanding diverse migrants’ needs. This understanding can support the design and implementation of appropriate public health programs and the delivery of health care that empowers migrants to protect their health. Additionally, programs promoting social cohesion and targeting the elimination of racism, discrimination and negative stereotypes about migrants are needed to improve migrants’ health and health equity in Australia.

Supplementary material

Supplementary material is available online.