Ilene Hyman The Centre for Research in Women’s Health SETTING THE STAGE Reviewing current knowledge of the health of Canadian immigrants: What is the evidence and where are the gaps? Presentation to the National Symposium on Immigrant Health Ottawa, Canada March 25, 2003 Ilene Hyman The Centre for Research in Women’s Health Department of Public Health Sciences, University of Toronto

Ilene Hyman The Centre for Research in Women’s Health Recently Completed Literature Reviews  Hyman I. (2001). Immigration and Health. Working Paper Health Policy Working Paper Series. Ottawa: Health Canada. September  Hyman I. (2002). Immigrant and Visible Minority Women. In, DE. Stewart, A. Cheung, L. Ferris, I. Hyman, M. Cohen, IJ. Williams (Eds..). Ontario Women's Health Status Report. Toronto: February

Ilene Hyman The Centre for Research in Women’s Health Focus of Literature Reviews  Review of research findings on the ‘healthy immigrant effect’ in Canada, including changes in specific health indicators over time.  Identification of determinants of changes in immigrant health status over time.  Identification of research gaps and future research directions.  Discussion of policy implications.

Ilene Hyman The Centre for Research in Women’s Health Methods

Ilene Hyman The Centre for Research in Women’s Health

Ilene Hyman The Centre for Research in Women’s Health Search Strategy  Databases: MEDLINE, HEALTHSTAR, CANCERLIT, CINAHL, and PSYCHLIT.  Included all published Canadian studies in English and French from 1990 to  Additional information from Metropolis Centres of Excellence, the Centres of Excellence for Women’s Health, government reports and key informants.  Selected international studies.  Whenever possible, reviewed evidence for immigrant sub-groups (recent immigrants, refugees, women, children and youth).  Quality of evidence assessed using established criteria.

Ilene Hyman The Centre for Research in Women’s Health Methodology  Health Canada Report - 7 Research team members affiliated with 4 institutions.  OWHC Report - 6 Steering committee members affiliated with 3 institutions Consultation Process

Ilene Hyman The Centre for Research in Women’s Health Findings - Sociodemographics  Approx. 230,000 immigrants per year; 16% the Canadian population (1996 census).  Immigration by source area (2001):  Asia (53%)  Africa and Middle East (19.2%)  UK and Europe (17.3%)  South and Central America (8.0%)  United States (2.4%)  55% of immigrants reside in urban centres - Toronto, Vancouver, Montreal.

Ilene Hyman The Centre for Research in Women’s Health Findings - Sociodemographics  Categories of immigrants to Canada (1999):  Economic class (56%)  Family class (29%)  Refugee (13%); 30,000 refugee claimants (2000)  “Other” (3%)  Leading source countries for refugees to Canada (2001):  Afghanistan (10.5%)  Sri Lanka (9.0%)  Pakistan (7.6%)  Yugoslavia (6.3%)  Iran (5.3%)  Highly educated.

Ilene Hyman The Centre for Research in Women’s Health Findings - Evidence of Healthy Immigrant Effect  Recent immigrants to Canada particularly from non-European source countries enjoy many health advantages over long-term immigrants and the native-born population in terms of their overall health status, the prevalence of certain chronic diseases such as cancer and heart disease, disability and life expectancy (Chen et al., 1996a; Chen et al., 1996b).  With time in Canada, physical health status and health care utilization begins to resemble that of the Canadian-born population.  Results confirmed using data from the 2000/01 CCHS (Perez, 2002).  Limitations to population surveys++

Ilene Hyman The Centre for Research in Women’s Health Findings - Differences between Chronic and Infectious Diseases  Health advantage of immigrants is not applicable to infectious diseases such as TB (Health Canada, 1998).  Most immigrants with infectious diseases, such as TB, experience improvements in health status over time given appropriate treatment and follow-up.  AIDS growing concern: some evidence that HIV/AIDS is increasing among immigrants to Ontario who were born in HIV- endemic countries; the majority of infants born to HIV-infected mothers born to immigrant women from HIV-endemic countries (Remis & Whittingham, 1999).

Ilene Hyman The Centre for Research in Women’s Health Findings - Mental Health  Mixed evidence regarding mental health (Canadian Task Force, 1986).  Data from the 2000/01 CCHS found evidence of a healthy immigrant effect with respect to mental health - Immigrants, particularly new arrivals had lower rates of depression and alcohol dependence compared to the Canadian-born population (Ali, 2002).  Studies of SEA refugees and Ethiopian immigrants suggest that changes in mental health may not be linear (Beiser et al., 1994; Fenta et al., 2003).  Certain sub-groups may experience an increased risk of mental health problems e.g., refugees (children and adults), seniors, visible minorities and women.

Ilene Hyman The Centre for Research in Women’s Health Findings - Partner Abuse Little Canadian data on:  Prevalence of partner abuse in immigrant communities  Risk factors for partner abuse in immigrant communities  Social constructions and definitions of abuse  Screening for abuse e.g., acceptability, cross-cultural validity and reliability of instruments

Ilene Hyman The Centre for Research in Women’s Health Findings - Subgroups  In Canada, as in other countries, there are ethnic differences in disease specific mortality rates (Nair et al., 1990; Sheth et al., 1999).  Certain immigrant sub-groups experience a higher risks of health problems e.g., heart disease among Asians (Sheth et al., 1999), increasing rates of breast cancer among Southeast Asian women (Saphir, 1997), poor pregnancy outcomes among refugee women (Kahler et al., 1996).

Ilene Hyman The Centre for Research in Women’s Health Findings - Determinants of Health  Immigrants are disproportionately poorer than the general population making SES confound the relationship between immigration and health (CIC, 2000).  Many immigrants’ health risk behaviours (e.g., smoking, obesity, drinking, diet) change over time to approximate the majority population (Matuk, 1996; Ali, 2002).  Few studies examined the relationship between stress, social support and health in immigrant populations.  Underutilization of health services more apparent in the use of preventive, mental health and violence response services than acute medical care (Kirmayer et al., 1996; Goel, 1994; Goel & Mercer, 1999; Health Canada, 1993).

Ilene Hyman The Centre for Research in Women’s Health Research Priorities - Health Outcomes  What is the health status/burden of disease among specific immigrant subgroups?  What determinants of health are associated with changes in immigrant health?  Are there other determinants of immigrant health that have not been addressed by the research literature?

Ilene Hyman The Centre for Research in Women’s Health Research Priorities - Health Outcomes  Why do immigrant men and women develop TB during the early resettlement years and what is the role of resettlement stress?  What personal and social resources allow immigrants to deal with adversity and successfully adapt to a new environment?

Ilene Hyman The Centre for Research in Women’s Health Research Gaps - Health Systems Little research on the identification and evaluation of culturally consistent systems of care.  Models of health care delivery for a diverse society  Impact of organizational/institutional change  Effectiveness and acceptability of complementary/alternative medicine (CAM)  Health promotion theory and practice for immigrant populations

Ilene Hyman The Centre for Research in Women’s Health Future Research Directions 1. Strengthen existing databases  Increase the amount of information available on ethnicity and migration in national and provincial surveys.  Use representative samples in health surveillance systems to reflect the diversity of the Canadian population.  Initiate discussions with the government and community stakeholders regarding the inclusion of information on country of birth, length of stay in Canada, ethnicity and language fluency for health planning purposes.  Continue and expand record linkage between provincial health records for hospital discharges and physician claims and the Citizen and Immigration Canada (CIC) database.

Ilene Hyman The Centre for Research in Women’s Health Future Research Directions 2. Develop new databases  Initiate longitudinal studies, to provide rich information on the health status and health determinants of immigrants over time.  Support health research within immigrant subgroups to document and address specific health problems and needs.  Support research on changes in DOH (e.g. health behaviours, social support and stress).  Use participatory and multi-method studies to further the knowledge and understanding of health beliefs and behaviours within different immigrant groups.  Increase health systems research.

Ilene Hyman The Centre for Research in Women’s Health Ilene Hyman, PhD Research Scientist The Centre for Research in Women’s Health