Health status and Canada's immigrant population

Abstract

Given the framework of the 1984 Canada Health Act, the health status of immigrants should be similar to average levels within whole of Canada. Yet, assuming equality of health status between immigrant and non-immigrants, or between immigrant groups is likely an unrealistic and simplistic assumption, given unseen barriers affecting accessibility, the restructuring of the Canadian health care system, and problems with the provision of health care resources to the immigrant population. Using the National Population Health Survey, this paper focuses upon the health status of the immigrant population relative to that of non-immigrants within Canada, with reference to diagnosed conditions, self-assessed health, and the Health Utilities Index Mark 3. Findings indicate that, with the exception of the most recent arrivals, immigrants experience worse health status across most dimensions relative to non-immigrants. Multivariate analysis reveals that age, income adequacy, gender, and home ownership are dimensions upon which health status differs between the two groups.

Introduction

In recent years, immigration has once again become a prominent national policy issue within Canada's political and academic arenas as demonstrated by the Metropolis project (see, for example, the annotated bibliography by Kobayashi and Peake (1997), and recent work by Bourne (1999), Lo and Wang (1999)). Accounting for five million or 17.4 percent of Canada's population in 1996, and with the addition of approximately 200,000 new immigrants each year, immigrants, including those born outside Canada and entering as legal immigrants (i.e., skilled workers, business immigrants, or family reunification) and refugees, represent an increasing proportion of Canadian society. This large, young, and rapidly growing population is geographically concentrated in metropolitan gateways, with nearly 74 percent settling in Toronto, Montreal, or Vancouver. The immigrant population is also diverse, showing greater variations with respect to education, income and poverty than the Canadian-born population (Kobayashi, Moore, & Rosenberg, 1998).

While the bulk of this research has focused upon issues relating to the adjustment of new immigrants to Canadian society, immigrant upon Canadian-born impacts (i.e., economic displacement, tax implications), and the effect of immigration upon the changing demographic profile of the Canadian population and urban areas, comparatively less attention has been directed toward immigrant health. This is surprising, since immigration intersects with public health through immigrant health status, along with the demands that immigrants place upon the system. Given the growth of the immigrant population, along with developments in the funding, management and configuration of the health care system within the past decade (Birch & Gafni, 1999), the importance of examining immigration and health care stems from the potential for immigration to mitigate or exacerbate the demand for health care along with possible differences in the type of health care demanded (i.e., Western versus traditional). This raises several important questions, including how immigrant health status differs from the Canadian-born and how the health status of immigrant populations change through exposure to the social, cultural, economic and physical environment within Canada.

Answering these questions is, however, difficult. Health status is, for example, obscured by multiple issues including age and gender effects, existing health status (i.e., health at arrival), knowledge and use of health care facilities, and changes in health status and utilization behavior as immigrants adjust to Canadian society. Indeed, a critical review of the literature demonstrates several important differences between immigrants and non-immigrants with regard to health status. Although immigrants are generally healthy at the time of arrival, their health status tends to converge (downward) toward the Canadian average, measured through self-assessed health or other measures including mental health (Ali, 2002; Chen, Wilkens, & Ng, 1996; Dunn & Dyck, 2000; Health Canada, 1999; Pérez, 2002; see also Deinard & Dunnigan, 1987; Frisbie, Youngtae, & Hummer, 2001; Muenning & Fahs, 2002 for insight into the US literature). Pérez (2002), for example, noted that the likelihood of reporting any chronic condition increased with time spent in Canada, despite initially superior health relative to the Canadian-born. Yet, this convergence also likely hides important variations within the immigrant population owing to differences in socioeconomic or sociodemographic issues. Moreover, the convergence does not imply that their health care needs are being met, or that their health care needs are similar to the Canadian-born population. In fact, an immigrant population characterized by dissimilar and unmet health needs is more likely, particularly if immigrants are disadvantaged with respect to income or education. Notwithstanding the ‘healthy immigrant effect’, variations in the health status and utilization behavior within the immigrant population and between immigrants and the Canadian-born are likely to be observed.

Although income barriers have seemingly been removed by the Canada Health Act (CHA), which resulted in the removal of user fees and promoted the standardization across provinces and territories in the funding of insured services, lower-income immigrants, for example, are two times more likely to report unmet health needs than those with higher incomes, although immigrants do not report any more unmet health needs than the general population (Chen et al., 1996). Other, non-income barriers have been observed as well (Dunn & Dyck, 2000; Matuk, 1996). Dunn and Dyck (2000) noted that immigrants were more likely to report ‘very good’ or ‘excellent’ health if they were born in Europe, the US, or Australia, had a trade school or college diploma, and reported high incomes. The implication of this observation is that other immigrant groups are defined by unmet needs. Pomerleau and Ostbye (1997), in a study based upon the Ontario Health Survey, found poor health and unmet needs to be pervasive within the immigrant population.

The set of factors which influence the health of a population may be particularly problematic among immigrants, as they may face considerable barriers associated with language, racism, discrimination, gender roles, fear of western medicine, and lack of knowledge of the opportunities that are not experienced by the broader population (Chen et al., 1996; Globerman, 1998; Health Canada, 1999; Kobayashi et al., 1998; Matuk, 1996). New arrivals, and particularly those from Asia, Africa, or Latin America, may feel ‘overwhelmed’ when so much is new, and potentially have little or no experience with Western medicine. Access may be especially limited among immigrant women whose family, job or cultural expectations make it difficult to use resources (Anderson, Blue, Holbrook, & Ng, 1993; Dyck, 1995). More generally, culturally specific belief patterns of illness, health, and health seeking behaviors will influence approaches to illness and health (Cook, 1994; Health Canada, 1999). Communication problems also create barriers to access, leading to poorer treatment, miscommunication of symptoms, and problematic follow-ups (Globerman, 1998; Saldov, 1991; Stephenson, 1995).

Set within the determinants of health framework (Evans & Stoddart, 1990) and drawing upon Cycle 3 (1998/99) of Statistic Canada's National Population Health Survey (NPHS), the purpose of this paper is twofold. First, the paper evaluates immigrant health, measured by self-assessed health and the Health Utilities Index—Mark 3 (HUI3), with respect to a set of indicators drawn from the determinants of health framework, along with duration of residence, origin, and race. Second, the paper compares the health status of immigrants with that of native-born Canadians (non-immigrants). Using the same set of health indicators, the intent is to identify areas where immigrant and non-immigrant health diverge, particularly with reference to particular sub-groups or other effects such as income differentials that potentially have adverse impacts upon health status. In both, the key questions are whether differences in health status exist, and whether they are explained primarily by socioeconomic, sociodemographic, or lifestyle factors, which may point to problems within the Canadian health care system.