Canada is a country of immigrants. In 2019, we welcomed more than 341,000 new permanent residents, including both immigrants and refugees. Immigration accounts for nearly all of the rise in Canada’s labour force, representing over 20 per cent of the population and expected to rise to 30 per cent by 2036.
Despite the significant roles newcomers play in Canadian society, we continue to face unknowns about how to best support the health and wellbeing of this population. Advancing Health Scientists are working to shed light on this important area.
Dr. Joseph Puyat, who has researched mental health and chronic and infectious diseases in immigrant populations, notes that one of the common shortcomings in research and programs focused on immigrants is that they are treated as one big group.
“We often speak about migrant populations as one homogenous group, but they’re not,” explained Dr. Puyat. “Refugees in particular are at risk of adverse health outcomes in the short term, whereas economic immigrants may actually be healthier than the general population in the short term, but at risk in the long run.”
A phenomenon where immigrants experience better health than non-immigrants in the country of their arrival is known as the healthy immigrant effect. This effect has been seen repeatedly across Western countries for a range of diseases. But there is more to this phenomenon than meets the eye.
“What we have found in our research is that this overarching pattern (i.e., the average) is often masking a lot of variation,” explained Advancing Health Scientist Dr. Anne Gadermann, whose program of research focuses on the mental health and wellbeing of new Canadians. “It is important to talk about the pattern and try to understand why we see it, but it is also important to talk about the variation that underlies it.”
Are immigrants healthier than non-immigrants?
One partial explanation for the healthy immigrant effect may be the protective role that culture and community can play in health outcomes. Drs. Puyat and Gadermann co-authored a recent paper that found a higher density of immigrants in B.C. neighbourhoods was associated with lower odds of mental health disorders among first-generation immigrant youth. This effect extended to second-generation as well as non-immigrant youth, a result that surprised the researchers.
“A greater sense of community may explain the protective effect in recent immigrants, but we aren’t sure why these types of neighbourhoods are protective for non-immigrants,” said Dr. Puyat. “This is being investigated currently.”
The country of origin may be an important factor when it comes to mental health risk. Dr. Carly Magee, an Advancing Health postdoctoral fellow supervised by Dr. Puyat, recently found that, in general, children of immigrants from East, South, and South-East Asia in the Lower Mainland are less likely to be diagnosed with psychotic disorders like schizophrenia, compared with non-immigrants. However, this effect was not seen in immigrants from other regions, like Europe, Oceania, or Africa.
Given the large and established Asian population in the Lower Mainland, a protective effect in these communities may not be surprising. But the researchers also think that it may be due, in part, to lower detection of these disorders by the health system and in research.
“Our understanding of mental health disorders and their symptoms are based to a large extent on studies conducted in a Western context,” explained Dr. Gadermann. “For this reason, our recognition of mental disorders and their symptomatology are likely better calibrated for a Western population, which means that we could very well be under-diagnosing or missing the signs of mental illness in non-Western populations.”
Other research has shown that for some immigrant groups, mental illness is highly stigmatized, making it less likely that people will seek help or access services.
Dr. Puyat also notes that immigrants likely interact with the health care system differently than non-immigrants. In collaboration with researchers from Simon Fraser University, he found that immigrants are more likely to receive primary care from a walk-in clinic or a solo practice, locations where access to mental health consultations is typically limited.
Health service use and access is also related to language skills. The researchers explained that Canada’s immigration system is highly selective, and based on factors like education, employment experience, and English or French language ability. But for those who don’t have strong local language skills, navigating the health system could be more challenging.
In their paper discussing country of origin, the researchers highlighted that first-generation migrants selected based on their economic position had a lower risk of adolescent-onset psychotic disorder compared with those selected through refugee programs.
This selection bias, whereby Canada’s immigration system largely selects those who have greater ability to contribute to the labour market, may be masking the challenges of important sub-populations, like refugees, if we only look at the immigrant population as one large group.
Regression to the mean
An important aspect of the healthy immigrant phenomenon is that it declines over time. In other words, although some people who immigrate to Canada may be healthier in the short term, their long-term health generally averages out to match that of the general population.
Regardless of how long it takes for this levelling out, immigrant groups represent an important target for prevention and management of long-term and chronic diseases.
Advancing Health Scientist and Head of UBC’s Division of General Internal Medicine Dr. Nadia Khan has investigated ways of addressing cardiovascular disease risk in B.C.’s South Asian population.
“South Asians bear a greater burden of cardiovascular disease compared to other ethnic groups,” she wrote in a paper co-authored earlier this year.
Dr. Khan found that in an immigrant Punjabi Sikh community in Vancouver, 42 per cent of participants had uncontrolled blood pressure — two-thirds of participants were aware of their condition, but were not managing it successfully.
“Findings suggest more efforts are needed to reduce the rates of uncontrolled blood pressure in this community,” the authors wrote, suggesting initiatives could be introduced such as blood pressure drives, community-based outreach programs, and physical activity and dietary interventions.
Dr. Khan has also noted that health promotion in immigrant populations has to consider non-traditional factors, like cultural practices and emotional functioning, in order to tailor disease prevention programs. Work co-authored by Dr. Puyat adds that social and structural contexts are important additions to consider.
An increasingly important area of study
Half of children in Canada aged 14 and younger are projected to be foreign-born or have at least one foreign-born parent by 2036. By 2041, if current trends continue, half of the Canadian population will be made up of immigrants and their Canadian-born children.
“Adjusting to life in Canada will be more challenging for some than others,” noted Dr. Gadermann. “Some will have a greater capacity to adapt and harness the resources they require to support their mental health and wellbeing. Our interest is in identifying the levers that help build that capacity.”
Advancing Health researchers like Dr. Mieke Koehoorn are looking at immigrant status, gender, and work disability; Drs. Naveed Janjua, Ehsan Karim, and Caren Rose aim to understand risk and outcomes related to infectious diseases like hepatitis C and tuberculosis; and graduate student Cindy Choi, working with Dr. Puyat, is investigating how skin colour may be a determinant of mental wellbeing in immigrants.
Research to understand the post-migration experiences and health outcomes of immigrants, not as a monolith but as specific, unique groups within an increasingly large portion of Canadian society, will only become more important into the future as demographics continue to shift. Advancing Health researchers are the forefront of this work and look forward to answering some of the big questions to shape a healthier collective future.