MUNK SCHOOL BRIEFINGS

Comparative Program on Health and Society

Lupina Foundation Working Paper Series,

2011–2012

Edited by Arif Jetha and Lisa Forman

Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

Anna Durbin

Mental Health Service Use by Immigrantsand Refugees after Arrival in Ontario:

Beginning to Fill a Research Gap

ByAnna Durbin

Lupina Junior Doctoral FellowCPHS Fellow, 2011–2012

PhD candidate, Institute of Health Policy, Management and Evaluation, University of Toronto

M U N K S C H O O L B R I E F I N G S

MUNK SCHOOL OF GLOBAL AFFAIRS

UNIVERSITY OF TORONTO

Munk School of Global AffairsAt Trinity CollegeUniversity of Toronto1 Devonshire PlaceToronto, Ontario, Canada M5S 3K7Telephone: (416) 946-8900Facsimile: (416) 946-8915E-mail: munkschool@utoronto.caWebsite: www.munkschool.utoronto.ca

© Anna Durbin

978-0-7727-0906-6ISSN 1715-3484

The Munk School of Global Affairs at the University of Toronto seeks to be an internationally recognised leaderin interdisciplinary academic research on global issues and to integrate research with teaching and public educa-tion. We place special emphasis on the fostering of innovative interdisciplinary knowledge through the exchangeof ideas and research among academics as well as the public, private, and voluntary sectors.

We are delighted to present this collection of research papers from the Comparative Program on Health and Societybased on work that our fellows undertook during 2010–2011. Founded in the year 2000, the Comparative Pro-gram on Health and Society (CPHS) is a vital and growing research institute based at the Munk School of GlobalAffairs at the University of Toronto. Generously funded by The Lupina Foundation, the CPHS supports innovative,interdisciplinary, comparative research on health, broadly defined through our extensive range of fellowships,which for 2010–2011 included CPHS Junior Doctoral Fellowships, CPHS Senior Doctoral Fellowships,Lupina/OGS Doctoral Fellowships, Post-Doctoral Top-Up Fellowships, and Research Associate Positions. Ourprogram builds on the scholarly strengths of the University of Toronto in the social sciences, humanities, andpublic health.As the CPHS moves into its second decade, we have adopted a renewed vision of the social determinants of healthwhich recognizes the complexity and interrelatedness of domestic, transnational, regional, and global factors thatmay impact on health conditions and access to health-related services within any country, including Canada. Werecognize similarly that emerging and entrenched health inequalities may require policy-makers, communities,and researchers to grapple with challenging ethical, human rights, and social justice questions. We have accord-ingly expanded the thematic focus of the Comparative Program to accommodate research which specificallyfocuses on these definitional and operational challenges. The research papers you will read in this year’s collectionreflect these themes, and demonstrate the variety, complexity, and importance of comparative health research.

COMPARATIVE PROGRAM ON HEALTH AND SOCIETY Munk School of Global AffairsUniversity of Toronto1 Devonshire PlaceToronto, Ontario, Canada M5S 3K7Telephone: (416) 946-8891Facsimile: (416) 946-8915E-mail: cphs.munk@utoronto.caWebsite: www.utoronto.ca/cphs

The CPHS Working Papers Series

The Comparative Program on Health and Society maintains a collection of academic papers which we call ourLupina Foundation Working Papers Series. These works can range from research papers to thought pieces; andfrom statistical analyses to historical case studies. Our series represents a snap-shot of the work being done byour Lupina Fellows, past and present. Taken together, our Working Papers Series encapsulates the wide-rangingapproaches to the study of the social determinants of health. We hope that you will find the individual papers inour series thought-provoking and helpful.

MUNK SCHOOL BRIEFINGS

1. Bound to Follow? US Foreign Policy, International Reactions, and the New Complexities of Sovereignty.By Louis W. Pauly. September 2005 ISBN 0-7727-0825-5.

2. The Multilateral Agenda: Moving Trade Negotiations Forward.By Sylvia Ostry. November 2005 ISBN 0-7727-0822-3.

3. The Jerusalem Old City Initiative Discussion Document: New Directions for Deliberation and Dialogue. By Michael Bell, Michael J. Molloy, John Bell and Marketa Evans. December 2005 ISBN 07727-0823-1.

4. Comparative Program on Health and Society Lupina Foundation Working Papers Series 2004–2005.Edited by Jillian Clare Cohen and Jennifer E. Keelan. January 2006 ISBN 0-7727-0818-5.

5. Comparative Program on Health and Society Lupina Foundation Working Papers Series 2005-2006.Edited by Jillian Clare Cohen and Lisa Forman.October 2006 ISBN 0-7727-0829-0.

6. Darfur and Afghanistan: Canada’s Choices in Deploying Military Forces. By Ambassador David S. Wright. October 2006 ISBN 0-7727-0830-4.

7. Trade Advocacy Groups and Multilateral Trade Policy-Making of African States. By Sylvia Ostry and Thomas Kwasi Tieku. April 2007 ISBN 978-0-7727-0832-8.

8. Water Diversion, Export, and Canada-U.S. Relations: A Brief History. By Frank Quinn. August 2007 ISBN 978-0-7727-8054-6.

9. Intersubjectivity in Literary Narrative. By Tomas Kubicek October 2007 ISBN 978-0-7727-0834-2.

10. Comparative Program on Health and Society Lupina Foundation Working Papers Series 2006-2007.Edited by Jillian Clare Cohen-Kohler and M. Bianca Seaton.November 2007 ISBN 978-0-7727-0838-0.

11. A Model Act for Preserving Canada’s Waters. Canadian Water Issues Council in collaboration with theProgram On Water Issues.February 2008 ISBN 978-0-7727-0839-7.

Loi type sur la protection de l’eau au Canada. Conseil sur les questions de l’eau au Canada en collaboration avec le Programme sur les questions de l’eau.Février 2008 ISBN 978-0-7727-0840-3.

12. The World’s First Anti-Americans: Canada as the Canary in the Global Mine. By Richard Gwyn.March 2008 ISBN 978-0-7727-0842-7.

13. Comparative Program on Health and Society Lupina Foundation Working Papers Series 2007-2009. Edited by M. Bianca Seaton and Sara Allin.April 2010 ISBN 978-0-7727-0844-1.

14. The Importance of Steel Manufacturing to Canada – A Research Study.By Peter Warrian.July 2010 ISBN 978-0-7727-0845-8

15. A Century of Sharing Water Supplies between Canadian and American Borderland CommunitiesBy Patrick Forest.October 2010 ISBN 978-0-7727-0846-5

16 Designing a No-Fault Vaccine-Injury Compensation Programme for Canada: Lessons Learned from an International Analysis of ProgrammesBy Jennifer Keelan PhD, Kumanan Wilson MSc, FRCP(C)February 2011 ISBN 978-0-7727-0847-2

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17. Socio-economic Status and Child Health: What is the Role of Health Care Utilization?By Sara Allin and Mark Stabile.July 2011 ISBN 0-7727-0849-6

18. Policy Implications of Neighbourhood Effects on Health Research: Towards an Alternative to PovertyDeconcentration.By Antony Chum.July 2011 ISBN 0-7727-0858-8

19. A Lifetime of Experience: Modelling Labour Market and Family Life Course Histories among Older Adultsin Britain.By Laurie M. Corna.July 2011 ISBN 0-7727-0850-2

20. The Corporatization of Sport, Gender and Development: Postcolonial IR Feminisms, Transnational PrivateGovernance and Global Corporate Social Engagement.By Lyndsay M.C. Hayhurst.July 2011 ISBN 0-7727-0859-5

21. Accountability in Health Care and the Use of Performance Measures.By Seija K. Kromm.July 2011 ISBN 0-7727-0857-1

22. Colonial Medicine, the Body Politic, and Pickering’s Mangle in the case of Hong Kong’s Plague Crisis of1894.By Meaghan Marian.July 2011 ISBN 0-7727-0860-1

23. Ojibwe Activism, Harm Reduction and Healing in 1970s Kenora, Ontario: A Micro-history of CanadianSettler Colonialism and Urban Indigenous Resistance.By Krista Maxwell.July 2011 ISBN 0-7727-0853-3

24. Spheres of Risk: Examining Targeted and Universal Approaches to Childhood Injury Prevention.Author: Tanya Morton.July 2011 ISBN 0-7727-0856-4

25. The Scope and Limits of Legal Intervention in Controversies Involving Biomedicine: A Legal History ofVaccination and English Law (1813–1853).By Ubaka Ogbogu.July 2011 ISBN 0-7727-0861-8

26. A Mixed-Method Approach to Examining Physical Activity among Canadian Girls of South Asian Ancestry in High School.By Subha Ramanathan.July 2011 ISBN 0-7727-0855-7

27. Abide with Me: A Story of Two Pandemics.By Kate Rossiter and Rebecca Godderis. July 2011 ISBN 0-7727-0851-9

28. Global Biopolitics and Emerging Infectious Disease. By Sarah Sanford.July 2011 ISBN 0-7727-0854-0

29. Re-visiting Traumatic Stress: Integrating Local Practices and Meanings in Explanatory Frameworks ofTrauma.By Eliana Suarez.July 2011 ISBN 0-7727-0852-6

30. Neighbourhood Effects on Family-to-Work Conflict and Distress.By Marisa C. Young.July 2011 ISBN 0-7727-0862-5

31. Armed Conflict Exposure, the Proliferation of Stress, and the Mental Health Adjustment of Immigrants in Canada.By Marie-Pier Joly. November 2012 ISBN 0-7727-0893-9

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Abstract

Despite the numerous stressors associated with pre and post migration, on average new immigrants havebetter health profiles, including mental health, than the Canadian-born population (“the healthy immigranteffect”). Over time, health status may decline and converge with that of long-term residents. Little is knownabout immigrants’ service use patterns for mental health care.

Immigrants often face barriers and circumstances that affect health status and health care use (such aslanguage, health beliefs, economic and social disadvantage). Understanding the role of financialdisadvantage is particularly important since immigrants to Canada are more likely than the generalpopulation to live in poverty. Financial disadvantage has both been associated with increased risk of manymental disorders and is an often cited barrier to accessing mental health care in Canada.

I will examine variation in mental health service use for psychotic and distress/mood disorders amonggroups of immigrants with different regions of origin and different lengths of time in Canada. Variationrelated to immigrant visa class (i.e., economic class versus family reunification class versus refugee) will alsobe examined.

Immigrants will be identified by using a database managed by Citizenship and Immigration Canada,formerly known as Landed Immigrant Data System (LIDS), that will be linked to other administrative datasources. This data source contains information collected at the time of application for immigrants whoarrived in 1985 and forward in time until 2009.

Anna Durbin is passionate about reducing inequalities related to use of mental health services throughresearch in Ontario. As a researcher, Anna aims to inform public policy with evidence that has a strongtheoretical foundation and a high degree of empirical rigour.

Anna is interested in mental illness and treatment responses, largely due to the high prevalence of mentaldisorder, the burden of disease, and the challenges associated with providing equitable access to appropriatemental health care. Accordingly, her doctoral dissertation will focus on use of mental services acrossimmigrant subpopulations in Ontario. She has also studied the implications of different physicianreimbursement models on delivery of primary mental health care. Specifically, Anna is interested in variationin access and quality of primary mental health care services for different model types.

She is a doctoral candidate in the health service research stream in Institute of Health Policy, Managementand Evaluation (IHPME) at University of Toronto. In spring 2010, Anna was awarded a Doctoral Award fromCanadian Institutes of Health Research for three years. She has also won the Canadian Association for HealthServices and Policy Research (CAHSPR) student essay competition for best doctoral submission.

Anna earned her Masters of Public Health (MPH), Community Health & Epidemiology at the Dalla LanaSchool of Public Health, University of Toronto. She graduated in June 2007 with Bachelor of Arts withSpecialized Honours in Psychology, from the Faculty of Health at York University.

Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario:

Beginning to Fill a Research Gap

Anna Durbin

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Anna Durbin

BACKGROUND

In Canadian provinces like Ontario that are both ethnically and culturally heterogeneous, delivery ofservices for management and prevention of various health disorders could benefit from a more detailedunderstanding of mental health service use patterns among immigrants (Rotermann 2011). Even thoughimmigrants constitute over one-quarter of the Ontario population, these groups are often viewed by policy-makers and researchers as a single population (McKenzie 2010). In practice, however, immigrantpopulations in Ontario are diverse, large, and growing (Lebrun & Dubay 2010). Many mental health studiesdo not assess variation within the immigrant population (e.g., related to region of origin), and even fewerof these studies examine associated service use among immigrants.

Researchers have acknowledged the need to adapt interventions to the specific needs of immigrantcommunities to promote wellness among immigrant populations (Lin et al. 2009; Wu & Schimmle 2005).The need for these services is accentuated because barriers to care are distinct for different immigrantgroups. Suboptimal care may result in illnesses advancing and/or avoidable health care costs (McDonald &Kennedy 2004; Lin et al. 2009).

OPPORTUNITIES TO CHANGE IMMIGRANT MENTAL HEALTH POLICY IN CANADA

Despite dialogue on the mental health needs of new immigrants and refugees in Canada over the past decades,there have not been significant changes in policy or service developments (MHCC Diversity Task Group 2009).In the late 1980s, the federal government’s Task Force on the mental health of immigrants and refugees releaseda final report, After the Door Has Been Opened (Beiser 1988), that contained a summary of the major issuesconfronting new settlers in Canada as well as a series of recommendations to governments about ways to helpalleviate the distress of immigrants and refugees, and to facilitate their integration into Canadian society. Of the27 recommendations, only six were adopted (MHCC Diversity Task Group 2009).

The need for these changes continues to be documented in Canada—the Mental Health Commission ofCanada recently accentuated the importance of improving delivery of mental health services to better meetthe needs of immigrant groups (ibid.) (See Appendix A on Diversity Task Force Recommendations).Discovering more about immigrant health was identified as a research priority by the international 2011Grand Challenges in Global Mental Health initiative, which included hundreds of researchers and cliniciansin more than 60 countries. The Global Mental Health initiative noted that this research could be associatedwith significant economic and quality-of-life benefits (Collins et al. 2011).

OVERARCHING RESEARCH QUESTIONS THAT WILL BE INVESTIGATED IN PROPOSED STUDIES

The proposed studies will help identify variation in mental health care service use patterns across immigrantpopulations in Ontario, Canada, based on three immigration characteristics: (i) time in Canada, (ii) region oforigin, and (iii) immigrant visa type (economic class, family class, and refugee class). Other characteristics(e.g., age at immigration, age at service use, comorbidities, education level, etc.) will be included in the analysisas control variables. Findings from the proposed studies will likely help policy-makers, administrators, andclinicians deliver mental health services that better serve specific immigrant populations (Glazier et al. 2004).This information can inform the development of diversity policies for different subgroups in Ontario.

The proposed studies will examine the mental health service use patterns of immigrants during the yearsfollowing arrival in Ontario by addressing the following questions: How do use patterns differ amongimmigrants based on region of origin and visa type? How do these patterns compare to long-term residents?Do mental health service use patterns change as immigrant time in Canada increases? For specific objectives,see Table 1.

RELEVANCE OF THESE STUDIES TO HEALTH CARE DELIVERY IN ONTARIO

Canadian immigration targets are determined by federal government policy. Each year, the federal Ministerof Citizenship and Immigration announces a target range for the level of immigration. For 2011, the nationaltarget was to admit 240,000–265,000 immigrants (Ontario Ministry of Finance 2011). Can adianimmigration policies have been under increased scrutiny over the past few decades (Ontario Ministry ofCitizenship and Immigration 2011).

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Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

An ongoing debate concerns how many immigrants to admit and the basis on which to admit them. Thesewere key issues in the 2011 federal election (Todd 2011). Despite Canadian legislation, such as theImmigration and Refugee Protection Act (Immigration and refugee protection act [S.C. 2001, c. 27]), whichemphasizes mutual obligations between Canada and immigrants (See Appendix B on Canadian Legislation),a common argument against admitting high levels of immigrants suggests that large inflows of immigrantsmay overburden the health care system, especially if immigrants have worse health than native-bornCanadians (Wu & Schimmle 2005). However, the burden on mental health services from immigrants inOntario is not well understood. The proposed studies will help fill this gap by assessing service use patternsfor immigrant subgroups.

IMMIGRATION TRENDS IN ONTARIO, CANADA

Migration patterns impact the demographic composition of countries such as Canada. Relative to countriesworldwide, Canada has the second largest proportion of foreign-born individuals (Statistics Canada 2007).According to the 2006 Canadian Census, 19.8% of the Canadian population was foreign born. This is amongthe highest percentages worldwide. It is nearly twice that of the United States, where the percentage of thelegal foreign-born population represents approximately 12% of the total population (Gushulak et al. 2011).

Since 1985, when approximately 80,000 immigrants were admitted to Canada, the number of immigrantsadmitted annually has generally been increasing, excluding a dip in 1998 (when the number dropped to over150,000) (See Figure 1). For over a decade, the annual number of immigrants admitted to Canada annuallyhas remained around 250,000. In 2010, Canada admitted the highest number of immigrants in 57 years(over 250,000) (Kenney 2011).

In recent years the most common regions of origin for immigrants to Canada has shifted from Europe toAsian source countries (DesMeules et al. 2005; Hyman 2001). In 2009, the greatest number of immigrantscame from China (29,000+), followed by the Philippines (27,000+) and India (26,000+).

Table 1. Study designs and objectives related to each of the proposed studies.

Study design: Cross-sectional

Study type: Descriptive

Objective: To describe immigrant mental health

service use in Ontario during the first

two years after an immigrant’s arrival

in Ontario.

Longitudina

Analytic

To examine patterns of immigrant mental health

service use over time in Ontario, starting from

immigrant arrival in Ontario.

300,000

250,000

200,000

150,000

100,000

50,000

0

1985 1987 1989

Family class

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Economic immigrants Refugees Other immigrants

Figure 1. Canadian immigration trends from 1985 to 2006 (Citizenship and Immigration Canada 2010)

Description of Immigrants in Ontario

More than one-quarter of Canadian immigrants move to Ontario. In 2006, almost 3.4 million foreign-bornindividuals lived in Ontario, which represented 28.3% of the province’s population (Ontario Ministry ofFinance 2009). Approximately 8% of the Ontario population had immigrated within the past 10 years;another 8% had immigrated within the past 10–20 years; and 14% immigrated over 20 years ago (AnalyticsBranch, Health System Information Management and Investment Division 2010). The overwhelmingmajority of new arrivals to Ontario reside in urban centres, mainly Toronto (Creatore et al. 2010; Todd 2011;Gushulak et al. 2011).

Insurance of Health Services for Immigrants and Refugees

The provincial and territorial governments are primarily responsible for the delivery of mental healthservices, although the organization and funding of these services varies across the country (MHCC DiversityTask Group 2009). The Ontario Health Insurance Program (OHIP) is Ontario’s single, government-run,universal health insurance plan, which pays for all medically necessary services (Dewa, Hoch, & Goering2001; Lofters, Moineddin, Hwang, & Glazier 2010, 2011). Immigrants in Ontario are eligible for healthcoverage from OHIP after three months of residence in Ontario. Based on the Canada Health Act, thethree�month waiting period is a ceiling—provinces may apply shorter wait times (Right to HealthcareCoalition 2011).

Refugees are admitted in the refugee visa class in Canada—they are individuals in need of protection orpeople who fear returning to their home country. Admitting refugees aligns with Canada’s humanitariantradition and international obligations, Canada provides protection to thousands of people every year(Citizenship and Immigration Canada 2012).

Refugees are distinct from other immigrants in terms of health care coverage. Refugees accepted forresettlement are often not eligible for OHIP coverage until they have been settled in Ontario for lengthyperiods, sometimes years. During the wait period for provincial insurance, refugee health care is a federalresponsibility. Refugees are eligible to apply for temporary health care coverage from the federal governmentthrough the Interim Federal Health Program (IFHP) while their claim for provincial or territorial health carefunding is being assessed. IFHP covers essential and emergency medical services, including mental healthservices such as consultations with a physician, hospitalization, and essential medication (Citizenship andImmigration Canada 2011; MHCC Diversity Task Group 2009). There is little research literature on mentalhealth care use for refugees after arrival in Canada, and research on how this differs from immigrant patternsafter arrival is particularly limited.

SELECTION OF IMMIGRANTS TO CANADA

There are two methods of immigrant selection: (1) immigrant self-selection, and (2) Canadian immigrationpolicies (McDonald & Kennedy 2004).

1. Immigrant self-selection—Healthier potential immigrants are most likely to be physically and/orfinancially able to migrate.

Classical migration theory suggests that voluntary immigrants are most likely to engage in cross-bordermovements if they have strong personal characteristics (i.e., good physical health, high level of education,etc.) (Lee 1966; Newbold 2009; Wu & Schimmle 2005). Individuals in poor health generally do not elect toimmigrate (Chen, Wilkins, & Ng 1996).

2. Health screening by Canadian authorities prior to an immigrant’s arrival in Canada

The interpretation of the excessive demand clause of Canada’s Immigration and Refugee Protection Act(IRPA) denies admission to hopeful immigrants who are expected to place excessive demands on Canadianhealth or social services as a result of a health condition. Citizenship and Immigration Canada policy is thata person may be denied a visa, refused entry to, or removed from Canada if their condition is likely toendanger public health or public safety, or cause excessive demands on health or social services.

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Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

This excessive demand provision applies to potential immigrants excluding family class sponsored spouses,common-law partners and children, and refugees or others in need of protection (Citizenship andImmigration Canada 2009a, ch. 11; Baker Law; Citizenship and Immigration Canada 2002). Family classimmigrants are exempt because IRPA requires Canada to help reunite families and uphold internationalhumanitarian obligations (Citizenship and Immigration Canada 2009b).

For these reasons, and because family class immigrants have sponsors who agree to support them in Canada,they do not have to meet the same employability criteria. However, they do have to go through medical,criminal, and background screening. In contrast, admission decisions for immigrants in the economic classare based on a point system determined from a set of criteria related to employability, education, experience,and facility in official languages (Chen, Ng, & Wilkins 1996; Gushulak et al. 2011; Laroche 2001;Zunzunegui, Forster, Gauvin, Raynault, & Douglas Willms 2006).

IMMIGRANT HEALTH: “THE HEALTHY IMMIGRANT EFFECT” AND ITS DECLINE

Although there are misconceptions that immigrants will have worse health than native-born persons, the“healthy immigrant effect” suggests that is not the case for most recent immigrants. The healthy immigranteffect describes a widely observed pattern in Canada—recent immigrants appear to enjoy a health advantageover long-term immigrants or native-born persons (Ali, McDermott, & Gravel 2004b; Chen et al. 1996;Gushulak et al. 2011; Newbold & Danforth 2003; Perez 2002) The healthy immigrant effect is also observedin other industrialized nations (Kennedy, McDonald, & Biddle 2006), including the United States (Antecol& Bedard 2006; Singh & Siahpush 2002) and Australia (Biddle, Kennedy, & McDonald 2007). This effect isparticularly notable given that immigrants migrating to developed countries from developing countries areleaving countries with worse mortality and morbidity indicators (Kennedy et al. 2006).

However, given that Canadian immigrant are a heterogeneous group, these advantages are not observed forall populations. For example, the health advantage is usually most pronounced among recent immigrants.Immigrants’ health often declines as years since immigration increase (Ali, McDermott, & Gravel 2004b;Chen et al. 1996; Dunn & Dyck 2000; Gushulak et al. 2011; Newbold & Danforth 2003; Perez 2002).

There are various explanations for the change in immigrant health over time. One is that as time in Canadaincreases, so does exposure to common environmental factors and similarity in the immigrant’s lifestyle tothe Canadian lifestyle. Contributing factors likely include diet, activity, nutrition, and the use of tobacco andalcohol (Gushulak et al. 2011; McDonald & Kennedy 2004; Stephen, Foote, Hendershot, & Schoenborn1994). In addition, as time in Canada increases immigrants may be more likely to recognize western healthproblems and be more inclined to use formal health services (McDonald & Kennedy 2004).

REFUGEE HEALTH

Generally immigrants or refugees are examined outside Canada. However, if refugee claimants make a claimafter they have arrived in Canada, they have their immigration medical examination once in the country.Citizenship and Immigration Canada makes a decision in Canada as to whether refugees have passed theirmedical examination (Citizenship and Immigration Canada 2002).

A small body of research suggests that refugees differ from other immigrants in a variety of ways, includinghealth and associated likelihood of service use. Refugees appear to have worse health than their immigrantcounterparts (DesMeules et al. 2005). Refugees may have suffered unusual stresses and assaults on theirhealth prior to coming to Canada and are in need of protection (Beiser 2005). Refugees may be influencedby various inter-related factors, including pre-migratory trauma such as war, torture, rape, and naturaldisasters, and post-immigration marginalization, socioeconomic disadvantage, acculturation difficulties, lossof social support, among others (Beiser 2005; Eisenbruch 1991; Porter & Haslam 2005). They seemparticularly vulnerable to infectious and parasitic diseases, although how refugees fare in terms of mentalhealth has not been established (DesMeules et al. 2005).

Moreover, there is little research internationally on the psychological health of refugees (Porter & Haslam2005). But the existing evidence suggests that compared to non-refugees, refugees have increased risks ofdeveloping anxiety and depression as well as post-traumatic stress disorder (MHCC Diversity Task Group

2009; Porter & Haslam 2005). Canada also suffers from a lack of research: there is little evidence on mentalhealth care use for refugees after arrival in Canada, and research on how this differs among refugees isparticularly limited.

IMMIGRANT AND REFUGEE HEALTH SERVICE USE

Health Care Use for Non-psychotic Disorders

Regarding non-psychotic disorders (such as psychological distress or mood disorders), the health advantageenjoyed by recent immigrants appears to decrease as time since immigration increases (Gushulak et al.2011). Existing research on immigrant health service use for distress/mood disorders suggests that overallmental health care use patterns appear less frequent than those of the Canadian-born population (Ali,McDermott, & Gravel 2004a; Newbold 2009). This is based on a small body of literature on use of mentalhealth service use for mood disorders among immigrants to Canada (Commander, Cochrane, Sashidharan,Akilu, & Wildsmith 1999; Commander, Odell, Surtees, & Sashidharan 2004; Schaffer et al. 2009; Stafford,Newbold, & Ross 2010). For example, Schaffer et al. (2009) noted that, despite few socio-demographic orclinical differences between immigrants and native-born persons with bipolar disorder, immigrants weresignificantly less likely to report any lifetime contact with mental health professionals. Similar findings havebeen reported by others (Fenta, Hyman, & Noh 2007; Snowden 1996). However, there is very limitedresearch on mental health care use patterns for distress over time and based on region of origin.

Health Care Use for Psychotic Disorders

Immigrant mental health care use patterns may differ for psychosis. Psychosis refers to more severe formsof psychiatric disorder, during which hallucinations and delusions and impaired insight may occur.Schizophrenia is a well-known type of psychosis (Gelder 2005). However, there is a dearth of research onrisk and service use for severe mental disorders, namely psychotic disorders, among foreign-born individualsin Canada. International studies have documented a higher risk for psychotic disorders among foreign-bornindividuals relative to native-born persons (Cantor-Graae, Pedersen, McNeil, & Mortensen 2003; Fearon &Morgan 2006; McGrath et al. 2004; Morgan & Hutchinson 2010).

A recent literature review suggested that immigrants—especially Africans—have an elevated incidence ofpsychotic disorders after immigration (Coid et al. 2008; Selten, Cantor-Graae, & Kahn 2007). A meta-analysis (Cantor-Graae & Selten 2005) reported a mean-weighted relative risk of schizophrenia among first-generation migrants of 2.7 (95% CI: 2.3–3.2). Studies on this topic were mainly done in European settings,including the United Kingdom and Sweden (Cantor-Graae et al. 2003; Dean, Downing, & Shelley 1981;Krupinski & Cochrane 1980; McGovern & Cope 1987; Selten & Sijben 1994; Van Os, Castle, Takei, Der, &Murray 1996).

A very small number of Canadian studies have been done on this topic. To the author’s knowledge, noOntario individual-level studies have investigated immigrant risk for psychotic disorders or immigranthealth use for psychotic disorders in recent decades. One study (Morgan & Andrushko 1977) conducted in1971 assessed 2,867 admissions for psychiatric diagnoses to 21 hospitals serving the Toronto catchmentarea. Admissions rates for schizophrenia for native-born Canadians exceeded rates for foreign-bornpopulations (ratio of rate of schizophrenia admissions by foreign-born individuals/rate of schizophreniaadmissions by native-born individuals: males=0.87; females=0.71). A much more recent Ontario-basedecological study reported an increased risk of admission for psychotic disorders in high immigrant areas inthe age- and sex-adjusted model (Durbin, Lin, Taylor, & Callaghan 2011). A British Columbia study (Chen,Kazanjian, Wong, & Reid 2009) reported that among persons who visited a psychiatrist, psychoticconditions accounted for a larger proportion of visits for Chinese immigrants than those from the non-immigrant population.

Observed health care use patterns for psychotic disorders may partially reflect pathways to care. AlthoughCanadian research on this topic is scarce, research from the United Kingdom and United States (Bao, Fisher,& Studnicki 2008; Cole, Leavey, King, Johnson-Sabine, & Hoar 1995; Commander et al. 1999; Merritt-Davis& Keshavan 2006) suggests that Blacks have less outpatient service use than their White counterparts, and

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Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

more complex routes into formal care (Compton, Kaslow, & Walker 2004; Merritt-Davis & Keshavan 2006;Snowden & Holschuh 1992). Reluctance to seek care among members of Black communities may reflectstigma and beliefs about causes of mental illness, as well as external obstacles to care that are particularlycommon (Merritt-Davis & Keshavan 2006). Delays to seeking outpatient care for psychotic illness maycontribute to increased rates of hospitalization, lengths of stay, and poor outcomes observed among Blackindividuals.

There is a large information gap on this topic since there are few Canadian studies and no individual-levelstudies have been done in Ontario over the past quarter century (Durbin et al. 2011). Accordingly, there isno information on variation in immigrant use of health services for psychotic disorders over time ordepending on the immigrants’ regions of origin.

BARRIERS TO MENTAL HEALTH SERVICE USE

A variety of barriers to use of mental health services may affect immigrants in particular. One example isincome- or education-related barriers. Despite the universality condition in the Canada Health Act, financialdisadvantage appears to create barriers to mental health service use (Kessler et al. 2001; Steele, Glazier, &Lin 2006; Steele, Ross, Epstein, Strike, & Goldfinger 2008; Tataryn, Mustard, & Derksen 1994; Urbanoski,Cairney, Bassani, & Rush 2008). Immigrants and visible minorities tend to have lower incomes than native-born Canadians and to be disproportionately represented in impoverished areas (Chow, Jaffee, & Snowden2003; Newbold 2009; Williams 1999). Another factor that may deter use of formal mental health services isuse of alternative services. One study (Fenta et al. 2007) assessed Ethiopian immigrants and refugees inToronto and reported a higher utilization rate of services from non-health care professionals (religiousleaders, traditional healers, and other non-health professionals) than formal mental health careprofessionals.

METHODOLOGICAL IMPROVEMENTS OF PROPOSED ADMINISTRATIVE DATA SOURCES OVEREXISTING RESEARCH

The proposed studies offer some methodological improvements over existing work. First, these studies willuse administrative data rather than population-based survey data. The survey data that have been used inpast studies have several limitations, including inadequate immigrant classifications (Rotermann 2011).Immigrant classifications are often not nuanced enough to capture variation between groups. For example,information on region of origin is not collected in the Canadian Community Health Survey (CCHS). Eventhe Canadian census does not include strong information on immigrant and other minority groups(Hansson, Tuck, Lurie, & McKenzie 2010). Studies often aggregate immigrants with different characteristicsinto one group (Beiser 2005; Fenta, Hyman, & Noh 2004; Sanmartin & Ross 2006; Stafford et al. 2010).Assessing immigrants as one group makes it difficult to detect subgroup differences (Stafford et al. 2010).The direction and magnitude of the effects may differ depending on immigrant time in the host country, asobserved in other studies. (Shaw et al. forthcoming). Rotermann (2011) stated that general patterns inimmigrant health often do not persist when the immigrant population is examined by birthplace and byduration of residence in Canada (Rotermann 2011). In sum, the proposed studies will contribute to agrowing body of literature that assesses immigrants as disaggregated groups. Canadian researchers (Chen etal. 1996; Rotermann 2011) accentuate a need to increasingly refine distinctions between immigrant groups.

In addition, the quality of data on mental health service utilization is typically worse when it is based onself-report rather than more objective measures. One study (Palin, Goldner, Koehoorn, & Hertzman 2011)found that, based on self-report data, there were more per-person mental health visits than were recorded inadministrative data. Among individuals with mental disorders high reporting was common, and the size ofthe difference was often substantial. For the proposed studies, immigrant characteristics will be ascertainedthrough a government computerized immigration database. Moreover, because notarized copies of thepersonal documentation of principal applicants and their family members are required by law, this databaseis highly accurate.

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Many studies on immigrants and service use have been cross-sectional (Beiser 2005; Rotermann 2011). Arecent study (Rotermann 2011) noted that cross-sectional data are inadequate to determine if there is adeterioration of immigrant health with longer residence in Canada because findings may reflect a cohorteffect (i.e., the majority of long-term immigrants may have immigrated in worse health than those whoarrived more recently) or differential patterns in diagnosis of health disorders. Immigrants’ use of healthservices may increase if there is a greater likelihood of a pre-existing condition being diagnosed when theyhave been in Canada for longer. Rotermann concluded that, without longitudinal data to track the healthstatus over time, it is not possible to determine if health changes are taking place.

In addition, survey studies may have selection bias in terms of the respondents who are reached and whoagree to participate. However, selection bias is minimized because Ontario permanent residents are insuredby the provincial health plan. Use of administrative databases also provides information on possibleconfounding variables. The proposed studies will include many immigrant subgroups, so variation acrossdifferent immigrant groups can be more reliably assessed than in studies that assess each group individually(Salant & Lauderdale 2003). Health care billing data are generally more reliable than self-report data.However, one notable limitation of the proposed studies is that they can only include non-immigrants whoare using health care. However, this bias should be minimized because most persons in Ontario are includedin OHIP.

These studies are also strengthened by examination of use of psychotic and non-psychotic disorders in thesame study. Typically, these outcomes are examined in separate studies. Examining both patterns of care canincrease confidence that our interpretation of results is correct. For example, if for one group we observelower use of primary care services and more use of hospital care for both disorders, one interpretation is thatthis group experiences more barriers to care than others.

LIMITATIONS

Administrative Data

Administrative data have some limitations. There is an absence of some individual-level socio-demographiccharacteristics (e.g., visible minority status), income data, and patient health information. Similarly, there isno measure of mental health need/severity, even though use of mental health services should be linked toneed. The severity of mental health disorders could differ between immigrant and non-immigrant groups,but this cannot be observed using available data. However, these studies aim to sidestep need by looking atmany comparisons (e.g., between immigrants and native-born persons, and across regions of origin), andidentifying pathways to care that are not desirable.

In addition, some variables measured on arrival may change over time (i.e., highest level of education). Asimilar problem limits variability for census-derived variables since census data are only available once perfive years. On a related note, imperfect measurement of some individual control variables may haveintroduced some residual confounding (Urquia et al. 2009; Urquia, Frank, Moineddin, & Glazier 2011).

Attribution Problems

It will be challenging to interpret findings because there are a variety of contributing factors. Differences inpatterns of mental health care use may be due to a variety of factors in addition to need and disease burden:

i: Differences in cultural expressions of illness,

ii: Differences in attitudes toward mental illness and manifestations of stigma in differentcommunities. For example, in Japan there is a long-standing culture and history of honourablesuicide. This practice has a historical context, such as ritual suicide by Samurai to avoid beingcaptured, to prevent bringing shame from falling on one’s family.

iii: Various barriers to mental health problems and care,

iv: Different levels of sickness/need, or

v: Differences in use of non-traditional, non-Western healers. Ethnic communities may elect not to

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Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

use to formal Canadian health services because of a preference for alternative remedies andtreatments, including services provided by religious leaders, elders, and folk healers (Snowden1996).

In addition, clinician biases about the types of disorders or symptom expression may contribute toattribution challenges. Clinicians may differ their decision-making rules depending on their patient’sbackground (Bao et al. 2008; Barnes 2004; Hickling, McKenzie, Mullen, & Murray 1999; Mulder,Koopmans, & Selten 2006; Selten & Hoek 2008). These biases appear to be magnified when patients withpsychotic disorders and mental health care professionals have different ethnic backgrounds (Bao et al. 2008;Patel & Hegginbotham 2007; Zandi et al. 2008).

Another limitation is that dividing mental health care use into only two categories (psychotic and non-psychotic) means that both categories will be quite heterogeneous. This creates a risk of failing to find aneffect because it is obscured through inclusion in the larger group. However, if more categories are used, thesample size would likely become too small.

Also, there are no data on immigrant health care use during three months following landing in Ontario; thereis evidence that the number of health care visits is inflated shortly after the wait period, and then declines(DesMeules et al. 2005). For refugees, the gap will be longer since there is no data on refugee health serviceuse while covered by IFHP and refugees may receive an OHIP number only years after arrival.

A further limitation is that immigrants whose stated destination was not Ontario will not be identified asimmigrants. Instead they will likely be misclassified as native-born persons. As noted earlier, immigrants canbe identified in Citizenship and Immigration Canada data if their planned destination was Ontario between1985 and 2009. Some immigrants may not be linked if they moved away from Ontario after their arrival.Lastly, only non-immigrants using formal, western health care included in this study will be identified.Selection bias will be minimized because of the large proportion of the Ontario population is insured by theprovincial health plan.

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APPENDICES

APPENDIX A: Recommendations from After the Door Has Been Opened and the resulting action that arerelevant to the proposed work (MHCC Diversity Task Group, 2009, November)

Recommendation: Number and content Result

3

12

15

21

27

CIC, Health and Welfare and Secretary of

State provide core funding to immigrant

service agencies to guarantee their

maintenance on a long-term basis

Health and Welfare establish a national

advisory body to coordinate and monitor

social, health and mental health services to

ethnic minorities, with participation from

professional associations, service

administration, and immigrant service

agencies

Health and Welfare and Secretary of State

encourage all funders of social and health

services to require that organizations

applying for funds provide evidence of

efforts to make their services to ethnic

minorities accessible and to provide

evaluations of their effectiveness.

Health and Welfare, in collaboration with

provincial ministries of health and

immigrant service agencies, develop a

curriculum for training interpreters used

by mental health services….

….Government, service providers,

planners and research workers are

constantly being encouraged to make

preventive programs and treatment

services more culturally sensitive and

appropriate. Although information exists

on which programs could be built, large

gaps in knowledge and experience remain.

Until these gaps are bridged, all the

goodwill in the world will not be sufficient

to address the concerns presented to the

Task Force.

• Provide funding to service organizations • Provide funding to settlement andwelcome centres

• CIC does not offer training fortranslators/interpreters

• Encourages resettlement to culture-specific areas

None

None

None

None

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Mental Health Service Use by Immigrants and Refugees after Arrival in Ontario: Beginning to Fill a Research Gap

Immigrant mental health has garnered policy attention in Canada since the late 1980s when the Canadianfederal government’s Task Force on the mental health of immigrants and refugees released a final report,After the Door Has Been Opened (1988) (Beiser 1988) that contained a summary of the major issuesconfronting new settlers in Canada as well as a series of recommendations to governments about ways inwhich to alleviate the distress of immigrants and refugees, and to facilitate their integration. Of these 27recommendations, only six were adopted (McKenzie 2010).

APPENDIX B: Canadian Legislation

The Immigration and Refugee Protection Act includes “objectives” related to immigration and refugees. Theobjectives related to immigration include: (e) to promote the successful integration of permanent residentsinto Canada, while recognizing that integration involves mutual obligations for new immigrants andCanadian society. Objectives related to refugees include: (f) to support the self-sufficiency and the social andeconomic well-being of refugees by facilitating reunification with their family members in Canada.

Despite these objectives, which emphasize mutual obligations between Canada and immigrants andacknowledge the goal of immigrant self-sufficiency, there are very few supports to help immigrants afterarrival in Canada. The months and year after arrival are a vulnerable time for many immigrants, whoexperience a number of stressors associated with resettlement in addition to other non-immigration relatedstressors.

The need for research on this topic has been documented by the Mental Health Commission of Canada(2010) and is accentuated by the large number of first generation immigrants in Ontario.

Diversity Task Force recommendations. The report, “Improving mental health services for immigrant, refugee,ethno�cultural and racialized groups: Issues and options for service improvement” report was prepared bythe Diversity Task Group, a subcommittee of the Commission’s Service Systems Advisory Committee andthe Social Equity and Health Research department of the Centre for Addiction and Mental Health (CAMH),Ontario.

The report’s plan is firmly rooted in the Commission’s development of a Mental Health Strategy for Canada.Sixteen specific recommendations were made. Five of the recommendations in CATEGORY 1:“Co�ordination of policy, knowledge and accountability” are listed below:

1. Each province and territory should include strategies and performance measures in their mental healthplans to address the needs of immigrant, refugee, ethno�cultural, and racialized (IRER) groups.

2. Each province should gather data on the size and the mental health needs of their IRER populations. Theyshould plan their services based on this population data.

3. The mental health strategy of each province should consider a cross�sectoral plan for improving the socialdeterminants of mental health problems and illness for IRER groups.

4. A virtual national centre for research into the mental health and mental health problems and illness inIRER groups should be developed. The Centre could perform a regular one�day mental health census ofmental health care service use and a community needs survey sampled by province.

5. Health Canada, Canadian Institutes of Health Research and the provinces and territories should producea research and development fund for studies aimed at answering strategic policy and practice questionsfor IRER groups’ mental health and service provision.