Elsevier

Social Science & Medicine

Volume 60, Issue 6, March 2005, Pages 1359-1370
Social Science & Medicine

Self-rated health within the Canadian immigrant population: risk and the healthy immigrant effect

https://doi.org/10.1016/j.socscimed.2004.06.048Get rights and content

Abstract

Set within the determinants of health framework and drawing upon Statistics Canada's longitudinal National Population Health Survey, this paper explores the self-assessed health of Canada's immigrant population. Using both descriptive and multivariate techniques, including logistic regression and survival analysis, the intent is to identify differences in self-assessed health between the immigrant and native-born populations, the factors that contribute to immigrant self-assessed health, and the factors associated with declining self-assessed health status. In each case, the key questions are whether differences in health status exist between the native- and foreign-born. Results indicate mixed support for the Healthy Immigrant Effect, with the native- and foreign-born neither more nor less likely to rank their health as fair or poor. However, results from the proportional hazards model indicated that the native-born were at lower risk to transition to poor health.

Introduction

The immigrant population, meaning residents of Canada who are born outside the country including refugees, legal, and illegal residents, may experience important health disparities, both relative to other immigrant groups as well as to the native-born population. For example, the observed ‘healthy immigrant effect’, whereby the health status of immigrants at the time of arrival is high, but subsequently declines and converges toward the native-born population, is well known within the existing literature (Ali, 2002; Blanton, Rushing, & Ruiz, 2003; Chen, Wilkens, & Ng, 1996; Dunn & Dyck, 2000; Frisbie, Youngtae, & Hummer, 2001; Gee, Kobayashi, & Prus, 2003; Hull, 1979; Muenning & Fahs, 2002; Newbold & Danforth, 2003; Parakulam, Krishnan, & Odynak, 1992; Pérez, 2002; Zambrana, Scrimshaw, & Collins, 1997). Recent immigrants are, for example, more likely to rank their health higher than the Canadian-born, and are less likely to have chronic conditions or disability, attributed to the fact that those in good health are more likely to immigrate to Canada along with the screening process at the time of entry that disqualifies those with serious medical conditions (Laroche, 2001; Oxman-Martinez, Abdool, & Loisell-Léonard, 2000). While initially high, measures including self-assessed health or the Health Utilities Index (HUI3) decline rapidly within as little as 10 years after arrival (Chen et al., 1996; Dunn & Dyck, 2000; Newbold, 2004). At the same time, the prevalence of chronic conditions among the immigrant population converges upwards toward that of the Canadian population (Chen et al., 1996; Dunn & Dyck, 2000).

The question remains, however, as to why immigrant health status deteriorates with duration of residence. The existing literature recognizes that immigrants, by definition, move from one set of health risks, behaviors and constraints, to an environment that potentially includes a very different mix, with probable adverse impacts upon health (e.g., Gordon, 1957; Marmot & Syme, 1976). While this does not provide a reason why health status declines after arrival, declines in health status have often been attributed to the uptake of unhealthy lifestyles including poor dietary habits, smoking, and/or drinking, upon settlement in the host country (Frisbie et al., 2001). Contributions to poor health stemming from unhealthy lifestyle choices are, however, likely to manifest themselves over decades, and not the years observed within the literature. Moreover, it would also imply that immigrants would need to reduce their health promotion behaviors below that of native-born Canadians.

Structural explanations provide an alternative line of reasoning. Birch and Gafni (1999), for example, argue that the restructuring of the Canadian health care system over the 1990s has meant than an increasing proportion of care is non-insured. In an era of cost-containment, the impacts within the Canadian health system are not equal across the population (Eyles, Birch, & Newbold, 1995), with low-income groups and the poorly educated less able to deal with system restructuring, even within the publicly financed system (Birch & Gafni, 1999). By extension, the immigrant population may be particularly disadvantaged. Unease or distrust of the medical system, or a medical system that does not provide culturally sensitive and appropriate care may create additional barriers (Anderson, Blue, Holbrook, & Ng, 1993; Bentham, Hinton, Haynes, Lovett, & Bestwick, 1995; Deinard & Dunnigan, 1987).

Third, declines in health status may reflect a broader set of health determinants that are magnified within the immigrant population. Articulated by the determinants of health (DOH) framework, health is influenced by a broad range of factors and interrelationships between factors, with demonstrated associations between health status and social, demographic, economic, and environmental variables (Dunn, 1996; Evans & Stoddart, 1990; Evans, 1994; Jones & Moon, 1992). Consequently, declining relative health within the immigrant population may represent a combination of issues including their social, political, economic, and cultural position within the host society. Conversely, loss of socioeconomic status, social networks, poor working conditions, and language barriers may contribute to declines in health (Anderson, 1987; Chen et al., 1996; Elliott & Gillie, 1998; Grossi, Soares, Angesleva, & Perski, 1999; Hanna, 1996; Lock, 1991; Saldov, 1991; Wozniak, 2001). Access to health services, and ultimately overall health, may be especially limited among immigrant women whose family, job, or cultural expectations and roles may make it difficult to access and use resources (Anderson et al., 1993; Dyck, 1995; MacKinnon & Howard, 2000; Oxman-Martinez et al., 2000; Weerasinghe, Mitchell, Hamilton, & Ragheb, 2000). Poor access and service use may lead to a worsening of health status over time owing to the relative under-use of preventative health screening and under-diagnosis and treatment of health problems. However, it is also likely that if health status continues to decline over time, barriers to care must also persist over time, while existing evidence suggests that utilization of health care services actually increases with increasing duration of residence (Newbold, 2003). Improved access and use of health services therefore likely leads to increased recognition and reporting of conditions, and consequently poorer self-assessed health.

Immigrants may also embody different perceptions of health relative to the broader population in general, and health professionals in particular, hindering understanding of health and illness. Indo-Canadian women, for example, perceive loneliness and depression as matters that do not warrant medical attention, but instead view them as personal problems (Anderson, 1987). If, on the other hand, health status is correlated with these effects, it is logical to assume that as acculturation progresses, language skills improve, and knowledge of and opportunities to access health services increase, health status should, at a minimum, stabilize. However, it is ultimately unclear from the literature what role acculturation has upon health outcomes, although acculturation, measured through (for example) community participation, social contacts, income adequacy, housing, etc., may be associated with improved health.

Notwithstanding the ‘healthy immigrant effect’, how does the health status of immigrants evolve over time after arrival in their host country? How quickly does their health status change? What covariates are associated with self-assessed health status and declines in health status? Set within the DOH frame work (Evans & Stoddart, 1990) and drawing upon Statistics Canada's longitudinal National Population Health Survey (NPHS) that allows a temporal dimension to be built into the analysis of health status, the purpose of this paper is to evaluate self-assessed health within the immigrant population. Specifically, the intent is to identify differences in self-assessed health between the immigrant and native-born populations, the factors that contribute to immigrant self-assessed health, and the factors associated with declining self-assessed health status. In each case, the key question is whether differences in health status exist between the native- and foreign-born.

Section snippets

Data and methods

Data are drawn from the longitudinal components of the 1994/95, 1996/97, 1998/99, and 2000/01 cycles of the NPHS, an on-going longitudinal survey administered by Statistics Canada. The target population of the NPHS consists of household residents aged 12 and over in all provinces and territories, excepting those living on Aboriginal reserves, Canadian Forces Bases, or resident in some remote places. The survey collects in-depth information on a randomly selected member of each household, with

Basic insights to self-assessed health

Table 1 reports the proportion of immigrants and native-born reporting fair or poor health (“unhealthy”) in 1994.2 Overall, 10.1% of immigrants report fair or poor

Discussion and conclusions

The existing literature has largely reinforced the notion of the ‘healthy immigrant effect’, whereby the health status of immigrants at the time of arrival is high but subsequently declines and converges toward that of comparable native-born. However, the results reported here offer mixed support for the healthy immigrant effect. The logistic analysis, for example, found that the native-born were not more or less likely to rank their health as poor relative to the foreign-born, controlling for

Acknowledgements

Research funded by the Canadian Institutes of Health Research (CIHR), #88682. The longitudinal versions of the NPHS used in this paper were accessed through Statistics Canada Research Data Centers.

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