Health status of refugees settled in Alberta: changes since arrival.
Maximova, Katerina ; Krahn, Harvey
Health status of refugees is an important aspect of their
successful resettlement in Canada. (1) Research on refugee health has
traditionally focused on acute post-traumatic response (e.g.,
post-traumatic stress disorder) to the stresses of war exposure. (2,3) A
recent meta-analysis highlighted that the multiple dimensions of
refugees' resettlement cannot be understood without consideration
of a wide range of pre- and post-migration stressors beyond those that
are acutely post-traumatic. (4,5) Yet, very little is known about which
pre- and post-migration factors are associated with mental or physical
health of refugees. (2,3) Using data on refugees destined to Alberta,
this paper sought to identify pre- and post-migration factors that are
associated with changes in their health status. Among pre- and
post-migration factors, we emphasized the role of risk factors that
refugees might have been exposed to prior to migration (e.g., having
been to a refugee camp) and following migration to Canada (e.g.,
discrimination, (un)employment, economic hardship), as well as
protective factors (e.g., settlement services utilization during the
first year in Canada).
METHODS
The study of Settlement Experiences of Refugees in Alberta was
based on a representative target population of 956 individuals
systematically selected (every kth name) from a Citizenship and
Immigration Canada (CIC) database of 5,208 government- and
privately-sponsored refugees destined to Alberta between 1992 and 1997.
(1) Excluded were refugees who claimed refugee status on arrival in
Canada, who had been sponsored by family members already in Canada, or
whose addresses were not available in the government database. Of these,
909 individuals were located. Since many had left their host communities
in Alberta to move to various communities across Canada, 648 individuals
(71% of those eligible) were invited to participate and 616 (response
proportion 95%) completed hour-long structured interviews between July
and October 1998 (525 adults and 91 youth aged 15-21 years). The study
was approved by the University of Alberta Research Ethics Board. This
paper is limited to information from 525 adult refugees.
Measures
Changes in Health Status
Participants were asked how mentally healthy they felt (very
healthy; somewhat healthy; unhealthy; very unhealthy) when they first
arrived in Canada and in the month previous to the interview (hereafter
called the "previous month"). The same questions were repeated
for physical health. Changes in mental or physical health status were
estimated as the arithmetic difference between respective health status
on arrival and in the previous month. Values of '0'
represented no change; less than '0' represented a decline in
health status; and greater than '0' represented an improvement
in health status.
Pre-migration Factors
Pre-migration factors included refugee camp experience (yes/no);
highest level of education completed prior to arrival (responses
collapsed into 'less than university' and 'university
complete'); occupation prior to arrival (responses collapsed into
'blue collar/clerical/ sales/service/technical' and
'professional/managerial'). (6)
Post-migration Factors
Post-migration factors included unemployment experience (yes/no);
current employment status (no job vs. one or more part-time
jobs/full-time job); discrimination experience in Canada (yes/no);
household income (categories of $10,000); perceived financial hardship
(enough income to cover living costs vs. sometimes have problems/often
have problems); settlement services utilization (the sum of 15 services
based on a checklist that asked participants to report all services
received from agencies in their host communities during the first year
in Canada (e.g., language training, job training, help with translation,
help finding housing, help with health problems, help with legal
matters)). In addition, all models included gender (male/female), age
(years), marital status (married vs. common-law/other), and number of
years in Canada.
Analysis
To examine which factors are associated with changes in
refugees' mental and physical health status, two separate linear
regression models that included pre- and post-migration factors were
fitted to the data for each of the two continuous dependent variables:
changes in mental health status and changes in physical health status.
RESULTS
Almost two thirds of participants (63%) were refugees from former
Yugoslavia--a major source country of refugees in the mid-1990s (Table
1). (7) The remainder came from Middle Eastern countries (17%),
Central/South America (9%), Africa (6%), East Asia (3%), and Poland
(2%). On average, refugees lived in Canada for 3 years; 18% had been in
Canada for 5-6 years, 44% for 3-4 years, and 38% for 1-2 years. One
third of participants (32%) spent time in a refugee camp prior to
arrival in Canada. About one quarter (27%) completed a university degree
prior to arrival in Canada and 39% had been employed in professional or
managerial jobs in their home countries.
Since arrival in Canada, 16% of refugees in the study had been
unemployed, in contrast to the Alberta unemployment rate of under 6% in
1998. (8) At the time of the interview, 68% were employed but only 49%
were employed full-time. One in four (25%) reported that they had
experienced discrimination in Canada. A majority (70%) reported having
annual household incomes of less than $40,000 and 48% acknowledged that
they (sometimes or often) had trouble covering their living costs.
<01_TB028>
Overall, refugees' mental health status improved following
arrival in Canada (Table 2). The majority (70%) reported being
'very healthy' in the month prior to the interview, compared
to 57% when they first arrived in Canada (p=0.000). Physical health
status declined following arrival in Canada.
Of pre-migration factors, refugees who spent time in a refugee camp
before coming to Canada and those who held professional/managerial jobs
in their home country had greater declines in mental health status since
arrival in Canada than those who did not (Table 3). Refugees who
completed a university degree in their home country had greater declines
in physical health status following arrival than those who did not.
Of post-migration factors, being employed in Canada (either
part-time or full-time) was associated with greater improvements in
refugees' mental health status, while perceived economic hardship
was associated with greater declines in physical health status. A higher
number of settlement services received during the first year in Canada
was associated with greater improvements in both mental and physical
health status. Longer residence in Canada was associated with greater
declines in physical health status but not in mental health status.
<01_TB029>
<01_TB030>
DISCUSSION
Refugees' self-rated mental health status improved following
arrival in Canada. Refugees often experience considerable trauma while
leaving their home countries as a result of war, genocide, or political
and economic crises. Their possibly compromised mental health status on
arrival may explain the overall improvement in their mental health
status in the years immediately following. Previous studies also report
that the rates of depression declined substantially among Southeast
Asian refugees during the first 10 years in Canada. (9)
Refugees' physical health status declined since arrival in
Canada, with longer residence in Canada associated with greater declines
in physical health status. This finding replicates previous reports
showing that immigrants are in better physical health on arrival in a
host country than the native-born population, a phenomenon known as the
"healthy immigrant" effect. (10-13) However, their health
status declines and converges with that of the host population after 10
years residing in a host country. (10-18) Few studies reported on
changes in physical health in a host country among refugees. The decline
in physical health status among refugees in our study was observed even
though refugees spent a maximum of six years in Canada, and we may see
even stronger evidence of declining physical health status as the time
in Canada increases for these refugees.
Of pre-migration factors, having been to a refugee camp was
associated with declines in mental health status. This finding points to
the need for considering refugees' unique experiences and needs
(e.g., the trauma of living in a refugee camp) in the provision of
counseling and support services. (19) Previous research found the number
of traumatic events and years spent in a refugee camp to be significant
predictors of psychological distress among 2,180 Southeast Asian
refugees in the United States that extended beyond the initial years of
resettlement, (20) but we did not have this information in our study.
Having better jobs in refugees' home countries was associated with
declines in mental health status, while having higher educational
credentials was associated with declines in physical health status.
These findings are not surprising since the story of refugee
underemployment in Canada is one of substantial occupational downward
mobility. (8) Compared to economic immigrants who encounter significant
labour market access problems, refugees face even more severe labour
market barriers as a result of credential non-recognition and
discrimination. (6,7) This finding underscores the need for more
effective labour market policies (both training and job access)
targeting refugees.
Of post-migration factors, being employed was associated with
improvements in mental health status, while experiencing economic
hardship in Canada was associated with declines in physical health
status. Although employment has been linked to higher self-rated health
among both immigrants and non-immigrants, immigrants appear to benefit
more from being in the labour force. (12,21) Studies of refugees also
report that employment after migration had positive effects on mental
distress of 2,180 Southeast Asian refugees in the United States. (20)
Access to employment opportunities was associated with better mental
health status among refugees from Bosnia-Herzegovina settled in Sweden.
(22) A decline in the unemployment rate was linked to a decline in
depression among Southeast Asian refugees during their initial years of
resettlement in Canada. (9) These studies further underscore the need
for elimination of structural barriers that lead to high rates of
unemployment among refugees to prevent negative health consequences.
(23) Finally, utilization of settlement services during refugees'
first year in Canada was associated with improvements in both mental and
physical health status in our study. This finding is not surprising
since social support has been shown to be key to refugees'
successful resettlement, (24,25) and reinforces the importance of
providing settlement services (beyond the first year of resettlement) to
help refugees settle more successfully in their host communities.
Data on refugee health are scarce and research methodologies are
fraught with biases since refugee populations are difficult to access
physically, linguistically and culturally. (4) Our dataset provided a
unique opportunity to examine the correlates of changes in
refugees' health status. The analyses were constrained by the
available measures. Generic self-rated measures of health status may
have limited utility but were used because of a concern that translation
of more widely-used specific health scales into 11 different languages
would compromise their reliability and validity. Assessments of
translated versions of existing health scales yielded varying results.
(26-29) Retrospective recall of health status on arrival in Canada has
the potential to introduce error, however the validity of recall
measures is likely not severely compromised since most refugees in the
study had been in Canada for a relatively short time (on average 3
years). Our study sample was drawn from the CIC database which included
a complete list of refugees settled in Alberta between 1992 and 1997 and
is therefore likely to be representative of refugees arriving in Alberta
during the early and mid-1990s. However, since refugees who moved from
their host communities in Alberta to other communities across Canada
were not invited to participate in the study, it is possible that our
study sample was older, more likely to have children or other
dependents, and less likely to have relatives in other parts of Canada.
Since 88% of study participants resided in Alberta and 64% were refugees
from former Yugoslavia, the results may not be generalizable to refugees
in other Canadian locations or from other source countries. While the
associations of interest may vary by ethnic group, we could not stratify
our analyses by ethnicity due to sample size limitations. Previous
research has shown that pre-migration trauma and refugee camp
experiences were significant predictors of distress regardless of
ethnicity and number of years in Canada. (20) Indeed, it has been argued
that the experiences of pre- and post-migration stresses are culturally
invariant. (23)
While little can be done to alter refugees' pre-migration
experiences, public policies can affect many of the post-migration
experiences in order to mitigate the negative health consequences
associated with resettlement. While settlement services can facilitate
the integration process and lead to improved health status, difficulty
in labour market access and poverty-related stress can have the opposite
effect. Yet, unemployment, discrimination, and non-recognition of
credentials continue to jeopardize/compromise refugee mental and
physical well-being. (30)
Acknowledgements: Dr. Tracey Derwing and Dr. Baha Abu-Laban (with
Harvey Krahn) were co-principal investigators for the study of
Settlement Experiences of Refugees in Alberta. The data were collected
by the Population Research Laboratory, Department of Sociology,
University of Alberta. We thank Sylvia So for help with the literature
review.
Conflict of Interest: None to declare.
Received: November 9, 2009
Accepted: April 5, 2010
REFERENCES
(1.) Abu-Laban B, Derwing T, Krahn H, Mulder M, Wilkinson L. The
Settlement Experiences of Refugees in Alberta. Edmonton, AB: Prairie
Centre of Excellence for Research on Immigration and Integration
(PCERII), 1999.
(2.) Miller KE, Rasmussen A. War exposure, daily stressors, and
mental health in conflict and post-conflict settings: Bridging the
divide between trauma-focused and psychosocial frameworks. Soc Sci Med
2010;70(1):7-16.
(3.) Porter M. Global evidence for a biopsychosocial understanding
of refugee adaptation. TranscultPsychiatry 2007;44(3):418-39.
(4.) Porter M, Haslam N. Predisplacement and postdisplacement
factors associated with mental health of refugees and internally
displaced persons: A meta analysis. JAMA 2005;294(5):602-12.
(5.) Ringold S, Burke A, Glass RM. JAMA patient page. Refugee
mental health. JAMA 2005;294(5):646.
(6.) Krahn H, Derwing T, Mulder M, Wilkinson L. Educated and
under-employed: Refugee integration into the Canadian labour market. J
Int Migration Integration 2000;1(1):59-84.
(7.) DeVoretz D, Pivnenko S, Beiser M. The Economic Experience of
Refugees in Canada. Discussion Paper No. 1088. Bonn, Germany: Institute
for the Study of Labour, 2004.
(8.) Krahn H, Derwing T, Abu-Laban B. The retention of newcomers in
second-and third-tier Canadian cities. Int Migration Rev
2005;39(4):872-94.
(9.) Beiser M, Hou F. Language acquisition, unemployment and
depressive disorder among Southeast Asian refugees: A 10-year study. Soc
Sci Med 2001;53(10):1321-34.
(10.) Newbold KB. Chronic conditions and the healthy immigrant
effect: Evidence from Canadian immigrants. J Ethnic Migration Studies
2006;32(5):765-84.
(11.) Newbold KB. Self-rated health within the Canadian immigrant
population:
Risk and the healthy immigrant effect. Soc Sci Med
2005;60(6):1359-70.
(12.) Newbold KB, Danforth J. Health status and Canada's
immigrant population. Soc Sci Med 2003;57(10):1981-95.
(13.) McDonald JT, Kennedy S. Insights into the 'healthy
immigrant effect': Health status and health service use of
immigrants to Canada. Soc Sci Med 2004;59(8):1613-27.
(14.) Patel JV, Vyas A, Cruickshank JK, Prabhakaran D, Hughes E,
Reddy KS. Impact of migration on coronary heart disease risk factors:
Comparison of Gujaratis in Britain and their contemporaries in villages
of origin in India. Atherosclerosis 2006;185(2):297-306.
(15.) Harding S. Mortality of migrants from the Indian subcontinent
to England and Wales: Effect of duration of residence. Epidemiol
2003;14(3):287-92.
(16.) Singh GK, Siahpush M. Ethnic-immigrant differentials in
health behaviors, morbidity, and cause-specific mortality in the United
States: An analysis of two national data bases. Human Biology
2002;74(1):83-109.
(17.) Singh GK, Hiatt RA. Trends and disparities in socioeconomic
and behavioural characteristics, life expectancy, and cause-specific
mortality of native-born and foreign-born populations in the United
States, 1979-2003. Int J Epidemiol 2006;35(4):903-19.
(18.) Moran A, Roux AVD, Jackson SA, Kramer H, Manolio TA, Shrager
S. Acculturation is associated with hypertension in a multiethnic
sample. Am J Hypertension 2007;20(4):354-63.
(19.) Watters C. Emerging paradigms in the mental health care of
refugees. Soc Sci Med 2001;52(11):1709-18.
(20.) Chung RC, Kagawa-Singer M. Predictors of psychological
distress among southeast Asian refugees. Soc Sci Med 1993;36(5):631-39.
(21.) Dunn JR, Dyck I. Social determinants of health in
Canada's immigrant population: Results from the National Population
Health Survey. Soc Sci Med 2000;51(11):1573-93.
(22.) Blight KJ, Ekblad S, Persson JO, Ekberg J. Mental health,
employment and gender. Cross-sectional evidence in a sample of refugees
from Bosnia-Herzegovina living in two Swedish regions. Soc Sci Med
2006;62(7):1697-709.
(23.) Beiser M. Resettling refugees and safeguarding their mental
health: Lessons learned from the Canadian Refugee Resettlement Project.
Transcultural Psychiatry 2009;46(4):539-83.
(24.) Simich L, Beiser M, Mawani FN. Social support and the
significance of shared experience in refugee migration and resettlement.
Western J Nurs Res 2003;25(7):872-91.
(25.) Lamba N, Krahn H. Social capital and refugee resettlement:
The social networks of refugees in Canada. J Int Migration Integration
2003;4(3):335-60.
(26.) Silove D, Steel Z, Bauman A, Chey T, McFarlane A. Trauma,
PTSD and the longer-term mental health burden amongst Vietnamese
refugees: A comparison with the Australian-born population. Soc
Psychiatry Psychiatric Epidemiol 2007;42(6):467-76.
(27.) Silove D, Manicavasagar V, Mollica R, Thai M, Khiek D,
Lavelle J. Screening for depression and PTSD in a Cambodian population
unaffected by war: Comparing the Hopkins Symptom Checklist and Harvard
Trauma Questionnaire with the structured clinical interview. J Nervous
Mental Dis 2007;195(2):152-57.
(28.) Noh S, Avison WR, Kaspar V. Depressive symptoms among Korean
immigrants: Assessment of a translation of the Centre for Epidemiologic
Studies-Depression Scale. Psychological Assessment 1992;4(1):84-91.
(29.) Charney ME, Keane TM. Psychometric analyses of the
Clinician-Administered PTSD Scale (CAPS)--Bosnian translation. Cultural
Diversity & Ethnic Minority Psychology 2007;13(2):161-68.
(30.) Beiser M. The health of immigrants and refugees in Canada.
Can J Public Health 2005;96(Suppl 2):S30-S44.
Katerina Maximova, PhD, [1] Harvey Krahn, PhD [2]
Author Affiliations
[1.] Department of Public Health Sciences, University of Alberta,
Edmonton, AB
[2.] Department of Sociology, University of Alberta, Edmonton, AB
Correspondence: Katerina Maximova, Department of Public Health Sciences,
School of Public Health, University of Alberta, 3-20D University
Terrace, 8303-112 Street, Edmonton, AB T6G 2T4, Tel: 780-248-2076, Fax:
780-492-8934, E-mail: katerina.maximova@ualberta.ca
Sources of Funding: The study of Settlement Experiences of Refugees
in Alberta was funded by Citizenship and Immigration Canada and by the
Prairie Centre of Excellence for Research on Immigration and Integration
(PCERII), University of Alberta. Katerina Maximova was supported by a
Doctoral Fellowship from the Canadian Institutes of Health Research
(CIHR) and the Strategic Training Fellowship in Transdisciplinary Public
and Population Health Research from the CIHR & Quebec Population
Health Research Network.
Table 1. Characteristics of Refugees (n=525) from the
Settlement Experiences of Refugees in Alberta Study,
1998
n %
Region came from
Former Yugoslavia 329 62.7
Poland 9 1.7
Middle East 88 16.8
Africa 34 6.5
Central/South America 49 9.3
East Asia 16 3.0
Age (mean, SD) 36.7 7.2
Gender
Female 265 50.5
Marital status
Married/common-law 384 73.1
Years in Canada
1 75 14.3
2 122 23.2
3 128 24.4
4 103 19.6
5 74 14.1
6 23 4.4
Pre-migration factors
Refugee camp experience
Been to refugee camp 167 31.8
Education prior to arrival
University degree 140 26.7
Occupation prior to arrival
Managerial/professional 168 39.4
Post-migration factors
Unemployment experience
Ever been unemployed since arrival 205 39.3
Current employment status
No job 167 31.9
Part-time (one or more) 99 18.9
Full-time job 258 49.2
Discrimination experience
Experienced discrimination in Canada 132 25.2
Household income
<$10,000 40 8.0
$10,000-19,999 178 35.5
$20,000-29,999 112 22.4
$30,000-39,999 63 12.6
$40,000-49,999 40 8.0
$50,000-59,999 30 6.0
([greater than or equal to] $60,000 38 7.6
Perceived economic hardship
Enough income to cover living costs 271 52.4
Sometimes have problems 160 30.9
Often have problems 86 16.6
Settlement services utilization (mean, SD) 6.84 3.1
Table 2. Distribution of Self-rated Mental and Physical Health Status
on Arrival and in the Previous Month among Refugees (n=525), from the
Settlement Experiences of Refugees in Alberta Study, 1998
Mental Health
On Arrival Previous Month p-value *
n (%) n (%)
Very unhealthy 9 (1.7) 3 (0.6) 0.345
Unhealthy 43 (8.2) 20 (3.8) 0.291
Somewhat healthy 172 (32.8) 133 (25.5) 0.000
Very healthy 300 (57.3) 366 (70.1) 0.000
Physical Health
On Arrival Previous Month p-value *
n (%) n (%)
Very unhealthy 5 (1.0) 8 (1.5) 0.409
Unhealthy 25 (4.8) 34 (6.5) 0.152
Somewhat healthy 152 (29.0) 121 (23.1) 0.000
Very healthy 343 (65.3) 361 (68.9) 0.000
* p-value for the two-sample significance tests of difference between
two proportions.
([dagger]) Previous month = month previous to interview.
Table 3. Pre-and Post-migration Factors Associated with Changes in
Mental and Physical Health Status among Refugees (n=525), from the
Settlement Experiences of Refugees in Alberta Study, 1998
Factors Mental Health
Beta 95% CI p-value
Age 0.02 (-0.01, 0.01) 0.772
Gender (female=1) -0.04 (-0.20, 0.10) 0.497
Marital status (married/common
law=1) 0.05 (-0.11, 0.27) 0.397
Years in Canada -0.04 (-0.08, 0.04) 0.534
Pre-migration factors
Refugee camp experience (yes=1) -0.13 (-0.36, -0.03) 0.024
Education prior to arrival -0.10 (-0.10, 0.01) 0.097
Occupation prior to arrival -0.11 (-0.18, 0.00) 0.046
Post-migration factors
Unemployment (been unemployed=1) 0.06 (-0.07, 0.23) 0.290
Current employment status
(employed=1) 0.13 (0.01, 0.19) 0.025
Discrimination experience (yes=1) -0.09 (-0.31, 0.04) 0.120
Household income 0.03 (-0.04, 0.06) 0.687
Perceived economic hardship -0.04 (-0.15, 0.07) 0.492
Use of settlement services 0.11 (0.00, 0.05) 0.046
Factors Physical Health
Beta 95% CI p-value
Age -0.04 (-0.01, 0.00) 0.395
Gender (female=1) -0.04 (-0.20, 0.10) 0.486
Marital status (married/common
law=1) -0.02 (-0.22, 0.16) 0.734
Years in Canada -0.13 (-0.12, -0.01) 0.026
Pre-migration factors
Refugee camp experience (yes=1) -0.02 (-0.19, 0.14) 0.768
Education prior to arrival -0.12 (-0.11, -0.01) 0.031
Occupation prior to arrival 0.06 (-0.04, 0.14) 0.265
Post-migration factors
Unemployment (been unemployed=1) 0.04 (-0.09, 0.21) 0.443
Current employment status
(employed=1) 0.09 (-0.02, 0.16) 0.110
Discrimination experience (yes=1) -0.07 (-0.29, 0.06) 0.187
Household income 0.01 (-0.05, 0.05) 0.910
Perceived economic hardship -0.12 (-0.22, 0.00) 0.042
Use of settlement services 0.13 (0.01, 0.05) 0.015
