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The Relationship Between Migration and Health

The Relationship Between Migration and Health. Professor Basanti Majumdar RN, MSc, MEd, MSc(T), PhD School of Nursing, McMaster University Faculty of Health Sciences.

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The Relationship Between Migration and Health

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  1. The Relationship Between Migration and Health Professor Basanti Majumdar RN, MSc, MEd, MSc(T), PhD School of Nursing, McMaster University Faculty of Health Sciences

  2. 1. Immigrants (focus: legal landed immigrants) in Canada constitute a diverse and generally healthy population 2. The health problems of arriving and returning populations will become an increasingly important concern for all Canadians Introduction

  3. Introduction 3. Recent changes in Canada's immigration patterns have made this country more ethnically diverse than ever before 4. People migrate from different cultural backgrounds where their experiences are different from the health and disease patterns that are common in Canada (Majumdar et al, 1995; Health Canada; 1998, Ray 2002)

  4. How does the health of migrants differ systematically from non-migrants?

  5. When immigrants arrive in Canada, they are a healthy group, (Chen et al 1994-95). This is assumed to be associated with:a. Good health - More inclined than those in poor health to emigrateb. Employability - Granting permission to immigrate requires a certain level of health.c. Screening - Screening that ensures that they do not suffer from serious medical conditions (Immigration Act of Canada) Health of Migrants Assumptions: Illegal and trafficked migrants do not go through this process

  6. Myths Immigrants are unhealthy bring diseases have low health habits believes in mysterious health practices

  7. 2. Recent immigrants, less likely than the Canadian-born population to have chronic conditions or disabilities(Chen at al, 1994-95) Health of Recent Migrants Studies Indicate • Recent immigrants are healthier than the Canadian-born population- • “healthy immigrant effect” • (Fowler N., 1998; Ali J.,2002)

  8. Physical Health • Study on physical health of recent immigrants (women) show • that they have healthier lifestyles. They • Smoked less • Drank less • Ate more fruits and vegetables 2. On the other hand, native–born Canadians, in general, exercise more than immigrants (Chen et al 1994-95, Perez CE 2002)

  9. Chronic Conditions 70% 60% Incidence of chronic conditions in general rose with time since immigration to Canada 50% 40% 30% Adjustments were made age, education and income (Ali J, 2002) 20% 10% 0% Canadians Recent Immigrants In general, but focuses mainly on heart disease, diabetes,high blood pressure, and cancer

  10. Mental HealthDepression in the previous 12 months(Age 15-75 yrs) 9 8 7 6 5 4 3 2 1 0 Recent Immigrants (Ali J, 2002) Canadians

  11. Mental HealthAlcohol Dependence in the previous 12 months (indicator of stress/ poor mental health) 5% Immigrant Canadians have a higher percentage of people from cultures and religions that forbid alcohol, specially in the past couple of decades where a high number of new Canadians have arrived from Africa and Asia(Ali J, 2002) 4% 3% 2% 1% 0% Canadians Recent Immigrants

  12. 1.Language barriers, immigrants’ higher unemployment rates, their lower sense of belonging to the local community did not diminish the gap with respect to depression or alcohol dependence. Mental Health Recent and Long Term Immigrants 2. Immigrants who had been in Canada the longest had health outcomes similar to those of their Canadian counterparts (Ali J, 2002)

  13. Mental Health Other Studies • immigrants represent a vulnerable population at risk • with higher rates of depression and alcohol dependence • (Beiser et al 1994) • Discrepancies may relate to the fact that literatures has • typically focused on specific subsets of individuals (such • as refugees)(Dunn et al 2000, Noh et al 1999)

  14. Mental Health • It is clear that there are vulnerable sub-groups • among immigrants • Though, recent immigrants, exhibit fewer mental health • problems than the Canadian-born population: • it cannot be assumed that immigrants have better mental health than the Canadian-born population • (Ali J, 2002) • Paradigm Shift ( Value/Norm difference in a societal context)

  15. In terms of chronic conditions in general, immigrants and non-immigrants appear to converge in health status over time Which shows that recent immigrants in Canada are in better health than the Canadian born population Chronic Conditions ( Chen et al 1994-95, Parakulam et al 1992,The Daily,Sept 19,2002; Ali ,J., 2002)

  16. How does the place of origin and destination factor into the health of migrants ?

  17. Origin and Destination The impact of mobility on health risk may be beneficial , neutral, orunfavorable with respect to the adult population . Example Movement from a tropical area endemic for malaria to a temperate region where the disease is not transmitted (MacPherson DW et al ,2001)

  18. 1. Health is directly related to the origin, behavior, environment and social make up of the population in question (Gushulak, 2001) 2. The volume of international travel precludes individual screening of travelers for infections (Gushulak, 2000)3. Recent major changes in migration health: concern for re-emergence and growing threat of infectious diseases Infectious Diseases

  19. Infectious Diseases 4. High speed air travel = the international movement of individuals within the incubation time of all virulent infections 5. Migrants come from developing areas with prevalence of infectiousdiseases such as tuberculosis, HIV/AIDS, hepatitis, malaria and parasitic diseases(Cookson et al 1998)

  20. Infectious Diseases Migrant children and the newly-born may have risks to certain diseases that are different from Canadian children. Examples are: • tuberculosis • malaria • intestinal parasites and • hepatitis (Mortenson J et al, 1989, Gushulak, 1999)

  21. Other Diseases Children who come from environmental polluted regions may carry the effects with them (e.g. lead poisoning , arsenic poisoning in Bangladesh) Increased risk of ill health due to a combination of dietary and cultural factors (e.g. low levels of Vitamin D & Iron deficiency anemia in children of Asian families) (Lawson M et al 1999, Carey E 1998, Gushulak, 1999)

  22. Tuberculosis Specific Diseases Dramatic increase in the proportion of foreign-born cases of TB has been observed over the past 20 years in Canada. TB in immigrants and refugees results from reactivation and a smaller proportion from primary infection just prior to post-migration (Applied Research and Analysis Directorate-http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/immigration03.html)

  23. A 5 year Alberta study (1990-1994) –351 cases of TB diagnosed, immigrants accounted for 70.6% of these cases. 73.4% were from Asian countries (Cowie & Sharpe 1998)Toronto Study- Immigrants account for 92% of TB cases(Applied Research and Analysis Directorate - http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/immigration03.html) Tuberculosis Risk of TB transmission within immigrant communities are considerable(Carballo et al 1998)

  24. Individuals born in countries with a high TB prevalence represent a high risk group (Brancker 1991, Wobeser et al 2000) Determinants of Tuberculosis Predisposing causes:povertysubstandard housingsubstance abusepoor sanitation and malnutritioncontribute to the reactivation of TB in immigrants(Applied Research and Analysis Directorate- http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/immigration03.html, Kent,1993; McSherry & Conner, 1993)

  25. stigmaMajor barriers to TB surveillance and treatment in Canada: lack of awareness / accessibility of available serviceslack of coordination between health care services(Applied Research and Analysis Directorate- http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/immigration03.html) Barriers to Surveillance and Treatment

  26. Human Mobility is associated with the risk of HIV infection.Major barriers to HIV/AIDS surveillance and treatment in Canada: HIV/AIDS Stigma and isolation of HIV-positive individualsSociocultural behavior and language differences within the immigrant communityAwareness of the condition, availability and accessibility of the health care services(Decostas and Adrien 1997,UNESCO/UNAIDS 2000, Calzavara et al 2000: Tharao et al, 2000)

  27. Studies have demonstrated negative psychological effects of migration on mental health. Others have suggested that immigrants have a mental health advantage over their native-born counterparts Controversies Related to Mental Health Suicide rates among 25 immigrant groups in Canada- converged with those of the Canadians (Kliewer and Ward 1988; Kliewer, 1991) For immigrant women, loneliness and depression were a daily feature and high suicide rate among Asian women were indicated (Anderson 1987, Kinnon 1999)

  28. Other Diseases • Certain conditions, including • anemia • dental caries • intestinal parasites • nutritional deficiencies • immunization irregularities appear more commonly in newly arrived refugees from developing countries (Fowler 1998)

  29. What are the impacts of migration on health?

  30. Immigrants go through three distinct resettlement stages: Impacts of Immigration a. initially a period of euphoria b. followed by a period of disillusionment, during which depression is common c. finally, a period of adaptation (Research and Analysis Directorate - http://www.hc-sc.gc.ca/iacb-dgiac/arad- draa/english/rmdd/wpapers/immigration03.html, Thompson 1986, Oberg 1954, Brink 1976, Thompson and MacDonald 1990)

  31. Impacts of Immigration Stresses faced by migrants: • sense of loss • helplessness • alienation • isolation/ segregation • Language difficulties • Multiple responsibilities • Financial and employment stressors • Lack of acceptance by their host communities • Culture conflict • Perceived lack of social support • (Research and Analysis Directorate - http://www.hc-sc.gc.ca/iacb-dgiac/arad- • draa/english/rmdd/wpapers/immigration03.html, MacKinnon)

  32. Impacts of Immigration Stresses faced by migrants (cont): • racism due to color and ethnicity rather than religion • poverty resulting from academic deskilling • under-employment and unemployment • the disruption of social ties • lack of immediate supportive networks (Cameron et al 1996, Brice-Baker 1994)

  33. Impacts of Immigration (Children) • Poor mental health outcomes : associated with • political violence in the country of origin and stress. • Unaccompanied migrant children have higher risks for • behavior and psychosocial problems (Hjern A 1998) • Intrafamilial conflict and disagreement: Children, may acquire • aspects of the new cultural environment more rapidly than adults • who maintain traditional values (Rakoff 1981, Freire 1985,1991, Gushulak1999)

  34. Impacts of Immigration: Women Multiple roles they are required to play within the home and the external society (Meleis, 1991) “Role overload” as one of the defining stressors in the lives of immigrant women (MacKinnon and Howard 2000) Poor pregnancy outcomes of women, due to: • social exclusion • being non-white • (Waterstone M et al 2001)

  35. Conclusion Canada has a long tradition of opening its doors to people from all over the world. As regional, international and global factors including wars and conflicts affect different parts of the world, patterns and profiles of migrants and mobile populations has and will continue to change

  36. Conclusion In summary, raising awareness of health issues related to migrants among • Health care providers • Educational institutions • Social agencies • NGO’s & communities Within the context of historical sociocultural & economical factors geographical backgrounds of the migrants is essential

  37. Conclusion • Appropriate prevention and control of health conditions • related to migrant population can be achieved by: • positive awareness • planning strategies and implementation of educational • interventions and • ongoing outcome evaluations • of health and social services

  38. References Ali,J., (2002). Mental Health of Canada’s Immigrants. (Statistics Canada, Catalogue 82-003-SIE)13,1-11 Anderson, Joan. "Migration and Health: Perspectives on Immigrant Women." Sociology of Health and Illness, 9, 4 (1987): 410-438. Applied Research and Analysis Directorate (ARAD) Working paper Series on Immigration and Health available online at http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/wpapers/immigration03.html Beiser, M., Edwards, R., G.(1994). Mental Health of Immigrants and Refugees. New Directions for Mental Health Services,61, 73-86 Brancker, A. (1991). Tuberculosis in Canada, 1989. Health Reports 3(1): 82-96. Brice-Baker, Janet R. "Domestic Violence in African-American and African-Caribbean Families." Journal of Social Distress and the Homeless, 3, 1 (1994): 23-38. Brink, P.,(Ed). (1976). Transcultural Nursing: A Book of Readings. Englewood Cliffs: Prentice Hall Calzavara, L., Tharao, E., & Myers, T. 2000. HIV/AIDS in East African Communities Living in Toronto: Results of a Feasibility Study, Final Report. Toronto: HIV Social, Behavioral and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto. Cameron, Rebecca P., Jennifer D. Wells & Stevan E. Hobfoll. "Stress, Social Support and Coping in Pregnancy." Journal of Health Psychology, 1, 2 (1996): 195-208.

  39. References Carballo, M., Divino, J.J., & Zeric, D. 1998. Migration and health in the European Union. Tropical Medicine and International Health 3(12): 936-944. Carey E,( Oct 27,1998). Immigrant kids better adjusted, study says, Toronto Star Chen,J., Ng, E., Wilkins, R., (1994-95). The Health of Canada’s Immigrants in 1994-95: Health Reports (Statistics Canada, Catalogue 89F0084XPE), 9-22 Cookson, S, Waldman, R, Gushulak, B., MacPherson, D, Burlke, F., Paquet, S., Kliewer, E., Walker, P. (July-Sept 1998). Special Issue: Immigrant and Refugee Health. Emerging Infectious Diseases, Vol 4 (3):1-3 Cowie, R.L., & Sharpe, J.W. 1998. Tuberculosis among immigrants: Interval from arrival in Canada to diagnosis: A 5-year study in Alberta. Canadian Medical Association Journal 158(5): 599-602. Decostas, J., & Adrien, A. 1997. Migration and HIV. AIDS 11(Suppl A): S77-S84. Dunn, J.R., Dyck, I.(2000). Social determinants of health in Canada’s immigrant population: results from the National Population Health Survey. Social Science and Medicine,51, 1573-93

  40. References Fowler,N., (1998). Providing primary health care to immigrants and refugees: The North Hamilton Experience CMAJ Vol159, 388-91 Friere, M. (1985). Political Repression. Its Impact on the Mental Health of Children: The Latin Experience. Paper Presented at University of Toronto, Wellesley Hospital, Toronto -- (1991). Immigrant and refugee children: Native language as a Factor in the Development of the Self and the Competent Acquisition of a Second Language. Paper Presented at Better Beginnings Better Future: Immigrant and Refugee Children's Mental Health Research Symposium, Toronto Gushulak, B.D. (Editor)(1999) Migration and Health Newsletter, Pediatric Migration Health: Looking to the Future Gushulak,B.D., MacPherson, D.W. (2000). Population Mobility and Infectious Diseases: The Diminishing Impact of Classical Infectious Diseases and New Approaches for the 21 st Century,31:776-80 Gushulak,B.D.(2001). Shifting Paradigms from Quarantine to Migration Health. Population, Health, and Globalization, 6th International Metropolis Conference,Rotterdam, The Netherlands

  41. References Health Canada. (June 1998). Notifiable Diseases Summary. Canadian Communicable Disease Report (CCDR), vol 24-10. Available online. Hjern, A.,Angel, B., Jeppson, O.,(1998). Political violence, family stress and mental health of refugee children in exile, Scand J Soc Med, 26:18-25 Intersecting Inequalities: Immigrant Women of Colour, Violence, & Health Care. Part 1: Race, Gender, Violence & Health Care: A review of the Literature. Available online at: www.harbour.sfu.ca/frieda/articles/hlth03.htm Kent, J.H. 1993. The epidemiology of multidrug-resistant tuberculosis in the United States. Medical Clinics of North America 77(6): 1391-1409. Kinnon, Dianne. Canadian Research on Immigration and Health: An Overview. Ottawa, ON: Health Canada, 1999. Kliewer, E.V., & Ward, D. 1988. Convergence of immigrant suicide rates to those in the destination country. American Journal of Epidemiology 127(3): 640-653. Kliewer, E.V. 1991. Immigrant suicide in Australia, Canada, England and Wales, and the United States. Journal of the Australian Population Association 8(2): 111-128. Lawson,M., Thomas, M. (1999). Vitamin D concentration in Asian children aged 2 years living in England: population survey, BMJ, 318, 28

  42. MacKinnon, Marion with Laura Lee Howard. Affirming Immigrant Women's Health: Building Inclusive Health Policy. Final Report. Halifax, NS: The Maritime Centre of Excellence for Women's Health, May 2000. MacPherson, D.W.,Gushulak, B.D.(2001) Human mobility and population health, Persp in Biol and Med, 44(3):390-401 Majumdar,B., Browne, G., Roberts, J., (1995). The Prevalence of Multicultural Groups Receiving In-Home Service from Three Community Agencies in Southern Ontario: Implications for Cultural Sensitivity Training J P H Vol 86,(3),206-210 Marrocco, F.N.,Goslett, H.M.(eds)(1993). The Immigration Act of Canada. McSherry, G., & Connor, E. 1993. Current epidemiology of tuberculosis. Pediatric Annals 22(10): 600-604. Meleis, Afaf, I. "Between Two Cultures: Identity, Roles and Health," Health Care for Women International, 12 (1991): 365-377. Mortensen, J., Lange, P.,Storm, H.K.,Viskum, K.(1989) Childhood tuberculosis in a developed country, Eur Respir J, 2: 985-98 Noh, S.,Beiser, M., Kaspar, V., et al.(1999) Percieved racial discrimination, depression, and coping: a study of South East Asian Refugees in Canada,40,193-207 Oberg, K., (1954) Culture Shock, Indianapolis: Bobbs-Merris References

  43. Pakulam,G., Krishnan,V., Odynak,D., (1992). Health status of Canadian-born and foreign-born residents, Canadian J Public Health, 83(4), 311-4 Perez, E., (May 2002) Health status and health behavior among immigrants.Statistics Canada, Catalogue 82-003-SIE) Ray, B., (May 2002) Canada: Policy Legacies, New Directions, and Future Challenges. Migration Policy Institute http://www.migrationinformation.org/Profiles/display.cfm?ID=20 Rakoff, V.,(1981).Children Immigrants. In L. Eitinger & D.S.Schawarz (Eds), Strangers In The World,133-45. Vienna: Han Huber Publishers References Tharao, E., Calzavara, L., & Myers, T. 2000. What Service Providers Need to Know to Provide Effective HIV/AIDS Programs and Services for African Immigrants in Canada: Findings from the East African HIV/AIDS Study. Toronto. The Daily (Thursday Sept 19, 2002), Health Status of Canada's Immigrants Thompson, P. (1986) Health Education for Immigrants Women: A manual and Resource Guide. Vancouver: Orientation Adjustment Services for Immigrants Society Thompson, P., & MacDonald, J., (1990). Multicultural health education: responding to the challenge . Health Promotion,28(2),Fall,8-11 UNESCO/UNAIDS 2000. Migrant Populations and HIV/AIDS. The Development and Implementation of Programmes: Theory, Methodology and Practice

  44. Wobeser, W.L., Yuan, L., Naus, M., Corey, P., Edelson, J., Heywood, N., & Holness, D.L. 2000. Expanding the epidemiologic profile: Risk factors for active tuberculosis in people immigrating to Ontario. Canadian Medical Association Journal 163(7): 823-828. References Waterstone, M., Bewley, S., Wolfe, C., (2001). Incidence and predictors of severe obstetric morbidity: case control study, BMJ, 7294: 1089-1093

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