Newcomers to Canada are an extremely diverse group. Their migration stories (why and how they’ve come to Canada) are just one of many factors influencing health, while other social determinants, such as education, income, housing and food security each play a role. The social determinants of health are grouped into 5 categories; economic stability, educatin access and quality, health care access and quality, neighborhood and built environment, and social and community context. Show Consider two different scenarios:
Even if the migration experience appears to be relatively smooth, as for the family from Eastern Europe, there are almost always difficulties associated with migration, including loss of status, unfamiliar social systems, and distance from friends and family. Children are often acutely aware of their parents’ sacrifices and may feel guilty. The Burmese family‘s experience will likely have a profound effect on both their health and the speed with which they adapt. The children’s education was interrupted, their father is dead, and their mother was disadvantaged in her first language. These children are likely to remain poor while growing up. In the absence of their father, the eldest son may assume the roles of protector, head of the household and, later, provider. Consequently his education may be sacrificed. Many people who reach a Canadian border and then claim , embark on a protracted application process. If their applications are refused, the consequences of returning to their home country may be frightening to the extent that they remain in Canada without status or health care insurance. An unsuccessful refugee claim and undocumented migration are tangled threads in an already complex migration story: they often lead to housing insecurity, low income, fear of discovery, the threat of deportation, limited access to health care and eventually, poverty. Health care professionals can improve patient treatment and better meet the needs of newcomers by being aware of their migration story and of how each story may affect their current status in Canada, their state of health or recovery, and their ability to navigate the health care system. How healthy are newcomers to Canada?Some studies show that newly arrived immigrants to Canada have better self-reported health and lower use of health care services than native-born Canadians.1,2 This so-called “healthy immigrant effect” is controversial, however, and is known to vary among specific groups. The vast majority of newcomers to Canada choose to come here, have successfully negotiated the immigration process, and have passed the required medical exams. It’s not surprising that they seem healthy, are able to access care as needed, and adapt quickly. The trouble is, not all immigrants fit this profile. Although refugees, as a group, face greater challenges than other newcomers, they also demonstrate the healthy immigrant effect. However, while it is possible that there are real differences in health status, refugees may also be more reluctant to disclose personal information and to avoid health care services because of language difficulties, lack of insurance, or for cultural reasons (e.g., perceptions of health, health care and disease, family dynamics or social norms). More information about barriers to access of health care for newcomers is available on this site. The healthy immigrant effect declines with years lived in Canada. Non-European female immigrants experience the greatest deterioration in self-reported health after arrival in Canada, and European males the least. Causes of this decline are thought to be related to factors such as changes in diet, activity levels, use of tobacco or alcohol, and changing socioeconomic status.3-7 It is also possible that newcomers are more likely to report symptoms and to access care in the later stages of adaptation, that is, after they have been in Canada for awhile. Even though many newcomers appear healthier than the average Canadian when they first arrive, some may have been exposed to diseases that are rare in Canada but common in their home country.8 Detailed information on some of these diseases, and screening for them, can be found elsewhere on this site, and in recent, Canadian evidence-based clinical guidelines for immigrants and refugees from the Canadian Collaboration for Immigrant and Refugee Health. Adaptation, acculturation and racial-ethnic identityAdaptation is the process of change in response to a new environment. It is one component of acculturation, which relates to the change in a group’s culture or the change in individual psychology in response to a new environment or other factors. Racial-ethnic identity development involves identifying with and relating to a specific group, and is found to be associated with particular health behaviours and mental health outcomes.9 The idea of culture adjustment as a process was described in 1955 by Norwegian sociologist Sverre Lysgaard, who proposed a U-curve model with four stages: honeymoon, culture shock, recovery and adjustment.10 The processes of adaptation and racial-ethnic identity development are complex and non-linear. They are complex because they are difficult to measure and extremely variable. They are non-linear because navigating through these steps includes both forward and backward movement, depending on what additional stressors are in the family’s life and how those stressors influence identification with a peer group. Past models of adaptation that have influenced policy and practice were linear, with immigrants being considered as more (or less) ‘acculturated’ or ‘assimilated’. These models are no longer accepted. It is challenging to describe any process that is complex and non-linear. How do people who have developed fully in one cultural setting experience and adapt to change when living in a completely different context? Here is one description:11 If culture is such a powerful shaper of behaviour, do individuals continue to act in the new setting as they did in the previous one, do they change their behavioural repertoire to be more appropriate in the new setting, or is there some complex pattern of continuity and change in how people go about their lives in the new society? The answer provided by cross-cultural psychology is very clearly supportive of the last of these three alternatives. Figure 1 shows the different responses to acculturation, where the value of maintaining an ‘old’ culture is balanced with exposure and adaptation to the ‘new’.11 The ‘choice’ of one response over another can change, depending on shifting of stressors. One model suggests four types of acculturation:
Compared with other acculturation styles, integration is associated with:
Newcomers’ ability to shift their cultural identity and engage with people outside of their ethnic group helps determine how successfully they integrate into their new homeland. Children’s self-esteem and social competence have been shown to be influenced by both parental and the child’s own acculturation styles.15 Stages of resettlementResettlement is considered to be a type of adaptation that can be divided into three or more personal stages, based on the literature on adaptation.16 Citizenship and Immigration Canada describes a commonly used four-step evolution. Knowing these stages can help health professionals to ‘locate’ newcomers in the adaptation process and, as a result, to better help with transitions from one stage to the next. The newcomer experience often follows this trajectory: Stage 1: Happiness and fascination
Stage 2: Disappointment, confusion, frustration and irritation
Whenever possible, encourage newcomers to integrate by maintaining their culture of origin while actively participating in Canadian society. Stage 3: Gradual adjustment or recovery
Stage 4: Acceptance and adjustment
Adapting to challenges in CanadaNewcomers must continually adapt to many factors to which native-born Canadians may be oblivious. Often these factors are also social determinants of health.
Comprehending health, disease and treatmentHow newcomers understand health issues can affect their ability to adapt and acculturate to Canada. Consider these scenarios:
Such scenarios are challenging for health professionals. You may need to meet with a family several times and try before progress is made or trust levels are high enough for effective messaging. Read more about cultural context and newcomer family perspectives on health. Some examples of specific cultural beliefs are given below. Remember that perceptions of health and disease can vary widely within cultures, so be careful not to overgeneralize:
These different understandings can affect the health of patients in terms of whether they accept a diagnosis, how they behave, and to what extent they comply with treatment suggestions. Encourage newcomer families to ask questions about the health system: how it can help them, and how to navigate it. Some patients may feel dissatisfied if you don’t prescribe medication, or they may seek alternative, unproven treatments that can have a potentially negative impact on their health. More information can be found in the on this page. Read more about strategies to deliver culturally competent care, how culture influences health and effective use of interpreters, elsewhere on this site. ResilienceResilience helps newcomers to cope and do well in Canada despite the difficulties they face while immigrating. Resilience can be a personality trait and also fostered by the migration experience. Imagine the personal resilience that a child needs to become the head of a family at 14 years of age; or to sacrifice an education because rebels have set fire to the only school; or to adjust to a father’s news that it is time to marry. Three types of factors promote resilience in children (see ):
Protective factors can work together to help newcomer children and youth establish and maintain a positive self-image, mitigate risk factors, and interrupt negative chain reactions. The resilient individual is more open to new experiences and opportunities, which in turn reinforce resilience. “Cultural connectedness” has been shown to be an important protective factor for youth.23 The health care provider’s role in identifying and maximizing such protective factors can help foster resilience in newcomer children and families and assist the adaptation process.24 Table 1: Factors that promote resilienceAbilities and skills Network factors Meaning, values and faith
Selected resources
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