'I thought we would be cherished and safe here': understanding the multi-faceted nature of mental health among Arab immigrants/refugees in Ontario, Canada- the CAN-HEAL study.

PURPOSE: Mental health (MH) is a critical public health issue. Arab immigrants/refugees (AIR) may be at high risk for MH problems owing to various unique stressors, such as post-September/11 demonization. Despite the growing AIR population in Western countries, there is a lack of AIR-MH research in these nations. The CAN-HEAL study examined MH experiences and needs among AIR in Ontario, Canada. METHODS: This study employed a cooperative community-based participatory research and integrated knowledge translation approach. The study used photovoice, qualitative interviews and a questionnaire survey. Sixty socio-demographically diverse AIR adults partook in this study. The research was informed by the "social determinants of health" framework and the "years since immigration effect" (YSIE) theory. RESULTS: The term "mental health" was deemed offensive for participants aged > 30 years. Participants proposed other culturally-appropriate words including "well-being" and "emotional state". The prevalence of poor mental well-being in the sample was alarming (55%). Of first-generation immigrant participants, 86.8% reported negative changes in MH since migration. The negative changes are not straightforward; they are complex and dynamic, and mainly related to micro/macro-aggression, cross-cultural pressures, dissatisfaction with the health and social care system, and poor living conditions. Intersections between different socio-demographic factors (e.g., gender, length of residency, income, parenthood, religion) amplified the negative changes in MH and exacerbated inequities. CONCLUSIONS: MH needs among AIR are distinct and intersectionality aggravated inequities. Culturally and structurally competent healthcare and structural/policy reformation are required to tackle MH inequities. This can be fulfilled through intersectoral cooperation and including AIR in decision-making.

'I thought we would be nourished here': The complexity of nutrition/food and its relationship to mental health among Arab immigrants/refugees in Canada: The CAN-HEAL study.

Nutritional psychiatry suggests that diet quality impacts one's mental health (MH). The relationship between food/nutrition and MH may be particularly salient for immigrants/refugees who often experience high risk for household food insecurity and MH challenges. An innovative collaborative community-based participatory research and integrated knowledge translation approach was adopted to explore food/nutrition needs as they relate to MH among Arab immigrants/refuges (AIR) in Ontario, Canada. The goal was to co-identify areas that require social change and co-produce applicable knowledge for service improvement. The CAN-HEAL study used a multi-methodological approach, employing qualitative interviews, photovoice and a questionnaire survey. A combination of three sampling approaches (convenience, snowball and purposive) was used to recruit sixty socio-demographically-diverse adult AIR participants. The research was guided by an integrated bio-psycho-socio-cultural framework. Participants reported various socio-economic and structural barriers to nutritious eating. Food quality/safety was a significant concern and source of anxiety among AIR; food mislabeling, the widespread presence of genetically/chemically modified foods and expired/rotten food products were associated with negative MH. Participants experienced an alarming prevalence of food insecurity (65%), which was associated with negative MH. Intersections among age, gender, religion, socio-economic status, parenthood, disability, and place of residence played a considerable role in how nutrition, food security, and dietary intake impacted AIR's MH and caused substantial disparities within the AIR community. The food/nutrition-MH relationship among AIR is multi-faceted, and various psycho-socio-cultural pathways/processes were found to shape MH. Intersectoral collaboration between health and non-health sectors is needed to implement a co-proposed socio-political and community-level action plan to achieve nutrition and health equity for AIR and other similar marginalized groups.

Enhancing Physical and Community MoBility in OLDEr Adults with Health Inequities Using CommuNity Co-Design (EMBOLDEN): Results of an Environmental Scan.

Background: Using the comparatively new environmental scan methodology, a protocol was developed and conducted to inform the co-design and implementation of a novel intervention to promote mobility among older adults in Hamilton, Ontario, Canada. The EMBOLDEN program seeks to promote physical and community mobility in adults 55 years and older who face barriers accessing community programs and who reside in areas of high inequity in Hamilton, and to address the following areas of focus: physical activity, nutrition, social participation, and system navigation supports. Methods: The environmental scan protocol was developed using existing models and drew insights from census data, a review of existing services, organizational representative interviews, windshield surveys of selected high-priority neighbourhoods, and Geographic Information System (GIS) mapping. Results: A total of 98 programs for older adults from 50 different organizations were identified, with the majority (92) supporting mobility, physical activity, nutrition, social participation, and system navigation. The analysis of census tract data identified eight high-priority neighbourhoods characterized by large shares of older adults, high material deprivation, low income, and high proportion of immigrants. These populations can be hard to reach and face multiple barriers to participation in community-based activities. The scan also revealed the nature and types of services geared toward older adults in each neighbourhood, with each priority neighbourhood having at least one school and park. Most areas had a range of services and supports (i.e., health care, housing, stores, religious options), although there was a lack of diverse ethnic community centres and income-diverse activities specific to older adults in most neighbourhoods. Neighbourhoods also differed in the geographic distribution number of services, along with the number of recreational services specific to older adults. Barriers included financial and physical accessibility, lack of ethnically diverse community centres, and food deserts. Conclusions: Scan results will inform the co-design and implementation of the Enhancing physical and community MoBility in OLDEr adults with health inequities using commuNity co-design intervention-EMBOLDEN.

Understanding the Healthy Immigrant Effect in the Context of Mental Health Challenges: A Systematic Critical Review.

The "Healthy Immigrant Effect" (HIE) suggests that immigrants have a health advantage over the domestic-born which vanishes with increased length of residency. Most HIE research focuses on physical health, with less attention given to mental health (MH). This systematic review of 58 MH studies examines whether there is a MH advantage among immigrants and explores changes in immigrants' MH, besides critically assessing the use of HIE theory. Inconsistent evidence was detected regarding the presence of MH advantage, whereas consistent, convincing evidence was revealed for a decline in immigrants' MH over years. Although the HIE theory can help reveal MH disparities, this theory alone does not explain the reasons for these disparities nor inform about potential avenues to improve immigrants' MH. A paradigm shift is needed to incorporate other potential theoretical concepts/frameworks, including the "Health Inequalities Action" framework, for a broader understanding of MH issues and to inform effective, culturally-sensitive interventions.

Low prioritization of latent tuberculosis infection-A systemic barrier to tuberculosis control: A qualitative study in Ontario, Canada.

BACKGROUND: Eliminating tuberculosis (TB) in low-incidence countries is an important global health priority, and Canada has committed to achieve this goal. The elimination of TB in low-incidence countries requires effective management and treatment of latent tuberculosis infection (LTBI). This study aimed to understand and describe the system-level barriers to LTBI treatment for immigrant populations in the Greater Toronto and Hamilton Area, Ontario, Canada. METHODS: A qualitative study that used purposive sampling to recruit and interview health system advisors and planners (n = 10), providers (n = 13), and clients of LTBI health services (n = 9). Data were recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Low prioritization of LTBI was an overarching theme that impacted four dimensions of LTBI care: management, service delivery, health literacy, and health care access. These factors explained, in part, inequities in the system that were linked to variations in health care quality and health care access. While some planners and providers at the local level were attempting to prioritize LTBI care, there was no clear pathway for information sharing. CONCLUSIONS: This multiperspective study identified barriers beyond the typical socioeconomic determinants and highlighted important upstream factors that hinder treatment initiation and adherence. Addressing these factors is critical if Canada is to meet the WHO's global call to eradicate TB in all low incidence settings.

Comparing disability amongst immigrants and native-born in Canada.

Given high levels of immigration into Canada and the associated requirement to understand the health needs of new arrivals, an extensive literature has developed over the past decade that has explored immigrant health issues, including the 'healthy immigrant effect'. Surprisingly, however, issues of disability within the immigrant population have received much less attention. Using data from Statistics Canada, 2006a, 2006b Participation and Activity Limitation Survey (PALS), this paper examines disability and its covariates amongst immigrants relative to non-immigrants in Canada. Compared with their native-born counterparts, recent immigrant arrivals (within the past 10 years) were less likely to report disability and less likely to report a severe disability than the native-born. However, differences in the rates and covariates of disabilities between males and female immigrants were observed, which are partially explained by socioeconomic and sociodemographic effects. The conclusion explores potential reasons why differentials in disability rates are observed, and points to future research directions.

Exploring socio-cultural factors that mediate, facilitate, & constrain the health and empowerment of refugee youth.

Studies on youth health and well-being are predominantly quantitative and expert-driven with less attention given to how youth understand what it means to be healthy themselves and the role of socio-cultural factors in shaping this. Knowledge on the perceptions and experiences of refugee youth is particularly lacking and notable given their unique stressors related to migratory, settlement and integration experiences. We contribute a better understanding of how refugee youth themselves define and contextualize health, with particular emphasis given to socio-cultural factors that enable or constrain health promotion efforts and individual health agency. This research was undertaken at a downtown drop-in centre in Hamilton, Ontario, Canada that provided settlement and integration services to newcomer youth. We employ a grounded theory approach and draw upon participant observation, focus groups and in-depth interviews. Twenty-six youth (age 18-25 years), representing 12 different countries of origin participated. The youth defined health very broadly touching upon many typical determinants of health (e.g. education, income, etc.). Yet factors of most importance (as demonstrated by the frequency and urgency in which they were discussed by youth) included a sense of belonging, positive self-identity, emotional well-being, and sense of agency or self-determination. We conceptualize these as "mediating" factors given the youth argued they enabled or constrained their ability to cope with adversities related to other health determinant categories. The youth also discussed what we interpret as "facilitators" that encourage mediating factors to manifest positively (e.g. informal, non-biomedical settings and programs that nurture trust, break down access barriers, and promote a sense of community amongst peers, mentors, and health professionals). When creating health promotion strategies for refugee youth (and perhaps youth more generally) it is important to understand the factors that may mediate the magnitude of effects from various risks/stressors, in addition to those which facilitate health agency.

Brokering for the primary healthcare needs of recent immigrant families in Atlantic, Canada.

AIM: This case study describes how broker organizations supported a network of community-based services to work together to address the primary healthcare needs of recent immigrant families with young children. BACKGROUND: In parts of Canada with low levels of immigration compared with large urban centres, service providers may need to collaborate more closely with one another so that cultural competencies and resources are shared. Providers within Atlantic Canada, with its relatively small immigrant population, were faced with such a challenge. METHODS: Social network analysis and qualitative inquiry were the methods used within this case study. Twenty-seven organizations and four proxy organizations representing other organization types were identified as part of the network serving a geographically bounded neighbourhood within a mid-sized urban centre in Atlantic Canada in 2009. Twenty-one of the 27 organizations participated in the network survey and 14 key informants from the service community were interviewed. Findings Broker organizations were identified as pivotal for ensuring connections among network members, for supporting immigrant family access to services through their involvement with multiple providers, and for developing cultural competence capacities in the system overall. Network cohesiveness differed depending on the type of need being addressed, as did the organizations playing the role of broker. Service providers were able to extend their reach through the co-location of services in local centres and schools attended by immigrant families and their children. The study demonstrates the value of ties across service sectors facilitated by broker organizations to ensure the delivery of comprehensive services to young immigrant families challenged by an unfamiliar system of care.

Disaggregating Canadian immigrant smoking behaviour by country of birth.

As of the 2006 census, nearly one fifth of Canada's population was foreign-born. With such a sizeable and fast-growing immigrant population, research in immigrant health in Canada is increasingly important, including research on the smoking behaviours of Canada's immigrants. Research has shown that immigrants are significantly less likely to smoke than non-immigrants, yet differences by immigrant origins have yet to be fully explored. This paper explores smoking prevalence and cessation amongst immigrants in Canada disaggregated by country of birth. Additionally, it examines the impact of neighbourhood level effects on smoking cessation to determine if residential location has an impact on the likelihood of quitting. Results reveal important heterogeneities previously unseen in studies employing aggregate data. While immigrants in general were less likely to smoke than non-immigrants, and are also more likely to quit than non-immigrants, considerable variation exists between immigrant groups defined by origin region or country. Asian immigrants were the least likely to smoke but exhibited the greatest variation between countries of origin. Vietnamese men were found to be the most likely immigrant group to smoke and among the least likely to quit. While neighbourhood disadvantage was negatively associated with quitting smoking, it is not as important as individual socioeconomic characteristics in explaining variations in smoking cessation. The research illustrates the need for disaggregated data to account for the diversity of Canada's immigrant population.

Individual and contextual determinants of blood donation frequency with a focus on clinic accessibility: a case study of Toronto, Canada.

The balance between supply and demand of blood products is a question of great interest for the long-term prospects of health care systems. Trends that affect this balance include an aging population and increasingly large immigrant communities with lower donation rates. Blood agencies must implement several strategies to ensure a sustained supply of blood products. A better understanding of the determinants of donation frequency is essential to develop strategies that encourage new and existing donors to donate more frequently. In this study, we investigate the individual and contextual determinants of the decision to donate multiple times, with a particular focus on accessibility to clinics. The case study is the Toronto Census Metropolitan Area. Analysis is based on discrete choice models estimated using the attributes of the geocoded donors and clinics, and Census data for contextual variables. The results indicate that higher levels of accessibility increase the probability of donor return and more frequent donations.

Forecasting Ontario's blood supply and demand.

BACKGROUND: Given an aging population that requires increased medical care, an increasing number of deferrals from the donor pool, and a growing immigrant population that typically has lower donation rates, the purpose of this article is to forecast Ontario's blood supply and demand. STUDY DESIGN AND METHODS: We calculate age- and sex-specific donation and demand rates for blood supply based on 2008 data and project demand between 2008 and 2036 based on these rates and using population data from the Ontario Ministry of Finance. RESULTS: Results indicate that blood demand will outpace supply as early as 2012. For instance, while the total number of donations made by older cohorts is expected to increase in the coming years, the number of red blood cell (RBC) transfusions in the 70+ age group is forecasted grow from approximately 53% of all RBC transfusions in 2008 (209,515) in 2008 to 68% (546,996) by 2036. A series of alternate scenarios, including projections based on a 2% increase in supply per year and increased use of apheresis technology, delays supply shortfalls, but does not eliminate them without active management and/or multiple methods to increase supply and decrease demand. CONCLUSIONS: Predictions show that demand for blood products will outpace supply in the near future given current age- and sex-specific supply and demand rates. However, we note that the careful management of the blood supply by Canadian Blood Services, along with new medical techniques and the recruitment of new donors to the system, will remove future concerns.

Defining socially-based spatial boundaries in the region of Peel, Ontario, Canada.

BACKGROUND: The purpose of the project was to delineate a series of contiguous neighbourhood-based "Data Zones" within the Region of Peel (Ontario) for the purpose of health data analysis and dissemination. Zones were to be built on Census Tracts (N = 205) and obey a series of requirements defined by the Region of Peel. This paper explores a method that combines statistical analysis with ground-truthing, consultation, and the use of a decision tree. DATA: Census Tract data for Peel were derived from the 2006 Canadian Census Master file. METHODS: Following correlation analysis to reduce the data set, Principal Component Analysis was applied to the data set to reduce the complexity and derive an index. The Getis-Ord Gi*statistic was then applied to look for statistically significant clusters of like Census Tracts. A detailed decision tree for the amalgamation of remaining zones and ground-truthing with Peel staff verified the resulting zones. RESULTS: A total of 15 Data Zones that are similar with respect to socioeconomic and sociodemographic attributes and that met criteria defined by Peel were derived for the region. CONCLUSION: The approach used in this analysis, which was bolstered by a series of checks and balances throughout the process, gives statistical validity to the defined zones and resulted in a robust series of Data Zones for use by Peel Public Health. We conclude by offering insight into alternative uses of the methodology, and limitations.

Health care providers' perspectives on the provision of prenatal care to immigrants.

In addition to facing barriers to health care and experiencing poor health status, immigrants to Canada and Sweden tend to have more negative birth outcomes than the native-born population, including low birth weight and perinatal mortality rates. Explored through interviews with health care professionals, including midwives, nurse practitioners, social workers and obstetrician gynaecologists, this paper evaluates their experiences in providing prenatal care to immigrants in Hamilton, Ontario, Canada. Results reveal the complexity of delivering care to immigrants, particularly with respect to expectations surrounding language, culture and type and professionalism of care. The paper concludes by discussing future research options and implications for the delivery of prenatal care to this population.

Geographical variations in the correlates of blood donor turnout rates: an investigation of Canadian metropolitan areas.

BACKGROUND: Like other countries, Canada's population is aging, and the implications of this demographic change need to be better understood from the perspective of blood supply. Analysis of donor data will help to identify systematic patterns of donation and its correlates. DATA: Geo-coded blood donor and donor clinic data are provided by Canadian Blood Services. Blood donor data is provided for the fiscal year 2006-2007 indicating the total number of donors for each Canadian postal code, excluding the province of Québec. Potential correlates of blood donation are selected based on social and economic characteristics, as well as descriptors of city size and geographical location in the urban hierarchy measures of accessibility, and capacity of donor clinics. METHODS: Data is aggregated to n = 3,746 census tracts in 40 Census Metropolitan Areas (CMA) across the country. The number of donors per population in a census tract is regressed against the set of potential donation correlates. Autocorrelation is tested for and results adjusted to provide parsimonious models. RESULTS: A number of factors are found to influence donation across the country, including the proportion of younger residents, English ability, proportion of people with immigrant status, higher education, and a population-based measure of accessibility. CONCLUSION: While a number of correlates of blood donation are observed across Canada, important contextual effects across metropolitan areas are highlighted. The paper concludes by looking at policy options that are aimed toward further understanding donor behaviour.

Health care use and the Canadian immigrant population.

Set within the "determinants of health" framework and drawing on Statistics Canada's longitudinal National Population Health Survey, this article explores health care utilization by Canada's immigrant population. Given the observed "healthy immigrant effect", whereby the health status of immigrants at the time of arrival is high but subsequently declines and converges toward that of the native-born population, does the incidence of use of health care facilities reflect greater need for care? Similarly, does the use of health care facilities by the native- and the foreign-born differ, and if so, are these differences explained primarily by socioeconomic, sociodemographic, or lifestyle factors, which may point to problems in the Canadian health care system? This study identifies trends in the incidence of physician and hospital use, the factors that contribute to health care use, and differences in health care use between the native- and foreign-born.

Health status of older immigrants to Canada.

Using the 2000/2001 Canadian Community Health Survey (CCHS), this paper examines the health status of the older (aged immigrant population relative to that of non-immigrants in order to identify areas where their health statuses diverge. First, we compare the health status of older immigrants (foreign-born) aged 55 and over in Canada to the Canadian-born in terms of age and gender using multiple measures of health status including self-assessed health. Second, we identify the factors associated with health status using the determinants of health framework. In both cases, the key questions are whether differences in health status exist and whether they are explained primarily by socio-economic, socio-demographic, or lifestyle factors that may point to problems with the Canadian health care system. Findings indicate that there is a relative comparability in the health status of older immigrants, even after controlling for age.

Use of dental services by immigrant Canadians.

Although the health status and health behaviour of foreign-born residents of Canada have been well documented, little is known about their use of dental services. The authors, hypothesizing that foreign-born people would have lower utilization of dental care services than native-born Canadians, undertook this study to identify the factors associated with dental visits by Canadians aged 12 years and older and to compare the use of dental services by foreign-born and native-born populations. According to data derived from Statistics Canada"s 1996-97 National Population Health Survey, foreign-born people were somewhat more likely than native-born Canadians to have visited a dentist within the previous year. Higher levels of education, greater income adequacy, and the presence of dental insurance were associated with greater use of dental services, whereas increasing age was associated with lower use. Although immigrants reported greater use of dental services than native-born Canadians, a variety of barriers to care may be present in this population.

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

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.

Health status and Canada's immigrant population.

Given the framework of the 1984 Canada Health Act, the health status of immigrants should be similar to average levels within whole of Canada. Yet, assuming equality of health status between immigrant and non-immigrants, or between immigrant groups is likely an unrealistic and simplistic assumption, given unseen barriers affecting accessibility, the restructuring of the Canadian health care system, and problems with the provision of health care resources to the immigrant population. Using the National Population Health Survey, this paper focuses upon the health status of the immigrant population relative to that of non-immigrants within Canada, with reference to diagnosed conditions, self-assessed health, and the Health Utilities Index Mark 3. Findings indicate that, with the exception of the most recent arrivals, immigrants experience worse health status across most dimensions relative to non-immigrants. Multivariate analysis reveals that age, income adequacy, gender, and home ownership are dimensions upon which health status differs between the two groups.