By Denis Daneman, MB, BCh, FRCP(C) and Elizabeth Lee Ford-Jones, MD, FRCP(C)
Canada is a nation of immigrants. Nowhere is this more evident than in Canada’s cities: nearly 4 million people born outside Canada live in Toronto, Montreal, and Vancouver alone. Toronto is one of the most culturally diverse cities in the world. As an experiment in diversity, Canada has been largely successful: peaceful, multicultural, and prosperous. Too often, though, immigrant families and children experience poverty, racism, and poor health.
Canada is selective about which immigrants it accepts. Those who make it through the screening process tend to be healthy, skilled, and highly motivated. Presumably, they are primed to succeed. Yet as a rule, their health declines after they arrive here. The medical literature shows that minorities, including immigrants, often receive poorer health care and social services and have poorer health outcomes. They are less likely to visit a doctor or dentist regularly or to have a usual health care provider. Adult immigrants are more likely to be unemployed or under-employed, even if they have a university degree, and just under half of children in recent immigrant families are living in poverty.
When considering the health of Canadian children, it is important to keep in mind that one in five is either an immigrant or the child of immigrant parents. The health of immigrant children is clearly a priority if we want all children in Canada to reach their full potential.
At the moment, we are not doing enough.
Different experiences, similar needs
Every child has broadly similar needs for healthy development: a loving family, a safe and healthy environment, nutritious food, education, and access to health care. But for immigrant children, these things can be harder to achieve.
Immigrant children may arrive with health problems that went untreated in their native country; they may speak neither English nor French; they may have different beliefs about health and illness and different expectations of the health system. Even the climate may be completely unfamiliar. For refugees, often fleeing hunger, violence, and chaos in their home countries, the challenges are still greater.
After they arrive in Canada, immigrant children may find themselves living in an area with high crime rates, poor public transportation, and few stores that sell familiar, affordable food. Their parents may have to work long hours for low pay, sometimes at more than one job, meaning less time spent together as a family. The family must adjust to a new school system and find health care providers they trust. In all cases, there is an intense period of adjustment in their new country during which less than optimal attention may be paid to routine health issues.
Despite these challenges, many immigrant children adapt and do well. But still, too often, immigrant children’s needs are not adequately met.
As a society, how do we go about developing supports for immigrant families that match up to our high quality of health care?
The label “immigrant” covers a multitude of backgrounds, ethnicities, cultures, and countries. Some immigrants are wealthy, some are not; some have faced long periods of deprivation, while others have had excellent nutrition, health care, and education. Most are here by choice, but some – for instance, refugees – are here because they cannot stay in their country of origin. Improving care must take these factors into account. There will be no one-size-fits-all solution.
Beyond language: Culturally appropriate care
Patients who do not speak English need access to qualified interpreters so that they and their health care providers can understand one another. But language is only the starting point. People from different cultures may also have very different health belief models – beliefs and expectations about health, illness, and treatment. A mismatch between health belief models can lead to misunderstandings or disagreements, inevitably resulting in poor compliance with treatment and follow-up.
This is especially true for chronic illnesses such as diabetes, which must be managed over the long term with both medication and lifestyle changes. To manage diabetes effectively, patients and families need to understand and use a vast quantity of information: how high and low blood sugar levels affect the body; how food, exercise, and insulin affect blood sugar levels; how to give insulin injections; how to measure blood sugar; what different patterns of blood sugar levels mean; what counts as an emergency.
In turn, understanding this information means fitting it in with, or in some cases overturning, a lifetime’s store of existing health beliefs. As a simple example, “Sugary foods are bad” is a health belief that is potentially dangerous to a child with hypoglycemia, but one that is widespread in our culture. Families from different cultures may have other beliefs that have an equally strong impact on treatment, and these need to be recognized and addressed.
In extreme cases, patients and health care providers may each decide the other is “wrong” or “stubborn” about the illness, leading to frustration on both sides – and, more importantly, poor control of the disease. Health care providers need to take the time to explore their patients’ beliefs about illness, discover how they compare to their own, and address any mismatches. At the same time, our society at large and our health care institutions in particular must recognize the need for, and foster, culturally competent care.
Beyond hospital walls: Formal and informal support networks
Social support networks, both formal and informal, are crucial to child and family health. A strong web of social connections does not just mean having a shoulder to cry on; it is a resource when looking for child care, employment, or good places to buy familiar food, and when trying to navigate confusing systems such as schools. Many new immigrants need resources like this to help them adjust to a new country, but they have left most of their existing support network – friends, colleagues, extended family – behind.
In Toronto and other large cities, social service agencies are part of the formal support network. Many serve particular immigrant communities, although not every community has a corresponding agency. By helping with employment, language training, and housing, social service agencies play an important role in helping new immigrants during their transition to a new country. By connecting immigrant families with one another, they may help to foster informal support networks as well.
Social support networks can also affect health more directly. A social service agency or another immigrant family may be the first point of contact for a parent with a sick child. If the family of a child with a chronic health care problem does not trust their health care team, a religious or community leader may serve as an important advocate and mediator.
Employment for new immigrants
Immigrants are more likely to have a university education than people born in Canada, and many immigrants have advanced degrees or professional credentials. Unfortunately, immigrants often do not find employment equal to their talents and energies after they arrive in Canada. This in turn means they are less likely to have jobs with health benefits and sick leave, and more likely to lose a day’s pay if they take time off work to care for a sick child. They also have fewer opportunities for on-the-job education and advancement. In 2007, the unemployment rate among immigrants aged 25 to 49 was 6.6%, compared to 4.6% for the Canadian-born.
A smile and a pat on the back are clearly not sufficient to welcome immigrants to their new home. Canada needs to keep working to identify and break down the barriers immigrants face when trying to find employment. This includes recognizing foreign credentials, helping foreign-trained professionals to upgrade their skills and use their training in Canada, and encouraging employers to hire skilled immigrants. Individual immigrants are not the only people who will benefit; their employers will also benefit from more diversity, as will their customers, clients, and patients.
The challenges are not limited to immigrant children
Immigrant children face health challenges, but they are not the only ones. We cannot forget about other disadvantaged groups, including aboriginal children, children living in poverty, children with chronic disorders or disabilities, and children of parents with drug addictions or serious mental health disorders.
Without support, these children will fail to reach their full potential. They are less likely to succeed in school and more likely to live in poverty. Rather than trying to solve these problems in 20 years, we need to prevent them now. Canada needs a national poverty reduction strategy, better support and funding for early childhood education and care, more opportunities in disadvantaged neighbourhoods. When children fail, we are all the poorer for it.
We must continue to be sensitive, as a society, as institutions, and as individuals, to the needs of disadvantaged children. We must also continue to work with under-represented communities to address their needs. Any solutions we find will result from this partnership.
Denis Daneman, MB, BCh, FRCP(C) is Paediatrician-in-Chief of The Hospital for Sick Children (SickKids), Chair of the Department of Paediatrics at the University of Toronto, and the RS McLaughlin Foundation Chair in Paediatrics. He is a specialist in paediatric endocrinology, with research interests that include diabetes mellitus, insulin resistance, eating disorders, and health care delivery.
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Elizabeth Lee Ford-Jones, MD, FRCP(C) is an infectious diseases specialist and clinical researcher at The Hospital for Sick Children and Professor of Paediatrics at the University of Toronto. She is co-editor of Paediatrics and Child Health, the journal of the Canadian Paediatric Society. She was also involved with the initiation of the Canadian Paediatric Society's book, Children and Youth New to Canada.