Every year more than 50,000 children arrive in Canada in search of a better life. Angus Warner of The Hospital for Sick Children's Community Health Systems Resource Group (CHSRG), calls these families' trips "the five-hour journey."
"Imagine that you're getting on a plane in Barbados, and five hours later you step off the plane in Toronto. In those five hours you've left all your friends behind you. The food is strange. You've gone from the top of the class to the bottom. The teacher doesn't understand your accent. You don't know your way around. Your family was comfortably off; now you're poor. In just five hours, your life has completely changed."
Warner is one of many people who are working to understand and improve the health of immigrant children. It's a large and nebulous field; along with the usual health issues every child encounters, immigrant children and their families must contend with culture shock, a new climate, language barriers, unfamiliar food, a new education system, parental underemployment, and downward social mobility.
Subtler but equally challenging issues - identity, belonging, parents and children adapting to the new culture at different speeds- surface later on. Because there has been comparatively little research into immigrant children's health in Canada, health care experts are only just starting to understand how these factors affect children's health over time.
"Not a lot is known," says Dr. Anneke Rummens, a research scientist with CHSRG and a co-principal investigator of the New Canadian Children and Youth Study (NCCYS). "What is the health status of immigrant children? What are the challenges to their health? What unique risk and protective factors are at play?"
A lot to learn
The NCCYS represents one attempt to learn what needs to be known about immigrant and refugee children's experiences, challenges, and opportunities. It is a national longitudinal survey of 4500 immigrant and refugee children from 16 different ethno-cultural communities living in six Canadian cities. The study aims to determine the health status of new Canadian children and to identify key risk and protective factors that affect their health and well-being. Research studies like this will provide much needed insight into how immigrant children adapt to their new lives, and in turn help governments and settlement agencies craft better policies and practices through which to support them in reaching their full developmental potential.
Even the term "immigrant children" itself is less straightforward than it first seems. Immigrant and refugee children are not a homogeneous group; in fact, it would be hard to find a more diverse group. As a result, each child's health and well-being will be influenced by a complex web of internal and external factors, including migration status, culture and ethnicity, age at arrival, prior health experiences, parent and family characteristics, the presence or absence of extended family and other informal support networks, and barriers to accessing health and social services.
Despite all the gaps in our knowledge, here are some of the things we do know:
Immigrant children are a diverse population
Children come to a new country for many reasons, from many different cultural and linguistic backgrounds under many different circumstances. They may be rich or poor, from a developed or a developing country, from Europe or Asia or Africa or Central and South America, and may or may or may not speak one of Canada's official languages. They may be "regular" immigrants, refugees, illegal immigrants, children staying in the country temporarily, or children adopted by Canadian parents from overseas. They may arrive with their parents, or they may face a long period of separation while their parents first try to get settled in a new country. And while children born in Canada to newly arrived parents aren't technically immigrants themselves, their family's living situation is such that they often face many of the same resettlement, acculturation, and integration challenges as their newcomer peers.
Children's health depends on the health and well-being of the whole family
Children do not exist in isolation. "Adults affect families and families affect kids," Rummens says. What is happening to parents powerfully affects the living environment of children raised in that family. Children depend on their parents for shelter, food, care, and emotional support; if a child's parents are having difficulty adjusting to a new country or finding work, their children cannot help but be affected in some way. For example, many immigrant parents work two jobs to make ends meet, meaning they are often out of the home. In turn, children may have to assume adult roles and responsibilities, such as cooking and taking care of siblings, earlier than they would otherwise. Equally, children's access to health services, social services, and informal support networks depends mostly on their parents' knowledge of the Canadian system and ability to access these resources.
Immigrant children have poor access to the health system
Getting access to the health care system is the first hurdle many immigrant families must face. In many provinces in Canada, new immigrants must wait for three months before they are eligible for provincial health coverage - three months during which health problems may go unaddressed.
Even after they get coverage, families often have difficulty navigating the health system and immigrant children may continue to have less access to preventive health care, such as well-child care and immunization. Similarly, mothers who give birth shortly after arriving in Canada may have difficulty accessing prenatal care, or may not even be aware that it is available to them.
A significant change in economic well-being often compounds these issues. It is very common for immigrant families to encounter a drop in their standard of living after coming to a new country, sometimes for years, although "this is often seen and experienced as a temporary condition on the way to a better life," says Rummens.
Newcomers without legal status are even less likely to have adequate health care, as they fear that approaching any part of the system will lead to exposure or deportation.
Immigrant health challenges change over time
Some health problems may be apparent when children first arrive in Canada. Others may arise after the child has been in Canada for some time.
In the short term, refugee children and their families may be recovering from physical deprivation, untreated disease, or mental or emotional trauma, especially if they come from a refugee camp or an area of natural disaster. They may need to catch up on preventive health care, including immunizations, dental care, and eye tests; even adults from some regions of the world are often missing crucial immunizations such as measles, mumps, and rubella. There may be great variation in terms of needs.
Most families can overcome these difficulties. Young children, in particular, often appear to adapt quite easily to a new country. However, researchers are recognizing that other challenges can emerge over time. Ironically, successful integration itself can be a source of family stress when children lose their mother tongue in the process of learning a new language, or when they adopt new values, attitudes, and behaviours that conflict with those of their parents.
While adult immigrants tend to be healthier on average upon arrival than people born in Canada, their health often deteriorates over time - a paradox known as the "healthy immigrant effect." The selection system tends to favour healthy immigrants, but it's less clear why some lose that advantage over time. It is also not yet known if the same effect holds for newcomer children as well. As with so many questions in immigrant children's health, more research is needed.
Cultural differences are important
Other important factors that may affect the health care of immigrant and refugee children are language and cultural differences. A patient and a health care provider who speak different languages have an obvious communication problem. But other cultural differences can cause even more serious communication problems, and are often much less visible. Different cultures have different 'health belief models' about what causes illness, how to treat an illness, how the illness will progress, when and where to seek care, and what to expect from the health care system. If the health beliefs of patients and providers do not match, the patient may lose confidence in the provider, and the provider may become frustrated with the patient's non-compliance with treatment. Providers need to take the time to learn what their patients are thinking, and work with those beliefs instead of assuming shared understanding and meaning.
"You can't make assumptions," Rummens says. "There's a danger in 'one size fits all' and 'recipe' approaches and treatments."
Similar issues appear in the education system. At a Toronto District School Board parent conference, reported by the Toronto Star, Ryerson University professor Mehrunnisa Ali observed that teachers and recent immigrants "don't really understand each others' backgrounds. They are brought up in different cultures, they don't necessarily know how to talk to each other, and they don't know what's expected of their children and of each other." These gaps in understanding mean that immigrant children often don't get the education they deserve, which can affect their whole lives.
Immigrant children deserve to have their unique needs met
One out of every five Canadian children is an immigrant or the child of immigrant parents. Like their Canadian-born peers, these children deserve the support, resources, and opportunities they need to reach their full potential. Research now and in the future will give more insight into what those needs are and how best to meet them -- and in so doing, benefit all Canadians.
Medical Writer/Editor, AboutKidsHealth.ca