Transcript Healthy Immigrant Effect? - Gender and Population Studies (GAPS

Healthy Immigrant Effect?
Population Indicators of Immigrant
Mental Health in the 2010 Canadian
Community Health Survey
Peter Kellett MN RN
Ph.D. Student - Demography
Prentice Institute for Global Population and Economy
Academic Assistant/Instructor -Nursing
Faculty of Health Sciences
University of Lethbridge
Background
Immigration is the biggest contributor to
Canadian population growth – more than
250 000 annually (Statistics Canada, 2010).
Diversity of immigrants is increasing – more
immigrants from Asia, the Middle East, the
Caribbean, and Africa (Nguyen et al., 2011; Pottie et al., 2008).
 On average recent immigrants are in better
overall health when compared to the
Canadian-born (“Healthy Immigrant Effect”) 
This effect starts to decline in as little as 2
years after arrival (Beiser, 2005; De Maio, 2010; De Maio & Kemp,
2010; Newbold, 2009; Nguyen, et al., 2011).
Research Objective
To describe the current state of Canadian immigrants’ mental
health through analysis of the 2010 public use Canadian
Community Health Survey (CCHS) data.
Research Questions
1. How does Canadian immigrants’ mental
health compare to the Canadian-born?
2. Is there a healthy immigrant effect for mental
health?
3. Is there a difference in immigrant mental
health status based on gender, duration of
residence in Canada, and cultural or racial
origin?
Method
Sample
2010 Canadian Community Health Survey (CCHS)
Annual cross-sectional survey collecting data on health
status, health care utilization, and health determinants
Self-report data (in person or via telephone)
Representative sample of Canadians 12 years & up
Public use file contains data on (n=62 909)
Immigrant Canadians (n=8848)
Accessed through Statistics Canada Data Liberation Initiative
Analysis
(Statistics Canada, 2011)
Subjected to statistical analysis using IBM SPSS Version 20.0
Tests of difference (Independent t-tests, Mann Whitney U,
ANCOVA)
Multiple Regression
Logistic Regression (weighted)
Calculation of Odds Ratios
Findings





Perceived Mental Health
(0=Poor, 2=Good, 3=Very
Good, 4= Excellent)
Immigrants had significantly
higher self-reported ratings of
mental health
No significant difference noted
based on gender
Recent immigrants had
significantly better selfreported ratings of mental
health when compared with
those in Canada for greater
than 10 years.
Within these groups – no
significant difference based on
gender
No significant difference based
on cultural or racial origin
Perceived Mental Health
Variable
Immigrant
Yes
No
Immigrant – Sex
Male
Female
Immigrant – Length of Time
in Canada
0-9 Years
10+ Years
Immigrant – Length of Time
in Canada – Sex
Male (0-9 Years)
Female (0-9 Years)
Male (10+ Years)
Female (10+ Years)
Immigrant – Cultural or
Racial Origin
White
Visible Minority
_____________________________
N
M
SD
Skew
Test
Statistic
8608
3.02
.932
-.693
t (11663.)=
51397
2.99
.930
-.676
3.310**
3770
3.04
.938
-.704
t (8058)=
4838
3.01
.928
-.685
1.242
1868
3.15
.869
-.730
t (8606)=
6740
2.99
.946
-.673
6.837***
858
3.16
.870
-.684
t (1866)=
1010
3.15
.868
-.770
.412
2912
3.00
.954
-.695
t (6738)=
3828
2.98
.940
-.657
1.01
4928
3.02
.941
-.708
t (8566)=
3640
3.03
.921
-.677
-.682
Note. N= Sample Size; M = Mean; SD= Standard Deviation; Skew= Skewness Statistic; t=
Independent t-test; * Statistically significant at 0.05 level; ** Statistically significant at 0.01
level; *** Statistically significant at <0.001 level
Multiple Regressiona Results for
Perceived Mental Health among
Immigrant Canadians
Perceived Mental Health
___________________________________
 The following variables were
significant predictors of positive
perceived mental health among
Canadian immigrants
 Increased sense of belonging to
the community
 Increased self-esteem
 Being a visible minority
 Being a recent immigrant (< 9
yrs)
 Higher household income
 Higher education levels
 Increased social support
These findings are consistent with those
of previous studies that have also found
these variable to have an influence on
the mental health of immigrants (Ali,
2002; De Maio, 2010; De Maio & Kemp, 2010;
Newbold, 2009; Nguyen, et al., 2011; Zheng &
Schimmele, 2005)
Model only makes a small 13.6%
contribution to the variance in the perceived
mental health variable
Regression
Coefficients
(B)
Standardized
Regression
Coefficients
(β)
Sense of Belonging to the
Community
Self-esteem Scale
Cultural or Racial Origin
Length of Time in Canada
-.117***
-.107
Squared
SemiPartial
Correlations
(sri2)
.0125
.085***
.121*
-.207***
.261
.066
-.096
.066
.0037
.0074
Total Household Income
Education Level
Social Support Availability
.043*
.124*
-.717***
.065
.058
-.092
.0037
.0035
.0079
Sex
Age
Languages –Can Speak
Common Law
Widowed/Separated/
Divorced
Single – Never Married
CONSTANT
.058
.016
-.177
.072
-.036
.032
.064
-.035
.019
-.015
.0021
.0021
.0013
.0004
.0002
Variable
.022
.010
.00006
1.684***
_________________________________
R= .377 and Adjusted R2= .136
Note. a Variables Entered Simultaneously;; * p<0.05; **p<0.01; ***p<0.001
Composite International
Diagnostic Interview – Short
Form for Major Depression
(CIDI-SF-MD) – Predicted
Probability
•
•
Provides a probability between 0.0 and 0.9
of receiving a diagnosis of depression if the
full CIDI questionnaire was completed
Reliable and valid instrument based on the
DSM diagnostic criteria for depression
 Immigrants had a significantly
lower predicted probability of
depression
 No significant differences
noted based on gender
 Recent immigrants (< 9 yrs)
had significantly lower
predicted probability of
depression, and there was no
significant difference in
probability based on gender
 There was no difference in the
predicted probability of
depression based on cultural
or racial origin
CIDI-SF-MD
Predicted Probability
_____________________________
N
M
SD
Skew
Test
Statistic
Variable
Immigrant
Yes
No
Immigrant – Sex
Male
Female
Immigrant – Length of
Time in Canada
0-9 Years
10+ Years
3628
.059
.215
3.48
24501
.069
.231
3.17
1636
.053
.204
3.70
1992
.063
.223
3.33
927
.044
.188
4.124
U=1 283
2701
.064
.223
3.314
700*
.050
.197
3.83
.040
.180
4.44
.055
.207
3.65
.071
.235
3.09
1895
.063
.221
3.34
1720
.054
.207
3.67
Immigrant – Length of
Time in Canada – Sex
437
Male (0-9 Years)
Female (0-9 Years) 490
Male (10+ Years)
1199
Female (10+
Years)
1502
Immigrant – Cultural or
Racial Origin
White
Visible Minority
U= 44 971
987*
U= 1 647
287
U=105
932.5
U= 916
374
U=1 613
586
Note. N= Sample Size; M = Mean; SD= Standard Deviation; Skew= Skewness Statistic; U =
Mann Whitney U; * Statistically significant at 0.05 level; ** Statistically significant at 0.01
level; *** Statistically significant at <0.001 level
CIDI-SF-MD Predicted Probabilityb
Multiple Regressiona Results for
CIDI-SF-MD Predicted Probability
among Immigrant Canadians
___________________________________
Sense of Belonging to the
Community
Self-esteem Scale
Cultural or Racial Origin
.010
Standardized
Regression
Coefficients
(β)
.038
-.007**
-.031*
-.083
-.068
.0064
.0035
Length of Time in Canada
.050**
.095
.0066
Total Household Income
-.006
-.035
.00096
Education Level
Social Support Availability
.007
.153
.013
.080
.00017
.0053
Sex
Age
Languages –Can Speak
Common Law
Widowed/Separated/
Divorced
Single – Never Married
CONSTANT
.022
-.009***
.030
-.019
.031
.049
-.151
.024
.023
.054
.002401
.010609
.00053
.0004
.0022
Variable
Significant predictors of increased
depression probability among
Canadian immigrants included:
 Decreased self-esteem
 Being White
 Increased length of time in Canada
(10+ yrs)
 Younger age
Note that this model only
contributes 3.6% to the predicted
probability of depression
Consistent with the findings of Ali
(2002) which reported that patterns
of depression among immigrants
were relatively unaffected by
demographic and socioeconomic
characteristics
Regression
Coefficients
(B)
Squared SemiPartial
Correlations
(sri2)
.0014
-.011
-.020
.00029
.097
__________________________________
R= .207 and Adjusted R2= .036
Note. a Variables Entered Simultaneously; b Variable CIDI-SF-MD Predicted Probability is
significantly positively skewed and was not transformable; * p<0.05; **p<0.01; ***p<0.001
Seriously Considered
Suicide (yes/no)
Immigrants were significantly
less likely to experience suicidal
ideation
Odds of suicidal ideation was
not significantly different based on
gender (different from adjusted
OR)
Visible minority immigrants
were at reduced risk of suicidal
ideation (Clarke et al., 2008)
Married immigrants were at
reduced risk of suicidal ideation
Widowed/Separated/Divorced
and single immigrants were at
increased risk
No significant difference in risk
based on education level or ability
to converse in one of the official
languages
Seriously Considered Suicide
Yes/No
______________________
Variable
Immigrant
Yes
No
Immigrant –Sex
Male
Female
Immigrant -Length of Time in Canada
0-9 Years
10+ Years
Immigrant - Cultural or Racial Origin
White
Visible Minority
Immigrant – Married
Yes
No
Immigrant – Common Law
Yes
No
Immigrant – Widowed/ Separated/
Divorced
Yes
No
Immigrant – Single
Yes
No
Immigrant - Education Level
Secondary School or Less
Some Post-secondary to Postsecondary Graduation
Immigrant - Languages Can Speak
English or French
Other
OR
95% CI
.680*
1.074*
[.539 - .745]
[1.051 - 1.097]
.897
1.084
[.748 - 1.077]
[.956 - 1.228]
.605*
1.111*
[.414 - .885]
[1.045 – 1.180]
1.245*
.723*
[1.114 - 1.391]
[.587 - .890]
.730*
1.381*
[.615 - .868]
[1.207 – 1.581]
1.351
.988
[.664 – 2.752]
[.957 – 1.021]
1.364*
.905*
[1.067 – 1.743]
[.823 - .994]
1.408*
.914*
[1.074 – 1.847]
[.840 - .995]
.851
1.059
[.651 - .971]
[.971 – 1.156]
1.023
.700
[.988 – 1.060]
[.364 – 1.344]
Note. OR= Odds Ratio (unadjusted); CI= Confidence Interval; * Significant at 0.05 level
Seriously Considered Suicide
Yes/No
Logistic Regression of Variables
Differentiating Immigrants’ Suicidal
Ideation
 Significant predictors of suicidal
Variable
ideation included
 increasing age (Melenfant, 2004)
 being female (interesting finding)
 increased sense of belonging
 increased self-esteem
 being white (Clarke et al., 2008)
 being widowed/separated/
divorced
Age
Length of time in Canada, total
household income, social support
availability, education level, ability to
speak one of the two official languages,
and being married or common law were
not significant predictors
Note that this model only accounted
for 10% of the likelihood of suicidal
ideation –other 90% unexplained
________________________________________________
___
Regression
Adjusted Odds Ratios
Coefficients
Wald Statistics
[95% CI]
(β)
.058
5.282*
1.060 [1.009 – 1.114]
Sex
-.553
Sense of Belonging in -.175
Community
Self-Esteem Scale
.060
19.673***
5.885*
.575
.839
8.332**
1.061 [1.019 – 1.105]
Length of Time in
Canada
Cultural or Racial
Origin
Total Household
Income
Social Support
Availability
Education
-.197
1.226
.821
.674
20.876***
1.962 [1.469 – 2.619]
.035
.460
1.035 [.936 – 1.145]
-.559
.965
.572
[.187 – 1.745]
-.219
2.104
.803
[.597 – 1.080]
Languages Can Speak .106
.141
1.112 [.639 – 1.934]
Married
-.165
.753
.848
[.583 – 1.231]
Common Law
-.320
1.067
.726
[.395 – 1.333]
16.403***
.431
[.287 - .648]
.440
.507
Widowed/Separated/ -.841
Divorced
Constant
-.593
[.450 - .734]
[.728 - .967]
[.579 – 1.164]
Note. Nagelkerke R2= .100; a Variable weighted so both groups were given equal
weighting in the analysis; * p<0.05; **p<0.01; ***p<0.001
Although suicide rates are generally low
among Canadian immigrants, other research
suggests that immigrants from different
origin groups may experience different
trajectories and rates across generations
(Hansson et al., 2012).

Putting these results in context
 These results are suggestive that there is a “healthy immigrant effect” for
mental health that declines over time; however, these findings should be
viewed with caution
– Self-report data for mental health is open to error – due to stigma
– This effect may be enhanced among men because admitting emotional distress is inconsistent
with common constructions of acceptable masculinity performance (Oliffe & Philips, 2008).
– CIDI-SF-MD is based on DSM criteria which outlines depressive symptoms as described by a
primarily westernized and medicalized perspectives on depression. Some evidence to suggest
that these criteria are culturally and gender biased and that individuals from non-westernized
countries may present with different (e.g. somatic) symptoms (Caetano, 2011; Cooksey&
Brown, 1998; Oliffe & Philips, 2008; Oliffe et al., 2010; Wright & Owens, 2001)
 Is the “healthy immigrant effect” genuine in the case of mental illness, or is
this an artifact of survey instruments and diagnostic criteria that articulate a
westernized social construction of mental distress – decreasing the sensitivity
in identifying mental and emotional distress among immigrants from nonwesternized countries?
• Although these regression models include many common variables known to
be related to mental health/illness, they appear to only contribute to
relatively small effect on perceived mental health, depression probability, and
suicidal ideation among immigrants to Canada.
– Clearly there are other factors that contribute in a larger way to the expression of mental
health/illness among immigrants
Limitations to Study
 The 2010 public-use CCHS data set does not include variables
to identify the country or region of origin; therefore, this
analysis has treated immigrants to Canada as a homogenous
group – problematic as immigrants are certainly a
heterogeneous group
 Although the sample frame for the CCHS is generally
representative of the Canadian population, this survey does
exclude individuals living on Crown Lands or Indian reserves,
institutional residents, full-time members of the Canadian
Forces, and residents of some remote regions
Implications for Future Research
 It may be beneficial to explore other measures of mental health and illness
that could be better at identifying the mental and emotional distress of our
diversifying Canadian population in future national surveys
 There may be a need to develop new survey instruments to assess mental
health at a population level and these new instruments will need to be tested
for reliability, sensitivity, and specificity.
 It is striking only 10 – 16 % of these outcomes could be predicted by these
common demographic and social criteria included in the models. Additional
research is needed to identify the additional factors that contribute to positive
mental health outcomes among Canadian immigrants
 How much is related to the barriers to successful arrival faced by immigrants?
 How much of the decline in the “healthy immigrant effect” is due to
acculturation? To a change in their social construction of concepts like
depression? To a change in perspective? To the cultural influences of their
country of origin?
 This situation illustrates the importance of contextualizing the interpretation
of statistics in the wider social science context  supports usefulness of
mixed-methods and multi-disciplinary studies
Acknowledgments
Thank you to Dr. Olu Awosoga and Dr. Robert
Williams from the Faculty of Health Sciences for
their guidance during the statistical analysis
Thank you to my Ph.D. committee members
Dr. Susan McDaniel (co-supervisor) – Prentice Institute
Dr. Brad Hagen (co-supervisor) – Faculty of Health Sciences
Dr. Olu Awosoga – Faculty of Health Sciences
Dr. Raphael Lencucha – Faculty of Health Sciences
Questions?
References
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across ethnic groups in Canadian adults: the possible role of social stress. Psychological
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Distress Scale K10
K10 Distress Scale –
proven to have a high
degree of sensitivity in the
identification of nonspecific stress
 Immigrants had significantly
lower K10 distress scores
than the Canadian-born
 Immigrant women had
significantly higher distress
scores than immigrant men
 No significant differences in
distress score based on
length of residence in
Canada
 No significant differences
were noted in distress scale
scores based on cultural or
racial origin
Variable
Immigrant
Yes
No
Immigrant – Sex
Male
Female
_____________________________
N
M
SD
Skew
Test
Statistic
1844
4.07
4.98
.137b
t (2218)=
17874
4.44
5.06
-.001b
-4.513***
860
3.83
4.92
.220b
t (1842)=
984
4.28
5.02
.066b
-2.51*
4.14
4.72
.102b
t (1842)=
4.04
5.09
.189b
1.53
3.76
.389
.142
t (597)=
4.51
.398
-.095
-1.02
3.87
.417
.257
t (1317)=
688
4.18
.408
.135
-.742
946
3.82
4.80
.195b
t (1812)=
892
4.34
5.16
.073b
-1.688
Immigrant – Length of Time
in Canada
577
0-9 Years
10+ Years
1267
Immigrant – Length of Time
in Canada – Sex
281
Male (0-9 Years)
Female (0-9 Years)
296
Male (10+ Years)
579
Female (10+ Years)
Immigrant – Cultural or
Racial Origin
White
Visible Minority
Note. N= Sample Size; M = Mean; SD= Standard Deviation; Skew= Skewness Statistic; t= Independent t-test; * Statistically
significant at 0.05 level; ** Statistically significant at 0.01 level; *** Statistically significant at <0.001 level; b reported
skewness based on lg10(var+1) transformed Distress K10 variable