The Healthy Immigrant Effect Health And Social Care Essay

Midterm Paper

Rajendra Subedi

Instructor: Prof. Mark W. Rosenberg

Department of Geography

Queen’s University

20th February, 2013

Healthy immigrant effect: A review of the existing literature to understand the causes of the declining health of immigrants in Canada

Introduction

Canada admits more than 250,000 immigrants every year, and about one fifth of the total populations in Canada now are foreign born (CIC, 2011). The introduction of point system has made the immigration system highly selective that facilitates the entry of young, healthy and economically active population (Setia, et al., 2011). Studies have shown that immigrants normally have a better health condition on arrival compared to their Canadian counterparts (e.g., Dean & Wilson, 2008; McDonald & Kennedy, 2004). However, the health condition of new immigrants deteriorates after few years of their arrival in Canada (Dean & Wilson, 2010, 2008; Newbold, 2009, 2006). This phenomenon has also been observed in the United States, Australia and several countries of Western Europe, and is popularly termed as ‘healthy immigrant effect’ (HIE) (Dean & Wilson, 2010; Finnelly, 2005; Kennedy et al. 2006; McDonald & Kennedy, 2004; and Setia, et al., 2011). Literature suggests that the HIE occurs after few years of arrival (e.g., Newbold, 2009; McDonald & Kennedy, 2004), and most commonly seen among visible minorities and non-European population (DeMaio & Kemp, 2010; Kobayashi & Prus, 2012; and Stafford, Newbold, & Ross, 2010). Although different hypotheses have been proposed to understand the HIE, the causes are subject to an ongoing discussion. Moreover, most of the studies that talked about this effect are based on self-rated physical health outcome of new immigrants, but only a few of them have considered other health measures including the mental health status (Stafford et al., 2010; Wu & Schimmele, 2005). One of the possible determinants of poor mental and physical health among new immigrant could be work-related stress, but there are hardly any studies that focus only on the employment status, nature of work, and work related stress to understand the causes of HIE. To overcome these shortcomings, this critical review is designed to answer the following research questions:

Is the healthy immigrant effect in Canada real? Or is it just apparent?

Do the studies based on other countries have similar findings?

What hypotheses have been used to understand the healthy immigrant effect in Canada?

To what extent does the health of immigrants deteriorate because of work-related stress?

Understanding HIE is important mainly for two reasons. First of all, immigrants are inseparable part of the Canadian health care system because, as mentioned earlier, about one fifth of Canadian populations now are foreign born (CIC, 2011). Therefore, understanding immigrants’ health helps to understand the overall health status of the Canadians and helps to develop population specific health care policy. The second reason is that the knowledge about HIE will help to convince opponents of liberal immigration policies who argue that large inflows threaten to over-burden the health care system in Canada (Wu & Schimmele, 2005). Furthermore, the main objective of Canada’s immigration program is to "foster the development of a strong, viable economy in all regions of the country by attracting skilled human resources" from different part of the world (CIC, 2011). This objective cannot be fulfilled unless the new skilled immigrants are healthy and productive. In this review, existing literature on ‘healthy immigrant effect’ published since 2005 are systematically examined and critically analyzed to understand the hypotheses behind the HIE.

Review of the existing literature

For the purpose of understanding the HIE in Canada, a literature search was made using Queen’s University Library Catalogue and Google Scholar search engine. Key word search was made for "healthy immigrant effect". Articles only published in English language since 2005 are included in the search criteria. General search for the term "healthy immigrant effect" yields too many results (Table 1) which was not helpful for specific article selection. Therefore, the title search was made to limit the results to those articles which have the phrase "healthy immigrant effect" in their titles.

Table 1: Search result for "Healthy Immigrant Effect" (Searched on 25/01/2013)

Search Criteria

Google Scholar

Queen’s Library Catalogue

General search for "Healthy Immigrant Effect"

98,600

2,779

Sort by relevance

1,280

2,529

Published since 2005

1,060

1,793

Title search for "Healthy Immigrant Effect"

22

16

Canada related

6

4

Altogether 22 and 16 articles were searched by Google Scholar and Queen’s library catalogue respectively. However, only six peer reviewed journal articles are found relevant to HIE in Canada (Table 1). Studies conducted in other countries at the same time period are used to make a comparison with the results from Canada based studies. Using the bibliography of the six selected articles, and based on the popularity in terms of their citation by other articles, four most frequently cited articles related to HIE are included in the list of review making the list of ten altogether. All of the articles selected for this review have made conclusion that new immigrants enjoy better health than their Canadian counterparts while arriving in Canada but this health privilege does not persist longer. The HIE has been examined using a wide variety of measures, including self-rated health status, diagnosed chronic conditions, mental health and body mass index in the selected articles.

Table 2: Summary of the articles selected for review

Study

Author/Data

Research Question

Health measure

Result

Examining the gender, ethnicity, and age dimensions of the healthy immigrant effect

Kobayashi & Prus (2012) / CCHS 2005 data

Do age, gender, and ethnicity matter in assessing the health of immigrants?

Self-rated health status

Yes they matter, the healthy immigrant effect applies more to midlife males; the health advantage of recent immigrants is more strong for visible minorities

The deterioration of health status among immigrants to Canada

DeMaio and Kemp (2010) /

LSIC data 2001-2005

To what extent does the health of immigrants deteriorates over time? Is this affected by visible minority status?

Self-rated health status

Immigrants’ health deteriorated over time; visible minorities were most likely to experience worsening health

Does the ‘‘Healthy Immigrant Effect’’ Extend to Smoking in Immigrant Children?

O’Loughlin, Maximova, Fraser and Gray-Donald (2010) / survey of 1,959 children aged 9–12 in Montreal

Does the number of years lived in Canada relates to the risk of smoking among immigrant children?

Self-reported smoking behaviour of students

10% of immigrant children who had lived in Canada <5 years were ever smokers as compared with 21% of those who had lived 6–10 years and 28% of those who had lived 11–12 years in Canada

A qualitative exploration of health improvement and decline among immigrants

Dean and Wilson (2010) / 23 in depth interviews in the GTA

What is the reason for health status change among immigrants?

Self-rated health status

Living standard, stress associated with migration and ageing process are responsible for the health status change

The short-term health of Canada's new immigrant arrivals: evidence from LSIC

Newbold (2009) /

LSIC 2001-2005

Is a deterioration of

Immigrants’ health detectable in the short-term? Does this vary by immigrant category?

Self-rated health status

Signs of worsening health among immigrants may be within 2 years. Refugees are more likely to transition to poor health

Chronic conditions and the healthy immigrant effect: evidence from Canadian immigrants

Newbold (2006) /

NPHS 1994/95 - 2000/01

Does the healthy immigrant effect apply to the presence, number and type of chronic conditions?

No. of chronic condition

Healthy immigrant effect exists. Equalization trends in general with immigrants moving toward native-born health status over time.

The healthy immigrant effect and immigrant selection: Evidence from four countries

Kennedy, McDonald, & Biddle (2006) / NPHS of Canada…

What are the factors that underpin the physical health of immigrants on arrival in their new country?

self-reported chronic conditions and general status

HIE exists in all four countries. Self-selection is an important determinant of HIE.

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

Newbold (2005) / NPHS

Are there differences in health status between the native- and foreign-born?

Self-rated health condition

Health status was not significantly different between the foreign- and native born but native-born were at lower risk to transition to poor health

Is migration to Canada associated with unhealthy weight gain? Overweight and obesity among Canada's immigrants

McDonald & Kennedy

(2005)/

NPHS 1996 & CCHS

2001

Is immigration to Canada associated with unhealthy weight gain?

Individual data on BMI

On average, immigrants are less likely to be obese or overweight than the Canadian-born population at the time of their arrival but this advantage is lost over time

The healthy migrant effect on depression:

Variation over time?

Wu and Schimmele (2005) /

NPHS 1996/97

Does the healthy immigrant effect apply to the risk of depression?

Number of depressive symptoms

Depression rates are lower for immigrants than the native-born upon arrival but increases soon after arrival

Interestingly, only one of the selected studies has used a primary in-depth interview survey and qualitative data analysis technique to understand HIE in Canada. Remaining nine studies have used secondary data and quantitative data analysis method. Five of the empirical studies have used the National Population Health Survey (NPHS) data, two of them have used the Longitudinal Survey of Immigrants to Canada (LSIC) data and only one study has used the Canadian Community Health Survey (CCHS) data. Out of the remaining two, one has used both NPHS and CCHS data while the other has used Heart Health Promotion Survey data from the city of Montreal.

Out of the ten studies selected for this review, self-rated health status is the most frequently used outcome health measure. Kobayashi and Prus (2012), DeMaio and Cemp (2010), Dean and Wilson (2010), O’Loughlin, et al. (2010) and Newbold (2009, 2005) have used self-rated health of immigrants to measure their health status. DeMaio (2010) argues that despite the questions concerning the validity and reliability of self-rated health status measures, they remain an essential and useful part of the research methodology in the population health research. Kobayashi and Prus’s research focus on the role of age, gender and ethnicity in determining health outcome of immigrants. They use CCHS data of 2005 and come to the conclusion that the HIE applies more to midlife males and the health advantage of recent immigrants is more strong for visible minorities compared to other immigrant groups. The study of DeMaio and Kemp (2010) echoes the similar result concluding that visible minorities are more likely to experience worsening health after a few years in Canada but they use the LSIC 2001 to 2005 data for their analysis. Although both the studies have some similarities in terms of their use of empirical analyses to make similar conclusions, one uses cross-sectional data whereas the other uses longitudinal data. Dean and Wilson (2010) also use self-rated health status but their study is a qualitative analysis of HIE based on 23 in-depth personal interviews of immigrants in Greater Toronto Area. They conclude that HIE persists and the deteriorating health status of immigrant is related to poor living standard, stress associated with migration and ageing process. O’Loughlin et al. (2010) use a slightly different approach to understand the relationship between the numbers of years lived in Canada and the risk of smoking among immigrant children. Using the survey data of 1,959 school age children from Montreal, they come to the conclusion that children of new immigrants are less likely to smoke in comparison to the children of immigrants who have been living in Canada for a long time and those of Canadian children. Their result shows that HIE extends to smoking behaviour of immigrant children. Similarly, Newbold (2009) tries to identify whether or not the deteriorating health of immigrant is detectable in the short term. Using the LSIC 2001 to 2005 data, he uncovers that the sign of worsening health among immigrants may be found as quickly as within two years since arrival.

Consistency with HIE was also observed by Newbold (2006) and Kennedy, McDonald & Biddle (2006) but they use chronic conditions as the outcome health measures. Newbold (2006) and Kennedy et al. (2006) both use NPHS data but for different research objectives. The former one looks if the HIE apply to the presence of chronic conditions whereas the latter one uses the same data to make a comparison between Canada, USA, UK and Australia to understand the causes of HIE. Yet, both the studies come to the conclusion that HIE exists and also suggest that recent immigrants held a health advantage over native born Canadians while adjusting for demographics and other socioeconomic conditions. Although the central research questions were different, McDonald and Kennedy (2005), and Wu and Schimmele (2005) come to an almost similar conclusion regarding HIE. McDonald and Kennedy’s study deals with the relationship of immigration status and unhealthy weight gain in Canada using individual data on BMI, whereas Wu and Schimmele’s study explores on the possibility of HIE applying to the risk of depression.

Evidence from other countries

The HIE is not only limited to Canadian immigrants but also is evident from other developed countries having similar immigration intake policies (e.g., Choi, 2012; Kennedy et al., 2006). Therefore, literature published at the same time period on the topic of HIE are also discussed here to make a reasonable conclusion.

Kennedy et al. (2006) make a comparison of HIE in Canada, the United States, the United Kingdom and Australia using the secondary national population survey database of each country. Using the self-reported chronic conditions and general status of health as outcome measure, they make a conclusion that the HIE exist in all four countries and immigration self-selection is the most important determinant of HIE. However, HIE is partially supported by a US based study by Choi (2012) where he observes the HIE among late-life immigrants using secondary data from three waves of the Second Longitudinal Study of Aging (1994-2000) and a linked mortality file. Choi’s results indicate that late-life immigrants had fewer chances of having chronic conditions at baseline, and displayed lower hazards of mortality even after 12-year follow-up. Yet, their self-rated health status were worse than those of their counterparts over time. Choi’s study is a good reference to compare the HIE in Canada, however the immigration system in Canada is more selective for skilled human resources, whereas the American immigration system is mainly dominated by Diversity Visa (DV) immigrants, and labour force migration. Therefore the HIE observed in the US may not be applicable to all the immigrants in Canada.

A similar study conducted in Australia (Anikeeva, et al., 2010) finds that the majority of migrants in Australia enjoy better health than the Australian-born population. New immigrants’ health is found better in all the conditions that are part of the National Health Priority Area (NHPA) except diabetes, but deteriorates over time. These results are consistent with most of the Canadian studies, which makes sense having almost similar immigration selection procedure in Australia and Canada. Surprisingly, Nolan (2012), using microdata from a nationally representative survey of the population of Ireland in 2007, finds only a limited evidence of HIE. However, the evidence of Ireland may not be comparable with Canada because majority of immigrant in Ireland are from the developed countries like Britain, Western Europe, Australia and North America with similar sociocultural settings of Ireland, whereas majority of immigrants in Canada are from the developing countries having diverse sociocultural status. Despite the diverse immigration intake policies in different countries, it is apparent from the literature that the HIE is evident in all the countries.

Hypotheses behind good health of immigrant on arrival

Eight out of the ten articles reviewed here confirm that the HIE exist in Canada. Two of the articles give mixed result which partially supports HIE. In addition to their findings about HIE, all the articles reviewed here have proposed following hypotheses to understand the good health conditions of immigrants on arrival in Canada.

Immigrant self-selection: A most dominantly used hypothesis in immigrant health

literature is immigrant self-selection hypothesis which states that healthier and potential people are most likely to migrate because they are physically and financially fit (Kennedy et al., 2006; McDonald & Kennedy, 2004). Out of the ten articles reviewed, eight of them consider that immigrant self-selection is the main reason behind good health of immigrants on arrival. A widening disparity in working condition and the quality of life in developing and developed countries makes young, well-educated, healthy individuals more likely to migrate because these people are always in search of better education and better economic status (Dodani & LaPorte, 2005). The top tire of the people who have both physical and financial means of migration are normally having better diets, better access to clean water and sanitation, less exposure to environmental risks and better child/maternal health care (Kennedy et al., 2006). These immigrants usually tend to be young adults, better educated, hard working, forward looking, and innovative. These characteristics accompanied with favorable labor market outcomes in the destination country would also be associated with favorable selectivity of migrants (Chiswick, Lee, & Miller, 2008).

Most of the developed countries that intake immigrants have given priority to young and healthy individuals making the immigration process selective (Setia et al., 2011). For an instant, the point-based selection system introduced in Canada in 1967 is an example of a selective immigration system where age, education and training, prearranged employment, knowledge of English and French languages, occupational demand and having family in Canada are included in the immigrants selection criteria. Wu and Schimmele (2005) argue that a larger portion of immigrants are self-selected for migration because they possess characteristics to meet the aforementioned criteria and have the ability to respond to push and pull factor for international migration.

4.2 Health Screening: Another prominent hypothesis behind the HIE in Canada is the health screening of immigrants. The Immigration and Refugee Protection Act (2002) requires that, regardless of the country of origin, all applicants for permanent residence in Canada are required to see a CIC Designated Medical Practitioner to complete a full medical exam, chest x-ray for tuberculosis, urinalysis, HIV/AIDS and syphilis testing, and optional serum creatinine testing before being admitted to Canada (CIC, 2009). As a result, a significant number of studies have hypothesized that the health of immigrants on arrival in Canada is better than that of their Canadian counterparts (Kennedy & McDonald, 2005, and Wu & Schimmele, 2005). Beiser (2005) elaborates on the health screening program of Canada as :

Canada’s Immigration and Refugee Protection Act refers to migrant health in only one place, s. 38.1, which mandates rejecting an applicant if he/she is (a) likely to be a danger to public health, or (b) to pose a danger to public safety, or (c) if he/she might reasonably be expected to cause excessive demand on health or social services (p S31).

Based on this regulation, it is very unlikely that people with chronic illness and major health problems will obtain permission to enter Canada. Therefore, the health of new immigrants in Canada is generally better than Canada born populations.

4.3 Under-diagnosed or under-reported health problems: There are a number of studies which have hypothesized that under-diagnosed or under-reported health problems may be an important factor behind HIE (e.g., Newbold, 2005; 2006). Newbold (2006) believes that the failure to identify and diagnose health problems of new immigrants may lower the measured prevalence rates of chronic conditions, which may lead to the conclusion of better health. Newbold (2005), for example, argues that there are more chances of recognition and reporting on health over time because immigrants normally have improved access and full use of health services after few years of arrival. Lack of social networks, and language and cultural barriers may prevent new immigrant to access health care facilities in the first few years of arrival which may result to conveying better immigrant health than that actually is.

4.4 Good health behavior before migration: Although this hypothesis looks similar to immigrant self-selection hypothesis, two of the studies selected for this review argue that the immigrants from developing countries typically involve in pre-migration behaviour (high level of physical activity, low consumption of fat and calories) which are supportive to good general health (Kennedy et al., 2006; McDonald &, Kennedy 2005). Using 1996/97 NPHS data, Kennedy et al. (2006) find that the smoking rate among new immigrants in Canada is quite lower than the smoking rate in their home countries. This result indicates that immigrants normally have better health behaviour than the people of their home country.

Hypotheses behind the deteriorating health conditions of immigrants

Based on the literature reviewed, in Canada and also in other countries, following hypotheses have been used to explain the deteriorating health conditions of the immigrants after a few years of settlement in the host county.

5.1 Acculturation and lifestyle change: The health of the immigrants in the host country is determined by the combination of their social, cultural, political and economic position. Acculturation, defined as the cultural modification of an individual, group, or people by adapting to another culture, is the most frequently used hypothesis to explain HIE. Seven out of the ten articles, included in this review, argue that acculturation is a process that makes significant changes in the social, cultural, political and economic status of new immigrant in the host society (e.g., Dean & Wilson, 2010; Newbold , 2009, 2006, 2005; O’Loughlin et al., 2010). Dean and Wilson (2010) and Newbold (2009) argue that, through a process of acculturation immigrants adopt a ‘Canadian lifestyle’ that includes unhealthy and risky health behaviors such as an increase use of tobacco and alcohol, poor dietary habit, and reduced mobility. The sedentary lifestyle increases the BMI and negatively influence the health status of new immigration after a few years of arrival in Canada (Newbold, 2006).

5.2 Barriers to the use of health services: Immigrant populations not only include economic immigrants but also family reunification class and refugees. There is a significant amount of literature on the barriers that these immigrants face in everyday life. Six out of ten articles, used in this review, use this hypothesis to explain the worsening health of immigrants in Canada (e.g., Dean & Wilson, 2010; Kobayashi & Prus, 2012; McDonald & Kennedy, 2005). Language, cultural differences, health care cost, and lack of social network are considered the most prominent barriers for new immigrants. Newbold (2009) argues that distrust of the medical system, a culturally less sensitive medical system, and culturally inappropriate care may create additional barriers to immigrants to access health services. Newbold (2009, 2006, 2005) also presents a slightly different view than other author by arguing that the health care restructuring of Canada in 1990s has posed some barriers to new immigrants because not all the health care are insured. Newly arrived immigrants may have difficulties accessing them because of the cost associated with the health care. An empirical study by Newbold (2005) using the data of the longitudinal survey of NPHS (1994/95 and 2000/01) finds that immigrants arriving in Canada between 1990 and 1994 experienced particularly remarkable declines in self-reported health status compared to earlier arrival cohorts.

5.3 Poor social determinants of health: Social determinants of health like income, education, housing, social safety network, employment status et cetera are frequently used to understand the health of immigrants (Dunn & Dyck, 2000). Five out of ten articles selected in this review use this hypothesis to explain the worsening health condition of immigrants in Canada (e.g., Kennedy et al., 2006; Wu & Schimmele, 2005). According to this hypothesis, immigrants usually have low levels of income, unemployment, poor quality housing and poor social safety networks. As a result, their quality of life is low and they usually have deteriorating health conditions (Kennedy et al., 2006; Newbold, 2009).

5.4 Discrimination and unfair treatment: Two of the articles (DeMaio & Kemp, 2010, and Wu & Schimmele, 2005 use this hypothesis to explain worsening health of immigrants in Canada. This hypothesis is based on the assumption that new immigrants, especially visible minorities, having language and cultural barriers are treated unfairly and therefore are less likely to use health care services. Studies have shown that immigrants are less likely to have family physician and more frequently visit walk-in clinics. For example, DeMaio and Kemp (2010) uses logistic regression method to analyze LSIC data and come to the conclusion that immigrants who experienced discrimination or unfair treatment are more likely to report poor health status. This hypothesis is postulated based on the self-reported discrimination.

Table 3: Hypotheses used to explain Healthy Immigrant Effect

Reviewed Articles

Hypothesis behind good health on arrival

Causes of worsening health condition

Dean and Wilson (2010)

Health screening

Self-selection

Ageing and life process

Barriers to use the health services

Acculturation/lifestyle change

Stress associated with settlement

DeMaio and Kemp (2010)

Health screening

Self-selection

Discrimination/ unfair treatment

Kennedy et al. (2006)

Good health behavior at home country

Health Screening

Self-selection

Under-diagnosed health problems

Lifestyle change

Poor social determinants of health

Kobayashi & Prus (2012)

Acculturation

Barriers to use the health services

Unemployment or underemployment

McDonald & Kennedy

(2005)

Good health behavior at home country

Health screening

Self-selection

Under-diagnosed health problems

Acculturation/lifestyle change

Barriers to use the health services

Exposure to common environmental

Newbold (2005)

Health screening

Self-selection

Under-diagnosed health problems

Acculturation/lifestyle change

Barriers to use the health services

Health system restructuring

Poor social determinants of health

Newbold (2006)

Newbold (2009)

O’Loughlin et al. (2010)

Acculturation

Wu and Schimmele (2005)

Health screening

Self-selection

Acculturation

Discrimination/ unfair treatment

Poor social determinants of health

Stress associated with settlement

5.5 Employment status and work-related stresses: Although employment status and work-related stress is the least considered hypothesis among the articles reviewed, it has been used as a cause of poor mental health in other literature. Houle and Yssaad (2010) claim that a barrier to finding suitable employment is a key contributing factor in psychological health. This finding is also supported by a study of Dean and Wilson (2008), where unemployed immigrants are found to have elevated levels of stress, anxiety, depression, unhappiness, worry, tension, irritation, and frustration. Newbold (2009) finds that unemployment, low income and deskilling (i.e., immigrants forced into lower-status jobs because of the employers failing to recognize educational credentials) has been associated with mental stress and poor health. The role of employment as a determinant of health is well established in the literature (e.g., Dean & Wilson, 2008; Newbold, 2009) but there is not sufficient literature on the health effect of underemployment, unfavorable employment and stressful employment. In addition, there is no specific study that looks at the mental and physical health status of skilled immigrants who are underemployed despite of their better qualifications, training and experience.

Discussion: A critical analysis of the reviewed articles

A methodological limitation of most of the reviewed literature on HIE is that most of them are typically based on a single cross-section of data. This type of analysis can be a good predictor of the health status at a point of time but are unable to provide an analysis of actual health transition over time. McDonald and Kennedy (2004) argue that with a single cross-section data it is not possible to separate true convergence in health from unobserved characteristics related to health that differ among immigrants arriving at different periods. DeMaio and Kemp (2010) echo the same argument reasoning that Immigration patterns have markedly changed in the recent history of Canada, and it is problematic to imply a pattern by comparing the health status of current immigrants with those who have been in the country for many years.

Most of the results presented in the reviewed literature are based on self-rated health status. However, self-rated health status may not reflect the biological health condition of an individual. The validity and accuracy of self-rated health may be compromised because some health problems are so sensitive that respondents may not want to report them to the interviewer. Brender et al. (2004) argue that most of the data collected by self-reports cannot be verified independently in a cost-effective, feasible, and ethical manner. Likewise, we have very less understanding about how immigrants’ perceptions about health changes after settling in Canada. DeMaio (2010), for example, argues that the changes in self-assessed health status of immigrants may be a reflection of growing expectations associated with better quality of life in Canada but not the real decline of their health status.

Although immigrants’ health screening is one of the most cited hypotheses, some literature suggests that host country health screening is not likely to be the key determinant of the health gap between new immigrant and Canada-born population. Laroche (2000) makes a comparison of health status and health service utilization of Canada’s immigrant and non-immigrant populations and reports that the percentage of applicants to Canada that are rejected on health grounds is very low. Furthermore, a medical examination is a screening process for the physical health of immigrants but it does not screen immigrants based on their mental or psychosocial health.

Barriers to health care service is also a most frequently used hypothesis to explain HIE. However, studies have shown that new immigrants usually have better jobs, income, social network and improved communication skill after a few years in Canada. If sociocultural and economic factors are the major barriers in health care service, the health of immigrants would have been improved along with improved sociocultural and economic status. But, in reality the health of immigrants is declining with years in the host country. Therefore, this hypothesis may not be a suitable hypothesis to explain HIE.

Another hypothesis that has been used to explain HIE in Canada (in other countries too) is that immigrants are under-diagnosed or under-reported for their health problems. In fact, the Canada Health Act (1984) has ensured that the governments in Canada adopt five basis principles of health care system which are accessibility, comprehensiveness, universality, public administration and portability. All new immigrants are eligible for comprehensive health coverage in Canada despite few month residency requirement imposed by some provincial governments. The accessibility principle ensures that all Canadians must have reasonable and uniform access to insured health services, free of financial or other barriers (Madore, 2005). Therefore, the HIE in Canada may not be the result of under-diagnosed or under-reported health problems.

Finally, acculturation is the most frequently used hypothesis to explain HIE in Canada. However, multiculturalism is an official policy in Canada. "Multiculturalism reflects the cultural and racial diversity of Canadian society and acknowledges the freedom of all members of Canadian society to preserve, enhance and share their cultural heritage" (Canadian Multiculturalism Act, 1988). The freedom that the new immigrants enjoy in Canada to practice their culture, language and food is an additional advantage. Therefore, immigrants do have a choice of either or not to adopt the culture of the host society. If the principles of multiculturalism are working well, acculturation should not be a good cause of declining health of immigrants at least in Canada.

Conclusion

Based on the literature reviewed in this paper, it seems that the HIE is real, but not just apparent. Canada has very good stacks of research on HIE in comparison to other developed countries having similar immigration programs. However, the causes behind HIE are not fully understood, but are subject to an ongoing debate. There seems to be a general consensus on HIE but there is no uniformity on how many years it takes to converge immigrant health to the condition of Canadian-born population. Underemployment and work related stress may be a prominent cause of deteriorating health condition but none of the articles reviewed have strongly put forward this hypothesis.