Background
As the number of immigrants grows worldwide, [
1] so does the attention to immigrants’ use of health and social services [
2,
3]. However, there is limited research on current service use patterns to inform efforts to improve quality of care. Moreover, existing research rarely accounts for the diversity of immigrant populations, [
4] such as that driven by world region of origin. Immigration is increasingly a global phenomenon and newcomers from varied regions often have distinct pre-immigration experiences (i.e., social, cultural, and political), as well as varied post migration re-settlement experiences [
5‐
7] that may influence both service need, and factors that assist or impede access to care [
7‐
9].
Given that immigration has been linked to a variety of mental health stressors, [
7,
8,
10] understanding use of mental health services by immigrant groups is particularly important [
11,
12]. While both the pre and post immigration context can influence health and help seeking, [
8,
10,
13] research rarely accounts for immigrant source region. In fact, only three mental health service use studies examined immigrants from different source countries. Of these, two studies were Dutch that showed variation by source country. One by Selten and colleagues [
14] showed lower use for care for mood disorders by immigrants from Turkey, Morocco, and Surinam than by native born Dutch as well as variation across the three source country immigrant groups [
14]. Suggested explanations for the variation included group differences in thresholds for seeking treatment, familiarity with pathways to psychiatric care, and likelihood of referrals by clinicians. The other Netherlands based study by Uiters and others [
15] examined primary and specialty mental health care utilization by immigrants from Turkey, Surinam, Morocco, and The Netherlands Antilles. Compared to indigenous people, newcomers from Morocco were less likely to use a combination of primary care and mental health services while people from the Netherlands Antillean were more likely to use these forms of care [
15]. The authors suggested that differences in use among immigrant groups may reflect their experience with service delivery in their home countries, particularly the role of primary care in facilitating access to speciality mental health services. A Canadian study [
16] on immigrants from the Caribbean, Vietnam, the Philippines living in Montreal, Canada found that Vietnamese and Filipino immigrants were one-third as likely as Canadian-born residents to use mental health care, although there were no differences between Caribbean newcomers and Canadian-born.
Regarding use of hospital services for non-psychotic disorders, studies have shown more use by immigrants compared to native born persons; [
17‐
19] less use; [
20] or no differences in use, [
21,
22] but have not disaggregated by world region of origin.
In the context of global immigration, profiling mental health service use by newcomers’ source countries can provide useful information. Existing studies of this type are sparse and have looked at specific source country groups. Investigating patterns across an entire immigrant population in the same setting and with respect to a common comparator can provide a more comprehensive picture. The underlying reasons for any distinct use patterns that are observed may then be further investigated.
We sought to contribute to existing knowledge by examining mental health service use by immigrants from the full range of regions in a large, diverse province with a single payer health care system. Ontario, Canada is a major destination for immigrants where 27 % of the population is foreign-born with source countries from almost every continent [
23]. This study compared rates of primary care visits, psychiatry visits and hospital use for non-psychotic mental health disorders for recent immigrants to Ontario from nine world regions of origin to long term residents (LTRs), a group of long term immigrants or Canadian born individuals to whom immigrants were matched on age.
Discussion
This population-based cross-sectional study examined mental health service by a heterogeneous population of recent newcomers representing all the major world regions. Descriptive data showed diverse immigrant profiles across the nine source regions for a number of characteristics that can affect service use, such as English language proficiency and visa admission class of entry. Patterns of mental health service use also differed by region, but showed that immigrants in Ontario from all world regions used less than their matched LTRs, especially for specialty mental health services.
Lower rates of mental health service use for newcomers have also been observed in other research [
16,
45‐
48]. One possible explanation for this finding is the healthy immigrant effect, which states that newly arrived immigrants exhibit (general and mental) health advantages over native-born persons [
49‐
54]. The healthy immigrant effect is likely due to multiple factors, including self-selection and screening prior to arrival. Selective migration has been raised as an explanation for the superior mental health of recent immigrants for almost one century [
55,
56].
For many immigrant groups and LTRs we found similar rates of initial contact with primary mental health care. This may be because in many countries primary care is the main contact for mental health services, as is the case in Ontario [
57,
58]. However, we also found that continued use of primary care was lower for almost all immigrant groups than LTRs. This may reflect that immigrants are more likely than others to become disengaged with western health services, perhaps due to culturally insensitive services, perceived over-willingness of physicians to provide pharmaceutical interventions, or recollections of physicians having a dismissive attitude and limited time in previous encounters [
45,
59,
60]. Early discontinuation of primary care services warrants attention since it may reduce the likelihood of patients’ needs being addressed in service that is the recommended contact point for mental health care in Ontario and other jurisdictions [
61,
62].
In contrast to primary care, in many countries specialty mental health services are minimally available [
57,
63]. Lack of familiarity with specialty mental health services as they are delivered in Ontario may have contributed to the consistently lower use of specialty mental health care [
64]. The exception was immigrants from industrialized countries (e.g., Australia, Denmark, England, France, New Zealand, etc.) who may be more accustomed to navigating mental health care systems that resemble those in Ontario (e.g., where insured mental health care is available following referral from primary care physicians who are the gate-keepers to specialized care) [
64,
65]. This familiarity may explain why newcomers from industrialized countries generally had higher estimates of intensity of use of these services. In fact, males from this region were the only immigrant group whose use estimates were not different from LTRs. These findings support a need to reduce health disparities among immigrants by engaging in active efforts to clarify the role of mental health services to those unfamiliar with such services, [
16,
60] especially since higher rates of initial contact with primary care services by some immigrant groups were not sustained.
In addition to variation in use related to type of service, patterns of use also varied depending on world region of origin. For example, newcomers from East Asia and Pacific showed relatively low estimates of use compared to LTRs, and those from Middle East and North Africa showed relatively high estimates of use. Within each region, a number of underlying system and personal factors may account for these results.
Regarding newcomers from Middle East and North Africa, other research has linked cultural practices and beliefs (e.g., health beliefs) to lower use in Asian immigrants [
20,
46,
47,
66,
67]. Common beliefs in the Korean and Chinese communities that mental health disorders are Western problems and demonstrate weakness may inhibit expressions of illness and help seeking [
57,
68,
69]. Corollaries of these beliefs are that newcomers from the East Asian and Pacific region may fear of being stigmatized by using Western health services and rely on informal support from strong familial and social networks [
46,
70,
71]. Present data showed lower rates of speaking English and French among immigrants from East, Asia and Pacific. This may also have impeded help-seeking by this region group. Limited English proficiency can contribute to less satisfaction and a reduced likelihood of following recommendations for treatment and follow-up visits [
72‐
75]. Another possible contributor to lower use by East Asian and Pacific newcomers is that in many countries in this source region the availability of specialty mental health care is limited, which may contribute to a lesser interest and familiarity with accessing speciality mental health services. In China, the ratio of psychiatrists per population is one-ninth of the ratio in Ontario [
76]. There is almost certainly variation in mental health service use patterns among newcomers from different countries in the same source regions, although this could not be measured. Finally, individuals from East, Asia and Pacific were more commonly admitted in the economic class, which has stringent entrance criteria linked to health and potential to contribute to the host country economy; this may have contributed to lower mental health need [
77].
In contrast to patterns observed among newcomers from East Asia and Pacific, this study found relatively high estimates of use of almost all services for immigrants from Middle East and North Africa. We speculate the reasons for this novel finding, since to the authors’ knowledge, no other potential reasons have been explored. Higher service use may reflect greater mental health need due to exposure to resettlement stressors (e.g., discrimination, unemployment) that appear more pronounced for this immigrant group. For example, Canadian unemployment rates for recent immigrants from Africa and the Middle East were higher than these rates for recent newcomers from other regions [
78,
79]. High levels of English or French language proficiency for this group may also have enabled access to care. Finally, persons from Middle East and North Africa may have higher needs because as our data indicate, individuals from this region were more commonly admitted as refugees than in other admission classes. Admission as a refugee is associated with the most lenient entrance criteria, permitting entrants to have greater mental health need at arrival [
77,
80]. Also, relative to other newcomers, refugees more commonly arrive as forced migrants who have had traumatic exposures, contributing to elevated rates of non-psychotic disorders, such as post-traumatic stress disorder [
10,
81‐
83]. Admission in this class has been linked to more mental health service use [
77]. Further investigation of prominent features and experiences among immigrants from varied source countries within the Middle East and North Africa region may help flag areas of potential vulnerability and contributors to high service use.
Present findings of heterogeneity in mental health service use among immigrants from different source regions aligns with research on general health disorders that has shown that both disparate health profiles [
49,
50,
52,
84‐
90] and disparate health service use [
91‐
93] among immigrants with different origins.
Strengths and limitations
This study takes advantage of linked provincial health service and immigration databases in a setting with a high portion of diverse newcomers. This linkage allowed for the examination of use of different types of mental health services for newcomers from the main wold regions compared to matched long term residents in the same setting. Theoretical frameworks [
10,
13,
94] and research on samples of immigrants [
14,
15,
83] acknowledge the far-reaching consequences of the pre-migration context on health and social factors related to mental health service use. They have noted potential drivers of differences across region groups (e.g., economy in the source region, family structure, ethnicity, etc.). However, to the authors’ knowledge, no empirical studies have systematically examined immigrants from the full range of source countries represented in a population. Our work described the differences among broad world regions by comparing them to standardized non-recent immigrant comparators. World region of origin is likely a proxy measure for the plethora of pre-migration factors that influence use, [
95] and its many underlying individual level factors need to be considered to make services more responsive to need.
The study also had a number of limitations. Given the numerous possible countries of origin, this study grouped people from geographically proximate regions together. This was done since these immigrants likely shared similar cultural and other characteristics that can affect service need and use. However, heterogeneity remained within groups and these region groupings did not allow for the examination of intragroup differences, or the identification of underlying factors that contribute to patterns of mental health service use observed for immigrants from each world region [
96]. Elucidating the drivers of service use patterns for newcomers is important since Canadian immigration policy and other factors contribute to variation in regional immigration patterns over time.
Another limitation is that while the CIC contains information usually not available in health service databases, some desired information (e.g., mental health need, ethnicity, or use of alternative supports such as traditional folk medicine) [
60] was not available. Since service use does not correspond to need, without further data we do not know if more limited use of services by immigrant region groups was linked to more unmet need, or no need for further services [
16]. In addition, since this study focused on immigrants and comparators in the general population to help provide a meaningful comparison. Given this approach, analyses could not examine the impact of immigration related variables on immigrant mental health service use that likely accounted for the differences in service use related to world region of origin to elucidate drivers of observed patterns.
Similarly, data on use of Community Health Centres (CHCs) in Ontario could not be included. Although CHC clients have direct access to mental health community-based services without physician referrals, since CHCs serve a relatively small proportion of the Ontario immigrant population (1.4 %), [
97] their exclusion likely did not significantly bias results.
The study also did not include immigrants who entered Ontario from a different province; refugee claimants who had not been accepted or were appealing; other temporary residents/workers/visitors; or ‘non-status’ residents. By erroneously attributing mental health care use by immigrants who were not included to LTRs, this study could have been biased against finding differences between immigrants and LTRs. However, the large sample of immigrants included in this study and the smaller relative size of excluded newcomers [
98] suggests that results were not strongly affected by this limitation.
Finally, the study’s cross-sectional design was a limitation. Since we examined mental health care use during a snapshot in time rather than following immigrants across time, we could not establish causation between world region and mental health service use.
Acknowledgements
Drs. Steele and Glazier are supported as Clinician Scientists in the Department of Family and Community Medicine at the University of Toronto and at St. Michael’s Hospital.
Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.
This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
The project was conceived by Anna Durbin, and Richard Glazier. Rahim Moineddin assisted Ms Durbin and Dr. Glazier with the development of the study design. Anna Durbin conducted the statistical analysis with advisement from Dr. Rahim Moineddin. All authors discussed how to present the study, data interpretation, and implications of this work. Anna Durbin drafted the manuscript, with input from all authors who also approved the final version of the manuscript and tables/figures for publication.
Dr. Anna Durbin is a Research Associate at the Canadian Mental Health Association Toronto, Email: anna.durbin@gmail.com.
Dr. Rahim Moineddin is an Associate Professor at the Department of Family and Community Medicine at the University of Toronto and a Scientist at Institute of Clinical Evaluative Sciences. Toronto, Canada. Email: rahim.moineddin@utoronto.ca.
Dr. Elizabeth Lin is an Associate Professor at the Department of Psychiatry at the University of Toronto and a scientist in the Provincial System Support Program, Centre for Addiction and Mental Health, Toronto, Canada. E-mail elizabethbetty.lin@camh.ca.
Dr. Leah S. Steele is an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto and a scientist in the Department of Family and Community Medicine and Keenan Research Institute of the Li Ka Shing Knowledge Centre at St. Michael’s Hospital, Toronto, Ontario. She is an Adjunct Professor at the Institute of Clinical Evaluative Sciences, Sunnybrook Hospital. Toronto, Canada. Email: lssteele@gmail.com.
Dr. Richard H. Glazier is a Professor in the Department of Family and Community Medicine at the University of Toronto and St. Michael’s Hospital. He is also a Scientist at the Centre for Research on Inner City Health in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and a Senior Scientist at the Institute for Clinical Evaluative Sciences, Sunnybrook Hospital, Toronto, Canada. Email: rick.glazier@ices.on.ca.