II Quick Methodology
III Key Highlights of the Report
IV Implications for Health Promoters and Other Service Providers
VII Key Resources
--submitted by Liz Corson, Toronto Public Health
As of 2006, half of Toronto’s residents were born outside of Canada.  Half a million immigrants and refugees settled in Toronto between 2000 and 2009 , and many others arrive each year as temporary residents, or live in Toronto without recognized immigration status.
Newcomers to Toronto bring many strengths and assets that enrich the city. These include high levels of education, professional experience and skills, cultural diversity and new and innovative perspectives. These assets help make Toronto a vibrant and prosperous place to live. An additional and very important asset that newcomers bring is their good health. After their arrival, however, there are many aspects of life in Toronto that affect their health and well-being. Research shows that after settling in Canada, newcomers lose their health advantage over time.
In order to effectively promote and sustain the health and well-being of newcomers in Toronto, planners, policy makers and service providers need timely and relevant information on the health status, health needs and determinants of health for this population. Toronto Public Health (TPH) and Access Alliance Multicultural Health and Community Services (AAMHCS) undertook research on this topic in order to better understand the health status and health needs of recent immigrants and refugees, populations that both organizations serve on a daily basis. The results of this work are featured in the report, The Global City: Newcomer Health in Toronto.
II Quick Methodology
The Global City brings together new and existing evidence related to newcomer health. Findings presented here draw from many data sources including:
- a review of academic and unpublished literature on newcomer health
- an analysis of existing health and socio-demographic data sources
- focus groups with local service providers, newcomers who use health services and researchers.
For the purposes of this report, “newcomer” is defined as someone who was born outside of Canada and who migrated here within the last ten years.
The project’s findings provide insight into how to best maintain, promote and improve the health of newcomers to Toronto. This knowledge is essential for policy makers, service providers and advocates.
III Key Highlights of the Report
Socio-Demographic Profile of Newcomers to Toronto
Largely as a result of immigration, the ethno-racial, cultural and linguistic composition of Toronto is continuously changing:
- Since the 1970s, the principal source region for immigrants to the city has shifted from Europe to Asia. Between 2001 and 2006, the top source countries for permanent residents to Toronto during this period were China, India, Philippines, Pakistan and Sri Lanka. 
- 81% of newcomers (arrived 2001–2006) identify themselves as members of a racialized group (visible minority). 
- While 90% of newcomers report knowledge of English or French, most newcomers speak a language other than English and French most often at home. 
- Immigrants are, on average, younger and have more children that the Canadian-born population. While immigrants make up 50% of Toronto's population, 66% of all births in Toronto in 2006 were to immigrants. 
The changing composition of the newcomer population may affect access to and use of existing health services while also increasing the need for services that are responsive to cultural and linguistic diversity. At the same time, newer and emerging communities may have unique health issues and needs.
Health Status and Needs
National and provincial research points to the idea that newcomers are healthier, overall, than Canadian-born residents. This health advantage is often referred to as the “healthy immigrant effect.” But a large body of research has shown that, after settling in Canada, immigrants lose this advantage over time. The rates of some health issues among immigrants increase until they equal or exceed rates seen in the Canadian-born population.
Local evidence supports the existence of a newcomer health advantage and subsequent decline. Research also shows that there are many differences among sub-populations of immigrants, and this trend does not apply to all areas of health. There are important exceptions to the health advantage, and the health of some groups of immigrants declines more quickly than others. The diversity of newcomers who settle in Toronto leads to a complex picture of the health status of this population.
The evidence outlined in The Global City illustrates that, compared to Canadian born residents and longer-term immigrants, newcomers are:
- Less likely to have several key risk factors for chronic disease, such as being overweight or obese, smokers, or heavy drinkers.
- Less likely to have or to die from some specific chronic diseases, including cancer, heart disease, and respiratory disease.
- Less likely to have a premature baby and more likely to breastfeed for up to six months.
- More likely to have positive self-reported mental health status, as well as lower rates of several self-reported mental health and addiction issues including depression, mood and anxiety disorders, suicidal thoughts and alcohol dependence.
- Less likely to be physically active in leisure time and similar in terms of dietary risk factors.
- More likely to have some chronic health conditions, particularly among certain newcomer sub-populations. For example, rates of diabetes are higher among immigrants from South Asia, the Caribbean, Latin America and Sub-Saharan Africa.
- More likely to suffer from some communicable diseases such as Tuberculosis (TB) and HIV/AIDS, particularly newcomers from regions endemic to these diseases.
- More likely to have a low birth weight baby and less likely to exclusively breast feed their babies.
Overall, newcomers' self-reported health declines over time and certain sub-populations of newcomers are more likely to report poorer or worsening health, including women, older immigrants, low-income immigrants and refugees. Research has also shown that rates of chronic diseases are higher among longer-term immigrants compared to more recent immigrants.
The health status of newcomers differs based on many characteristics, such as their age, gender, region of origin, ethno-racial identity, and immigration status. Some of these differences are discussed in more detail in The Global City report.
Access to Health Services
Access to quality primary and preventive care is important for maintaining good health. Research shows that newcomers are
- Less likely to access primary and preventive care, particularly those who experience language barriers, older men and women, those without health insurance, and those without immigration status.
- Less likely than longer-term immigrants to have a regular family doctor.
- Less likely than Canadian-born residents to have visited a dentist recently or to have had cervical or breast cancer screening.
Local stakeholders have identified a number of specific newcomer health needs that are not being met:
- mental healthcare and services
- perinatal care
- dental care
- services and care not covered by the Ontario Health Insurance Plan (OHIP)
- sexual health services
- nutrition and recreation programs.
Local stakeholders also identified a number of barriers that affect newcomers’ access to health services:
- cost and eligibility, particularly with respect to health services not covered by OHIP
- lack of awareness of services and difficulties navigating the healthcare system
- inadequate language interpretation and lack of cultural competency among service providers
- long wait times
- stigma related to issues such as mental health and HIV/AIDS
- transportation difficulties.
In some cases, these barriers may lead newcomers to forgo or delay care, which can lead to more serious health problems and increased future costs to the health system.
Obtaining healthcare is especially difficult for newcomers who are not eligible for OHIP or for the Interim Federal Health Program (which covers refugees and refugee claimants). Permanent residents in Ontario must wait three months before they are eligible for OHIP; local stakeholders have frequently identified this waiting period as a significant and unfair barrier. Newcomers without status also lack OHIP coverage and face many other serious barriers to accessing healthcare as a result of their precarious situation, fear of deportation and the possibility of being denied services.
Social Determinants of Health
Many different social, economic and political factors influence the health of Toronto’s newest residents. Among the top issues facing newcomers are those related to income and employment. After arriving in Canada, many newcomers experience systemic barriers to employment and income security that impact their health and also hinder their access to services. In spite of the fact that newcomers are highly educated overall, many are under-employed or working in jobs that are unrelated to their experience and qualifications. Newcomers face a particular set of barriers to finding secure and stable jobs, including lack of what is often referred to as "Canadian experience”, non-recognition of foreign credentials and discrimination.
While newcomers make a crucial contribution to Toronto’s economic prosperity, many struggle to realize their full economic potential:
- In 2005 46% of newcomers (less than 5 years since arrival) in Toronto were living in low-income households, compared to 23% of more established immigrants and 19% of the Canadian-born population. 
- In 2009, the unemployment rate for newcomers (less than 5 years since arrival) in the Greater Toronto Area was 19%, compared with 9% unemployment for the total city. 
- Levels of poverty and unemployment tend to be greater for certain sub-populations of newcomers, including some ethno-racial groups, women and refugees.
Additional important determinants of newcomer health discussed in The Global City are race-based discrimination, education, language proficiency, transportation, and family and social support networks.
IV Implications for Health Promoters and Other Service Providers
The findings of The Global City report have important implications for health service providers, some of which are highlighted here:
- Most newcomers arrive in good health and bring considerable health knowledge and healthy behaviours with them. Ways in which newcomers can maintain a healthy lifestyle while also adhering to religious beliefs and cultural practices should therefore be acknowledged and promoted. For example, health promotion initiatives could feature stories of newcomers who have successfully adapted and integrated their positive health behaviours into their new lives in Toronto.
- Our findings underscore the need to expand and coordinate efforts across the health, settlement and other sectors to advocate for policy changes that promote the social and economic inclusion of newcomers. The direct engagement of newcomers can improve the effectiveness of outreach, research and advocacy efforts, while also helping participants to expand their knowledge, skills and social networks.
- Efforts to improve access to health services may include increasing points of access (e.g., in schools, settlement agencies, workplaces and places of worship), connecting newcomers to primary and preventative care within the first months of arrival, as well as better coordination and integration between health and settlement services.
- Increasing the cultural competency among service providers and providing professional language interpretation are essential components of effective health service delivery, outreach and public health programming for newcomers.
- “One-size fits all” approaches to addressing the health needs of newcomers are unlikely to be effective given the diversity of this population. It is therefore important to tailor programs, services and outreach strategies to the needs of specific sub-populations whenever possible and to use a client-centred approach that recognizes and responds to the unique needs of diverse individuals and families.
In conclusion, the health needs of newcomers are different from those of Canadian-born populations and migration and settlement experiences may significantly impact health. In order to promote and sustain the health of newcomers, health and settlement services need to coordinate with each other to meet their diverse needs. TPH, AAMHCS and many other local organizations are working to improve service access and health outcomes for newcomers and longer-term immigrants. However, more work remains to be done in order to meet the health needs of newcomers in Toronto and to provide the necessary conditions and supports that will enable newcomers to stay healthy and to fulfil their potential.
- Statistics Canada, 2006 Census of Canada
- Citizenship and Immigration Canada. (2010). Canada facts and figures 2009: Immigration overview, Permanent and temporary residents. Ottawa, ON: Research and Evaluation Branch, Citizenship and Immigration Canada.
- Toronto Community Health Profiles Partnership (TCHPP). (2010). Births to women born in a country other than Canada, 2006. Source: Office of the Registrar General of Ontario (ORG) Live Birth Database. Toronto, ON: TCHPP. Available at: http://www.torontohealthprofiles.ca/a_documents/TM_allCateg_maps/TM_maps...
- Statistics Canada, Labour force estimates by Immigrant Status, Greater Toronto Area, Ontario 71F0004XVB.2010 Table - 102.ivt, 2010
VII Key Resources
For more information, more references, and data sources, please see the full The Global City report at http://www.toronto.ca/health/map/pdf/global_city/global_city.pdf.
Toronto Newcomer Initiative: http://www.toronto.ca/newcomer/
Access Alliance: http://accessalliance.ca/
Toronto Public Health's Surveillance and Epidemiology Site: http://www.toronto.ca/health/map/index.htm
Toronto's Immigration Portal: www.toronto.ca/immigration/