Ethnicity and mental health: Conceptualization, defi nition and operationalization of ethnicity from a Canadian context

DE Clarke, PhD (1-4); A Colantonio, PhD (3-6); AE Rhodes, PhD (2,3,7-9); M Escobar, PhD (3)

Abstract relevance. Much of the existing studies in this area were conducted in the United The current study provides a critical review of Canadian studies on ethnicity and mental States (US)10-15 and the United Kingdom health with respect to the definition, conceptualization and operationalization of ethnicity. (UK),16-19 which has uncertain applicability It provides a discussion on the methodological issues related to these factors and their to Canada. The political, social and implications to guide future research and enable comparability of results across studies. economic ramifications associated with Sociological Abstracts, PsycINFO, MEDLINE and CINAHL were used to identify relevant ethnicity or ethnic identity, likely differ Canadian articles published between January 1980 and December 2004. The review from country to country. Differences in highlights a number of key issues for future researchers to consider such as the need for: the countries’ ethnic compositions, his- 1) clear rationales as to why ethnicity is important to their outcome of interest; 2) clarity tories of immigration policies and racism/ on the definition of ethnicity, which affects its conceptualization and operationalization; slavery and ethnic or racial categorizations 3) a theoretically driven conceptualization of ethnicity, which should be related to the hinder cross-country comparisons. The research question of interest; and 4) clear rationales for the decisions made regarding the history of slavery and segregation has a data source used, the operationalization of ethnicity, and the ethnic categories included great deal of meaning for ethno-racial in their studies. groupings in the US.2 Furthermore, the US is seen as a society that assimilates immi- Key words: ethnicity, ethnic origin, culture, race, mental health grants by the “melting pot” phenomenon, in which the immigrants are expected to Introduction systemic inequalities, including access to adapt to the American way of life rather educational and employment opportunities, than retaining their culture.3 Canada has Canada’s immigrant population originates housing, health and mental health care, are not had the same history of racial from all over the globe with increasing still evident across ethnic groups,7,8 which segregation and is viewed as a mosaic in numbers from Africa, Asia, the Caribbean, can impact the mental health of the popula- which immigrants are encouraged to and the Middle East (i.e. visible minori- tion.2,9 For instance, Aboriginal peoples con- retain their unique cultural background ties).1 Its culturally diverse Aboriginal tinue to have poorer mental health compared while partaking in the greater Canadian population adds to the ethnic mix.2 Canada to the general population and, along with society.3,6,20 Also, Latin Americans com- prides itself on being a multicultural society visible minorities, have ongoing difficulties prise a larger component of the US by acknowledging the right of every person accessing culturally sensitive mental health immigrant population than Canada’s.2,3 to identify with his/her cultural background care.9 Better understanding of the relationship while partaking in the Canadian way of between ethnicity and mental health is The time of arrival and ethnic composition life.3-6 This was advocated in its 1971 compelling and highly relevant for policy- of the immigrant population in the UK and legislated policy on multiculturalism, which makers and mental health practitioners in Canada also differ. Up to 1962, citizens of emphasized fair treatment of everyone, the Canadian context. previously colonized countries such as regardless of race, colour or ethnicity; Jamaica and India (countries that remained particularly in terms of educational and Canadian literature on ethnicity and within the Commonwealth) were granted occupational opportunities.3-6 Evidence of mental health is quite limited despite its open access and actively recruited for

Author References 1 Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 2 Department of Psychiatry, University of Toronto, Toronto, Ontario 3 Graduate Department of Public Health Sciences, University of Toronto 4 Toronto Rehabilitation Institute, Toronto, Ontario 5 Department of Occupational Science and Occupational Therapy, University of Toronto 6 Department of Rehabilitation Sciences, University of Toronto 7 Suicide Studies Unit, St. Michael’s Hospital, Toronto, Ontario 8 Inner City Health Research Units, St. Michael’s Hospital 9 Institute for Clinical Evaluative Sciences, Sunnybrook & Women’s College Hospital, Toronto, Ontario Correspondence: Diana E Clarke, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Room 802, 624 N Broadway, Baltimore, MD 21205, Tel : (410) 955-0416, Email: [email protected]

Vol 28, No 4, 2008 128 Chronic Diseases in Canada immigration to the UK.21 During this time, Canadians; 3) involved more than one permanent.”20,76,81-85 Accordingly, the indivi- Canada’s immigrant population came ethnic group; 4) were published between dual’s identity includes the biological, primarily from Europe, the UK and the January 1980 and December 2004; and 5) cultural, political and economic conditions US.22,23 Post-1971, when the UK changed were quantitative in nature. of the group into which s/he is born, be it its immigration act, the majority of its dominant over, or dominated by, other immigrant population originated from General review articles and chapters on the groups.20,78,81,84 A softer primordialist view Europe and South Africa,21 while the theories and definition of ethnicity, not stresses the social and non-biological basis majority of Canada’s immigrants came specific to Canada, were used to provide an of ethnicity, acknowledging that ethnic from Asia, Africa, the Caribbean, Latin overview on the definition and conceptua- identity can also be socially constructed America and the Middle East.23-26 These lization of ethnicity. As well, they guided and based on “the circumstances at hand” points indicate that results based on UK the critique of the identified studies on thereby being “situational not biological” and/or US data might not be applicable to ethnicity and mental health reviewed and “flexible not fixed.”81 The constructivists Canada. herein. Articles on ethnicity and immigration view ethnicity as “a social construction policies specific to Canada were used to with ecological and social factors being its With respect to the operationalization of provide historical context to facilitate key determinants.”12,24-26 Kaufman85stated ethnicity, variations exist across the understanding of the ethnic composition of that distinction between the two perspectives literature on ethnicity and mental health. the Canadian population over time and its is artificial, so the definition of ethnicity Lack of a clear definition of ethnicity and impact on the studies reviewed. should include a synthesis of both. Hence, ongoing debate regarding how the variable the underlying theme is that ethnicity should be conceptualized might account involves sharing of a common culture, for this.27,28 Other factors such as data Results which may be based on a combination of source used, feasibility, time period of data factors such as language, religion, national collection, region of study and sample size After all duplicates were removed, 49 identity, customs, social and/or political also affect the operationalization of the empirical quantitative studies that involved position within a country’s social system.81 variable. To date, there is no seminal two or more ethnic groups were identified Canadian paper that discusses the metho- and included in this review (Figure 1) and dological issues related to the definition, summarized in Appendix 1. Twenty-seven 2. Conceptualization conceptualization and operationalization studies2,5,29-53 were based on population or of ethnicity and their implications, to guide community surveys with secondary data There are two major perspectives on how future research and to enable comparability analysis, 12 were smaller studies using non- ethnicity is conceptualized: 1) ethnic across studies. This paper provides a clinical samples54-65 and 10 were smaller identity which refers to self-identification critical review of the original empirical studies based on clinical/specialized with particular cultural group/s,20,76,80,81 or Canadian studies on ethnicity and mental samples.66-75 The year and region of 2) ethnic origin which refers to classification health with emphasis on these issues. A publication, sample size, ethnic groups due to the ethnic or cultural groups to general overview of the definition and included and critique regarding the which the individual’s ancestors belong.20 conceptualization of ethnicity is first pro- definition of ethnicity are outlined in Specific cultural traits such as language, vided to guide the review process. Appendix 1. surnames, or region of birth were used as Quantitative studies involving population- proxies for ethnic origin in some studies. based data with more than one ethnic group are highlighted. Discussion From a Canadian perspective, the country’s policy on multiculturalism, which has 1. Definition guided government policies since 1971 and Methods advocated for individuals to retain their The lack of consensus on the definition of ethno-cultural background,8 dictates that The bibliographic databases Sociological ethnicity20,76-80 was reflected in the 49 ethnicity comprised “ethno-cultural parti- Abstracts, PsycINFO, MEDLINE and included Canadian studies on ethnicity and cularism” and adherence to Canadian CINAHL were used to identify relevant mental health,2,5,29-75 which failed to “values.”76 This is reflected in the con- original empirical studies that were explicitly define the variable. There are two ceptualization of ethnicity across national quantitative in nature for this review with major perspectives on how ethnicity surveys, which forces participants to the application of Group 1 and 2 search emerges: the primordialist and constructivist identify with their ancestral background terms outlined in Figure 1. Studies were views.20,76,81 Traditional primordialists view regardless of time in Canada. As well, this included if they: 1) concerned ethnicity ethnicity as “an ascribed status, given at policy accounts for the designation of all and mental health; 2) involved data on birth, that is more or less fixed and non-Aboriginal persons who originate

Chronic Diseases in Canada 129 Vol 28, No 4, 2008 alth FIGURE 1 FIGURE Results of the search strategies used across bibliographic databases to identify Canadian literature on ethnicity and mental he databases to identify Canadian literature bibliographic used across strategies Results of the search

Vol 28, No 4, 2008 130 Chronic Diseases in Canada from Africa, Asia, the Caribbean, Latin A major weakness with self-identification belong?” has been used to capture ethnic America and the Middle East, “who are of ethnicity is that it is based on the origin.90,91,84,95 This method of conceptualiza- non-Caucasian in race or non-white in individual’s perception, which may change tion is reportedly more objective and colour” as visible minorities.1,3,6 from situation to situation and over time produces well-defined ethnic groups that and likely produce different results are representative of the population, but Conceptualization based on Ethnic depending on the time and research fails to capture level of adherence with Identity question being investigated.27,28 This cultural ideologies or customs.27,92,93 possibly accounted for the lack of Ethnic identity can be internal or external.20,78 conceptualization of ethnicity based on Conceptualization of ethnicity based on Internal ethnic identity refers to the ethnic identity across studies, with the ethnic origin was observed in some individual’s self-identification with specific exception of the respective studies of De Canadian studies on ethnicity and mental ethnic group/s.78,86,87 This conceptualization Wit et al.,40 De Wit and Beneteau,41,42 and health, particularly those that used national reflects the individual’s level of adherence Feldman et al.43 De Wit et al.40-42 conducted or regional survey data,2,5,31,32,35,46-48,52 to and identification with the values, secondary data analysis on the 1990 including the National Population Health customs and ideologies of a particular Ontario Health Survey in which respondents Survey (NPHS),90 Canadian Community culture,87 which can be internally or were asked to select up to four ethnic Health Survey (CCHS),91 National externally driven.78,86-89 Individuals may categories that matched their “ethnic or Longitudinal Survey of Children and Youth choose to identify with particular ethnic cultural identity.” De Wit and Beneteau41,42 (NLSCY),94 National Survey of Giving, group/s because of their belief in the further utilized information on the primary Volunteering and Participating (NSGVP)95 customs, norms and ideologies and the language that respondents used at home to and the 1971 Aging in Manitoba (AIM) meaning such identification gives to their help “better identify ethnic groups.” If survey.31 Each survey inquired about the life (i.e. internally driven). However, respondents identified French or French- ethnic or cultural group/s of the individuals’ circumstances in the individuals’ external plus other ethnic groups but did not select ancestors and provided a list of ethnic environments, such as discrimination based French as their primary language they categories to enable multiple choices.90,91,94,95 on ethnicity and the feeling of being were reclassified as Anglophones41,42 This acknowledged the existence of multi- different from the ethnic majority, may indicating externally driven classification ethnic groups, which are typical of cause some to self-identify with particular of ethnic identity. This externally driven Canada,8 and improved the reliability of ethnic groups because of the sense of classification of ethnic identity might have the groups identified.27 Reflective of the solidarity and belonging they may garner been in conflict with the individual’s true emphasis of the country’s multiculturalism from such groups (i.e. externally ethnic identity. If level of adherence to policy, survey respondents who identified driven).78,80,87 particular cultural values, customs and themselves as “Canadian” were required ideologies are important in the individual’s to select their ancestral origin even if they Since external ethnic identity relates to perception of, and subsequent likelihood were Canadian-born. categorization by others based on the to acknowledge, discuss or report a mental person’s nationality or ethnic origin and health condition, and this is a key issue Specifi c Cultural Traits as Proxies for does not reflect the individual’s adherence being investigated, then the use of ethnic Ethnic Origin to and/or identification with specific identity would provide more appropriate culture/s,15 it is discussed in the context of information. Feldman et al.43 used the One might assume that studies utilizing ethnic origin in the ensuing section. Such item, “Please write down the term that data from surveys in which ethnicity was external assignment of ethnicities to best describes the ethnic character of your based on ethnic origin would conceptualize individuals by the dominant society might everyday home environment,” which ethnicity accordingly; however, this was conflict with their subscription and implies an ethnic identity conceptualization not the case. Ali5 and Ma47 used country of adherence to particular ethnic groups and of the variable. birth in thinking about ethnicity despite is potentially distressing. This was utilization of the CCHS91 and the NLSCY94 illustrated by Mahtani6 in her interview Conceptualization based on Ethnic data respectively, both with specific with Canadian-born visible minority Origin ethnicity questions. The rationale for using mixed-racial women who often feel forced country of birth rather than responses to by the ethnic majority to identify their Ethnic origin refers to categorization of the ethnicity questions was not provided ancestral background when asked about individuals into ethnic group/s based on but likely due to the use of public-use data. their ethnic identity (i.e. by the question, ancestral origins.78 The question “To which Public-use versions of Canadian national “but where are you from?”). ethnic or cultural group/s do your ancestors surveys are readily available to researchers

Chronic Diseases in Canada 131 Vol 28, No 4, 2008 but are stripped of unique identifying descent,57 and these individuals were more scale. Ethnicity refers to mutual cultural information and lack the detailed informa- or less likely to have depression, their characteristics such as religion, language, tion on ethnicity and culture available in exclusion would have biased the results customs, and ancestry,20,76,78 but race refers the restricted-use versions. obtained. Bagley58 also used surnames and to common physical characteristics.28,65,78,86- language, but in combination with an 101 Winker,28 Williams77 and LaVeist97 Penning32 utilized the Social Change in unspecified “ethnicity” question to con- stressed the importance of differentiating Canada Survey (SCCS) data, in which ceptualize ethnicity. Surnames were race from ethnicity or culture. Race is a country of birth was used to determine initially used to identify Chinese elderly poor proxy for ethnicity despite overlapping ethnicity. Ascertainment of ethnicity based persons living in Calgary, Alberta, with features28,97 and is questionable as its sole on country of birth in the study pinpoints follow-up phone calls by the study recruiters indicator in respective studies by Fry and an inherent limitation with conducting who identified eligible Cantonese-speaking Grover54 and Devins et al.74 secondary data analyses where one has to individuals and inquired about their make do with whatever variables are ethnicity. This combination of factors Wu et al.2 used ethnic origin and racial available. With this in mind, it is still overcame the shortcomings of using background to create ethno-racial groups. important to mention that with increasing surnames alone. This enabled the identification of visible global industrialization and migration it minority groups2 and acknowledged the has become inappropriate to use country/ Walter37 and Dion59 used language as a argument that power and status differences region of birth as the sole indicator of proxy for ethnicity, which might have also exist across racial groups.77 This is ethnicity. Individuals might have been accurately classified some ethnic groups important since “the dominant or minority born in one country to parents from but not others (e.g. Chinese for individuals status of the group mirrors its position another country, spent only a few years in who specified Chinese dialect). The within the stratification system of the that country and returned with their English-speaking population is ethnically larger society,”101 which in turn affects parents to the countries of their ancestral heterogeneous, with English being the access to social, political, and economic background thus choosing to identify with primary language for many countries, so resources.3,4,101 The authors2 explained that their ancestral culture. Therefore, country/ treating the group as homogenous is their ethno-racial groups reflected the region of birth, also utilized by Ali,5 Barnes erroneous.59 Also, although French and social stratification of the Canadian society et al.,35 Ma,47 Cohen and MacLean,51 Spanish are primary languages for France (i.e. the vertical mosaic),2-4,7,8 which Rousseau et al.53,61 and Aubert et al.,65 and Spain respectively, they are also the provided a context that facilitated inter- would inaccurately classify such indivi- primary languages for some countries in pretation of results obtained. The vertical duals. Most countries are comprised of the Caribbean and Africa. The assumption mosaic refers to the hypothesis that ethnic many ethnic groups and most ethnic that all individuals who endorsed these groups are differentially integrated in the groups can be found to have many different languages are of European descent would larger Canadian society based on histories countries of birth. Country of birth as a be inaccurate.59 Different ethnic groups of immigration policies that were linked to proxy for ethnic origins fails to capture may speak the same language or there may changing industrial and employment such complexities and likely misclassifies be language differences within ethnic demands over time.2-4,7,8 This differential some people. This does not negate the use groups, which would not be captured with integration into the Canadian society of country/region of birth as a proxy for language as the sole proxy for ethnic affected the groups’ socioeconomic ethnicity but it underlines the need for origin. status,2-4 which is significantly associated detailed discussions of the inherent limita- with mental health outcomes. tions of its use and implications for the Ethnicity, Race or Ethnicity plus Race interpretation of subsequent results. Summary In examining the studies by Weekes, et Language and surname were proxies for al.71 and Cohen and McLean,51 respectively, The identified studies appeared to have ethnic origin in some studies37,54-59 but are it became apparent that categorization was conceptualized ethnicity on the basis of susceptible to misclassification of some based on race, despite the use of the term ethnic origin by using ethnicity questions, individuals. The utilization of surnames to “ethnicity”. Also, the researchers51,71 cultural traits as proxies for ethnic origin, identify ethnic groups by Dion and implied that race and culture were the or a combination of ethnic origin and racial Giordano57 in their investigation of ethnic same concepts despite numerous theoreti- background. For some studies, although difference in depression in university cal articles indicating otherwise.28,76-79,85-99 the term “ethnicity” was used it was students in Toronto, failed to correctly To illustrate, Cohen and McLean51 utilized unclear how it was conceptualized and as- classify non-white/non-Caucasian indivi- data from the 1999 General Social Survey certained.30,33,34,54,55,70,75 The intrinsic weak- duals with non-ethnic last names. If (GSS) in which respondents were asked nesses of using proxy measures such as specific ethnic groups were more likely to about their “cultural or racial back- country of birth, language or surnames have individuals with non-ethnic sur- grounds”96 and Weekes and colleagues71 underline the need for ethnicity to be names, for example Blacks from the expressed interest in examining the ascertained using rigorously tested and Caribbean and South Asians of Christian “cultural sensitivity” of their outcome validated questions. Questions aimed at

Vol 28, No 4, 2008 132 Chronic Diseases in Canada capturing ethnic identity or ethnic origin 57% of immigrants in 1970 but only 20% Canada to fill the demands for laborers are unable to tell which aspect of ethnicity in 1996.22,105 Changes in the ethnic and farmers.66,102 Studies conducted in the individual brings forward in response composition of the immigrant population Western Canada (e.g. Manitoba,31,35,70 during an interview and whether this occurred gradually with small numbers Alberta66 and the Northwest Territories67) might be affected by the interviewer and/ from Africa, Asia, the Caribbean, Latin were likely to have significant representation or by the specific question being asked.76 America, and the Middle East initially of British, European, North American and This highlights the need for clear and before their proportions increased Aboriginal ethnic groups but almost no theoretically driven rationales for studying significantly over time.22,24,25,102,105,106 This representation of visible minority groups. ethnicity across mental health outcomes. was reflected in the 3 to 5% representation of these immigrants in Canada up to the Later immigrants from Asia, Africa, the 1980s compared to their 73% representation Caribbean, Latin America and the Middle 3. Operationalization between 1996 and 2001.107 Variations in the East were more likely to settle in Montreal, proportions of these immigrant groups Toronto and Vancouver102,108 because of The operationalization of ethnicity is relative to each other and to immigrants their perception of better employment important for interpretation of study from Britain, the US and Europe were opportunities that corresponded to their results and enabling cross-study compari- reflected in studies conducted with skills and educational background.102 son. However, variations existed in the ethnicity data collected over the years. Supportive data showed that only 58% of operationalization of ethnicity across Earlier studies had little or no visible recent immigrants settled in these areas in studies. Even studies that utilized the minority groups29,31,35,66,67 but their numbers 1981 but the percentage rose to 78% by same data sources and conceptualized increased in later studies.2,5,35,38,43,46-49,53,61-63 2001.102 Recent studies based on data that ethnicity similarly operationalized the Whether these groups were kept as includes these three regions had varying variable differently. Factors that influenced separate categories depended on the proportions of visible minority this included diversity of the study outcome of interest and the nature of the ethnicities.2,5,32,43,44,46-51,53-55,57-63,65,72,74,75 population, time period and region of data study (i.e. secondary data analysis using Reliance on public-use data prevented collection, sample size restrictions and public-use data that lacked detailed examination of very specific ethnic purpose of the study. The effects of these ethnicity information). In the investigation categories because of the inaccessibility of issues are discussed in the ensuing of rare outcomes, such as some mental such detailed information. sections. health conditions, small sample sizes for specific visible minority ethnic groups The Purpose of the Research Study Time Period of Data Collection and resulted in them being collapsed into a Study single category, which likely failed to As seen in the respective studies of Barnes capture the individuals’ perception of their et al.,35 Lavallee and Bourgault, 45 Seltzer Time period of data collection and study ethnic identity. This also limited the and Langford,67 and others,29,30,34,37,50,51,58,61,64 influenced the operationalization of interpretation of the results of such ,66,69,70,73,75 there is flexibility in whether ethnicity across studies. Time period of studies. broad or specific categories are used when data collection is related to changes in the operationalizing ethnicity in descriptive or immigration policy over time, which were Region of Data Collection and Study enumerative studies as long as they reflect influenced by economic changes that the ethnic composition of the population dictated labour shortages and the need for Variations in settlement patterns of under investigation.20 However, the use of immigrants to fill specific employment different ethnic groups in Canada resulted specific ethnic categories is more opportunities.20,102 Canada’s earlier in different ethnic compositions across informative.20 For analytic studies, opera- immigration policy was based on national geographic regions. This affected the tionalization of ethnicity needs to be origin and gave preference to immigrants operationalization of ethnicity as it relates theoretically driven to provide a framework from Britain, Europe and the US to fill to the region of data collection and study. for the analyses and interpretation of the such occupational demands.22,25,103-105 Settlement patterns of immigrant groups results.20 Operationalization of ethnicity in Hence, immigrants from these regions have always been related to the location of the analytic studies reviewed in this represented approximately 95% of employment opportunities, which were paper2,5,31,32,36-43,45-49,52,58,59,75 appeared to be Canada’s immigrant population up to dictated by economic changes over based on the social stratification system in 198622,25 and studies using data collected time.78,102 Earlier immigrants from Britain, Canada, though not always explicitly at this time had little or no representation Europe and the US106 came to Canada in stated. of other ethnic groups.29,31,32,35,66,67 response to the rapid expansion of the Canadian West with integration of the Studies interested in examining the mental The 1967 change to a universal point region with the domestic and world health status or outcome in specific ethnic system was the force behind the increased markets and international demand for groups tended to be clear in their selection ethnic diversity of the Canadian population, wheat.78 Therefore, many earlier and ascertainment of those groups but with European immigrants comprising immigrants settled in rural areas of Western often aggregated all other ethnic

Chronic Diseases in Canada 133 Vol 28, No 4, 2008 groups.30,31,33,34,36,38-42,44,45,51,54,61,67-71 For example, across groups. It further implied that either European group. These factors affected the Fry and Grover54 were interested in the ethnic categories included in the study ability to compare the results of the two examining mental health outcomes in were culturally similar to each other yet studies. Asians compared to Caucasians and different from Aboriginal peoples or that therefore only included these groups. the individual ethnic groups that comprised Understanding the mental health of Liban and Smart,30 Tonkin,34 Beiser et al.,39 each broader ethnic category were Canada’s immigrant population in terms Borzecki et al.,68 Tcheng-Laroche and culturally similar but the individual ethnic of depression and alcohol dependency was Prince33 and Dewit and Beneteau,35,42 in groups that comprised the broader the aim of the study by Ali.5 Ethnic their studies, were mainly interested in the Aboriginal category were too culturally differences were examined as a secondary mental health of Native Indians30,34,39,68 and dissimilar to be combined. objective in the immigrant group only.5 Francophones33,41,42 respectively and Using region of birth, the ethnic groups therefore selected these groups specifically Penning32 included similar ethnic groups examined (i.e. US/Mexico, South and while aggregating all other ethnicities in as Havens and Chappell31 in examining the Central America and the Caribbean, the comparison groups. same hypothesis with psychosocial well- Europe, Africa and Asia) mirrored the being as the outcome and using a nationally variation in time of entry into Canada by Havens and Chappell, in investigating the representative sample of Canadians aged the different immigrant groups and their effects of age, sex and ethnicity on mental 30 and over. The groups also mirrored the differential incorporation in the social health in Manitoba, included North social stratification of the Canadian society. hierarchy of the country. This provided a American, British, French, Polish/Russian/ Havens and Chappell,31 but not Penning,32 framework for analyses and interpretation Ukrainian and ‘Other European’ ethnic found ethnic differences in mental health of the results. Disaggregation of only the groups.31 These groups were reflective of functioning with a “triple jeopardy” effect immigrant group based on ethnicity the time period and region of study. North of age, sex and ethnicity. Methodological implied that either the investigation of Americans, British and French were among issues related to differences in the definition ethnic variation in mental health was only the earlier immigrants admitted to Canada and ascertainment of the mental health important for immigrant groups and not to fill occupational demands based on the outcomes, the conceptualization (e.g. use Canadian-born or all Canadian-born country’s immigration policy at that time. of country of birth32 versus a specific individuals had similar experiences that The ‘Other European’ group, which ethnicity question31) and operationalization potentially affected their mental health. included immigrants from Germany, of ethnicity, the ethnic and age composition Since the Canadian-born group probably Norway, Denmark, Sweden, Iceland, the of the study populations, and the regions had many first generation Canadians who Netherlands and Belgium,31 was granted of study likely played a role in the likely had similar experiences as their entry into Canada over the Polish/Russian/ discrepancy observed. immigrant parents, these assumptions Ukrainian when the demand for more were likely inaccurate. Given the report of immigrants arose.22,106 After World War II Since Penning32 used country of birth to poor mental health in Canada’s Aboriginal and prior to the change to the universal ascertain ethnicity and mentioned no population,8 combining them into the points system immigration policy, excluded ethnic groups, it is assumed that Canadian-born group might not be immigrants from Poland, Russia, the Aboriginal peoples and any Canadian-born appropriate. The use of region of birth has Ukraine and other Eastern European visible minority individuals, though numerous drawbacks that could have countries were admitted to Canada to help minimal, were included into the Canadian potentially biased the results obtained but survivors of the Nazi Holocaust and to fill group. This would make the Canadian was likely used because of the lack of specific occupational roles.22,106 Therefore, group heterogeneous and different from ethnicity-related information in the public- the ethnic groups included in the study31 those included in the North American use version of the CCHS Cycle 1.1 dataset, were incorporated into the social hierarchy group in Havens and Chappell.31 Also, which is assumed to be the data source of Canada at different levels and different since Penning32 utilized data from a used by Ali.5 points in time, emphasizing the segregation national survey, the ethnic category ‘Other’ of the Canadian society along ethnic probably comprised participants who were In examining behavioural and emotional lines.22,104 Aboriginal peoples also contri- members of Canada’s visible minority problems in immigrant versus non- buted to the ethnic diversity of Manitoba’s groups whereas these groups were immigrant children in Canada, Ma47 population, specifically its rural regions,109 excluded by Haven and Chappell31 because considered ethnicity relevant but only for but were excluded from the study to of small sample size. Penning,32 separated the immigrant group. Immigrant children “reduce cultural bias”.31 This statement Canadians and Americans while combining were disaggregated into ethnic groups implied that cultural aspects of ethnicity immigrants from France, Germany, based on region of birth, including those were important in mental health Norway, Denmark, Sweden, Iceland, the from the US, Europe, Asia and other functioning and needed to be kept constant Netherlands and Belgium into a Northern regions47 possibly due to the use of the

Vol 28, No 4, 2008 134 Chronic Diseases in Canada public-use version of the NLSCY.94 These categories without rationale limited the support to combining the groups into this ethnic categories differed from Ali5 despite interpretation and comparability of the category. The use of such a broad ethnic the same method of conceptualizing results. It would have been beneficial if the category is appropriate if the researchers ethnicity. The studies tested different ethnic categories were guided by a were asserting that it is the common hypotheses, and were interested in different theoretical framework so as to provide experience of being ‘non-White’ that populations and different outcomes, which more meaning to the results and decrease impacts mental health above and beyond affected the ability to compare results the observed ambiguity.20 the effect of cultural differences in across studies. individuals’ perceptions of, and attitudes Wu et al.2 tested the hypothesis that ethnic towards, mental health problems, but this Beiser et al.46 utilized NLSCY94 data to differences in depression could be explained was not stated.98 examine familial poverty and emotional by variations in SES and access to social and behavioural problems in immigrant support resources (1996 NPHS90 data). The Dion and Giordano included ‘Anglo- children versus Canadian-born and included included ‘ethno-racial’ groups were ‘East/ Celtics’, ‘North European’, ‘South ethnicity as a control variable. Unlike Ma,47 Southeast Asian’, ‘Chinese’, ‘South Asian’, European’, ‘East European’, ‘East Asian’, ethnicity was examined in the entire ‘Aboriginal’, ‘Black’, ‘Arabic/West Asian’, and ‘South Asian’ in their study.57 These sample46 thereby eliminating the ambiguities ‘Latin American’, ‘Jewish’, ‘French’, ethnic groups were said to parallel the observed in interpreting the results of the ‘English’, ‘Other Whites’, and ‘mixed ethnic composition of the University of former studies. Although the study utilized racial’, were “representative of the social Toronto population in 198857 and reflected a data source in which various ethnic stratification of the Canadian society” and variations in immigration experiences, categories were available, ethnicity was reflected differences in SES and access to entrance status and adaptation to life in operationalized by using four broad social support resources.2 The partial Canada with respect to parental conflicts, categories including White/European, disaggregation of the Asian group into and the likelihood to perceive economic Asian, Black and Other.46 This implied an ‘East/Southeast Asian’ and ‘Chinese’ was discrimination.57 According to the study, interest in, or expectation of, an effect based likely due to the overwhelming presence of ‘South Asians’ and ‘Southern Europeans’ on visible minority status. The NLSCY ‘Chinese’ (approximately 56%) in the were more likely to suffer depression than included Aboriginal peoples living off- group, which would have obscured the the ‘Anglo-Celtics’ and ‘Northern reserves,94 and since there was no explicit interpretation of any association with Europeans’ because of higher likelihood of indication of their exclusion, it is assumed depression. A clear rationale for this partial parental conflict and perceived economic that they were either combined in the disaggregation was not provided but left to discrimination.57 Surnames were used to ‘Other’ category or included in the ‘White/ the readers to assume. Lack of sufficient ascertain ethnicity,57 which likely European’ category. The appropriateness of sample size prevented the disaggregation of misclassified ‘Blacks’ and ‘South Asians’ the inclusion of Aboriginal children into other ethnic groups including Blacks and of Christian background. Since ‘South either category is questionable given major South Asians.2 Asian’ was an ethnic group of interest in cultural and social differences. the study,57 this misclassification would Wang and El-Guebaly52 used a ‘White’ have likely affected the results obtained by The NSGVP95 was utilized by Mata48 to versus ‘non-White’ dichotomy in diluting the measure of effect and affected investigate satisfaction with life in Canada operationalizing ethnicity despite the the generalizability of the results to all across ethnic groups and to test the utilization of the 1996 NPHS90 data. This ‘South Asians’ in Toronto. The researchers57 hypothesis that any variations could be was likely due to the use of the public-use explained that since an earlier study explained by ethnic differences in version of the survey data, though not including 300 students at the same socioeconomic status (SES). Nineteen explicitly stated. This dichotomy, although university found less than 3% indicating mutually exclusive ethnic categories were handy in separating visible minorities from West Indian heritage, the potential derived for the study with sample size the ethnic majority, has been criticized for misclassification by surnames created little limitations being integral in the collapsing its inadequacy in giving a clear view of or no bias to their results. This inaccurately of different ethnic groups into broader ethnic differences in mental health.2,27,104 implied that among ‘South Asians’ only categories (e.g. ‘Black’, ‘South Asian’, Refinement is needed to account for those of West Indian heritage had non- ‘Italian’ and ‘Portuguese’ ethnic groups cultural and/or ecological differences ethnic last names. India’s Christian collapsed into ‘Black/South Asian’ and within such broad ethnic groups,104 which population accounted for about 2.3% of its ‘Italian/Portuguese’).48 The distinction might include cultural biases in reporting total population according to its 1991 and between certain other ethnic categories mental health issues. Although the specific 2001 censuses.110 was unclear. For instance, the categories ethnicities within the broad ‘non-White’ ‘European’, ‘Italian/Portuguese’, ‘German’, group are distinct from each other in Summary ‘French’ ‘Ukrainian’, ‘Polish’, etc., all of languages, histories, customs and social definite European origin were used without mobility,2 discrimination in educational In summary, the operationalization of the provision of a clear rationale. This and occupational opportunities based on ethnicity in the existing Canadian studies combination of specific and broad ethnic visible minority status2,22,103,109 lends some differed depending on how the variable

Chronic Diseases in Canada 135 Vol 28, No 4, 2008 was conceptualized, on which data sources ties, given the relevance to the Canadian to ascertain the representativeness of the were used, on time period and region of context. Secondary data analysis is ethnic categories to the general data collection, the purpose of the study, valuable in such research efforts. population. and whether the study involved secondary Therefore, making detailed information data analysis using public-use versions of on ethnicity more readily available to f) Operationalization of ethnicity varied national surveys. Some studies tried to researchers while maintaining survey from very broad to very specific ethnic disaggregate ethnic categories but were participants’ confidentiality is vital. categories even if ethnicity was con- faced with sample size limitations that led ceptualized similarly or the same data to collapsing of distinct ethnic groups c) Some researchers seemed to have source was used. These variations were while keeping others disaggregated, with utilized public-use versions of survey related to the lack of a clear definition no clear rationale. Sample size limitations data, which hindered their ability to of ethnicity, differences in the time were found across national survey datasets, disaggregate ethnic groups due to lack period, region of study and data particularly for the visible minority ethnic of such detailed information in these collection, the purpose of the studies groups, thus underlining the need for files. Their use need to be stated and the utilization of public-use data. future population surveys aimed at explicitly and their inherent limitations Researchers are encouraged to provide providing information on the health and/ discussed. a clear outline of the decisions made or mental health of the Canadian population regarding the data source used (parti- to over-sample these groups. This would d) Ethnicity can be conceptualized based cularly in secondary data analysis), the enable the examination of mental health on ethnic origin, ethnic identity, or a operationalization of ethnicity, and the differences across visible minority groups, combination of ethnic origin and race. categories included in their studies. which is important for the planning of Each method has strengths and weak- This will facilitate the interpretation of mental health programs to serve Canada’s ness. Its conceptualization should be the results and attempts to replicate the ethnically diverse population. theoretically driven and related to the research findings. research question of interest. The identified studies conceptualized g) Differences in the outcomes of interest, Conclusions ethnicity based on ethnic origin, how such outcomes were measured whether through the use of a specific and variability in the relevant variables This critique of the definition, questions or proxy measures such as controlled for were additional factors conceptualization and operationalization language, surname or country of birth. that affected the ability to compare of ethnicity across Canadian studies on Countries of birth, language and results across studies. Therefore, ethnicity and mental health uncovered a surnames are prone to misclassification researchers should clearly define their number of key issues that are highlighted of certain ethnic groups and biased outcomes of interest and summarize below. results if rate of misclassification the strengths and weaknesses of the differed across outcome groups. This measures used to ascertain outcomes a) Ethnicity is a complex and abstract does not negate their use as proxies for and other relevant variables. term for which a single and generally ethnicity; however, there is a need for accepted definition has not been researchers to clearly outline their derived. However, the underlying theme inherent limitations and the implications Acknowledgements is that it involves the sharing of a for the results obtained. common culture. Across studies, Diana E. Clarke is a Research Associate in ethnicity was not defined a priori, e) Ethnicity based on ethnic origin can be the Department of Mental Health at Johns which was likely due to lack of more stable if participants are given a Hopkins Bloomberg School of Public consensus on its definition. Therefore, list of ethnic categories with the option Health and Fellow in Population Health as suggested by reviewers from the of choosing multiple categories.27,93 This Studies in the Department of Psychiatry at US28,77,79 and UK,27,92,93 clear rationales list should be based on preliminary University of Toronto. Dr. Clarke is as to why ethnicity is important to the fieldwork to identify common ethnic supported by a Canadian Institute for outcome of interest are necessary. categories. An open-ended ‘other’ option Health Research Post-doctoral Fellowship should be included so as not to restrict Award (Grant # 200602MFE-159564- b) Examination of the relationship between the individuals’ choices. The list should 115967), the Toronto Rehabilitation ethnicity and mental health needs to be be appended to the research results or Institute Foundation and in part by the encouraged with better infrastructure made available upon request to enable Population Health Fellowship Award from involving improved funding opportuni- study replication and to enable readers the Department of Psychiatry at the

Vol 28, No 4, 2008 136 Chronic Diseases in Canada University of Toronto. This study was 9. Kirmayer LJ, Minas H. The future of 19. McKenzie K, van Os J, Samele C, van Horn funded in part by the Ministry of Health cultural psychiatry: An international E, Tattan T, Murrau R. Suicide and and Long-term Care and the Ontario perspective. Can J Psychiatry. 2000;45:438- attempted suicide among people of Mental Health Foundation. 446. Caribbean origin with psychosis living in the UK. Br J Psychiatry. 2003;183:40-44. 10. Centers for Disease Control and Prevention. References Suicide among Black youths – United 20. Isajiw WW. Definitions of Ethnicity. States, 1980-1995. MMWR Morb Mortal Ethnicity. 1974;1:111-124. 1. Statistics Canada. 2001 Census Visible Wkly Rep. 1998;47:106-193. Minority and Population Group User Guide. 21. Bell, BD. The Performance of Immigrants URL: http://www12.statcan.ca/english/ 11. Shiang J. Does culture make a difference? in the United Kingdom: Evidence from the census01/Products/Reference/tech_rep/ Racial/ethnic patterns of completed suicide GHS. The Economic Journal. 1997;107:333- vismin.cfm. in San Francisco, CA 1987-1996 and clinical 344. implications. Suicide Life Threat Behav. 2. Wu Z, Noh S, Kaspar V, Schimmele CM. 1998,28:338-354. 22. Green AG, Green DA. The Economic Goals Race, Ethnicity, and Depression in of Canada’s Immigration Policy, Past and Canadian Society. J Health Social Behav. 12. Joe S, & Kaplan MS. Suicide Among African Present. Departmet of Economics, 2003;44:426-441. American Men. Suicide Life Threat Behav. University of British Columbia. 1996. 2001;Vol.31:S¹106-121. 3. Esses VM, Gardner RC. Multiculturalism in 23. Li PS. Race and ethnicity. In Li PS (Ed) Canada: Context and Current Status. 13. Oquendo MA, Ellis SP, Greenwald S, Race and Ethnic Relations in Canada, Canadian Journal of Behavioral Science. Malone KM, Weissman MM, Mann JJ. Second Edition. Oxford University Press, 1996;28:145-152. Ethnic and sex differences in suicide rates Canada. 1999;3-20. relative to major depression in the United 4. Li PS. Social Inclusion of Visible Minorities States. Am J Psychiatry. 2001;158:1652- 24. Beaujot R. Immigration and Canadian and Newcomers: The Articulation of 1658. Demographics: State of the Research. “Race” and “Racial” Difference in Canadian Citizenship and Immigration Canada. Society. Prepared for 2003 Social Inclusion 14. Price JH, Dake JA, Kuchareswki R. Assets 1998. URL: http://www.cic.gc.ca/english/ Conference. What Do We Know and Where as predictors of suicide attempts in African research/papers/demographics.html Do We Go: Building a Social Inclusion American inner-city youths. Am J Health Research Agenda. Ottawa, March 27-28, Behav. 2001;25:367-375. 25. Citizenship and Immigration Canada. 2003. URL: http://www.ccsd.ca/events/ Citizenship and Immigration Statistics, inclusion/papers/peter_li.pdf. 15. O’Donnell L, O’Donnell C, Merrit Wardlaw 1966-1996. 2004. URL: http://epe.lac-bac. D, Stueve A. Risk and resiliency factors gc.ca/100/202/301/immigration_statistics- 5. Ali J. Mental Health of Canada’s influencing suicidality among African ef/index.html Immigrants. Supplement of Health Reports. American and Latino youth. Am J 2002;13:1-11. Community Psychol. 2004;33:37-49. 26. Belanger A, Malenfant EC. Population projections of visible minority groups, 6. Mahtani M. Interrogating the hyphen- 16. Neeleman J, Mak V, Wessely S. Suicide by Canada, provinces and regions 2001-2017. nation: Canadian multicultural policy and age, ethnic group, coroners’ verdicts and Ottawa: Statistics Canada, Demography “mixed race” identities. In Hier SP and country of birth: A three year survey in Division. 2005. Cat. No. 91-541-XIE. Bolaria BS, eds. Identity and Belonging: Inner London. Br J Psychiatry. Rethinking race and ethnicity in Canadian 1997;171:463-467. 27. Aspinall PJ. Operationalising the collection society. Toronto, Canada: Canadian of ethnicity data in studies of the sociology Scholars’ Press Inc, 2006;Chapter 2:31-42. 17. Neeleman J, Wessely S. Ethnic minority of health and illness. Sociol Health Illn. suicide: A small area geographical study in 2001;23:829-862. 7. Porter J. The Vertical Mosaic: An Analysis South London. Psychol Med. 1999;29:429- of Social Class and Power in Canada. 436. 28. Winker MA. Measuring Race and Ethnicity: Toronto: University of Toronto Press, Why and How? JAMA. 2004;292:1612- 1965:60-103. 18. Bhugra D, Desai M, Baldwin D. Attempted 1614. suicide in west London: Rates across ethnic 8. Lian JZ, Matthews DR. Does the Vertical communities. Psychol Med, 1999;29:1125- Mosaic Still Exist? Ethnicity and Income in 1130. Canada, 1991. Can Rev Sociol Anthropol. 1998;35:461.

Chronic Diseases in Canada 137 Vol 28, No 4, 2008 29. Murphy HBM. European cultural offshoots 39. Beiser M, Sack W, Manson SM, Redshirt R, 49. Wu Z, Hart R. Social and health factors in the New World: Differences in their Dion R. Mental and the academic associated with support among elderly mental hospitalization patterns. Part II: performance of First Nations and majority- immigrants in Canada. Research on Aging. German, Dutch, and Scandinavian culture children. Am J Orthopsychiatry. 2002;24:391-412. influences. Archiv fur Psychiatrie und 1998;68:455-467. Nervenkrankheiten (Archives of Psychiatry 50. Blackstock C, Trocme N, Bennett M. Child and Neurological Sciences). 1980;228:161- 40. De Wit ML, Embree BG, De Wit DJ. maltreatment investigations among 174. Determinants of the risk and timing of Aboriginal and Non-Aboriginal families in alcohol and illicit drug use onset among Canada. Violence Against Women. 30. Liban CB, Smart RG. Drinking and drug natives and non-natives: Similarities and 2004;10:901-906. use among Ontario Indian students. Drug differences in family attachment. Soc Biol. Alcohol Depend. 1982;9:161-171. 1999;46:100–121. 51. Cohen MM, MacLean H. Violence against Canadian Women. BMC Women’s Health. 31. Havens B, Chappell NL. Triple Jeopardy: 41. DeWit DJ, Beneteau B. Predictors of the 2004;4:S22. Age, Sex, and Etnicity. Canadian Ethnic prevalence of alcohol use and related Studies. 1983;15:119-129. problems among Francophones and 52. Wang JW, El-Guebaly N. Sociodemographic Anglophones in the province of Ontario, Factors Associated with Comorbid Major 32. Penning MJ. Multiple Jeopardy: Age, Sex, Canada. Journal of the Study of Alcoholism. Depressive Episodes and Alcohol and Ethnic Variations. Canadian Ethnic 1998;59:78-88. Dependence in the General Population. Studies. 1983;15:81-105. Can J Psychiatry. 2004;49:37-44. 42. DeWit DJ, Beneteau B. Predictors of the 33. Tcheng-Laroche F, Prince R. Separated and prevalence of tobacco use among 53. Rousseau C, Drapeau A. Premigration divorced women compared with married Francophones and Anglophones in the exposure to political violence among controls: Selected life satisfaction, stress province of Ontario. Health Educ Res. independent immigrants and its association and health indices from a community 1999;14:209-223. with emotional distress. J Nerv Ment Dis. survey. Soc Sci Med. 1983;17:95-105. 2004;192:852-856. 43. Feldman L, Harvey B, Holowaty P, Shortt 34. Tonkin RS. Suicide methods in British L. Alcohol use beliefs and behaviors among 54. Fry PS, Grover SC. Cognitive Appraisals of Columbian adolescents. J Adolesc Health high school students. J Adolesc Health. Life Stress and Depression in the Elderly: A Care. 1984;5:172-177. 1999;24:48-58. Cross-Cultural Comparison of Asians and Caucasians. International Journal of 35. Barnes GE, Currie RF, Segall A. Symptoms 44. Beiser M, Dion R, Gotowiec A. The Psychology. 1982;17:437-454. of Depression in a Canadian Urban Sample. structure of attention-deficit and Can J Psychiatry. 1988;33:386-392. hyperactivity symptoms among Native and 55. Dyal, James A; Chan, Carolina. Stress and Non-Native elementary school children. J distress: A study of Hong Kong Chinese 36. Sack WH, Beiser M, Phillips N, Baker- Abnorm Child Psychol. 2000;28:425-437. and Euro-Canadian students. Journal of Brown G. Co-morbid symptoms of Cross-Cultural Psychology. 1985;16(4):447- depression and conduct disorder in First 45. Lavallee C, Bourgault C. The health of 466. Nations children: Some findings from the Cree, Inuit and Southern Quebec Women: Flower of Two Soils Project. Cult Med Similarities and Differences. Can J Public 56. Blandford AA, Chappell NL. Subjective Psychiatry. 1993;16:471-486. Health. 2000; 91:212-216. well-being among Native and non-Native elderly persons: Do differences exist? Can 37. Walters, V. Stress, Anxiety and Depression: 46. Beiser M, Hou F, Hyman I, Tousignant M. J Aging. 1990;9(4):386-399. Women’s Accounts of their Health Poverty, Family Process, and the Mental Problems. Soc Sci Med. 1993;36:393-402. Health of Immigrant Children in Canada. 57. Dion KL, Giordano C. Ethnicity and Sex as Am J Public Health. 2002;92:220-227. Correlates of Depression Symptoms in a 38. Beiser M, Cargo M, Woodbury MA. A Canadian University Sample. Int J Soc comparison of psychiatric disorder in 47. Ma X. The First Ten Years in Canada: a Psychiatry. 1990;36:30-41. different cultures: Depressive typologies in Multi-Level Assessment of Behavioral and Southeast Asian refugees and resident Emotional Problems of Immigrant Children. 58. Bagley CR. Mental health and social Canadians. Int J Methods Psychiatr Res. Canadian Public Policy. 2002;28:395-418. adjustment of elderly Chinese immigrants 1994;4:157-172. in Canada. Canada’s Mental Health. 48. Mata F. A Look at Life Satisfaction and 1993;Fall:6-10. Ethnicity in Canada. Canadian Ethnic Studies. 2002;34: 51-63.

Vol 28, No 4, 2008 138 Chronic Diseases in Canada 59. Dion KL. Ethnolinguistic Correlates of 70. Norton GR, Rockman GE, Malan J, Cox BJ, 80. Trimble JE, Dickson R. Ethnic Identity. In Alexithymia: Toward a Cultural Perspective. Hewitt PL. Panic attacks, chemical abuse Fisher CB and Lerner RM, eds. Applied J Psychosom Res. 1996;41:531-539. and suicidal ideation: A comparison of developmental science: An encyclopedia native and non-native Canadians. of research, policies, and programs. 60. Heine SJ, Lehman DR. Culture, Self- Alcoholism Treatment Quarterly. Thousand Oaks: Sage. In press. Discrepancies, and Self-Satisfaction. Pers 1995;12:33-41. Soc Psychol Bull. 1999;25:915-925. 81. Allahar A. The social construction of 71. Weekes JR, Morison SJ, Millson WA, Fettig primordial identities. In Hier SP and Bolaria 61. Rousseau C, Mekki-Berrada A, Moreau S. DM. A comparison of Native, Métis, and BS, eds. Identity and Belonging: Rethinking Trauma and extended separation from Caucasian offender profiles on the MCMI. race and ethnicity in Canadian society. family among Latin American and African Canadian Journal of Behavioural Science. Toronto: Canadian Scholars’ Press Inc., refugees in Montreal. Psychiatry. 1995;27:187-198. 2006;Chapter 2:31-42. 2001;64:40-59. 72. Pawliuk N, Grizenko N, Chan-Yip A, 82. Connor W. Ethnonationalism: The Quest 62. Howard LA, Ahluwalia JS, Lin SK, Sellers Gantous P, Mathew J, Nguyen D. for Understanding. Princeton: Princeton EM, Tyndale RF. CYP2E1*1D regulatory Acculturation style and psychological University Press, 1994:89-117. polymorphism: association with alcohol functioning in children of immigrants. Am and nicotine dependence. Pharmaco- J Orthopsychiatry. 1996;66:111-121. 83. Smith AD. The ethnic origins of nations. genetics. 2003;13:321-328. New York: Basil Blackwell, 1986:1-20. 73. Zapf PA, Roesch R, Hart SD. An examination 63. Tweed RG, White K, Lehman DR. Culture, of the relationship of homelessness to 84. Van Den Berghe PL. Ethnicity and the stress and coping: Internally- and mental disorder, criminal behaviour, and sociobiology debate. In Rex J and Mason, externally-targeted control strategies of health care in a pretrial jail population. D, eds. Theories of Race and Ethnic European Canadians, East Asian Canadians Can J Psychiatry. 1996;41:435-440. Relations. Cambridge University Press, and Japanese. Journal of Cross-Cultural 1986:246-263. Psychology. 2004;35:652-668. 74. Devins GM, Edworthy SM, Aramis Lupus State Models Research Group. Illness 85. Kaufman SJ. Ethnic fears and ethnic war in 64. Khanlou N. Influences on adolescent self- intrusiveness explains race-related quality- Karabagh. Centre for Strategic and esteem in multicultural Canadian of-life differences among women with International Studies. 1998. URL: www. secondary schools. Public Health Nurs. systemic lupus erythematosus. Lupus. csis.org/ruseura/pronars/working_papers 2004;21:404-411. 2000;9:534-541. .

65. Aubert P, Daigle MS, Daigle JG. Cultural 75. Hodelet N. Psychosis and offending in 86. Cheung YW. Approaches to ethnicity: Traits and Immigration: Hostility and British Columbia: characteristics of a Clearing roadblocks in the study of Suicidality in Chinese Canadian Students. secure hospital population. Crim Behav ethnicity and substance abuse. International Trancultural psychiatry. 2004;41: 514-532. Ment Health. 2001;11163-172. Journal of Addictions. 1993;28(12):1209- 1226. 66. Bland RC, Orn H. Schizophrenia: 76. Troper H, Weinfeld M. Ethnicity, Politics Sociocultural Factors. Can J Psychiatry. and Public Policy: Case studies in Canadian 87. Phinney J. Ethnic identity and acculturation. 1981;26:186-188. Diversity. Toronto: University of Toronto In Chun K, Organista PB, and Marin G, Press, 1999:3-25. eds. Acculturation: Advances in theory, 67. Seltzer A, Langford A. Forensic psychiatric measurement, and applied research. assessments in the Northwest Territories. 77. Williams DR. Race and Health: Basic Washington, DC: American Psychological Can J Psychiatry. 1984;29:665-668. Questions, Emerging Directions. Annual Association, 2003:63-81 Review of Epidemiology. 1997;7:322-333. 68. Borzecki M, Wormith JS, Black WH. An 88. Tajfel H. Social identity and intergroup examination of differences between native 78. Isajiw WW. Understanding diversity: relations. Cambridge: Cambridge University and non-native psychiatric offenders on Ethnicity and race in the Canadian Context. Press, 1982:207-240. the MMPI. Canadian Journal of Behavioural Toronto: Thompson Educational Publishing Sciences. 1988;20:287-301. Inc., 1999:17-36. 89. Weinreich P, Saunderson W, eds. Analyzing identity: Cross-cultural, societal and 69. Chandrasena R, Beddage V, Fernando 79. Comstock RD, Castillo EM, Lindsay SP. clinical contexts. New York: Routledge, MLD. Suicide among immigrant psychiatric Four-Year Review of the Use of Race and 2003:7-110 & 115-170. patients in Canada. Br J Psychiatry. Ethnicity in Epidemiologic and Public 1991;159:707-709. Health Research. Am J Epidemiol. 2004;159:611-619.

Chronic Diseases in Canada 139 Vol 28, No 4, 2008 90. Statistics Canada. National Population 97. LaVeist TA. Beyond Dummy Variables and 104. Breton R, Roseborough H. Ethnic Health Survey, Cycle 2. 1996. URL: http:// Sample Selection: What Health Services differences in status. In Blishen BR et al., www.statcan.ca/cgi-bin/imdb/p2SV.pl?Fu Researchers Ought to Know about Race as eds. Canadian Society. Toronto: Macmillan, nction=getSurvey&SDDS=3225&lang=e a variable. Health Serv Res. 1994;29:1-16. 1968:683-701. n&db=IMDB&dbg=f&adm=8&dis=2 . 98. Yinger JM. Ethnicity: Source of 105. Thompson EN. Immigrant Occupational 91. Statistics Canada. Canadian Community Strength? Source of Conflict? New York: Skill Outcomes and the Role of Region-Of- Health Survey, Cycle 1.1. 2000. URL: State University of New York Press, 1994:1- Origin-Specific Human Capital-September http://www.statcan.ca/english/concepts/ 67 & 167-198. 2000. Ottawa: Human Resources Develop- health/ . ment Canada. 2000. Cat. No. W-00-8E. 99. Stolley PD. Race in Epidemiology. Int J 92. Nazroo JY. Genetic, cultural or socio- Health Serv. 1999;29:905-909. 106. Wallace M. “Planning Amidst Diversity: economic vulnerability? Explaining ethnic The Challenges of Multiculturalism in inequalities in health. Sociol Health Illn. 100. Chaturvedi N. Ethnicity as an Urban and Suburban Greater Toronto.” 1998;20:710-730. epidemiological determinant-crudely racist PhD Thesis. University of Waterloo, 1999. or crucially important? Int J Epidemiol. 93. Nazroo JY. The structuring of ethnic 2001;30:925-927. 107. Beshiri, R. Immigrants in rural Canada: inequalities in health: economic position, 2001 update. Rural and Small Town Canada racial discrimination and racism. Am J 101. James CE. Race, ethnicity and cultural Analysis Bulletin. 2004;5:1-27. Cat. No. Public Health. 2003;93(2):277-84. identity. In Hier SP and Bolaria BS, eds. 21-006-XIE. Identity and Belonging: Rethinking race 94. Statistics Canada. National Longitudinal and ethnicity in Canadian society. Toronto, 108. Schellenberg G. Trends and Conditions in Survey for Child and Youth, Cycle 1. 1994. Canada: Canadian Scholars’ Press Inc., Census Metropolitan Areas: Immigrants in URL: http://www.statcan.ca/cgi-bin/imdb/ 2006;Chapter 3:43-55. Canada’s Census Metropolitan Areas. p2SV.pl?Function=getSurvey&SurvId=44 Statistics Canada. 2004. Cat. No. 89-613- 50&SurvVer=0&InstaId=16044&InstaVer 102. Di Biase S, Bauder H. Immigrants in MIE - No. 003. URL: http://www.statcan. =1&SDDS=4450&lang=en&db=imdb&d Ontario: Linking Spatial Settlement ca/english/research/89-613-MIE/2004003/ bg=f&adm=8&dis=2 . Patterns and Labour Force Characteristics. 89-613-MIE2004003.pdf . Department of Geography, University of 95. Statistics Canada. National Survey of Guelph. 2004. URL: www.uoguelph.ca/ 109. Manitoba and Northern Affairs. Aboriginal Giving, Volunteering and Participating, geography/research/ffw/papers/ People in Manitoba 2000. URL: http:// Cycle 1. 1997. URL: http://www.statcan. Settlement%20in%20Ontario_report.pdf . www.gov.mb.ca/ana/apm2000/index. ca/cgi-bin/imdb/p2SV.pl?Function=getSur html . vey&SurvId=4430&SurvVer=0&InstaId=1 103. Ali J, Grabb E. Ethnic origin, class origin 6024&InstaVer=1&SDDS=4430&lang=en and educational attainment in Canada: 110. Office of the Registrar General, India. &db=imdb&dbg=f&adm=8&dis=2 . Further evidence on the mosaic thesis. Proportion and growth rate of population Journal of Canadian Studies. 1998;32: by religious communities - India : 1961- 96. Statistics Canada. General Social Survey – 3-21. 2001. URL: http://www.censusindia.net/ Victimization. 1999. URL: http://www. religiondata/statement.pdf . statcan.ca/cgi-bin/imdb/p2SV.pl?Function =getSurvey&SDDS=4504&lang=en&db =IMDB&dbg=f&adm=8&dis=2.

Vol 28, No 4, 2008 140 Chronic Diseases in Canada APPENDIX I Quantitative empiric studies on ethnicity and mental health conducted in Canada (or with Canadian data) that included two or more ethnic groups

N = Sample size of study, A = Age range of study individuals, S = Source(s) of data, D = Data type, DA = Data analyses, T = Type of study, DV = Dependent Variable, IV = Independent Variable

Author(s), year of Study Sample publication & region (sample size, data source, age of study group included and study design) Ethnic groups included Outcome Examined Comments Studies based on population-based or large community-based surveys/samples (n = 27)

1. Murphy, 1980 N = not given German Origin; DV: Mental hospitalizations 1. A clear definition of ethnicity not given. 29 (Canada) A = 15+ Dutch Origin; 2. Ethnicity based on “country from which the S = Dominion Bureau of Statistics reports on Scandinavian Origin; individual’s ancestors on the male side first admissions to Canadian Mental Hospitals Canadian-born came when they settled in Canada”, in 1961 and the 1961 Population Census. therefore an ethnic origin conceptualization. D = Cross-sectional 3. Ethnic groups reflective of the immigration DA = Standardized Morbidity Ratio (SMR) pattern in Canada during the time period T = Descriptive (i.e. 1960’s)

2. Liban & Smart, 1982 N =128 Native Indian [64]; DV: Frequency and problems 1. A clear definition of ethnicity not given. 30 (Ontario, Canada) A = 10 to 20 (i.e. Grade 7 to 13) Non-Native Indian [64] with alcohol and drug use 2. Ethnicity based on cultural background but S = 1979 Survey of Alcohol and Drug Use how ascertained not specified. among Ontario students 3. Although cultural background in the survey D = Cross-sectional included a breakdown into English DA = Descriptive and Chi-square analyses Canadian, French Canadian, Asian, Native T = Descriptive Indian and other, the non-Native Indian categories were aggregated for the study based on matching.

3. Havens & Chappell, N = 3647 North American [370]; British DV: Perceived well-being, 1. The ethnic groups in the study not 1983 (Manitoba, A = 65+ [1633] perceived health status, representative of the whole of Canada but Canada)31 S = Aging in Manitoba Survey (1971) French [216]; Polish/Russian/ mental health functioning of Manitoba specifically. D = Cross-sectional Ukrainian [685]; 2. Ethnic groups reflective of the immigration DA = ANOVA Other European (German, pattern in the province and of the time T = Analytic Norwegian, Danish, Swedish, period. Icelandic, Dutch, Belgian) 3. Ethnic origin based on ethnicity question in [743] the survey

4. Penning, 1983 N = 2253 Canadian [1720]; American DV: Perceived psychological 1. A clear definition of ethnicity not given. 32 (Canada) A = 30+ [57]; British [159]; North well-being 2. Some ethnic categories not clearly S = Social Change in Canada Survey (1977) European (France, Germany, explained for example the ethnic group D = Cross-sectional Austria, Scandinavia, referred to as “Other”. DA = ANOVA Netherlands) [96]; South 3. Ethnic origin based on country of birth. T = Analytic European (Greece, Portugal, Spain, Italy) [65]; East European (Russia, Hungary, Poland) [96]; Others [62]

5. Tcheng-Laroche & N = 128 Francophone [62]; DV: Psychosocial stress per the 1. A clear definition of ethnicity not given. Prince, 1983 (Montreal, A = not given Anglophone [66] Langner Scale, self-esteem per 2. Study interested in examining “cultural 33 Quebec, Canada) S = Community survey of a representative the RSE and life satisfaction effects”. sample of separated or divorced mothers in 3. Study included French- and Montreal English-Canadians in Montreal. It is unclear D = Cross-sectional how being French and/or English-Canadian DA = Chi-square, ANOVA were ascertained. T = Analytic

6. Tonkin, 1984 (British N = 122 Native Indian [33]; DV: Suicides and psychiatric 1. A clear definition of ethnicity not given. 34 Columbia, Canada) A = < 20 years old Non-Natives [89] diagnoses 2. Ethnicity used as a covariate but how it was S = Vital statistics data (with follow-up review ascertained not indicated because it was of all deaths reported to the provincial Chief abstracted from the coroners’ records. Coroner’s office 1978/9) 3. The rationale for the inclusion of ethnicity D = Cross-sectional as a covariate not explained. DA = Descriptive and chi-square analyses T = Descriptive

7. Barnes et al., 1988 N = 524 English [84]; DV: Depression (CES-D) 1. Ethnicity examined as a predictor of (Winnipeg, Manitoba, A = 18 to 80 East European [62]; depression. 35 Canada) S = 1983 Winnipeg Area Study West European [82]; Canadian 2. Ethnic groups reflective of the ethnic D = Cross-sectional [193]; composition region of study. DA = ANOVA, X2, & multiple classification Other [97] 3. Ethnic origin based on country of birth. analyses T = Exploratory

Chronic Diseases in Canada 141 Vol 28, No 4, 2008 Author(s), year of Study Sample publication & region (sample size, data source, age of study group included and study design) Ethnic groups included Outcome Examined Comments

8. Sack et al., 1993 N = 1115 First Nation children from the DV: Depressive symptoms 1. No explicit definition given for ethnicity. 36 (Canada & US) A = 7 to 9 (Grades 2 and 4) Plains (South Dakota, US), using new measures of 2. Study specifically interested in cultural S = Flower of Two Soils Project Northern Woodlands psycho-pathology and mental differences between the various First Nation D = Prospective and longitudinal (3 year follow- (Manitoba, Canada), Desert health (the SOS) groups across North America, hence it is up) (New Mexico, US) and Coastal implied that ethnicity is based on culture. DA = Correlation analyses, ANOVA, chi-square (British Columbia, Canada) analyses compared to a sample of T = Analytic non-Native children at each site

9. Walters, 1993 N = 356 English-speaking vs. other DV: Stress, anxiety and 1. Ethnic origin based on primary language. (Hamilton, Ontario, A = 21+ language depression 2. No definition for ethnicity. Canada)37 S = A stratified random sample of women in 3. Language stated as a possible proxy for Hamilton ethnicity. D = Cross-sectional DA = Chi-square T = Descriptive

10. Beiser et al., 1994 N = 1667 Southeast Asians [1348]; DV: Psychiatric disorders 1. No explicit definition given for ethnicity. (Vancouver, British A = ? Resident Canadians [319]; including depression, anxiety 2. Researchers interested in 38 Columbia, Canada) S = 1348 refugees from the Refugee Southeast Asian group and somatization per the “psychopathological expression among Resettlement Project and an area-probability disaggregated: Chinese [755]; CES-D, DIS and the Senegal different ethno-cultural groups”, therefore sample of 319 Vancouver residents matched to Vietnamese/Laotian [593] Health Scales ethnicity based on culture. refugees on age and sex 3. Ethnicity based on where the individual D = Cross-sectional emigrated from. DA = Grade of Membership analysis (GOM: a multivariate clustering technique) T = Analytic

11. Beiser et al., 1998 N = 1708 First Nation children from the DV: Depressive symptoms 1. No explicit definition given for ethnicity. 39 (Canada & US) A = 7 to 9 (Grades 2 and 4) Plains (South Dakota, US), using new measures of 2. Study specifically interested in cultural S = Flower of Two Soils Project Northern Woodlands psychopathology and mental differences between the various First Nation D = Prospective and longitudinal (Manitoba, Canada), Desert health (the SOS) groups across North America. DA = Principal component factor analysis on (New Mexico, US) and Coastal the psychopathology measure, correlation (British Columbia, Canada) analyses, ANOVA, chi-square analyses [1251] compared to a sample T = Analytic of non-Native children at each site [457]

12. DeWit et al., 1999 N = 4531 Native Indian [876]; DV: Alcohol drug use and 1. No explicit definition given for ethnicity. 40 (Ontario, Canada) A = 19+ Non-Natives [3655] onset 2. Study specifically interested in cultural S = Native Ontario Community Survey and the differences between Native Indians and Mental Health Supplement of the Ontario non-Natives in Canada. Health Survey. D = Cross-sectional (but age at onset information used to look at incidence) DA = Descriptive and chi-square and survival analyses T = Analytic

13. DeWit and N = 5150 Anglophone [4023]; DV: Alcohol consumption (i.e. 1. No explicit definition of ethnicity given. Beneteau, 1999 A = 16+ Francophone [1127] frequency and volume); 2. Ethnicity based on a combination of ethnic 41 (Ontario, Canada) S = 1990 Ontario Health Survey alcohol-related problems (i.e. identity and primary language used at D = Cross-sectional but age at onset driving under the influence, home. information allowed survival analyses family conflicts, work conflicts, DA = Chi-square, survival and logistic sought help for drinking, regression analyses hospitalization for drinking, T = Analytic and/or arrested for drunk behaviour)

14. DeWit and N = 5150 Anglophone [4023]; DV: Daily tobacco 1. No explicit definition of ethnicity given. Beneteau, 1999 A = 16+ Francophone [1127] consumption (i.e. frequency 2. Ethnicity based on a combination of ethnic 42 (Ontario, Canada) S = 1990 Ontario Health Survey and volume) identity and primary language used at D = Cross-sectional but age at onset home. information allowed survival analyses DA = Chi-square, survival and logistic regression analyses T = Analytic

15. Feldman et al., 1999 N = 1236 Canadian [379]; DV: Alcohol use beliefs and 1. No definition given for ethnicity. (Toronto, Ontario, A = Grade 9 to 13 students European [277]; behaviour 2. “Please write down the term that best 43 Canada) S = 1994 Survey of Grade 9 to 13 students in Asian [314]; describes the ethnic character of your the Borough of East York, Toronto Other [140]; everyday home environment” was used to D = Cross-sectional Not stated [126] ascertain ethnicity indicating an ethnic DA = descriptive analyses, stratified analyses identity conceptualization. and multiple logistic regression analyses T = Analytic

Vol 28, No 4, 2008 142 Chronic Diseases in Canada Author(s), year of Study Sample publication & region (sample size, data source, age of study group included and study design) Ethnic groups included Outcome Examined Comments

16. Beiser et al., 2000 N = 2044 First Nation children from the DV: Attention Deficit/ 1. No explicit definition given for ethnicity. 44 (Canada & US) A = 7 to 9 (Grades 2 and 4) Plains (South Dakota, US), Hyper-activity Disorder 2. Study specifically interested in cultural S = Flower of Two Soils Project and the School Northern Woodlands (ADHD) per DSM symptom differences between the various First Nation Option for Native Children Study (Manitoba, Canada), Desert criterion but items measured groups across North America, hence it is D = Prospective and longitudinal (New Mexico, US) and Coastal by the TIF, the CAP and the implied that ethnicity is based on culture. DA = Principal component factor analysis on (British Columbia, Canada) SOS scales which contained the psychopathology measure, correlation [1555]; compared to a sample items drawn from the CBCL, analyses, ANOVA, chi-square analyses non-Native children at each the CPTRS and the DIS for T = Analytic site [489]. Children

17. Lavallee & Bourgault, N = 27 130 women Cree [1999]; DV: Alcohol consumption, 1. Researchers interested in the mental health 2000 (Canada)45 A = 15+ Inuit [1597]; illicit drug use, psychological of Cree, Inuit and Southern Quebec women, S = 1991 Cree Health Survey, 1992 Inuit Health Southern Quebecers [23 564] distress, lifetime suicidal so no mention or definition of ethnicity. Survey & 1992-93 Quebec Health and Social thoughts 2. The group ‘Southern Quebec’ likely Survey included multiple ethnic groups. D = Cross-sectional DA = Weighted Frequency distribution, Chi-square and ANOVA analyses T = Descriptive

18. Ali, 2002 (Canada)5 N = 92 379 US/Mexico [952]; S. America, DV: Depression & alcohol 1. Ethnic origin based on region of birth. A = 15 to 75 C. America, Caribbean [2273]; dependence 2. Although immigrants broken down into S = Canadian Community Health Survey, Cycle Europe [7749]; Africa [1139]; regions migrated from, the Canadian-born 1.1 Asia [6314] group wasn’t, which limited comparisons D = Cross-sectional based on ethnicity. DA = Multiple logistic regression analysis T = Analytic

19. Beiser et al., 2002 N = 13 349 Immigrants [684]; Born in DV: Emotional and 1. Ethnicity examined as a covariate. 46 (Canada) A = 4 to 11 Canada to immigrant parents behavioural problems 2. Ethnic origin based on ethnicity question. S = National Longitudinal Survey of Children & [2573]; Canadian-born to 3. The “Others” race/ethnicity category not Youth (NLSCY/1994-1995) Canadian-born parents [10 clearly defined. D = Cross-sectional 092]. DA = Multiple logistic regression analyses Ethnicity then examined T = Analytic (Asian, Black, other, White/ European).

20. Ma, 2002 (Canada)47 N = 2304 Immigrant Children [182]; DV: Conduct disorder, indirect 1. Ethnic origin based on region of birth. A = 7 to 11 Non-immigrant Children aggression, property offences, 2. Ethnicity examined as a covariate. S = NLSCY 1994/5 [2122]. Ethnicity then hyperactive behaviour, 3. No definition given for ethnicity. D = Cross-sectional examined as a covariate (US, pro-social disorder, emotional DA = Factor analysis and mixed level modeling Europe, Asia, other regions). disorder & a composite T = Analytic behavioural /emotional disorder index

21. Mata, 2002 N = 17 109 19 Single/multiple ethnic DV: Life satisfaction (4-pt 1. Ethnic origin based on the ethnicity (Canada)48 A = 15+ categories (Canadian, French, Likert scale) question in the survey. S = National Survey of Giving, Volunteering and British, German, Ukranian, 2. Mutually exclusive ethnic groupings driven Participating Polish, Italian/Portuguese, in part by sample size issues. D = Cross-sectional Dutch, Chinese, Black/South 3. Rationale for some ethnic groupings DA = Multiple regression analyses Asian, Aboriginal, Canadian & unclear. T = Analytic French, Canadian & British, Canadian & Other, British & 4. No definition of ethnicity. French, French & Other, European, Rest of singles, Rest of multiples)

22. Wu & Hart, 2002 N = 3009 elderly immigrants Chinese/South Asian [274]; DV: Emotional problems and 1. Ethnicity based on the ethnic origin (Canada)49 A = 65+ Other [2735] psychological distress (CIDI) question in the survey. S = National Population Health Survey (NPHS, 2. The combination of Chinese and all South 1996) Asians indicate that ethnic origin based on D = Cross-sectional component large geo-cultural region. DA = Descriptive and multiple linear regression analyses T = Analytic

23. Wu et al., 2003 N=70 538 East & Southeast Asian [624]; DV: Depression (CIDI) 1. Ethnicity based on the ethnic origin (Canada)2 A=12+ Chinese [800]; South Asian question in the survey and in combination S= NPHS, 1996 [809]; Aboriginal [975]; with race used to create ethno-racial D=Cross-sectional component Black [788]; Arabic & West groups. DA: Descriptive and multiple linear regression Asian [325]; Latin American 2. Offered definitions of race and ethnicity a analyses [176]; Jewish [197]; French priori. T = Analytic [5580]; English [9281]; “Other” Whites [50 294]; Mixed race [689]

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24. Blackstock et al., N =3159 Aboriginal [614]; DV: Frequency of Child 1. No explicit definition of ethnicity given. 50 2004 (Canada) A = childhood (range not given) White [2114]; Maltreatment (physical and 2. Ethno-racial classification determined by S = 1998 Canadian Incidence Study of Reported Other Visible Minority [431] sexual abuse and neglect); ethno-racial status of one or both biological Child Abuse and Neglect (CIS-98) psychosocial problems parents. D = Cross-sectional 3. Conceptualized based on ethnic origin. DA = Chi-square and ANOVA analyses T = Descriptive

25. Cohen & Maclean, N = 26 000 Visible minority vs. non-visible DV: Physical, sexual, financial 1. Ethnicity based on country of birth. 51 2004 (Canada) A = 15+ minority; or emotional abuse; 2. No definition given for visible minority. S = All females from the 1999 General Social Aboriginal vs. non-Aboriginal medication use for anxiety, Survey depression or insomnia in D = Cross-sectional those abused. DA = z-test with p < 0.05 significance level T = Descriptive

26. Wang & El-Guebaly, N = 72 940 White [67 802]; DV: Major depressive episode 1. Ethnicity examined as a covariate. 52 2004 (Canada) A = 12+ Non-White [5138] (MDE), alcohol dependence 2. No description of the groups included in the S = NPHS (1996/7) (AD) and mental health non-white category. D = Cross-sectional service use 3. Non-white population likely included DA = Multiple logistic regression analyses Aboriginals, a group with great likelihood T = Analytic of MDE and AD, which likely explains the higher risk observed in non-immigrant non-whites. 4. Race only categorization despite use of the term “ethnicity”.

27. Rousseau & N = 1871 Chinese; DV: Emotional distress (i.e. 1. Explicit definition of ethnicity not given. Drapeau, 2004 A = 15 to 87 Arab; depression and anxiety) per 2. Researchers interested in recent immigrants (Montreal, Quebec, S = Quebec Cultural Communities Survey Haitian; the SCL-25 based on the in the Montreal area who were born in one 53 Canada) (survey of recent immigrants living in the Hispanics Hopkins Symptom Checklist of four geocultural areas (China, Hong metropolitan Montreal area who landed in Note: indicated in the article Kong, Taiwan and Macao [Chinese], Haiti Canada between 1988 and 1997) that equal numbers of each [Haitian], North Africa and the Middle East D = Cross-sectional ethnic group were selected [Arabs] and Latin America [Hispanics]. DA = Chi-square, t-test, ANOVA from the registry to represent Therefore, ethnicity conceptualized based T = Descriptive the target population [n = 750 on region of birth. * 4 = 3000] but the eligible population was 1871 with no breakdown of the numbers in each ethnic group Smaller studies with primary data collection – non-clinical sample (n = 12)

28. Fry & Grover, 1982 N = 320 Asian-Indian [160]; Caucasian DV: Depression (per the BDI), 1. Definition of ethnicity not given. 54 (Canada & USA) A = 65 to 80 [160] life stress [per the Life Event 2. How ethnicity ascertained unclear. S = Random sample drawn form professional Inventory], cognitive appraisal 3. Seem to be a race only categorization. clubs, community associations, recreation and locus of control centres for elderly, social welfare agencies and private homes. D = Cross-sectional DA = ANOVA T = Analytic

29. Dyal & Chan, 1985 N = 251 Euro-Canadian [112]; DV: Stressful life events per 1. No explicit definition given for ethnicity. (Waterloo, Ontario, A = 17 to 29 Hong Kong Chinese [100]; the Problems with Living 2. Implication that ethnicity based on culture 55 Canada) S = Samples of convenience (i.e. students in Chinese immigrants to Adjustment scale (developed since the study interested in cross-cultural undergraduate courses and some volunteers) Canada [39] for the study); distress per the differences. D = Cross-sectional DSS based on Langer 22-item 3. Unclear whether the Euro-Canadian groups DA = ANOVA and ANCOVA scale of impaired functioning; actually identified themselves as such or if T = Analytic 12- items from the DDS; worry this categorization based on the per the worry scale of the researchers’ observations. SEAS.

30. Blandford & N = 390 Natives [193] DV: Satisfaction with life; 1. Ethnicity not specifically defined. Chappell, 1990 A = 50 and over Non-Natives [197] loneliness per the UCLA 2. Conceptualized based on ethnic identity but (Winnipeg, Manitoba, S = Survey of Natives in Winnipeg in 1981 Loneliness Scale no indication of how ethnic identity was 56 Canada) D = Cross-sectional ascertained. DA = Chi-square and logistic regression analyses T = Analytic

31. Dion & Giordano, N = 352 Anglo-Celtic [165]; North DV: Depression (total & item 1. Ethnic origin based on surnames, with the 1990 (Toronto, Ontario, A = 1st-year university students – mean age of European [22]; scores for the BDI) aid of a number of dictionaries of Canada)57 20.32 years (1988) South European [79]; East surnames/family names. S = A sample of undergraduate students in an European [36]; 2. This limited the ability to identify black introductory psychology course East Asians [25]; individuals with West Indian ethno-cultural D = Cross-sectional South Asians [25] background and South Asians of Christian 2 DA = ANOVA, X , and multivariate log-linear IV: Sex and ethnicity background. analyses T = Analytic

Vol 28, No 4, 2008 144 Chronic Diseases in Canada Author(s), year of Study Sample publication & region (sample size, data source, age of study group included and study design) Ethnic groups included Outcome Examined Comments

32. Bagley, 1993 N = 300 Canadian born of European DV: Physical and mental 1. Explicit definition given for ethnicity. (Calgary, Alberta, A = 60 to 74 years old descent [100]; health as measured by the 2. Different techniques seem to have been Canada & Kowloop, S = The 100 Canadian-dwelling elderly Chinese immigrants long GHQ; loneliness per the UCLA used to establish ethnicity across groups. 58 Hong Kong, China) Cantonese-speaking Chinese sample was established in Canada [50]; Loneliness Scale; quality of Surnames, language and unknown question recruited by randomly selecting Chinese Chinese immigrants newly life & acculturation; & global for Canadian dwelling Chinese; country of surnames from the telephone directory with an arrived in Canada [50]; satisfaction with life birth for Hong Kong Chinese and unknown initial call by a Cantonese-speaking individual Chinese in Hong Kong [100] method for Euro-Canadians. who established the presence of an elderly person (aged 60 to 74) and then inquired about and established the ethnic origin of the individual. Stratified sampling of young to elderly in Kowloop, Hong Kong to match the age and sex profile of Canadian-dwelling Cantonese-speaking elderly Chinese group. D = Cross-sectional DA = Comparison of the standardized scores T = Descriptive

33. Dion, 1996 (Toronto, N = 950 Language as indicator of DV: Alexithymia (TAS-20) and 1. Language identified by Dion as a possible Canada)59 A = ?18-21: 1st-year university students ethnic origin three under-lying factors proxy of ethnicity (i.e. ethnic origin). S = Convenience sample English; (DIF= difficulty identifying 2. No definition for ethnicity. D = Cross-sectional Chinese; feelings, DDF= difficulty DA = ANOVA European describing feelings, EOT= T = Exploratory externally oriented thinking)

34. Heine and Lehman, N = 402 Japanese [161]; DV: Personality traits: 20 1. No explicit definition given for ethnicity; it 1999 (Canada & A = 18 to 25? Asian-Canadian [151]; items to capture the appeared to be based on culture. 60 Japan) S = Survey of university students Euro-Canadian [90] individuals’ ratings of their 2. Method of sample selection unclear. D = Cross-sectional actual & ideal self and what 3. SES and/or SS hypotheses not tested. DA = ANOVA with post hoc tests (Tukey’s HSD) they thought described the T = Analytic average student traits; difference between actual & ideal self, and importance of traits to success in one’s country were also assessed; depression (ZSDS)

35. Rousseau et al., N = 113 Latin American [60]; DV: Emotional profile of 1. Ethnic origin based on geo-cultural region 2001 (Montréal, A = 20 to 65 African American [53] subjects based on the of birth. 61 Canada) S = Sample of refugees who sought help from SCL-90R; Post-traumatic stress 2. Explicit definition of ethnicity not given. community organizations that provide services disorder per the DSM-IV. to refugees/immigrants in the Montreal area D = Qualitative & cross-sectional quantitative design combined DA = Descriptive analyses and Spearman rank correlation and t-tests for comparative analyses T = Descriptive

36. Howard et al, 2003 N = 3030 From Canada: DV: CYP2E1*1D allele; alcohol 1. Ethnicity not explicitly defined. (Toronto, Ontario, A = not given Indo-Asian [48]; inactivation 2. Ethnic background based on the Canada; USA; Taipei S = All participants from Canada are volunteers Chinese [210]; individual’s grandparents therefore an 62 City, Taiwan) recruited through newspaper and flyer Japanese [128]; ethnic origin conceptualization. advertisements in Toronto; Taiwanese recruited African Canadian [58]; at the Taipei City Psychiatric Center; African Native Indian [228]; American smokers recruited at the University of Caucasian [1734] Kansas Medical Center (Clinical and community Elsewhere: settings) Taiwanese [420]; D = Association Analysis (Cross-sectional) African American [204] DA = ANOVA; T-test, Mann-Whitney U-test and Chi-square analyses T = Analytic

37. Tweed et al., 2004 N = 123 (Study 1) Study 1: DV: Stressful and negative life 1. Ethnicity not explicitly defined but based on (British Columbia, 415 (Study 2) Western European Canadian events; coping skills per the culture. 63 Canada and Japan) A = 18 to 47 [22]; WCCL and Japanese coping 2. Conceptualized based on descent, therefore S = Undergraduate students from the University East Asian Canadian [57]; items ethnic origin. of British Columbia, Canada and from South Asian/Mixed descent Ritsumeikan University (Study 1) or Kurume Canadian [18]; University (Study 2), Japan Japanese [26] D = Cross-sectional Study 2: DA = MANCOVA European Canadian [68]; T = Analytic East-Asian Canadian [106]; Japanese [241]

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38. Khanlou, 2004 N = 550 Information given for the DV: Self-esteem per the RSE 1. No definition given for ethnicity. (Hamilton, Ontario, A = Grades 9 to 13 three most frequently and the CSE scales 2. Ethnicity based on the “parents’ original 64 Canada) S = Survey of students at 4 secondary schools occurring ethnic/cultural ethnic or cultural background” indicating an in the Hamilton Wentworth region in 1998 background of the mothers ethnic origin conceptualization. D = Cross-sectional and fathers of the students. 3. Specific ethnic groupings were used with DA = Chi-square and ANOVA analyses Based on mother: some having very small sample size. As a T = Descriptive Italian [48]; result comparison only done on the top Portuguese [43]; three ethnic categorizations. Irish [35]; 4. The study indicated that close to 30% of English [35] the sample reported 2 or more ethnic Based on Father: backgrounds indicating a “mixed” ethnic Italian [69]; group. Portuguese [42]; Canadian [38]

39. Aubert et al., 2004 N = 170 Other Canadian [81]; Chinese DV: Hostility (HDHQ); suicide 1. Ethnicity examined as a covariate 65 (Canada) A = 18+ Canadian [89] probability (SPS); lifetime 2. It is unclear if “Other Canadian” group S = Convenience sample of students aggressive behaviour incl. include ethnicity other than D = Cross-sectional suicide attempt; suicidal Anglo-Canadians. DA = ANOVA thoughts and deliberate self 3. Ethnic origin based on country of birth. T = Analytic harm Smaller studies with primary data collection – clinical/specialized sample (n = 10)

40. Bland & Orn, 1981 N = 43 (33 non-immigrants & 10 immigrants) 10 immigrants classified as DV: Schizophrenia 1. Ethnicity examined as a covariate. 66 (Alberta, Canada) A = 15 to 49 “other European” [6], & 2. The term “ethnic group” used but no S = 1963 First episode hospitalization data Eastern European [4] definition of what it means. D = Retrospective follow-up on a cohort of 3. Ethnic origin based on place of birth. persons with schizophrenia compared to the general population DA = Descriptive and Chi-square analyses T = Descriptive

41. Seltzer & Langford, N = 85 Inuit [41]; DV: DSM-III psychiatric 1. No explicit definition given for ethnicity. 1984 (Northwest A = 15 to 25 Métis/Dene [27]; diagnosis and type of criminal 2. The Native group broken down into Inuit 67 Territories, Canada) S = Sample of convenience (i.e. all persons Caucasian [17] offences committed and Metis, indicating cultural distinctions, referred by the courts or legal counsel to the but the Caucasian group not disaggregated. Department of Psychiatry at the regional hospital in the calendar year 1981) D = Cross-sectional DA = Descriptive T = Descriptive

42. Borzecki et al., 1988 N = 275 (all males) Natives (i.e. Inuit, Métis, and DV: Psychological profile per 1. No explicit definition of ethnicity given. (Saskatoon, A = 28.41 = mean age at admission Indians) [57]; the MMPI 2. Ethnicity based on ancestry (ethnic origin), at st Saskatchewan, S = successive 1 admission to the facility Non-Natives [218] least for the native sample, while all 68 Canada) between January 1978 and September 1982 non-natives, despite ancestral heterogeneity D = Cross-sectional are grouped together. DA = ANOVA, ANCOVA, and Pearson’s correlation T = Analytic

43. Chandrasena et al., N = 117 Canadian-born [94]; DV: Suicide 1. Ethnicity mentioned but not defined. 1991 (Ontario, A = range not given Foreign-born [23] 2. Canadian-born versus foreign-born indicate 69 Canada) S = All suicides in 3 psychiatric facilities in a country of birth conceptualization but not Ontario between 1967 and 1990 explicitly stated. D = Cross-sectional DA = Descriptive Analyses T = Descriptive

44. Norton et al., 1995 N = 80 Native-Canadians [37]; DV: Suicidal ideation (per 1. No explicit definition of ethnicity given. 70 (Manitoba, Canada) A = ? Anglo-Canadians [43] NIMH Epidemiologic 2. Unclear how ethnicity was ascertained. S = Attendees at the Alcoholism Foundation of Catchment Area survey), panic Manitoba (PAQ), chemical abuse (the D = Cross-sectional BMAST & DAST) and DA = Chi-square depression (BDI) T = Descriptive

45. Weekes et al., 1995 N = 301 Caucasian [203]; DV: Psychopathology per the 1. No explicit definition of ethnicity 71 (Ontario, Canada) A = 18 to 59 Native [59]; MCMI 2. The terms ethnicity, “cultural group”, and S = Sample of convenience: Adult males Métis [39] “racial identification” used in the article but incarcerated in a medium security federal categorization based on the individuals prison self-report of “racial identification”. D = Cross-sectional DA = MANOVA, T-TEST, correlation and principal component analyses T = Analytic

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46. Pawliuk et al., 1996 N = 34 multiethnic families (one parent Ethnic breakdown of the DV: Revised CBCL; Depression 1. No explicit definition given for ethnicity 72 (Montreal, Canada) included) with a total of 48 children (of which 8 parents given but not for the Self-rating Scale; the What I 2. There were 34 parents and 48 children so born in Asia and 3 in India. No other mention children. Think and Feel Scale; the unclear of the ethnicity breakdown of the of the ethnic breakdown of the children). Asian [26]; Children’s Psycho-somatic children. A = age range of parents not given but children Symptom Checklist; and the European [5]; 3. Since ethnicity for parents given but not for ranged in age from 6.5 to 17 years old Hare Self-Esteem Scale. Indian/S. American/Middle children, it appears that ethnicity based on S = convenience sample of the parents and Eastern [3] region/place of parent’s birth. their children seen in a Pediatric Clinic in Montreal, Canada D = Cross-sectional DA = ANOVA and MANOVA T = Analytic

47. Zapf et al., 1996 N = 790 Although the term “ethnicity” DV: Mental disorder per the 1. Ethnicity stated as a covariate. (Vancouver, British A = not specified used, there was no BPRS and the Diagnostic 2. No definition given for ethnicity. Columbia, Canada)73 S = Adult males randomly selected from breakdown of the ethnic Profile 3. No indication of how ethnicity Vancouver Pretrial Service Centre between group. conceptualized or operationalized. August 1, 1989 and July 31, 1990 D = Cross-sectional DA = Chi-square and Pearson Correlation Analyses T = Descriptive

48. Devins et al., 2000 N = 405 White [335]; DV: Psychosocial well-being 1. The Black and Asian groups comprised of (Canada & US)74 A = not specified Black [40]; (ABS); learned helplessness mostly (i.e. 97% & 83%) individuals from S = The Arthritis, Rheumatism and Aging Asian [30] (RAI); emotional distress the US, whereas almost equal proportion of Medical Information System Lupus Project (all female) (CES-D); musculo-skeletal pain whites from the US and Canada). D = Longitudinal (HAQ); overall psycho-social 2. Racial classification rather than ethnicity. DA = Principal component and path analyses well-being T = Analytic

49. Hodelet, 2001 N = 175 White [153]; DV: Type of offence; type of 1. Explicit definition of ethnicity not given. (British Columbia, A = 19 to 75 Native American [26]; psychiatric diagnosis; 2. “Ethnic origin” indicated but unclear how 75 Canada) S = Secure Forensic Psychiatry Hospital, all case Oriental/East Asian [11]; psychosis; psychotic drive this was ascertained in the individuals’ records for patients in hospital between South Asian [5]; medical records. December 1, 1998 and February 28, 1999 Black [1] D = Cross-sectional DA = Chi-square and ANOVA analyses T = Descriptive

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