Journal of Immigrant Health, Vol. 7, No. 4, October 2005 (C 2005) DOI: 10.1007/s10903-005-5123-1

Providing Social Support for Immigrants and Refugees in : Challenges and Directions

Laura Simich,1,5 Morton Beiser,2 Miriam Stewart,3 and Edward Mwakarimba4

In this article we report research findings from a qualitative study of social support for immi- grants and refugees in Canada. We focus on challenges from the perspectives of 137 service providers and policymakers in health and immigrant settlement who participated in in-depth interviews and focus groups in three Canadian cities. Results show that social support is perceived to play an important role in immigrant settlement and to have a positive impact on immigrant health, although immigrants face many systemic challenges. Systemic issues— limited resources, lack of integration of policies and programs and narrow service mandates— also limit service providers’ abilities to meet newcomer’s needs. This research suggests that changes in public discourse about immigrants’ contributions, improved governance and ser- vice coordination, and a holistic, long-term perspective are important to more effectively support immigrant settlement and to promote immigrant health and well being. KEY WORDS: social support; immigrants; Canada; policy and services; barriers.

INTRODUCTION family members, friends, peers and ...professionals that communicate information, esteem, practical, or Social support is a basic determinant of health, emotional help,” (3) plays a particularly important as vital to maintaining well being as food, shelter, role during major transition periods by enhancing income, and access to health care and social opportu- coping, moderating the impact of stressors and nities (1). Social support also influences use of health promoting health (4). Most desirable for immigrants services (2). Life transitions, such as immigration and refugees may be social support that functions as and settlement, are situations that place health at a “springboard,” not just a “safety net” (1), working risk. Social support, defined as” ...interactionswith directly in terms of social relations and indirectly by facilitating access to employment, education and other basic needs. Although a fundamental 1Department of Psychiatry, University of , , Canada; Scientist, Culture, Community and Health Studies Pro- health determinant, social support may be defined gram, Centre for Addiction and Mental Health, Toronto. and perceived quite differently by people requiring 2Department of Psychiatry, Faculty of Medicine, University of services, and the people charged with providing or Toronto, Ontario, Canada; Senior Scientist, Centre of Excellence planning them. These difficulties are compounded for Research on Immigration and Settlement, Toronto. in immigrant settlement situations, often marked 3Institute of Gender and Health, Canadian Institutes of Health Research; Professor, Faculties of Nursing, Public Health Sci- by differing culturally based perceptions and ences and Medicine, University of , Edmonton, Alberta, expectations. As population health scholars have Canada. noted, the social determinants of health most critical 4Social Support Research Program, University of Alberta, Ed- for immigrants and refugees “are the outcome of monton, Alberta, Canada. 5 highly context-sensitive process that cannot be fully Correspondence should be directed to Dr. Laura Simich, Culture, understood in the absence of concrete, in-depth re- Community and Health Studies Program, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8 search on the meanings associated with typical health Canada; e-mail: laura [email protected]. determinants like ‘social,’ ‘coping,’ or even ‘health’

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1096-4045/05/1000-0259/0 C 2005 Springer Science+Business Media, Inc. 260 Simich, Beiser, Stewart, and Mwakarimba itself.” (5:1591). Moreover, policymakers and service learning where and how to get help—“navigating the providers also face systemic challenges in providing system”—when support is needed. supportive services to immigrants and refugees. Social support serves several functions and has To help fill knowledge and policy gaps about many potential sources (14, 15). Several studies have these challenges, our research team undertook a suggested that using all available personal and so- qualitative study of the meaning of social support cial resources to obtain social support is critical to from the perspectives of service providers, policy reducing stress, maintaining health (16) and achiev- makers, and newcomers in three Canadian cities. The ing eventual self-sufficiency and well being (17, 18). current article focuses on the perspectives of service Social support helps individuals cope in an immedi- providers and policy makers. We address such ques- ate way with stress during crisis situations and rein- tions as: How do providers and policy makers per- forces the self-confidence needed to manage ongoing ceive the needs of a multicultural clientele? To what challenges critical to the adaptation process. Many extent do they see themselves as able to meet im- newcomers to Canada today rely on friends and fam- migrant and refugee needs for professionally based ily for support to overcome settlement difficulties, social support? Where do the problems and chal- rather than formal health and social service organi- lenges lie—with the immigrants and refugees, with zations (19). During settlement, familiar sources of the providers, or at a more systemic level? Which support such as friends and family, the existence of a factors facilitate and which factors block the ability like-ethnic community and a strong sense of belong- of service providers and policy makers in health ing may enable newcomers to gradually enlarge their and health-related sectors to meet the needs of social networks and lead to help-seeking and oppor- newcomers? tunity within the wider society (18, 20, 21). The im- Approximately 5.4 million , or 18.4% portance of informal supports in no way abrogates of the total population, were born outside of the the necessity of effective formal services, which serve country (6). Enriching this demographic picture, a complimentary purposes and ensure access and eq- large proportion of recent arrivals (within the last ten uity in health care and social services. Furthermore, years) come from “non-traditional” source countries. help-seeking strategies are influenced by perceptions Before 1960, over 90% of immigrants to Canada of the appropriateness and accessibility of social sup- came from Europe, whereas 58% of the 1.8 million of ports in the larger society, which may be seen in ei- those who arrived between 1990 and 2001 have come ther a positive or a negative light depending upon from Asia, the Middle East and Africa (7). Most im- how effectively social support is delivered (2). migrants and refugees to Canada settle in the major Our overall research objectives were: 1) To de- urban centres, particularly Toronto, Ontario, which scribe the meanings of social support from the per- has one of the highest proportions of foreign-born spective of newcomers in Canada and its perceived (44%) of all cities in the world. More diverse than impact on health; 2) To identify newcomers’ methods Miami, Florida, Toronto’s residents speak over 100 of support-seeking; 3) To compare immigrants’ and languages in total (7). In addition, Canada is a lead- refugees’ meanings of social support and support- ing refugee-resettlement country (8). seeking methods; and 4) To determine mechanisms On arrival in Canada, immigrants tend to be that may strengthen support by identifying unmet healthier than the population at large with respect to support needs and services, programs and policies chronic disease and disability (9, 10), although this that might be helpful. This article focuses on the final “healthy immigrant effect” does not necessarily hold objective. true for refugees who tend to be more vulnerable (11). During settlement, numerous disadvantages may affect immigrants’ and refugees’ health—stress, STUDY METHODS underemployment, downward mobility, discrimina- tion, poor housing, lack of access to services, and A multidisciplinary national research team con- inadequate social support. Most newcomers need ducted the study from 2000 to 2003 in three to rebuild disrupted social networks (12, 13). Many cities selected because of their sizable multicultural face social isolation, especially in the beginning, populations: Toronto, Ontario; Vancouver, British and are usually without the social supports they Columbia; and Edmonton, Alberta. The team car- were accustomed to in their homeland. One of the ried out the research in three phases: Phase 1—in- most important challenges for newcomers is simply depth interviews with 60 service providers and policy Providing Social Support for Immigrants and Refugees in Canada 261 makers (20 in each site); Phase 2—in-depth inter- In Phase 1, investigators administered a semi- views with 120 Chinese immigrants (from Mainland structured interview guide incorporating open-ended China and Hong Kong) and Somali refugees (40 to- questions for service providers and policy makers tal in each site); and Phase 3—six focus groups with across all three sites. Questions inquired about new- service providers and policy makers to solicit policy comers’ challenges and changing needs, the types and program recommendations. In this article, we of support programs provided by the agency, the present findings from Phases 1 and 3. Our findings respondent’s appraisal of supportive programs and represent the views of 134 professionals (practition- strategies, and concepts of social support and its re- ers, service providers, policy makers, advocates) in lationship to the health of newcomers. For Phase 2, total. the team developed a similar semi-structured ques- The research design followed a collaborative tionnaire, translated into Somali and Chinese, to be process of questionnaire development and pre- administered by bilingual or trilingual (in the case testing. Census information and settlement service of Cantonese and Mandarin speakers) research as- reports served as a triangulation on the data col- sistants. Phase 3 focus group participants included lected in interviews with different participants (im- policymakers and service providers from different migrants, refugees, service providers, and policymak- levels of government and from a range of agen- ers). Methodological triangulation was achieved by cies and sectors. Investigators presented a sum- collecting data from focus groups as well as individ- mary of findings to focus group participants, in- ual interviews (22). cluding recommendations given by immigrant and refugee interviewees, and asked them to discuss the implications of the findings and to generate ideas Sample Recruitment and Community Participation about strategies to enhance supportive policies and programs. Following a review of relevant services in The research team used NUD*IST (Non- each city, investigators composed representative numerical Unstructured Data Indexing, Searching lists of agencies providing services to newcomers and Theorizing) software for qualitative analysis. Re- and relevant policy-making bodies at all levels of searchers in the three sites coded transcripts accord- government, including ethno-specific and advocacy ing to a common coding framework following pro- organizations, in order to recruit service providers cedures of inter-rater reliability, cross-site discussion and policy makers for Phase One interviews. Criteria of emerging themes, and exchange of coding sum- for choosing the newcomer sample for Phase maries. Rigour was achieved through saturation. Two included the size of immigrant and refugee populations in the three cities and experiences of multiple barriers to health and social services during STUDY FINDINGS settlement and integration in Canada, resulting in the selection of Chinese immigrants and Somali refugees The 60 service providers and policy makers in- as study populations across cities. The list of Phase terviewed in the first phase of the study were pro- 1 participants was later expanded with the assistance fessionals who worked directly with immigrants and of Community Advisory Committee members to refugees or on related policy issues. Often they had invite participants for Phase 3 focus groups. first-hand experience as immigrants.

Data Collection and Analysis Service Providers’ and Policy Makers’ Views of Challenges Facing Newcomers Investigators, project coordinators, and research assistants in the three project sites coordinated data Service providers and policy makers believed collection and analysis through regular discussions that immigrants and refugees faced many common and exchange of documents. In all phases, we in- challenges, such as communication and economic formed study participants of the study’s purpose and integration, although they felt that refugees face asked them to sign consent forms translated into greater barriers. Study participants observed that their preferred language. All interviews, which aver- “learning where to go for what” is difficult for aged 1.5 h in length, were audio taped for later tran- most newcomers, who encounter a confusing, frag- scription and analysis. mented health and social service sector. Financial 262 Simich, Beiser, Stewart, and Mwakarimba insecurity is also a source of stress, especially in ing process which increases a newcomers’ sense of ef- the initial period, and particularly for refugees who ficacy in a new environment: have been unable to plan ahead or bring personal resources to Canada. Achieving permanent, regular Social support is a kind of a concept that immigration status in Canada in a timely manner encompasses the economic, political, and cul- also can be a challenge, especially for refugees who tural....Peoplehaveculturalneedsthatrelatetothe values of the place they grow up, values of their lack documentation. Family separation, intergener- friends and values of their families. When those ational strains and gender role changes create spe- change, the values in the communities around, they cial stresses for many newcomers. For refugees, re- need some type of, maybe not ‘support,’ but maybe uniting with family members is an especially long brokerage or translation. They need to know what process. the things mean here. People say, ‘I need to be able to understand the value set of where I now live, so I Service providers and policy makers also per- can interact effectively and efficiently in the way I’m ceived systemic discrimination in policy and practice used to’ [Service Provider #9a]. as a major challenge, especially with respect to em- ployment and educational opportunities. Seen from Policy makers and service providers noted sev- a systemic perspective, settlement challenges are in- eral common forms of social support, including in- terrelated. For example, one policy maker-advocate formational, instrumental, and emotional (14). They said: described particular needs for information prior to immigration to prepare people for the reality of re- Economic survival is the major issue and it could be settlement challenges, and post migration to present specifically due to three reasons. One is the exploita- tion of immigrants and refugees–I would call it ‘slave the range of services available to them. They recog- labour’ because their professional qualifications are nized that information is critical for accessing ser- not accepted by Canadian regulatory bodies. They vices, and best if culturally and linguistically appro- become a huge labour pool, which can be exploited. priate. Instrumental or practical support is critical to Secondly, there is discrimination based on race, eth- meet basic needs, but also to break down structural nic origin, language, colour of skin, and accent, so people are prevented from getting jobs that match barriers, for example, to employment and education. their qualifications or being paid for what they are Emotional support is important for those experienc- skilled at. Thirdly, I would say there is the language ing isolation, enduring family separation and facing barrier for those who don’t speak English fluently family crises. Affirmation from other immigrants is [Policy Maker #6a]. significant for giving guidance, sharing experiences, and empowering newcomers to meet challenges. Ser- vice providers and policy influencers also described Service Providers and Policy Makers’ newcomers’ lack of awareness of the reality of im- Views of Social Support migrating to Canada and specific challenges associ- ated with resettlement, including a lack of knowledge Most service providers and policy makers de- about health and health-related “systems” (educa- scribed a holistic concept of social support that en- tion, employment, and community services). ables newcomers to meet challenges effectively. For Service providers and policy makers described example, one said, a continuum of formal and informal social supports. [Social support] is contextual, because it can mean Formal supports most frequently accessed by different things at different moments. What often newcomers were mainstream agencies, resettlement comes to my mind is the Alma Ata Declaration of agencies, gender- and ethno-specific organizations, WHO [World Health Organization] and the under- and language schools. Common informal sources of standing of primary health care ...looking at the total being, not only the physical being, but also support for all newcomers included friends, relatives the mental, psychological, the economic, the polit- and neighbours from the same ethnic groups. Other ical, the social, the cultural. Understanding social sources were independent sponsors, religious orga- support, it is trying to adopt that kind of model or nizations, and ethno-cultural associations. Service framework. The terrific challenge is how to make providers and policy makers realized newcomers’ it real. How do you ...actually develop potential? [Service Provider #5a]. need to build new and stronger support networks. Some respondents also noted the differences in Others added cultural and social dimensions to support systems between the newcomers’ home their definition of social support, alluding to a learn- country and adopted countries, particularly the Providing Social Support for Immigrants and Refugees in Canada 263 relative lack of support from extended family and social support has negative impacts, such as increas- community members in Canada. ing feelings of loneliness and social isolation, loss of As for barriers to help-seeking, service providers identity, discouragement (e.g. about seeking employ- and policy makers felt that some newcomers lack ment), and lack of knowledge of available options. awareness of services as a result of language and eco- Service providers and policy makers believed that nomic limitations, social isolation, inadequate infor- they directly helped immigrants and refugees meet mation from government or agencies, and a tendency specific challenges and affected newcomers’ overall to stay within their own social/ethnic groups for sup- health and well being. For example, as one service port. They also described other impediments to new- provider stated: comers’ support-seeking efforts, such as distrust of We attack a critical aspect of people’s well being— agencies, cultural barriers, privacy issues, stigma, and accommodation. As I say, the way you live is the family dynamics. way you socialize. You begin to build relationships Respondents recognized that many existing with neighbours. It’s simple, right? When you create supports are inaccessible to many newcomers due places where immigrants are dumped by the rental to inadequate funding, geographical and other market in poor quality housing, then invariably it will affect their well-being and ability to integrate limitations on service provision. For example, some into larger society. That’s not a good start for any- agencies are unable to provide needed services such one. [Service Provider #10a] as translation/interpretation for clients, financial or health-related services. Given the many and diverse Despite the challenges and inadequacy of social backgrounds of clients, few service providers are supports, respondents noted that many immigrants able to offer a range of supportive services in a and refugees demonstrate remarkable resilience and culturally competent manner, which may be defined willingness to retrain, to share information and sup- as having three domains: awareness of attitudes, port with other newcomers, to work collaboratively values and biases (affective), knowledge (cognitive) to identify common needs and to create programs to and skills (behavioral) that are actually required to fill service gaps. be effective in cross cultural encounters (23). Other In keeping with their holistic perspective on the barriers for immigrant clients of health and social challenges facing newcomers and the social supports service agencies include restricted eligibility due needed, most policy makers and service providers de- to time limits or immigration status, circular or in- fined health comprehensively and with concern for consistent bureaucratic processes, perceived racism an individual’s ability to function effectively. For ex- and lack of understanding by mainstream agency ample, policy makers suggested: staff. Health and well being? It is being able to be healthy. Service providers and policy makers repeatedly I guess there is a physical aspect, but also to feel pointed out structural barriers in Canadian society. great and to grow. I would say well being is perfor- As one policy maker argued: mance. Being able to perform optimally on a daily basis and getting the kind of opportunities that you We believe that systemic issues are the major source need to do that. [Policy Maker #2a]. of oppression, reinforcing the disadvantaged posi- Study participants also commented on the links tion. We also believe systemic issues need systemic solutions. That is why we are all so much concerned between social determinants of health, such as social with the policies and the social structure in Canada support, and health. [Policy Maker #6a]. You asked us to look at what we felt is a priority. It’s all connected and it’s really tough to single out, but [for] a lot of people, self worth, self esteem, self- The Perceived Impact of Social Support confidence ...isattachedtotheirwork.Ifwedidn’t on Health and Well Being have our work, how would we feel? I think em- ployment is probably one of the key things.” [Focus group participant] Service providers and policy makers observed that having social support helps newcomers by foster- Social support makes you feel emotionally well and ing a sense of empowerment, community and social I believe that influences your physical health...And it goes the other way around, too. The lack of so- integration, building networks, sharing experiences cial support or a threat from your surroundings can and problems, reducing stress, and contributing to hugely impact your health....” [Service Provider physical and mental health. Conversely, inadequate #15b] 264 Simich, Beiser, Stewart, and Mwakarimba

Challenges Affecting the Provision collaborative working relationships, although these of Social Support are encouraged by government funders, because funding cutbacks have reduced cooperation and Service providers and policy makers have faced increased competition among service agencies and three major challenges in providing social supports: community organizations. limited resources, lack of integration of policies and programs, and narrow mandates. Although we are being told to collaborate in part- nerships . . . it is not being done to the same degree or level within government. So [we] continue. . . to In the mid ’90s when there were program cutbacks, hit our heads against these funding silos and min- what the politicians and government wanted was istries that are looking at their mandates as very nar- quick results. ‘We are going to give you little money, rowly defined. [Policy Maker #18b] but we want high results,’ which means you were not going to spend much time with people. Many As the foregoing comment suggests, the second people lost out—the people that were hardest to major challenge is the multiplicity of players, jurisdic- serve....[ServiceProvider#9a]. tions, and boundaries that impede coordination. One The greatest challenge described by participants participant noted, is loss of resources. Limited financial and human Policies are added on top of policies and added on resources have had a negative impact on service top of policies. It just creates all these layers and it delivery, collaboration with other sectors, and staff is just very confusing for everyone involved. [Policy morale. Maker #11b]

[Service organisations] receive less money and This situation has resulted in a lack of inte- their mandate is much narrower than people ex- gration of constituent groups and policies; gaps and pect....They don’t have resources to deal with sys- perceived inequities in services; unfriendly political temic issues. So, I think there is a huge crack, lots of relationships between governments or government people are falling through . . . It seems we are push- departments; and under–representation of smaller ing people away. [Policy Maker #1a] ethnocultural service organizations and personnel Limited resources affect service provision in within policymaking bodies, contributing to a power several ways: decreased staff and organizational re- imbalance. sources despite an increase in number of newcomers The third reported challenge is the negative im- served; inability to provide follow-up for clients; pact of narrow agency mandates on service delivery. inability to hire new staff to work with emerging Restrictive mandates prevent service providers from language groups; services provided in “piecemeal assisting newcomers in a holistic way. When new- fashion” rather than the full spectrum of services; comers’ needs extend beyond the services available “borrowing” hours from one program to respond in an ethnospecific agency, newcomers are referred to needs in another; lack of adequate translation to mainstream agencies. However, many mainstream services; inability to provide outreach services; and agencies lack culturally competent service providers inability to contribute to community development. and/or translation and interpretation services. The effects of limited financial and human resources on staff morale include physical fatigue Directions in Enhancing Social Supports from work demands; fear that short-term project for Immigrants and Refugees funding may be terminated; feelings of helplessness and powerlessness due to limited ability to help; The major challenges noted by policymakers disillusionment about whether efforts contribute to and service providers interviewed across study sites substantive change; personal dissonance with policies in the first phase of the research—limited resources, that may contribute to inequities; resentment regard- lack of integration and restrictive mandates—were ing employers’ expectations that additional hours reiterated in the final phase focus groups. These worked are voluntary; and reduced time for service impede the provision of holistic and sustainable delivery due to staff involvement in fund raising. social supports that enable immigrants and refugees Service providers also have difficulty demonstrating to overcome the multiple barriers to healthful social short term outcomes, particularly when their services integration. For example, participants noted that center on promotion and prevention, which are outreach, referral and advocacy efforts that promote long term. Limited resources also negatively affect active support-seeking and provide bridges among Providing Social Support for Immigrants and Refugees in Canada 265 services have been severely curtailed in the last ating structures, for ongoing consultation between decade. The review of research findings resulted in a government and organizations working with immi- discussion of the linkages among social determinants grants and refugees. In practical terms, the public of health and policy implications and brought out sector needs to be accountable for implementing cul- overarching themes related to communication and tural competency, such as translation and interpre- coordination. In particular, participants empha- tation services, in its service delivery at all levels. sized the need to alter public discourse, improve Participants further recommended greater coordina- governance, and remedy the dissonance between tion of information, referral and services to achieve immigrant expectations and reality. more seamless support. Given an apparent informa- Focus group participants suggested that it is tion and accessibility gap for newcomers, who are of- necessary to promote a positive shift in public dis- ten unfamiliar with or experience barriers to existing course, from a tendency to categorize newcomers to services, participants recommended more consistent Canada as needy service recipients to an emphasis on use of mainstream contact points, such as schools, newcomers’ contributions, resilience and well being. health centres, libraries and community centres to They observed that newcomers are often presented reach immigrants and refugees. More follow-up is in public discourse as the source of social problems, needed after information is initially provided to en- when it is government policy that may be failing sure access to health and social services. Focus-group them. As one participant said: participants also recommended better use of the In- ternet and ethnic media. The obstacles in the system are very much the same The discrepancy between newcomers’ expecta- in different cities. They take particular forms de- pending on the relative concentration of different tions and reality and between efforts to integrate and immigrants in terms of the country of origin, et resulting disappointments in Canada was also a com- cetera. I think it is more a question of the dis- mon theme in focus group discussions. Many focus course . . . Some of the solutions may be in articulat- group participants felt that Canada should acknowl- ing this as a problem for Canadian society in terms of edge that the dissonance of expectations and reality making use of the capacity and the energies and the contributionsofimmigrants....[Focusgrouppartic- takes a toll on immigrant health and on the poten- ipant]. tial for social integration of large newcomer groups within the society. Participants discussed the need Participants also emphasized the need for to reduce the discrepancy as a responsibility of both greater organizational sustainability due to a decade sending and receiving societies: of deep funding cutbacks and restrictions. Many pro- grams eliminated in Ontario, for example, were those What expectations people bring with them and how that facilitated social support. Consider the following they are met, or not met, impacts on how they feel . . . people are coming with inflated expectations comment: and may be disappointed. We have to change the cir- cumstances when they arrive, but also information Anti-racism and employment equity programs just and assessment of their opportunities before they were completely eliminated, and yet, I think in terms come [Focus group participant]. of broadening the ability to provide support, those typesofinitiativeshavetobecombined...It’snot something you do once and forget about it, obvi- DISCUSSION ously. It is something that has to be part of the way in which your organization lives [Focus group par- ticipant]. Canadian service providers and policymakers who are concerned with the health of immigrants and According to study participants, social support is refugees agree that there are fundamental challenges most meaningful when it is enabling and comprehen- to providing supportive services to newcomers. Such sive, satisfying needs and aspirations in all areas of a challenges are linked to larger problems of marginal- newcomer’s life. Immigrants and refugees most value ization of immigrants, the political discourse that has supports in areas that fall outside the current man- supported neoliberal policies and funding cuts, and dates of federal health or immigration and settlement the discrepancy between migrants’ expectations and policy per se, such as local labour market integration the reality of life in Canada. Just as immigrants face and increased access to education. many systemic challenges during settlement and in- Participants also suggested facilitating account- tegration, so do service providers and policymakers. ability, coordination, and information-sharing by cre- Systemic issues–limited resources, lack of integration 266 Simich, Beiser, Stewart, and Mwakarimba of policies and programs and narrow service markets that marginalize newcomers (36); reductions mandates—limit service providers’ abilities to meet in health and welfare programs that have been dele- newcomer’s needs. Understanding and enhancing terious to immigrant wellbeing (37); restrictive immi- social supports for immigrants and refugees on a gration and settlement service mandates (38); health systemic level is therefore important to help close research and policy agendas that treat immigrant and the gap between “the promise of citizenship and the refugee populations as homogeneous (39) and out- reality of exclusion” that impacts unequally on the dated public health approaches to migrant popula- health and well being of newcomers. (24, p. 246) tion health, which focus on control and containment Study participants suggest some directions: changing rather than health promotion (40, 41). Moreover, pubic discourse to focus on immigrants’ contribution, the scope of services has been restricted over the thereby creating a climate for investing more re- years, which means that Canadian government pro- sources in supportive services, improving governance grams are “weakest in dealing with the area of great- and coordination of information and services, and est need—the second stage of settlement—involving adopting a more holistic, long-term perspective on labour market integration and equitable access to the settlement and integration process. general health, housing and social services.” (38:20). The challenges facing immigrants and refugees Canadian service providers and policy makers also and the equally important challenges facing service acknowledge that conventional social policies have providers and policy makers are intertwined. We not met complex, contemporary needs such as immi- may highlight two underlying problems: First, immi- grant settlement, because economic inequalities are grants and refugees in Canada currently experience entrenched and social problems and responsibilities great difficulty in becoming economically integrated for their resolution cut across multiple sectors, as so- (25) and poverty among new Canadians has reached cial analysts have observed elsewhere (42). unprecedented levels (26). Second, responsibilities Short-sighted social support policies are at odds for immigrant settlement, health and social services with operational needs of service organizations, the are under funded and uneasily divided between na- continuum of social support needs in immigrant tional, provincial and local jurisdictions, confounding communities, and the complex, protracted nature of accountability for service gaps related to immigrant immigrant settlement (18, 38). The immigrant adap- health and giving the Canadian cities where most im- tation process warrants a longer-term, holistic per- migrants settle little influence over the integration spective to improve supportive policies and pro- process (27, 28). The holistic social supports neces- grams. The current situation of providing social sup- sary to promote health, economic and social integra- port to immigrants and refugees in Canada illus- tion are inadequate due, in part, to these systemic trates Hart’s “Inverse Care Law,” which states “the barriers and governance issues. availability of good medical care tends to vary in- Among study participants, there was clear con- versely with the need for it in the population served” sensus that most problems are systemic, rather than (43). According to Hart, “the inverse care law is not attributable to immigrants and refugees themselves. a law of nature, but of dehumanised market eco- Although immigrants to Canada bring in consider- nomics, which could be unmade by a rehumanised able human capital–the majority are skilled work- society” (44:19). In the same vein, a ‘rehumanised’ ers and on average more highly educated than the Canadian society would do best to transform the na- Canadian-born–they experience lower levels of eco- tional support structures for the speedier adaptation nomic achievement (29). Lack of access to jobs and of newcomers. lack of recognition of foreign credentials is part of the explanation (26). Recent research has also shown ACKNOWLEDGMENTS that visible minority immigrants are more likely to be stigmatized due to discrimination (30, 31, 32), which The Multicultural Meanings of Social Support is known to have deleterious effects on health (33). project was funded the Social Sciences and Humani- Lack of knowledge about how to provide bet- ties Research Council (SSHRC) of Canada, with Dr. ter support to immigrants as well as policies that are Miriam Stewart as Principal Investigator (PI). Site incongruent with public health and welfare have hin- PIs were Dr. Morton Beiser, dered service provision to immigrants and refugees and Dr. Joan Anderson, Faculty of Nursing, Uni- (34, 35). In Canada, detrimental changes attributable versity of British Columbia. Co-Investigators were to recent policies have included restructuring of labor Dr. Anne Neufeld, Dr. Denise Spitzer, University Providing Social Support for Immigrants and Refugees in Canada 267 of Alberta; and Dr. Laura Simich, University of 20. Aroian KJ: Sources of social support and conflict for Polish Toronto. The project was coordinated by Edward immigrants. Qual Health Res 1992; 2(2):178–207 21. Baker C: The Stress of Settlement Where There is No Eth- Mwakarimba, with Zhi Jones and Sylva So, in Ed- nocultural Receiving Community: In: Masi R, Mensah L, monton; Farah Mawani, with Fei Wu and Ardo Noor McLeod K, eds. Health and Cultures, Volume II: Programs, in Toronto; and Joanne Reimer with Teresa Gray, in Services and Care. Oakville, ON: Mosaic Press; 1993: 263– 276 Vancouver. We also wish to thank members of the 22. Janesick VJ: The choreography of qualitative research de- Community Advisory Groups in all sites for their ad- sign: Minuets, improvisations and crystallization: In: Denzin vice and participation in the project. N, Lincoln Y. eds. Handbook of Qualitative Research, 2nd edition. Thousand Oaks, CA: Sage Publications; 1994:379– 400 REFERENCES 23. Sue DW, Arredondo P, McDavis RJ: Multicultural coun- selling competencies and standards: A call to the profession. J Multicultural Counsel Develop 1992; 20:64–88 1. Wilkinson R, Marmot M (eds.): Social Determinants of 24. Galabuzi GE: Social exclusion: In: Raphael, D, ed. Social De- Health: The Solid Facts. Copenhagen: World Health Orga- terminants of Health: Canadian Perspectives. Toronto: Cana- nization, Centre for Urban Health; 2003 dian Scholars Press; 2004: 235–251 2. Stewart MJ (ed.): Chronic Conditions and Caregiving in 25. Lochhead C: The Transition Penalty: Unemployment among Canada: Social Support Strategies. Toronto: University of Recent Immigrants to Canada. CLBC Commentary. Ottawa: Toronto Press; 2000 Canadian Labour and Business Centre; 2003 3. Stewart, MJ, Lagille, L: A framework for social support as- 26. Kazemipur A, Halli S: Immigrants and ‘New Poverty:’ The sessment and intervention in the context of chronic conditions Case of Canada. Inter Migration Rev 2001; 35(4):1128– and caregiving: In: Stewart, MJ, ed. Chronic Conditions and 1156 Caregiving in Canada: Social Support Strategies. Toronto: 27. McIsaac E: Nation Building through Cities: A new deal for University of Toronto Press; 2000:3–28 immigrant settlement in Canada. Ottawa: The Caledon Insti- 4. Bloom JR: The relationship of social support and health. Soc tute of Social Policy; 2003 Sci Med 1990; 39(5):635–637 28. Edgington DW, Hutton T: Multiculturalism and Local Gov- 5. Dunn JR, Dyck I: Social determinants of health in Canada’s ernment in Greater Vancouver, Working Paper Series No. immigrant population: Results from the National Population 02–06. Vancouver: Vancouver Centre of Excellence for Re- Health Survey. Soc Sci Med 2000; 51: 1573–1593 search on Immigration and Integration in the Metropolis; 6. Statistics Canada: 2001 Census, Ottawa, ON: Statistics 2002 Canada; 2002 29. Citizenship and Immigration Canada: The Monitor: High- 7. Statistics Canada: Canada’s Ethnocultural Portrait: The lights for the Third Quarter, 2003. Ottawa: Citizenship and Changing Mosaic. 2001 Census: Analysis Series. Ottawa, ON: Immigration Canada; 2004. Available at http://www.cic.gc. Statistics Canada; 2003 ca/english/monitor/issue04/index.html. 8. United Nations High Commissioner for Refugees: Refugee 30. Badets J, Howatson-Leo L: Recent Immigrants in the Work- Resettlement: An international handbook to guide reception force. Canadian Social Trends 2000; 3:15–21 and integration. Melbourne: Victorian Foundation for Sur- 31. Kunz JL, Milan A and Schetagne S: Unequal Access: A Cana- vivors of Torture, with UNHCR, Geneva; 2002 dian Profile of Racial Differences in Education, Employment 9. Chen J, Ng E, Wilkins R: The health of Canada’s immigrants and Income. Toronto: Canadian Race Relations Foundation; in 1994–1995, Statistics Canada. Health Rep 1996; 8(3): 29–37 2002 10. Perez CE: Health Status and Health Behaviour among Im- 32. Li P: Earning disparities between immigrants and native-born migrants, Supplement to Health Rep. Ottawa, ON: Statistics Canadians. Canadian Rev Sociol Anthropol 2000; 37(3):289– Canada; 2002 311 11. Hyman I: Immigration and health. Health Policy Working 33.NohS,BeiserM,KasparV,HouFandRummensJ:Per- Paper Series. Working paper 01–05. Ottawa, ON: Health ceived racial discrimination, depression and coping: A study Canada; 2001. Available at http://www.hc-sc.gc.ca/iacb-dgiac/ of Southeast Asian refugees in Canada. J Health Soc Behav arad-draa/english/rmdd/wpapers/wpapers1.html. 1999; 40:193–207 12. Grieco E: The Effects of Migration on the Establishment of 34. Quill BE, Aday L, Hacker CS and Reagan JK: Policy in- Networks: Caste Disintegration and Reformation among the congruence and public health professionals’ dissonance: The Indians of Fiji. Int Migr Rev 1998; 32:704–736 case of immigrants and welfare policy. J Immigr Health 1999; 13. Hagan J: Social Networks, gender, and immigrant incorpora- 1(1):9–18 tion: Resources and constraints. Am Sociol Rev 1998; 63(1): 35. Richmond T, Shields J: Third Sector Restructuring and the 55–67 New Contracting Regime: The Case of Immigrant Serving 14. House JS: Work, Stress and Social Support. Reading, MA: Agencies in Ontario, CERIS Policy Matters No. 3. Toronto: Addison-Wesley; 1981 Centre of Excellence for Research in Immigration and Settle- 15. House JS, Umberson D, and Landis KR: Structures and Pro- ment; 2004 cesses of Social Support. Annu Rev of Sociol 1988; 14:293–318 36. Shields J: No Safe Haven: Markets, Welfare, and Migrants, 16. Thoits P: Social Support as Coping Assistance. J Consult CERIS Policy Matters, No. 7. Toronto: Centre of Ex- Clinic Psych 1986; 54(4):416–423 cellence for Research on Immigration and Settlement; 17. Anderson JM: Immigrant women speak of chronic illness: 2004 The social construction of the devalued self. J Adv Nurs 1991; 37. Steele LS, Lemieux-Charles L, Clark JP, Glazier R: The im- 16(6):710–717 pact of policy changes on the health of recent immigrants 18. Beiser M: Strangers at the Gate: The ‘Boat People’s’ First Ten and refugees in the inner city. Can J Public Health 2002; Years in Canada. Toronto: University of Toronto Press; 1999 93(2):118–122 19. Statistics Canada: Highlights of the Longitudinal Survey of 38. Mwarigha MS: Towards a Framework for Local Responsibil- Immigrants to Canada, Wave 1, 2000–2001. Ottawa, ON: ity: Taking Action to End the Current Limbo in Immigrant Statistics Canada; 2004 Settlement. Toronto: Maytree Foundation; 2002 268 Simich, Beiser, Stewart, and Mwakarimba

39. Gold J, DesMeules M: National symposium on immigrant 42. Saint-Martin D: Coordinating Interdependence: Gover- health in Canada: Afterword. Can J Public Health 2004; nance and Social Policy Redesign in Britain, the Euro- 95(3):I38–39 pean Union and Canada. CPRN Research Report F/41. 40. MacPherson DW, Gushulak B: Human mobility and popula- Ottawa, ON: Canadian Policy Research Networks, Inc; tion health: New approaches in a globalizing world. Perspect 2004 Biol Med 2001; 44(3):390–401 43. Hart J T: The inverse care law. Lancet 1971; 1:405– 41. Gushulak B, William, L: National Immigration Health Policy: 12 Existing Policy, Changing Needs and Future Directions. Can 44. Hart JT: Commentary: Three decades of the inverse care law. J Public Health 2004; 95(3):I27–I29 Brit J Med 2000; 320:18–19