Why Do Some Nonnative People Who Migrate to Another Country Have Better Health Status Than Their Native-Born Counterparts?

See article by Chiu et al

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Why Do Some Nonnative People Who Migrate to Another Country Have Better Health Status Than Their Native-Born Counterparts?

Mario Cruz, MDa,*

It is well known that racial and ethnic differences exist in the utilization of mental health services.1-10 These differences have been posited to be secondary to a various array of factors such as different mental health beliefs among ethnic groups that act as barriers to or facilitators of mental health services11,12; barriers to mental health care access secondary to low socioeconomic status,8,10 lack of health insurance,8,10 discrimination,13,14 institutional racism,10 lack of culturally sensitive and appropriate services,10 racial/ethnic and cultural mismatches between providers and patients,10 and shame and stigma10; and social differences in the path chosen for patients of different ethnic groups to mental health.15-18

Immigration status is another factor influencing utilization of mental health services. Immigration status plays a role in the health and mental health status of racial and ethnic groups. Recent migration status has been linked to better health status in nonnative compared to Canadian and US populations.19 The positive association between recent migration and better health status has not been clearly shown in people who have migrated to European countries.20 In addition, immigrants with mental illnesses who live in areas that are densely populated by individuals (ethnic density hypothesis) from the same ethnic group have been shown to be associated with reduced illness severity.21-23

Global migration is estimated at 200 million individuals per year.19 With the recent migration of millions of individuals from war-torn Syria, Afghanistan, and Iraq, this number will surely continue to rise. Understanding how immigration status influences the mental health status of different racial/ethnic groups and understanding the sociocultural barriers to and facilitators of mental service utilization for different immigration groups would be helpful in terms of future global and national health policy.

Maria Chiu and colleagues’ article "Ethnic Differences in Mental Illness Severity: A Population-Based Study of Chinese and South Asian Patients in Ontario, Canada"24 addresses an important mental health care service delivery question: How does immigration status and ethnicity influence psychiatric presentations that lead to inpatient psychiatric hospitalization for mainland Chinese and South Asian populations?

Canada is one of the key destinations for many immigrants. Twenty percent of the Canadian population is foreign-born. As the authors point out, many of these immigrants are from the Republic of China and South Asia (ie, India, Pakistan, Bangladesh, Sri Lanka).

The health status of Chinese and South Asian immigrants appears to be better than that of native Canadians for the first 10 years after their arrival.19 Thereafter, the health status of these immigrant groups becomes consistent with the general population. The health trajectory of Chinese and South Asian immigrants is consistent with the healthy immigrant hypothesis.20,25 That is, individuals who travel great distances to migrate from their country of origin are healthier than the native population in the country they migrate to. One limitation of the health status data on Canadian immigrants is that they do not thoroughly address the mental health status of immigrant groups.

As the authors point out, our knowledge of the mental health presentation of Chinese and South Asian populations for inpatient psychiatric admission is limited by small sample sizes and inconsistent findings in the published studies on these population groups.

The objective of their study24 was to enhance our understanding of how sociocultural factors such as race/ethnicity and immigration status influence the clinical presentation and treatment decision making of providers regarding inpatient psychiatric admission.

To achieve their objective, the authors’ investigated whether a population-based sample of Chinese and South Asian patients aged from 19 to 105 years who were hospitalized for psychiatric reasons between April 1, 2006, and March 31, 2014, in Ontario, the most populous province within Canada’s single-payer universal health care system, differed from the general hospitalized population on 4 measures of disease severity: involuntary admissions, aggressive behaviors, and the number and frequency of positive symptoms. In addition, they examined the role of sex, diagnosis, and immigration status on the relationship between Chinese and South Asian ethnicities and disease severity.

Pooling data from several large health (Ontario Mental Health Reporting System and the Canadian Institute for Health Information’s Discharge Abstract Database) and citizenship databases (the Registered Persons database and the Immigration, Refugees and Citizenship Canada Permanent Resident database), the authors captured patient-level sociodemographic characteristics, diagnoses, clinical ratings on aggressive behaviors, the number and frequency of positive psychotic symptoms, prior psychiatric hospitalizations, age, sex, area-level income, rurality of residence, and immigration status. Using a novel surnames algorithm the authors created and validated,26 they were able to classify all patients within the study time period into Chinese, South Asian, or general population groups. Thereafter, the authors employed appropriate statistical measures to identify relationships between sociocultural characteristics and the clinical presentation and type (voluntary or involuntary) of inpatient psychiatric admission.

The authors identified 133,588 unique patients, with 2,582 being Chinese, 2,452 being South Asian, and 128,554 being the general population. Important study findings were that Chinese and South Asian patients were younger, more likely to be immigrants, more likely to be admitted involuntarily because they were a threat to others (ie, exhibiting severe aggressive behaviors as measured by the Resident Assessment Instrument-Mental Health [RAI-MH]27,28 Aggressive Behavior scale29) or unable to care for themselves, and significantly more likely to be diagnosed with schizophrenia than the general population. In terms of positive psychotic symptoms, a disproportionately large number of Chinese and South Asians exhibited 3 or more positive symptoms (ie, hallucinations, command hallucinations, delusions, abnormal thought process or form) compared to the general population on the RAI-MH. In summary, Chinese and South Asian patients who were psychiatrically admitted were younger, were more often admitted involuntarily, and exhibited severe aggressive behaviors as well as psychotic symptoms compared to the general admitted population in Ontario, Canada. The authors aptly rule out ethnic differences in disease prevalence and propose that delays in treatment seeking explain these findings. They then discuss several of the previously mentioned patient/family and health system/provider barriers to accessing mental health services as potential causes.

An interesting additional finding was that Chinese patients’ illness severity was greater than the general population regardless of immigration status while Canadian-born South Asian patients had greater illness severity for most severity measures than their immigrant peers compared to the general population. These findings do not support the healthy immigrant hypothesis, for illness severity was greater for Chinese patients than the general population irrespective of immigrant status, while illness severity was greater for Canadian-born South Asians.

I propose these findings could be explained by the ethnic density hypothesis if there are variations in ethnic density between Chinese patients and Canadian-born South Asian patients. If we posit that Chinese populations, irrespective of immigration status, reside in more Chinese-dense areas while Canadian-born South Asian patients reside in less South Asian-dense areas compared to their immigrant peers, according to the ethnic density hypothesis, illness severity would be significantly greater for the South Asian Canadian-born group compared to their immigrant group peers. Future studies should assess the influence of ethnic density on illness severity at the time of psychiatric admission.

In conclusion, Chiu and colleagues’ study24 is a thoughtful, well-designed, and important contribution to our understanding of the influence of sociocultural factors, particularly immigration status, on clinical presentation and provider admission decision making of Chinese and South Asian psychiatric patients.

Submitted: September 21, 2015; accepted September 24, 2015.

Potential conflicts of interest: Dr Cruz has no conflicts of interest to disclose.

Funding/support: None.

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