How are new refugees doing in Canada?

How are new refugees doing in Canada? Comparison of the health and settlement of the Kosovars and Czech Roma

Canadian Journal of Public Health, Sep/Oct 2003 by Redwood-Campbell, Lynda, Fowler, Nancy, Kaczorowski, Janusz, Molinaro, Elizabeth, Et al

ABSTRACT

Background: In 1999, a group of Kosovars arrived in Hamilton, Ontario, with a coordinated international pre-migration plan, as part of the United Nations Humanitarian Evacuation Program. Since 1997, a substantial number of Roma refugees from the Czech Republic also arrived in Hamilton, with no special pre-migration planning. This study examined whether the organized settlement efforts led to better adaptation and perceived health for the Kosovars, using the Czech Roma as a comparison group.

Methods: Adult members of 50 Kosovar (n=157 individuals) and 50 Czech Roma (n=76 individuals) randomly selected families completed a questionnaire on sociodemographics, health, well-being, and perceived adaptation to Canada. Differences between groups were examined using univariate and multivariate analyses. Comparison was made to the Ontario population where possible.

Results: There were more Kosovars than Czech Roma over the age of 50 (22.1% vs 10.5%, p=0.03). Nearly one quarter (21.7%) of the Kosovars had a score indicating post-traumatic stress disorder (PTSD) on the Harvard Trauma Questionnaire (HTQ), compared to none of the Roma (p

Conclusions: The health and adaptation of the Kosovars was not better than that of the Czech Roma. Reasons for this finding may include differences in demographics, the presence of PTSD, and differing length of time since arrival in Canada.

As part of its role in the United Nations Humanitarian Evacuation Program,1 Canada received approximately 5,000 refugees from Kosovo in the spring of 1999, 500 of whom arrived in Hamilton, Ontario. The majority of Kosovars destined for Hamilton came directly into community "settlement" houses set up in two local hotels. The refugees received social supports and sponsor groups were assigned to each family. Unlike with the usual arrival of refugees in Canada, there was a coordinated effort by health and other professionals to assist with the health and settlement needs of this large influx of Kosovar refugees. Since 1997, Hamilton has also received approximately 500 Roma refugees from the Czech Republic. In contrast, the Czech Roma were self-selected asylum seekers who applied individually for refugee status. As such, there was no pre-migration organizational planning for this group.

Studies examining refugee health profiles are often conducted in the context of international refugee camps,2,3 and relatively little information pertains to refugee groups in receiving host countries.4 One recognized barrier to settlement is the common presence of mental health difficulties, and often there is little data on the post-arrival physical health and self-perception of health of refugees.4,5 Many host countries have poor criteria for assessing how well refugees have integrated,6 compounding the difficulties in evaluating health. Canada has been a leading country in 'best settlement practices',7 encompassing areas such as language, employment and cultural orientation.

As a result of the special settlement efforts, we hypothesized that the Kosovars would report better adaptation and perceived health compared to other recent refugees. We compared the Kosovars and Czech Roma to generate their respective health profiles and highlight issues that may be helpful for planning future humanitarian efforts.

This paper describes the results of a questionnaire administered to individuals in randomly selected Kosovar and Czech Roma families regarding their health and adaptation to Canada. Comparisons were also made to the Ontario general population, where possible.

METHODS

Sample selection

The Settlement and Integration Services Organization in Hamilton (SISO), a community-based agency that serves local immigrant and refugee groups, used their records of all Kosovar and Czech Roma families that were active with the organization in the spring of 2001. All Kosovar families who arrived as part of the UN evacuation program and the majority of Czech Roma families (> 80%) in Hamilton were listed and active with SISO at the time of the study (personal communication, SISO director). The Czech Roma list contained 423 members of 166 families, with 268 individuals aged 18 and older. The Kosovar list contained 480 members of 161 families, with 350 individuals aged 18 and older. The majority of the Czech Roma study participants (90.8%; 69/76) arrived in Hamilton in 1997, six arrived in 1999 or 2000, and one arrived in 1994. The majority of the Kosovar study participants (87.3%; 137/157) arrived in the spring or summer of 1999 and 18/157 arrived in 2000 (two did not indicate their arrival date). Two individuals representing the refugee groups, and who were affiliated with SISO, conducted the fieldwork. One was a refugee physician from Kosovo and the other was active in settlement activities for Czech Roma in Southern Ontario. To maintain confidentiality before consent was obtained, a list of random numbers was supplied by the researchers to SISO and assigned to the list of families. The fieldworkers then contacted the randomly selected families. All families on the list, including family members aged 18 or older, were eligible. Families were approached until 50 from each group agreed to participate. The fieldworkers contacted the families, explained how they obtained the family name and phone number, and invited the family to participate. The person with whom the fieldworker arranged the interview consented verbally for all family members, and at the time of questionnaire administration, each family member over 18 years of age gave written consent.

The questionnaire was self-completed in most cases, however the fieldworker assisted participants where necessary. The questionnaire took approximately 30 minutes to complete. The Hamilton Health Sciences Research Ethics Board approved the study.

Data collection instruments

The questionnaire was developed by the research team and included demographic information, social support, general health, presence of stress, specific health conditions, tobacco and alcohol use, and health care services utilization questions. In order to compare to normative Canadian data, general health, specific health conditions, presence of stress, tobacco and alcohol use, and some demographic questions were taken directly from the Ontario Health8 and the Canada Health9 surveys. In addition, the Harvard Trauma Questionnaire (HTQ)10 was used to assess mental health status in relation to experiences in the home country. The HTQ was designed to measure symptoms associated with post-traumatic stress disorder (PTSD) in refugees. Existing translations of some of the questions were obtained from the Czech Ministry of Health and from other researchers who had translated and back-translated the HTQ into Albanian.3 The fieldworkers translated remaining questions. Fieldworkers conducted pilot interviews with two families from each group to pre-test the questionnaires.

Statistical analyses

Data were entered and analyzed using SPSS v 10.0.5 (SPSS Inc., Chicago IL). Univariate analyses were performed to compare socio-demographic characteristics, self-reported health and well-being, perceived adaptation, and variables relating to mental and physical health between the Kosovar and Czech Roma refugees using the Chi-square test or Student's t-test, as appropriate. A score of > or =2.5 on Harvard Trauma Questionnaire was used to indicate the presence of PTSD.10 For variables that were significantly different between the two groups in univariate analyses (p

Ontario population results from the 1996/97 National Population Health Survey12 or the 1990 Ontario Health Survey8 are presented, where available.

RESULTS

Sample description

The response rate for the families was 97.1% (100/103). Two Kosovar families refused and one Czech Roma family had moved out of the city. The demographic characteristics of the two groups are shown in Table I. On average, the mean size of the Kosovar families was significantly larger than the Czech Roma, there were significantly more Kosovars over the age of 50, and the Kosovars were more likely to have come from smaller towns or villages compared to the Czech Roma.

Health and well-being

A higher proportion of Kosovars compared to Czech Roma (11.5% vs. 1.3%) reported that their health was poor. The proportions of respondents who reported excellent or very good health was similar for the Kosovars (45.9%) and the Czech Roma (48.7%) (Table II). A similar pattern was seen for satisfaction with health, happiness with life, life stress, and adaptation to Canada, with more Kosovars choosing responses at the extreme ends of the scales compared to the Czech Roma (Table II). The responses to all of these variables were significantly different between the two groups by univariate analysis. The prevalence of PTSD was 21.7% (34/157) in the Kosovars, and 0% in the CzeIn comparison to the Ontario population (10.3%), more Kosovars (26.8%) reported fair or poor health, however the proportions reporting excellent health were similar (24.0% for Ontario vs 25.5% for the Kosovars). In contrast, the Czech Roma were similar to Ontario for fair or poor health, but a lower proportion (10.5%) reported excellent health. A similar pattern was seen for satisfaction with health. The Kosovars were more likely and the Czech Roma less likely than the Ontario population to report that life was stressful. The frequency of reporting three or more chronic conditions was lower in both the Kosovars (10.3%) and Czech Roma (2.7%) compared to the Ontario population (20.1%).

DISCUSSION

Our initial hypothesis that the Kosovar group would have better self-perceived health and settlement experiences than the Czech Roma group, as a result of the extra services received, was not supported. These results may be partially explained by differences between the groups in terms of age and the presence of PTSD symptoms. The Kosovars were older, more likely to lack formal education, and tended to come from smaller towns and villages. These factors have been reported to interfere with adaptation to a new country.11,13 We speculate that differences in demographics may be the result of the immigration approach, in that the refugee families included older Kosovars, who likely would not have come to Canada on their own. These differences may also explain the different response profiles between the Kosovars and the Czech Roma on several variables. For example, a higher proportion of Kosovars reported both 'excellent' and 'poor' health compared to the Czech Roma respondents. The Czech Roma, in contrast, less frequently provided responses on the extreme end of the scales, with most of their responses being in the middle of the scales. The dichotomy of the responses to the question of 'adaptation to Canada' within the Kosovar group may be partly explained by the contrast of 'euphoria' and PTSD symptoms described in the resettlement and integration literature.14,15 This 'euphoria' stage is sometimes observed soon after leaving a war zone but may be suppressed by those with PTSD. The more frequent reporting of poor health in the Kosovars may also be related to PTSD. Nearly one quarter of the Kosovars in this study were experiencing PTSD, an even higher proportion than recently reported ethnic Albanians living in Kosovo (17.1%) in 1999.3 That study also found that three quarters of respondents reported lacking food or water, and almost half reported ill health without access to medical care during the time of aggression. These physical and mental hardships experienced by the Kosovars would be expected to have an impact on their perceived current health and well-being.

There were several limitations in this study. We did not adjust for the effect of the clustered design, in which the family was the sampling unit but individual was the unit of analysis, which may have led to overestimates of the statistical significance of differences between groups. The questionnaires were filled out individually, but not in private, and the Kosovars especially may have felt obliged to respond more favourably as a result of the special treatment they received on their arrival. In addition, some of the response patterns suggest that despite our efforts to accurately translate the questionnaire, there may have been differences in the cultural interpretation of the questions or differing experience between the groups in responding to health questionnaires. For example, two thirds of the Czech Roma reported no chronic health problems - more than the Kosovars or the Ontario population - however few of the Roma reported excellent health. Our comparison group for the Kosovars was a different ethnic group and it would have been interesting to compare these Kosovars to another group of Kosovar refugees who had arrived without the special settlement services. Finally, the Czech Roma had been in Canada approximately twice as long as the Kosovars, and many of the differences reported here may disappear over time.

It is almost certain that another global refugee crisis will occur in the future and the international community must be prepared. An organized international evacuation plan could result in improved health and settlement for refugees, however more research is needed on this issue. Our study suggests that the Kosovar evacuation resulted in a demographically different group than the usual 'healthy immigrant' population. Key issues that emerged for the Kosovars were the high prevalence of PTSD and poorer adaptation to life in Canada. As a result of these issues, we could not conclude that the Kosovars fared better than refugees who arrived through the 'traditional' approach. Canada could expand on its current approach and take a leadership role in the future to critically examine the most effective methods for the optimal settlement and health of refugees in an emergency evacuation situation.

Copyright Canadian Public Health Association Sep/Oct 2003

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