Social support and health: immigrants’ and refugees’ perspectives

Miriam J Stewart PhD1*, Edward Makwarimba PhD2, Morton Beiser MD3, Anne Neufeld RN PhD4, Laura Simich PhD5 and Denise Spitzer PhD6

Professor, Faculty of Nursing and School of Public Health Sciences, University of Alberta, Canada

Research Program Administrator, Social Support Research Program, University of Alberta, Canada

Professor of Distinction, Department of Psychology, Ryerson University, Ontario, Canada

Professor, Faculty of Nursing, University of Alberta, Canada

Assistant Professor, Department of Psychiatry and Department of Anthropology, University of Toronto; Scientist, Social Equity and Health Research, Centre for Addiction and Mental Health, Canada

Research Chair, Institute of Women’s Studies and Institute of Population Health, University of Ottawa, Canada

*Corresponding Author:
Edward Makwarimba, Social Support Research Program, University of Alberta, 5–22 University Terrace, 8303–112 Street, Edmonton, AB, T6G 2T4, Canada. Tel: (780) 492 8030; fax: (780) 492 8045; email: [email protected]

Received date: 22 September 2008 Accepted date: 6 February 2010

 
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Abstract

Migration and integration are linked to depleted support networks. Although social support is a key determinant of health, newcomers’ appraisal of social support and its impact on health have not been adequately studied. This investigation focused on immigrants’ and refugees’ views of social support, its perceived influence on health and the use of health-related services. Individual in-depth interviews were conducted with 60 Chinese immigrants and 60 Somali refugees in Canada. The study revealed many stressful situations, including health problems that signified a need for support. Just as inadequateand inappropriate support has a negative impact on health, poor health can diminish available support. Social support facilitated employment and ability to meet basic needs, reduced stress, and improved physical and mental health. Support from others reduced loneliness and despair and enhanced the mental health of newcomers. Newcomers believedthat inadequate support exerted a negative influence on their health and use of health-related services, and that poor health had a detrimental effect on the ability to seek or offer support.

What is known on this subject

• Newcomers (i.e. immigrants and refugees) experience numerous settlement and integration challenges, including health problems, which increase their support needs.

• Newcomers experience social support deficiencies in their countries of settlement.

• Cultures differ in the way that they define, receive and give support.

What this paper adds

• It examines newcomers’ perceptions of social support and its impact on health and use of services as influenced by their cultures.

• It describes a comparative analysis of support appraisal across two different cultures and newcomer groups (i.e. immigrants and refugees) and how their cultures influence support-seeking strategies.

• It considers the contextual nature of support expectations and perceptions among newcomer groups as they interact with their host environments/communities.

Key words

Canada, immigrants, newcomers, refugees, social support, well-being

Introduction

International migration has increased in the past two decades (United Nations High Commissioner for Refugees, 2004). Canada has admitted between 28 000 refugees and 235 215 immigrants annually (Citizenship and Immigration Canada, 2009). As a result of immigration, 18% of Canada’s current population was born in another country; 70% of new Canadians are considered to be members of visible minorities (Statistics Canada, 2005). Emerging evidence points to the settlement and integration challenges experienced by newcomers, including social support deficiencies and health problems (Simich et al, 2003; Stewart et al, 2008). Despite contextual variations, such as immigration policies, immigrants and refugees have faced similar challenges with resettlement for the past five decades (Beiser, 1988; Balgopal, 2000). Newcomers experience many barriers to support, intensified by government cutbacks which inhibit social and health service provision (Gagnon, 2002). The interaction between social support and health is bi-directional (cf. Stewart, 2000; Krause and Wulff, 2005). Support enhances well-being and reduces or buffers the adverse psychological effects of exposure to stressful life events. Conversely, good health can facilitate supportive and/or reciprocal relationships (Stewart, 2000).

Sources and appraisal of support differ across cultures (Leduc and Proulx, 2004), and there are persistent gaps in research on support appraisal for newcomers (McDonald and Kennedy, 2004). Moreover, the role of social support and its effects on health have not been investigated from the perspectives of immigrants and refugees. Given the influence of social support on health, and the social and systemic barriers to support for newcomers, we investigated how immigrants and refugees perceive social support and its effects on health and the use of health-related services.

Social support and health of newcomers: review of relevant research

The disruption to family and cultural ties that is associated with migration contributes to the extensive support needs of immigrants and refugees (Hernandez- Plaza et al, 2004). Newcomers face particular struggles in obtaining social support in their host countries, intensifying problems with integration (Wu and Schimmele, 2004). Social relationships that provide meaning in the natal environment may be either disrupted or devalued in the receiving country (Warner, 2007).While there are different reasons for migration, which include making a personal choice to migrate and being forced to do so, the process of acculturation in the new country is linked to numerous challenges. These include problemswith language,finances (Warner, 2007; Stewart et al, 2008), housing, childcare, and access to services, which have been noted previously among refugees from Eastern Europe (Stein, 1981; Gerrand, 1988) and more recently among refugees from Africa, Asia and Latin America (Davis, 2000). Refugees also experience deteriorated physical, mental and cognitive health (Beiser, 1988; Davis, 2000).

For newcomers, social support is a key determinant of health (Warner, 2007; Nicdao et al, 2008) and use of health services (Abe-Kim et al, 2007). Social support is a resource for coping with stress caused by immigration and resettlement challenges. Support provided by community members of similar ethnicity is associated with positive health outcomes, whereas lack of social support has a detrimental effect on mental health (Palinkas et al, 2003; Nicdao et al, 2008). Separation from family exacerbates the severity of psychological problems (Rousseau et al, 2001). Newcomerswith extensive social support are more likely to access professional services (Alegria et al, 2004). However, ethnic groups differ in their attitudes toward the health system, and may mistrust health professionals (Davies and Bath, 2001). Despite emerging evidence pointing to the influence of social support on the health of newcomers, health-related challenges that require social support and mechanisms by which support influences health and the use of health services have not been investigated (Leduc and Proulx, 2004) from the perspective of immigrants and refugees.

In this study, key dimensions of social support, namely source, function, appraisal of positive and negative features (Stewart, 2000), use of support seeking as a coping strategy (Thoits, 1995), and perceived impact on health (Bloom, 1990), were assessed. The perceived links between social support and health, health behaviour and use of health services are emphasised in this paper. Comparison of less established refugees with more established immigrants enabled examination of the influence of support resources in the host community on health and the use of health-related services. Comparison of the two newcomer groups is warranted as, unlike other migrants, refugees are unable or unwilling to return to their homeland, have lower annual earnings (Cortes, 2004) and fewer social networks, and cannot access certain services (Davis, 2000; Stewart et al, 2008). The top five source countries of immigrants in Canada at the time when the study was conducted included China. We selected Chinese immigrants because of their long history in Canada and their strong community infrastructure of support services (Griffin, 1993). Given our limited access to refugee claimants (asylum seekers), we focused on Convention refugees. These refugees are accepted by Canada for permanent residence either before or after arrival in Canada as persons in need of protection and resettlement because of a well-founded fear of persecution according to the definitions in the United Nations 1951 Geneva Convention. In recent years, Somalia was one of the top 10 source countries of refugees in Canada (Citizenship and Immigration Canada, 2007).

Conduct of the project

Research questions

Five research questions guided this study.

1 What stressful situations that are faced by newcomers require social support?

2 What are newcomers’ perceptions and experiences of social support?

3 How does social support influence newcomers’ health?

4 How does social support influence newcomers’ use of health and health-related services?

5 What support services and programmes can enhance newcomers’ lives?

Research design

The interdisciplinary team of investigators represented diverse fields, namely anthropology, epidemiology, nursing, medicine, psychiatry and sociology. The research design was based, in part, on critical social theory to attend to unheard voices, such as vulnerable populations, and interpret participants’ experiences within the context of broader social relationships (Morse and Chung, 2003). Critical social theory was invoked because relocation and integration experiences are situated within a complex context of cultural, political and economic circumstances that can mediate the personal and social experiences of immigration and resettlement. The study sought an emic understanding of meanings that newcomers attach to social support.

In-depth semi-structured interviews were used to gather descriptions of the reality of newcomers’ perceptions and experiences (Hammersley and Atkinson, 1995; Nastasi and Schensul, 2005). These interviews were supplemented with census data, field notes, and settlement service reports to provide comprehensive information about newcomers’ perceptions and experiences of social support, implications for their health and the use of health and health-related services. Ethical approval for the study was obtained from the appropriate university committees in all three provinces.

Data collection

The participants received information about the study and consent forms that had been translated into their preferred language, and gave permission to have their confidential interviews audiotaped. Interviews lasted on average one and a half hours. The participants were given an honorarium of $20 each, and $20 for childcare.

We conducted in-depth individual interviews with 60 Chinese immigrants and 60 Somali refugees (n = 120) to elicit their perceptions and experiences of social support and its influence on health (see Table 1). A 24-item interview guide was used in which broad initial questions elicited newcomers’ responses, which in turn generated specific probes. The guide was translated into Somali, Mandarin and Cantonese. Trained interviewers, who were bilingual or trilingual, conducted the interviews in each participant’s language of choice and preferred venue. The guide focused on challenging situations that required support, sources and types of current support, appraisal of support, comparison with support in the homeland, unmet support needs, and desired programmes and policies in health and social sectors (see Table 2). Open-ended questions that focused on health and social support included the following:

• What does ‘health’ mean to you?

• Do you believe that the support/help you receive affects your health? (If yes, in what ways?)

• How is your health affected when you do not get the support you expect?

The guide was pilot tested with two participants from each ethnic group at each site (n = 12). In an iterative process akin to respondent validation, the pilot test results were shared with site community advisory committees that guided modifications of the interview guide (Rich and Ginsburg, 1999).

Data analysis

An inductive form of data analysis driven by theory and research questions was used to identify categories, concepts and themes in interviews (Nastasi and Schensul, 2005). Research assistants drawn from each ethnic and geographic community translated and transcribed recorded interviews, which were then subjected to content analysis using a category system of key concepts and themes. The categories were identified by inductive analytical processes, moving from participants’ particular experiences to general categories. These categories met the following criteria: inclusive, useful, mutually exclusive, clear and specific (Creswell, 2003). The selected categories were included in a common coding framework, which was jointly developed by investigators and research assistants at all sites. The Non-Numerical Unstructured Data Indexing Searching and Theorizing (NUD*IST) software package was used to facilitate qualitative datamanagement (Richards and Richards, 2002). Using the same initial transcripts across sites, inter-rater agreement by three independent coders was assessed until it reached 80%, to increase consistency and promote comparative analysis of data (Rich and Ginsburg, 1999). Following the comprehensive coding process, thematic and ethnographic analyses were applied to qualitative data in order to classify common themes within the framework into larger clusters (Creswell, 2003). Direct quotations from informants were used to enrich the accuracy and relevance of descriptions. Rigour was achieved through data saturation, theoretical sampling, identification and analysis of negative cases, audit trail, methods triangulation, inter-rater reliability, and reflexivity (Lather, 1991; Hammersley and Atkinson, 1995).

diversityhealthcare-demographic-characteristics

Table 1 :Summary of phase II participant demographic characteristics

diversityhealthcare-Somali-refugees

Table 2 :Interview guide for Chinese immigrants and Somali refugees.

Sampling procedures

The study was conducted in three provinces in Canada. Three majormetropolitan regions of Canada, namely Toronto (population 4 682 897), Vancouver (population 986 965) and Edmonton (population 937 845), were selected because of a concentration of immigrants and refugees in these cities (Statistics Canada, 2005). Criteria for choosing the newcomer groups included length of establishment and barriers to health and social services during settlement and integration. Although sample sizes in qualitative research are often small, the large sample size in this study (n = 120) enabled a comparative examination of different settings and varied socio-demographic characteristics (Sandelowski, 1995) (see Table 1).

Agencies that serve immigrants and refugees facilitated the recruitment process. Inclusion criteria limited participants to adults who had been living in Canada for less than nine years, as research suggests that a period of ten years is required for economic integration (Stein, 1981; DeVoretz, 1995). Using a purposeful sampling strategy (Malterud, 2001; Creswell, 2003), we ensured diversity with regard to age, level of education, region of origin within homelands, number of years in Canada, gender and marital status. A demographic data form elicited information on factors such as employment and living arrangements, which were relevant to social support experienced by newcomers (see Table 1). Purposive sampling was combined with network or snowball sampling (Davis, 2000; Creswell, 2003). The participants referred researchers to other members of their social network, who were assessed for inclusion to ensure a varied mix of social demographics and promote transferability of findings (Malterud, 2001).

Recruitment from the target ethnic communities was facilitated by site advisory committees consisting of members of newcomer and ethno-specific community agencies. Research assistants drawn fromeach of the twocommunities were able to reassure potential participants. These approaches minimised recruitment problems, and there were no refusals.

Findings

Stressful situations influencing health and requiring support

The participants reported mental and physical health problems and inadequate healthcare coverage for medications, supplies or supplementary health services. When they or their children experienced health problems, they had difficulty in focusing on settlement challenges. They argued that the barriers which they experienced during migration and settlement increased their levels of stress and ill health. Lack of employment had a detrimental effect on their mental and physical health, and having to cope with financial constraints increased their anxiety. Some of the participants maintained that they could not risk becoming ill because they could not afford services that were not covered by government. Some of them worked in jobs without extended health benefits, and could not take time to seek physician services. Family separation was linked to loneliness, anxiety and distress, particularly for Somali refugees.

Perceptions of social support

The participants identified four types of social support, namely information (e.g. advice, suggestions, directives), practical/instrumental support (e.g. aid, money, labour, aid in kind), emotional support (e.g. listening, understanding, sympathy, empathy, caring, sharing feelings) and affirmation (e.g. appraisal, feedback, social comparison). They defined social support broadly as encompassing both informal (i.e. family members, friends, neighbours) and formal (i.e. government, organisations) supports. Helpful support was associated with peace of mind, alleviation of stress, and a reduction in isolation and loneliness, whereas unhelpful support was attributed to systemic barriers such as eligibility restrictions to services.

However, the participants assigned different meanings to social support. Chinese immigrants defined social support as either formal support from the Canadian government or informal support from friends and family. Influenced by their cultural heritage, they typically regarded support as consisting of tangible forms of help:

‘Help, from a Chinese person’s point of view, refers more to the help among friends, among individuals ... most Chinese’s notion about help is something tangible.’

(Chinese participant)

The Chinese participants indicated that support in their homeland was available throughout the lifespan, first from school friends and then from work colleagues. These social networks diminished when they came to Canada. Most of the Chinese participants indicated that they had no expectations about (formal) support when they arrived, as it was lacking in their home countries. Following arrival in Canada they had to depend on the formal service system, which many described as under-resourced.

Somali definitions and experiences of social support also displayed the influence of their cultural and religious upbringing. They embraced a holistic concept that included financial, psychological and moral support. The Somali participants believed that people should help each other, that the ability to do so came from God, and that they should be thankful to God when they received needed support. Most of the Somalis described support from family members and friends in their homeland as helpful:

‘Social support comes in different forms. When we [Somalis] think of social support it means someone helping or giving something to another person. But in this country it [social support] means someone who helps in providing health, housing, and jobs.’

(Somali participant)

Somalis refugees described a shift in patterns of support. In Somalia, younger people were normally supported by their families. In Canada, they supported themselves, as well as their parents and relatives in their homeland. Many newcomers built strong relationships with family members as a source of encouragement in times of difficulty.

Most of the Chinese and Somali participants agreed that the provision of social support helped them to overcome obstacles in the immigration process, and to adapt to the new social environment. Religious institutions and community centres provided a sense of community and support for newcomers. Some of the participants viewed service providers from the same background as the most helpful source of support, because they had lived in Canada for some time, had learned about Canadian culture and customs, and so could help in the settlement process.

During the initial stage of immigration, most of the participants were primarily concerned with survival needs. The Somali refugees arrived in Canada with fewer financial resources, and so faced more pressing needs for basic support such as food and housing, than Chinese immigrants. Over time, with basic survival needs met, language skills mastered and jobs secured, newcomers began to seek support to facilitate longterm settlement. Although help with initial settlement was important, some participants believed that support should also enable newcomers to achieve wellbeing and integration in Canadian society.

Perceived impact of social support on health

Most of the participants described links between social support and health, and believed that support from friends, service agencies or government programmes had a positive impact on their physical and mental well-being. With sufficient support, they felt relaxed and could concentrate on their work, study, family and life goals. Most of the newcomers noted the interrelationship between their mental and physical health and the availability or absence of support:

‘When you’re worried ... have problems ... you talk to yourself, then you are not healthy. In such a situation, if people talk to you or give you some advice, then you feel well and you are healthy. And that’s a big support.’

(Somali participant)

The participants experienced peace of mind when they knew that support was available in times of need. When family, friends, government and other organisations provided emotional support, they were more optimistic, and coped with difficulties such as illness more easily. Immigrants and refugees viewed emotional, information and practical support as resources for overcoming challenges. In their view, support reduced their loneliness, fear and despair and enhanced their mental health:

‘I feel that although I’m in a foreign country, there are people who care for me. When I have difficulties in life, I am not so scared anymore because I believe that others will help me. My mind is calmer.’

(Chinese participant)

The participants perceived that support from family and friends had a positive effect on their health. Understanding and encouragement improved their confidence and alleviated distress. Sharing with friends and family was an effective strategy for relieving stress, and in the participants’ view it had a positive effect on their mental health. The impact of support on wellbeing depended on the closeness of the relationship between the support provider and recipient:

‘When I first came, I felt so lonely and was uncertain about my future ... [when] I felt that I was helped by someone, [I felt that] the society is full of love, therefore the feelings of loneliness and despair were gone.’

(Chinese participant)

The participants appreciated financial support from the government. In their view, this practical support was an important factor contributing to their health and it boosted their self-confidence and self-esteem:

‘The greatest help I received here was the opportunity to go back to school again. On the psychological level, it was very helpful. You wouldn’t feel that you were totally useless all of a sudden, being mute or crippled, etc.’

(Chinese participant)

Church and ethno-cultural organisations also provided practical and emotional support to newcomers, helping to alleviate the stress generated by settlement challenges. Employment and financial support from agencies promoted financial stability. From the participants’ perspective, this kind of support indirectly exerted a positive influence on the family’s health. Newcomers recognised that health facilitated participation in the labour force, which in turn fostered financial stability, met basic needs, and enabled support provision to others:

‘Ideally once you’re healthy, you should work, and that is exactly what I do. I pay all my bills. I can support anybody that I want.’

(Somali participant)

The participants also referred to the significance of healthcare coverage provided by government. Appropriate services provided by government and agencies reduced newcomers’ stress and enhanced their emotional well-being:

‘I think the effect [of services] is mainly mental. That is, you are not so stressed. The support services can help you reduce the stress level because the adjustment to a new society, a new community, brings a lot of stress.’

(Chinese participant)

Some of the participants revealed that they suffered from physical illness during the initial stage of immigration, which they attributed to social isolation and emotional loneliness. They perceived a connection between their emotional state and their physical health. They believed that if they were optimistic and happy they would enjoy good physical health, but that worry or anxiety would have a negative effect on their body:

‘If you have too many thoughts, you are not healthy. If a person doesn’t have somewhere to sleep, and no peace [of mind], he is not healthy ... if you don’t have a house, no bedding, nowhere to sleep, you’re finished.’

(Somali participant)

When newcomers were faced with the challenge of coping with their children’s physical health problems, they had difficulty focusing on integration and employment. Health, to most participants, meant lack of mental and physical problems:

‘[Health] means to me having good sleep, that I’m not hungry and have met all my nutritional requirements, that I’m physically fit and I have no psychological problems.’

(Somali participant)

Deficient and depleted social networks had a negative effect on both physical and mental health. Some participants reported that they became angry or distressed if they did not receive anticipated support. When they believed that support was inadequate or inaccessible, they perceived a negative impact on health:

‘When you needed something, no one was there to help you; of course you would feel sad, lonely and unhappy.’

(Chinese participant)

The participants reported worry, loneliness and isolation when support for coping with settlement challenges was absent. When their support needs were not met, they reported depression and distress:

‘If when I first got here, no one offered any help to me ... that would affect my health. I would worry. If that period prolongs, it will impact my mental [health], spirit and body.’

(Chinese participant)

When participants did not receive specific support to which they were entitled, based on their immigration status or skills, their confidence and self-esteem diminished. They became distressed when support could not be accessed due to systemic barriers. Indeed, lack of support generated negative psychological reactions:

‘Sometimes when you do not get help and you are frustrated, you become stressed. It affects you not only mentally but also physically. ... Well, you feel demoralised, also frustrated, it also leads to stress. You feel downtrodden; you have a sense of desperation, disappointment, despair. So a lot of things that have [a] very negative mutual effect on you physically, mentally and psychologically.’

(Somali participant)

Just as inadequate social support had a negative effect on health, poor health could have a detrimental influence on support. Newcomers who were unhealthy could not support others. Chronic illness was linked to dwindling support, and inadequate support in turn escalated other health problems.

Barriers to accessing health and health-related services

Barriers were exacerbated by insufficient information about available services, and inadequate informal support from small, weak social networks. Some participants believed that support in the form of health insurance had a positive effect on their health. Healthcare benefits helped newcomers who had physical health problems. Some agencies provided free health services for people on a low income, although many newcomers were not aware of these services:

‘The healthcare – because I need to visit a doctor frequently – is very good here. I don’t need to spend so much money for doctor visits. That was a big effect on my health.’

(Chinese participant)

Some participants noted that it was difficult to understand the healthcare system in Canada because it differed from that in their home countries. Health services that were deemed inadequate by participants increased their stress. When they did not receive necessary support from government or community agencies, the resultant stress had a detrimental effect on their work, studying and health:

‘Let’s say if you needed something either from your friends or a government or a community organisation, and if you don’t get it, you feel bad. You feel as if you are going through a lot of difficulties in life. That affects your health because you feel frustrated and lonely and so you get sick.’

(Somali participant)

Refugees reported challenges related to access to health services and unmet support needs. Barriers stemmed from a three-month waiting period that was imposed prior to processing landed immigration status, inadequate coverage by the Interim Federal Health Program, language difficulties, social isolation, bureaucratic processes, perceived racism, and negative attitudes of staff.

Support strategies to enhance newcomers’ lives

Immigrants and refugees suggested services, programmes and policies in health and social sectors that could fulfil their support needs. These newcomers recommended that health and social agencies should communicate their policies and services to the public, play a bridging role between them and the government, advocate policy-level changes pertaining to culturally appropriate support, address their challenges, and help them to navigate the health and social systems. They suggested that professionals should participate in cultural sensitivity workshops, and they wanted information about health and health-related services and support to be available in English and in their native language. To increase accessibility to and use of health and social services, the participants wanted long-term coordinated supports, interpreters or multilingual service providers, and information about available resources and benefits. Table 3 summarises the key findings, highlighting the similarities and differences between Chinese immigrants’ and Somali refugees’ perceptions and experiences.

Discussion

In this study, the participants’ perceptions of social support depended on experiences in their homeland, their cultural and religious heritage, and assumptions about supportive acts and expressions of support. Social networks were diminished and dislocated during immigration and resettlement. These newcomers perceived that interactions between social support and ethnicity influence health. Strategies that foster expansion of newcomers’ social networks can enhance their health and use of health and social services.

diversityhealthcare-Chinese-perceptionsn

Table 3:Similarities and differences between Somali and Chinese perceptions and experiences.

The under-use of services and supports that were not considered to be linguistically and culturally relevant, which was observed in our study, indicated that newcomers are active agents in seeking support, and that their perceptions of social support and helpseeking strategies were influenced by their cultural backgrounds. Although meanings and sources of support differ between Chinese and Somalis, they also evolve in social interactions with the host community. Indeed, culture provides a contextual ground for soliciting, providing and receiving social support (Owens and Randhawa, 2004). However, our study also revealed that newcomers’ expectations and perceptions of support changed as they interacted with the host community, and that support services vary according to the home country. The participants’ views reflect the assertion that social support is a resource for coping with stress linked to immigration and resettlement challenges (Palinkas et al, 2003).

The participants shared varied conceptualisations of health consistent with the World Health Organization’s holistic definition encompassing mental, physical, spiritual and social well-being (World Health Organization, 1998). The picture painted by these newcomers reflected synergistic interactions between physical, mental and psychosocial health. To most Somali participants, mental health incorporated spiritual well-being. For them and for the Chinese participants, health incorporated social determinants of health, such as income, employment and social support. Social–ecological models give primacy to social structures as determinants of health status (Raphael, 2004). While some newcomers emphasised social (e.g. social networks) and personal (e.g. skills, qualifications, language) resources, others noted the importance of physical capabilities (e.g. ability to work) in their definitions of health.

These newcomers described pathways through which social support influenced physical, mental, spiritual and psychosocial health. They emphasised the significant effect of social networks on health outcomes. Other studies point to the importance of social networks and social support for health and health services utilisation among Latino and Asian immigrants in the USA (Alegria et al, 2004; Nicdao et al, 2008). These newcomers’ perceptions, that adequate and appropriate social support had a direct effect on well-being, supplement empirical evidence of this link in other population groups (c.f. Krause and Wulff, 2005). Furthermore, the newcomers in this study linked formal supports (including employment insurance and housing) to health, reflecting the importance of other social determinants of health. Conversely, they also contended that inadequate support had a negative effect on health. The view that deficient social relationships lead to negative psychosocial and physical outcomes (Bloom, 1990; Stewart, 2000) was reinforced in our investigation.

Inadequate information support had a negative impact on participants’ use of health and health-related services. Some participants experienced difficulty in understanding the Canadian healthcare system and comprehending the English language used in service settings. These findings complement those of studies in other countries that depict the negative influence of language and cultural distance between providers and immigrants when using health services in the UK (Walls and Sashidharan, 2003) and Australia (Lam and Kavanaugh, 1996). Other research reveals inadequate access for immigrants to culturally appropriate services/supports in the UK (Owens and Randhawa, 2004) and the USA (Salant and Lauderdale, 2003). These barriers prevent equitable access to services, and have a negative impact on newcomers’ health. Insufficient health coverage resulted in under-utilisation of health services, according to the newcomers in this study. Other empirical evidence from Canada attests to the limited use of healthcare services by newcomers due to the financial and cultural inaccessibility of those services (Wu and Schimmele, 2004).

Conclusion

Despite its limitations, this study highlights the previously noted need for linguistically and culturally appropriate services in Canada (Neufeld et al, 2002; Wu and Schimmele, 2004) and other newcomer destination countries (Salant and Lauderdale, 2003; Owens and Randhawa, 2004; Warner, 2007). It helps to fill an empirical void by analysing sources and appraisal of support and the influence of culture in the process of settlement across newcomer groups (Leduc and Proulx, 2004; McDonald and Kennedy, 2004), and by investigating the effect of social support on health and utilisation of healthcare services, from the perspective of immigrants and refugees. Most of the studies of services utilisation among immigrants and refugees have been quantitative (e.g. Alegria et al, 2004; Abe-Kim et al, 2007; Nicdao et al, 2008), and do not illustrate personal experiences or the impact of contextual factors on settlement experiences obtained fromqualitative methods.

This study adds to the existing literature on immigration and settlement by revealing how service providers and policy influencers can facilitate the integration of newcomers. Service providers’ lack of understanding of the beliefs, practices and perspectives of refugees has been observed but has not been addressed through sensitive support (Stein, 1981; Beiser, 1988; Davis, 2000). The participants in this study proffered policy and practical strategies that would strengthen supports. Newcomers’ participation in policy recommendations is the first step towards an inclusive process that values participatory strategies (Ahmed et al, 2004). The findings can guide the design and testing of intervention strategies (Rich and Ginsburg, 1999) and influence social and political will because policy and programme partners were drawn from ethno-cultural organisations. Another strength of this study lies in the interdisciplinary nature of the research team and its commitment to varied techniques that increased transferability (Nastasi and Schensul, 2005) and reflexivity (Stein, 1981; Malterud, 2001).

However, this study depended on cross-sectional narratives concerning relocation experiences that, for some, occurred nine years ago, and are therefore subject to recall and reporting biases. The findings may not be generalisable to other immigrant and refugee populations and other urban or rural centres, due to the effect of culture and contextual factors. Chinese immigrants are a heterogeneous group from varied countries, and varying within-group perceptions may not have been captured.

Future research should focus on within-group differences in experiences and perceptions of support needs, and on testing salient support interventions. This type of inquiry should be expanded to include other immigrant and refugee groups, and the implications of newcomers’ views of social support from their preferred services, and their satisfaction with the services received, should be fully explored.

CONFLICTS OF INTEREST

None.

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