Purpose
This document presents an overview of Canadian research on immigrant and refugee women’s health, drawing upon the earlier work of Kinnon (1999) and Janzen (1998), as well as research conducted by Canada’s Centres of Excellence for Women's Health (CEWH) and Metropolis Centres of Excellence (MCE). The report also presents preliminary policy issues, research questions and policy implications arising from the research. It further suggests next steps to advance a strategic dialogue in policy and research development on immigrant and refugee women's health. It can serve as a tool to help decision makers assess their policies and programs. The document can be used as a catalyst for discussion and action in this area. It is intended to be of interest to policy audiences at the municipal, regional, provincial and federal levels, as well as to researchers and non-governmental organizations engaged in the policy process.

Approach
In general, "immigrants" are regarded as voluntary migrants and "refugees" as involuntary migrants, but these terms also represent complex and varied social realities. In Canada, the population of immigrant and refugee women is not only distinct from the general population in many ways, but is diverse within itself. Thus, policy and research concerning the health of immigrant and refugee women needs to consider issues of gender and diversity, as well as a determinants of health perspective and populationhealth approach. Together these lenses offer the view that health is the result of a complex interplay of socio-economic factors, and that health issues and health care may affect different groups of women differentially.

Themes in the Research
The search of recent Canadian literature on the health of immigrant and refugee women revealed a number of key themes in the research, and the findings of this document are presented along these themes:

Applying the analytical tools and approaches mentioned above to the research findings, brought a number of future research issues and policy implications/issues to light, that are highlighted and presented in tables at the end of each research theme area.

Key Policy and Research Issues
Socio-cultural Context of Immigrant and Refugee Women’s Lives
The research in this area raises questions about how variables such as country of origin, age, circumstances of migration, lifestyle changes and economic status impact health.¹ It is also important to know if that influence persists or changes over time, and how. Research is needed to explore whether immigrant women under-utilize preventive services due to differences in concepts of health, health care, or because of systemic barriers. There are policy implications for the allocation of resources for health promotion and disease prevention, and for improving accessibility and the capacity in health and social services to meet the health needs of immigrant and refugee women.

Income and Employment
A significant body of research is available on the economic integration of immigrant and refugee women in Canada. However, there is a need for more research that explores the links between economic well-being and health status. The finding that health status improves with each step up the economic ladder in mainstream populations ² suggests that policies and programs directed at improving the economic situation of immigrant and refugee women, such as language and employment programs, may have significant impacts on their health.

Rethinking Mental Health
Recent research has argued that, although they are usually treated as problems of the individual, there are important social dimensions to the mental health issues of immigrant and refugee women. This raises the need for more research into accessibility of mental health services, particularly for refugee women who have experienced premigratory trauma. Reducing social isolation through initiatives such as immigrant women’s centres, networking and mentoring, language, employment and re-training programs has been identified as an important mental health policy issue. The impact of legislation, policies and programs on immigrant and refugee women’s vulnerability to family violence also needs further examination.

Migration and Aging
There are still significant gaps in the research on migration and aging, particularly on aging within recent immigrant and refugee populations, and community-centred approaches to health care delivery. Targeted programs and services are needed to promote and maintain the health and well-being of this population. Women’s primary role as informal caregivers also requires special consideration in the design and delivery of community-based health care and home care.

Accessibility of Health Care Services
Understanding the complex context of immigrant and refugee women’s lives is critical to developing culturally appropriate and accessible health care practices and programs. Developing degrees of cultural competency at all levels of the health care system is a priority for increasing accessibility, as is investigating: language barriers; cultural diversity; the effectiveness or necessity of ethnic/gender matching between health care providers and users; the use of alternative/traditional forms of healing; and investing in outreach strategies.

Impacts of Health Care Reform
Research in this area highlights some key policy gaps, including a lack of benchmarks to capture the potential differential impact of health reform on immigrant and refugee women. Aspects of health reform need closer examination from a gender and diversity perspective, particularly health promotion and prevention education; the effects of the shift to ambulatory care; and increasing demands on community organizations and on women as informal (unpaid) caregivers. Health reform also needs to include communitybased programs that incorporate initiatives such as the use of bi/multi-cultural liaison/advocacy workers.

Next Steps
It is clear that better links between research and policy, and community involvement in both processes, can better meet the health needs of immigrant and refugee women. In the complex health policy environment, this document recommends a step-by-step coordinated approach. The first step is to identify and bring together key players from CEWH and MCE, select federal departments, and immigrant and refugee women’s groups. The second step is to establish a strategic planning approach that identifies federal policy priorities, as well as existing – or needed – mechanisms to ensure the impact of research on the development of gender- and diversity-sensitive health policy. The third recommended step is to share this overview paper with stakeholders at the regional, provincial, municipal and community levels to promote awareness dialogue and planning of appropriate policies and programs. CEWH and MCE are well placed to provide leadership in developing this integrated approach. A co-ordinated multi-level approach would improve the short- and long-term health status of an increasingly important and significant population in Canada – immigrant and refugee women.

Prepared for the Centres of Excellence for Women's Health
by: Mary Ann Mulvihill, Louise Mailloux and Wendy Atkin
Funded by the Women’s Health Bureau and the Research Management and Dissemination Division, Health Canada

NOTES
¹ Janzen, B. (1998), Gender and Health: A Review of the Recent Literature, Winnipeg: PWHCE, pp. ii, 22.

² Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) (1999), Toward A Healthy Future: Second Report on the Health of Canadians, Ottawa: Health Canada, p. 31.