EXAMINING THE ORAL HEALTH, ACCESS TO DENTAL CARE … › bitstream › 1807 › ...services. To Dena Taylor from the Health Sciences Writing Center for proofreading all my writing

EXAMINING THE ORAL HEALTH, ACCESS TO DENTAL CARE AND TRANSNATIONAL DENTAL CARE UTILIZATION

OF ADULT IMMIGRANTS: ANALYSIS OF THE LONGITUDINAL SURVEY OF IMMIGRANTS TO CANADA

(2001-2005)

by

Paola Gondim Calvasina

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy

Graduate Department of Dentistry University of Toronto

© Copyright by Paola Gondim Calvasina 2014

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Examining the oral health, access to dental care and transnational

dental care utilization of adult immigrants: Analysis of the

Longitudinal Survey of Immigrants to Canada (2001-2005)

Paola Gondim Calvasina

Doctor of Philosophy

Graduate Department of Dentistry University of Toronto

2014

Abstract

Immigrants form a significant and growing proportion of Canadian society. Around 250,000

immigrants are admitted into the country each year. Recent immigrants to Canada are, on

average, healthier that the general Canadian population, in a phenomenon called “the healthy

immigrant effect”. However, over the years after immigration, their health declines. Very little is

known about the oral health of adult immigrants to Canada, and there is no evidence that “the

healthy immigrant effect” applies to oral health. Little and inconsistent evidence is also found

regarding immigrants’ access to dental care and dental care utilization. A secondary data analysis

was conducted on the Longitudinal Survey of Immigrants to Canada (LSIC 2001-2005). Using a

generalized estimating equation (GEE) approach, we examined socio-demographic and

economic factors associated with changes in self-reported dental problems among a sample of

adult immigrants to Canada over a four-year period. Using logistic regression, we also examined

predictors of barriers to accessing dental care (i.e., unmet dental care needs) and transnational

dental care utilization over a three point five year. Results revealed that immigrants were more

iii

likely to report dental problems than Canadians over the period of observation (OR=2.77; 95%

CI: 2.55-3.02). Lack of dental insurance predicted immigrants’ unmet dental care needs (OR=

2.63; 95% CI: 2.05-3.37) and transnational dental care utilization (OR=2.05; 95% CI:1.55-2.70)

post-migration. Immigrant women were also more likely to report dental problems, and to use

transnational dental care services over time. In conclusion, this study identified an increased

likelihood of reporting dental problems over time, suggesting that the healthy immigrant effect

applies to oral health. Immigrants lacking dental insurance were more likely to face barriers to

accessing dental care and to use transnational dental care strategies to overcome those barriers.

Shortcomings in immigration policies and the features of the Canadian dental care system, which

tend to exclude most socially marginalized groups, may contribute to immigrants’ oral health

deterioration. Importantly, immigrant women who over time were more likely to report dental

problems should be at the forefront of public policies aiming to improve the oral health of

immigrants.

iv

Acknowledgements

My doctoral journey would not have been possible without the support of many individuals who

deserve my heartfelt acknowledgement. I would like to especially thank my committee members

who gave me freedom to pursue a topic that I was passionate about: Dr. Carles Muntaner

(supervisor) for his patience and guidance; Dr. Carlos Quiñonez (co-supervisor), for his

mentorship, support, and for always setting the bar high; and Dr. Denise Gastaldo, for her

encouragement and for constantly reminding me that the power was with me.

I must also acknowledge Dr. Herenia Lawrence, Dr. Laurie Hoffman-Goetz and Dr. Cameron

Norman for their guidance in the initial years of my program. I will always be grateful to Dr.

Lawrence for opening the door of an academic program at the University of Toronto, and for

initiating me in the world of statistics.

To Dr. Donald Cole for accepting me in the Global Health Program, and Dr. Morrie Manolson

for supporting my transition to that program. I also would like to thank Dr. Olesya Falenchuk, for

her invaluable statistical support, and Dr. Arjumand Siddiqi for her generosity and expertise in

social epidemiology.

To Maria Buda, for her promptness to help whenever I needed the Faculty of Dentistry library

services. To Dena Taylor from the Health Sciences Writing Center for proofreading all my

writing pieces during my PhD program. She understood my writing difficulties and helped me

master them.

To my colleagues in the Dental Public Health and Global Health Department, especially Rafael

Figueiredo for his promptness to help whenever I needed; Patti Tracey and Kathy Moscow who

taught me how pleasant learning together can be.

I would like to express my deepest gratitude to my “Brazilian family” in Toronto for their

friendship and emotional support: Bilal Farooq, Maíra Perotto, Bryce Sharman, Patrícia Galvão,

Ana Gomes, Anil Verma, Keri Bennet, Mariana Ferraz, and Hewton Tavares. Without your

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words of encouragement and motivation, I would not have made it.

I would like to thank the financial support I received from the Faculty of Dentistry through the

Harron Scholarship, the Delta Kappa Gama World Felowship, the Population Health

Improvement Research Network, Government of Ontario, and the Global Health Research

Award. These financial supports allowed me to study in one of the best universities in the world,

and I will always be grateful to have had such opportunity.

A special thanks to my family in Brazil, my mother Léa and father Alessandro, who learned to be

apart from their only child, so that she could pursue her dream. I will always be grateful for the

investment they made in my education.

I would like to thank my husband Rinaldo Cavalcante, my best friend, and partner in life, for his

statistical and research support, ongoing encouragement and for enduring two years of long

distance relationship, so that I could also complete my PhD. This thesis is dedicated to you my

love.

Last but not least, I would like to thank Marta for making the journey with me, and to my

resilience, determination and persistence that kept me going whenever I thought of giving up.

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Dedication

To my husband Rinaldo for his unconditional love and support

and

to all immigrants to Canada for their courage and resilience.

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Table of Contents

ACKNOWLEDGEMENTS ....................................................................................................... IV

DEDICATION ............................................................................................................................ VI

TABLE OF CONTENTS .......................................................................................................... VII

LIST OF TABLES ........................................................................................................................ X

LIST OF FIGURES .................................................................................................................... XI

CHAPTER 1 INTRODUCTION .................................................................................................. 1

1.1. RATIONALE ............................................................................................................................. 5 1.2. RESEARCH GOAL ..................................................................................................................... 5 1.3. RESEARCH OBJECTIVES ........................................................................................................... 6 1.4. CONCEPTUAL FRAMEWORK .................................................................................................... 6 1.5. THESIS OUTLINE ................................................................................................................... 10

CHAPTER 2 LITERATURE REVIEW .................................................................................... 11

2.1. UNDERSTANDING INTERNATIONAL MIGRATION: GLOBAL AND CANADIAN CONTEXTS ......... 11 2.2. UNDERSTANDING INTERNATIONAL MIGRATION: THE CANADIAN CONTEXT ......................... 13 2.3. IMMIGRANTS’ HEALTH .......................................................................................................... 15 2.4. IMMIGRANTS’ ORAL HEALTH ................................................................................................ 18 2.5. POST-MIGRATION DETERMINANTS OF ORAL HEALTH .......................................................... 20 2.6. POST-MIGRATION DETERMINANTS OF ORAL HEALTH: THE CANADIAN DENTAL CARE

SYSTEM .......................................................................................................................................... 27

CHAPTER 3 METHODS ........................................................................................................... 29

3.1. DATA SOURCE ....................................................................................................................... 29 3.2. VARIABLES ........................................................................................................................... 31

3.2.1. Outcome Variables ..................................................................................................... 31 3.2.2. Independent Variables ................................................................................................ 31

3.3. STATISTICAL ANALYSIS ........................................................................................................ 34

CHAPTER 4 DOES “THE HEALTHY IMMIGRANT EFFECT” APPLY TO ORAL HEALTH? AN ANALYSIS OF THE LONGITUDINAL SURVEY OF IMMIGRANTS TO CANADA ...................................................................................................................................... 35

4.1. INTRODUCTION ...................................................................................................................... 37 4.2. METHODS .............................................................................................................................. 38

viii

4.2.1. Data Source ................................................................................................................ 38 4.2.2. Indicators and Variables ............................................................................................ 39 4.2.3. Data Analysis .............................................................................................................. 41

4.3. RESULTS ................................................................................................................................ 42 4.4. DISCUSSION ........................................................................................................................... 44

4.4.1. Does “the Healthy Immigrant Effect” Apply to Oral Health? ................................... 44 4.4.2. The Role of Socio-demographic and Economic Factors Explaining Immigrants’ Self-reported Dental Problems .................................................................................................... 45 4.4.3. Policy Implications ..................................................................................................... 47 4.4.4. Limitations .................................................................................................................. 48

4.5. CONCLUSION ......................................................................................................................... 48 4.6. WHAT THIS STUDY ADDS ...................................................................................................... 48

CHAPTER 5 PREDICTORS OF UNMET DENTAL CARE NEEDS AMONG IMMIGRANTS: ANALYSIS OF THE LONGITUDINAL SURVEY OF IMMIGRANTS TO CANADA ............................................................................................................................... 56


5.2.1. Data Source ................................................................................................................ 60 5.2.2. Study Variables ........................................................................................................... 60 5.2.3. Statistical Analysis ...................................................................................................... 62


5.4.1. Policy Implications ..................................................................................................... 66 5.4.2. Limitations .................................................................................................................. 66


CHAPTER 6 PREDICTORS OF TRANSNATIONAL DENTAL CARE UTILIZATION AMONG IMMIGRANTS: ANALYSIS OF THE LONGITUDINAL SURVEY OF IMMIGRANTS TO CANADA ................................................................................................... 75


6.2.1. Study Design ............................................................................................................... 78 6.2.2. Study Variables ........................................................................................................... 79 6.2.3. Statistical Analysis ...................................................................................................... 81


ix

6.4.1. Policy Implications ..................................................................................................... 85 6.4.2. Limitations .................................................................................................................. 85


CHAPTER 7 CONCLUSIONS .................................................................................................. 94

7.1. FINAL CONCLUDING REMARKS ............................................................................................. 94 7.2. POLICY IMPLICATIONS .......................................................................................................... 97 7.3. FUTURE RESEARCH ............................................................................................................... 98

REFERENCES .......................................................................................................................... 101

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List of Tables

Table 4.1: Baseline Sample Characteristics and Weighted Proportions from the Longitudinal

Survey of Immigrants to Canada (2001-2005)* ............................................................................ 50

Table 4.2: Unadjusted and Adjusted Associations between Self-reported Dental Problems and

Socio-demographics, Socio-economic and Other Independent Variables from a Sample of

Immigrants: Longitudinal Survey of Immigrants’ to Canada, 2001-2005 .................................... 52

Table 5.1: Sample Characteristics - Unmet Dental Care Needs Model (Weighted Proportions)* 68

Table 5.2: Unadjusted Associations with Unmet Dental Care Needs among Adult Immigrants:

Longitudinal Survey of Immigrants to Canada, 2001-2005 (Weighted Proportions) ................... 70

Table 5.3: Multiple Logistic Regression Analyses of Factors Associated with Unmet Dental

Care Needs among Adult Immigrants: Longitudinal Survey of Immigrants to Canada, 2001-

2005 ............................................................................................................................................... 72

Table 6.1: Sample Characteristics – Transnational Dental Care Utilization Model* .................... 87

Table 6.2: Unadjusted Associations with Transnational Dental Care Utilization among Adult

Immigrants: Longitudinal Survey of Immigrants to Canada, 2001-2005 (Weighted

Proportions) ................................................................................................................................... 89

Table 6.3: Multiple Logistic Regression Analyses of Factors Associated with Transnational

Dental Care Utilization: Longitudinal Survey of Immigrants to Canada, 2001-2005 ................... 91

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List of Figures

Figure 1.1: Conceptual Model of Immigrants’ Oral Health, Access to Care, and Transnational

Dental Utilization ............................................................................................................................ 9

Figure 4.1: Sample Size – Self-reported Dental Problems Model (Longitudinal Survey of

Immigrants to Canada, 2001-2005) ............................................................................................... 54

Figure 4.2: Average Prevalence of Self-reported Dental Problems among Adult Immigrants

(Longitudinal Survey of Immigrants to Canada, 2001-2005) ....................................................... 55

Figure 5.1: Sample Size – Unmet Dental Care Needs Model (Longitudinal Survey of

Immigrants to Canada, 2001-2005) ............................................................................................... 74

Figure 6.1: Sample Size – Transnational Dental Care Utilization Model (Longitudinal Survey

of Immigrants to Canada, 2001-2005). .......................................................................................... 93

1

Chapter 1

Introduction

“…Knowledge emerges only through invention and re-invention, through the restless, impatient,

continuing, hopeful inquiry human beings pursue in the world, with the world, and with each

other” (Paulo Freire, 1921-1997).

“I am an intellectual who is not afraid to be loving…”

(Paulo Freire, 1921-1997).

International migration movements are closely linked to broader processes of economic

integration, in a phenomenon referred to as globalization. Places that are integrated by the flow

of goods, capital, commodities, and information are also integrated by an increased flow of

people. Aside from individual reasons to move to another country, including the search for more

personal security, larger social, economic and political transformations are considered the main

driver of contemporary international migration (Massey, Arango, Hugo, Koauouci, Pellegrino,

& Taylor, 1993; Massey, & Taylor 2004). In low- and middle-income countries, the extension

of global markets and forms of production produce social and economic disruption, displacing

people from their livelihoods, thus creating mobile populations (Massey et al., 1993; Massey &

Taylor 2004). Meanwhile, in high-income countries, patterns of economic development create

segmentation in the labour market, and a demand for low paid, precarious and unstable jobs that

are mostly filled by immigrants (Massey et al., 1993; Massey, & Taylor, 2004).

In this regard, Canada is an active participant in global economic trade and has traditionally

relied on immigrants to contribute to the development of its economy. Immigrants form a

significant and growing proportion of Canadian society. Around 250,000 immigrants are

admitted into the country each year (Citizenship and Immigration Canada, 2009). Currently,

2

most immigrants come from Asia and Pacific Rim countries (49%), Africa and the Middle East

(24%) (Citizenship and Immigration Canada, 2011). Immigrants are selected based on their

education level, job skills and health status. The premise behind the selection criteria is to

maximize immigrants’ contributions to the Canadian economy with minimal financial burden on

the health and welfare system. Prior to immigrating, immigrants undergo a comprehensive

medical screening that helps ensure they are healthy at the time of arrival. In fact, the literature

has consistently shown that recent immigrants to Canada enjoy better health than the general

Canadian population in a phenomenon called “the healthy immigrant effect” (Beiser, 2005; De

Maio, 2010; De Maio & Kemp, 2010; Dunn & Dyck, 2000; Hyman, 2001; Newbold &

Danforth, 2003; Newbold, 2009; Vissandjee, Desmeules, Cao, Abdool & Kazanjian, 2004;

Smith, Matheson, Monineddin, & Glazier, 2005). However, over the years after immigration,

their health deteriorates to levels equal to or worse than native-born Canadians (De Maio, 2010;

De Maio & Kemp, 2010; Hyman, 2001; Newbold & Danforth, 2003; Newbold, 2009;

Vissandjee et al., 2004; Smith et al., 2007).

Although empirical studies overwhelmingly support “the healthy immigrant effect”, it remains

unclear what contributes to changes in immigrants’ health over time. Some reviews on the

health and determinants of health of Canadian immigrants suggest that immigrants’ initial better

health status is an effect of the immigration self-selection process (Hyman, 2001). Over time,

changes in environment and living conditions, especially related to the amplified pressure

associated with poverty, marginalization, class inequity, and lack of services (Hyman, 2001),

may lead to health deterioration. Importantly, while there is a large body of literature examining

the health status of immigrants to Canada, very little is known about the oral health of adult

immigrants, and there is no evidence that “the healthy immigrant effect” applies to oral health.

Very few studies have examined the oral health of immigrants in Canada, of those, most have

focused on the oral health of children/adolescents (Locker, Clarke, & Murrat, 1998; Werneck,

Lawrence, Kulkarni, & Locker, 2008) and elderly (Dong, Loignon, Levine, & Bedos, 2007;

Lai & Hui, 2007). Recently, one study explored the oral health of a convenience sample of adult

immigrants and refugees to Nova Scotia (Ghiabi, Matthews, & Brillant, 2014). All these studies

suggest that immigrants have a higher rate of oral disease than the native born population, a

3

pattern that improves with longer residency in Canada (Locker et al., 1998; Werneck et al.,

2008).

Yet internationally, evidence on the effect of immigration on oral health remains controversial.

Some studies have shown that immigrants carry a disproportionate burden of oral disease

(Ahluwalia & Sadowsky, 2003; Almerich-Silva & Montiel-Company, 2007) that tends to

improve with higher acculturation (Bower & Newton, 2007; Cruz, Chen, Salazar, & Le Geros,

2009; Cruz, Shore, Le Geros, Tavares, 2004; Mariño, Stuart, Wright, Minas, & Klimidis, 2001)

and longer residency in the host country (Gao & MacGarth, 2011), whereas other studies have

found that immigrants have better oral health status (Cruz, Xue et al., 2001; Sgan-Cohen

Steinberg, Zusman, & Sela, 1992; William, Summers, Ahmed, & Prendergast, 1996) that

deteriorate over time post-migration (Vered, Zini, Livny, Mann, & Sgan-Cohen, 2008; Vered,

Zini, & Sgan-Cohen, 2009; Zini, Vered, & Sgan-Cohen 2009). These studies also focus mostly

on children and elderly. Importantly, the large majority of both national and international studies

based their results on limited samples and cross-sectional study designs, posing challenges to

inferences on the impact of the immigration process on oral health.

Little and inconsistent evidence is also found regarding Canadian immigrants’ access to dental

care and dental care utilization. While earlier studies have provided equivocal findings as to

whether immigrants have worse (Bedos, Brodeur, Benigeri, & Olivier, 2004) or better access to

dental care (Newbold & Patel, 2006) than Canadian born populations, recent analyses of the

Canadian Health Measure Survey (CHMS 2007-2009) revealed that, in comparison to the

overall Canadian population, immigrants have a higher risk of reporting various negative

outcomes associated with poor oral health and access to dental care (Health Canada, 2010;

Ramraj, 2012; Thompson, 2012). For instance, immigrants had a higher prevalence of self-

reported untreated dental conditions (Health Canada, 2010), a lower prevalence of dental

insurance coverage (Health Canada, 2010), and were more likely to have untreated periodontal

disease (Ramraj, 2012). In addition, immigrants had higher odds of reporting cost barriers to

dental care than those born in Canada (Thompson, 2012). Cost barriers such as a lack of income

and dental insurance are known to be the dominant predictors of access to care in the

predominantly private fee-for-service Canadian dental care system (Quiñonez, Grootendorst,

4

Sherret, Azarpazhooh, & Locker, 2007), especially because they help to eliminate the upfront

costs of care (Millar & Locker, 1999; Locker, Maggirias, & Quinõnez, 2011).

As a result, immigrants experiencing financial barriers to accessing dental care in Canada may

be prone to utilizing transnational dental care, that is, immigrants may go abroad in pursuit of

dental care. Transnational dental care can be described as the experience of immigrants seeking

dental care outside Canada, which can involve immigrants’ participation in dental tourism, as

well as opportunistic dental visits while travelling to their country of origin. No definite research

exists on Canadian immigrants’ transnational dental care utilization. Much of what is known is

based on anecdotes (Kaufman 2013; Rothe, 2007), brief reports (Cohen & Rogers 2012; Turner,

2009), and two qualitative studies in which the topic is tangential (Dong et al., 2007; MacEntee

et al., 2012). In the US, studies have suggested that cost, convenience, lack of health insurance,

and cultural preferences for the health care of the immigrants’ home country of origin are

among the main reasons for immigrants’ use of transnational dental care strategies (Batisda,

Brown & Pagán, 2008; Brown, 2008; De Jesus & Xiao, 2013; Wallace, Mendez-Luck &

Castañeda, 2009).

In summary, there is a dearth of information on immigrants’ oral health, access to dental care

and transnational dental care utilization. Most national and international studies on the oral

health of immigrants are limited by the cross-sectional nature of the study design. In addition,

there is only scarce and inconsistent literature on adult immigrants’ access to dental care and

there is no information on Canadian immigrants’ transnational dental care utilization. Another

gap found in the general literature on immigrants’ oral health is the narrow focus on the role of

culture, or acculturative process and behavioural factors in determining immigrants’ oral health

and access to dental care (Bower & Newton, 2007; Cruz et al., 2004; Cruz et al., 2009; Gao &

McGrath, 2011; Mariño et al., 2003). Overall, immigrant oral health research has failed to

adequately reflect the complexity of the social determinants that shape population oral health;

specifically, it has neglected the social, political and economic contexts that determine oral

health inequalities in Canada.

5

Using a conceptual framework based on the social determinants of health (Solar & Irwin, 2010),

this study examines immigrants’ oral health, access to dental care, and transnational dental care

utilization over time. The social determinants of health framework is used to understand how

socio-economic, demographic (i.e., income, education, ethnicity, discrimination, employment

status, sex), social support and official language factors influence oral health, access to dental

care and transnational dental care utilization in a sample of adult immigrants to Canada. In this

study, oral health is measured as perception of dental problems; access to dental care is

measured through an indicator of barriers to care, namely unmet dental care needs; and

transnational dental care utilization is measured as dental services utilization outside Canada.

1.1. Rationale

Scarce and inconsistent information is available on the oral health, access to dental care and

transnational dental care utilization of adult immigrants to Canada. Because immigrants are

important economic, social and demographic assets to the Canadian economy, ensuring access

to appropriate resources and services so that they can fulfill their human capital is equally

important. The Longitudinal Survey of Immigrants to Canada (LSIC, 2001-2005) (Statistics

Canada, 2005) provides a unique opportunity to examine the effect of immigration on oral

health, access to dental care and dental care utilization over time. This survey offers a specific

opportunity to indirectly assess the effect of the immigration process on the oral health of the

adult immigrant population. Results drawn from this study can be used to inform future policies

and facilitate targeted programming aimed at improving immigrants’ oral health and access to

dental care, helping to reduce oral health inequalities in Canada.

1.2. Research Goal

To investigate if the “healthy immigrant effect” applies to oral health, and to explore the

determinants of immigrants’ oral health, access to dental care, and transnational dental care

utilization over time among adult immigrants to Canada.

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1.3. Research Objectives

The specific objectives of this study are:

Objective 1: To examine: 1) changes in self-reported dental problems among a sample of adult

immigrants to Canada over a four-year period; 2) the socio-demographic and economic factors

associated with immigrants’ self-reported dental problems over a four-year period.

Objective 2: To determine predictors of unmet dental care needs over a three-point-five-year

period among a sample of adult immigrants to Canada.

Objective 3: To determine predictors of transnational dental care utilization over a three-point-

five-year period among a sample of adult immigrants to Canada.

1.4. Conceptual Framework

This study examined immigrants’ oral health status, access to dental care and transnational

dental care utilization within a social determinant of oral health framework. The conceptual

framework was built upon the following bodies of literature: 1) academic public health literature

on the health (De Maio, 2010; De Maio & Kemp, 2010; Newbold, 2005; Newbold 2009;

Newbold & Danforth, 2003) and oral health of immigrants (Ahluwalia & Sadowsky, 2003;

Almerich-Silva & Montiel-Company, 2007; Bower & Newton, 2007; Cruz, Galvis, et al., 2001;

Cruz, Xue, et al., 2001; Cruz et al., 2004; Cruz et al., 2009; Cruz et al., 2010; Dong et al., 2007;

Gao & MacGrath, 2011; Locker et al., 1998; Mariño et al., 2001; Sgan-Cohen et al., 1992;

Vered et al., 2009; Vered et al., 2005; Werneck et al., 2008; Zini et al., 2009); 2) the social

determinants of health (Solar & Irwin, 2010) and oral health (Watt, 2007; Sabbah et al., 2009a);

and 3) literature on immigrants’ access to care and transnational health care utilization (Bedos,

et al., 2004; Cohen & Logan, 2012; Dong et al., 2007; Johnston et al., 2010; Labonté et al.,

2013; MacEntee et al., 2012; Newbold & Patel, 2006 ; Turner, 2009). The framework

emphasizes that the oral health and access to dental care of immigrants varies based on different

post-migration structural and intermediary determinants. This study framework advances

previous studies on immigrants’ oral health that have emphasized the role of behavioural,

7

cultural factors and acculturative strategies as major determinants of immigrants’ oral health and

access to dental care (Bower & Newton, 2007; Cruz, et al., 2004; Cruz et al., 2009; Gao &

McGrath, 2011; Mariño et al., 2003).

The oral health status of immigrants is unclear upon immigrants’ arrival. Screening for oral

health is limited to a single self-report assessment of whether ear, nose, throat, mouth and teeth

are normal or abnormal (McNally et al., 2011). However, the social and political context of the

host country, can determine immigrants’ socioeconomic positions, which in turn shape some

specific intermediary determinants (such as psychosocial and behavioural factors) that generates

different exposures and vulnerabilities that impact immigrants’ overall oral health and access to

dental care. For instance, the absence of robust immigration settlement and employment policies

might determine immigrants’ low socio position over time. Immigrants’ low socio position, may

generates different exposures and vulnerabilities; for instance, low income and/or lack of dental

insurance that impact immigrants’ overall oral health and ability to access dental services in

Canada.

Other variables that impact immigrants’ oral health and access to dental care differently include

employment status, discrimination, poverty, gender, the presence and lack of social support, and

language proficiency. These oral health inequalities may be balanced by oral health policies,

including universal access to preventive and restorative dental care services.

Dental care systems can be considered an intermediary determinant of oral health. They promote

equitable access of care, and mediate the differential consequences of oral disease in people’s

lives (Solar & Irwin, 2010). For instance, access to dental services for immigrants may ensure

that dental problems will not lead to further deterioration of their social status, and will facilitate

social integration and insertion in the workforce.

Unfortunately, in Canada dental care is predominantly private, with exceptions (Quiñonez et al.,

2007). Public dental coverage is available for target groups such as children, elderly, and those

receiving social and disability assistance (Quiñonez et al., 2007). For the adult population, only

emergency treatment may be available (Quiñonez et al., 2007). In this context, access to dental

care for adults is mostly based on employment-based dental insurance and out-of-pocket

8

expenditures (Locker et al., 2011; Millar & Locker, 1999). Therefore, immigrants’ employment

status and income are important determinants of their oral health and access to dental care. For

those immigrants experiencing barriers to accessing dental care in Canada, transnational dental

care utilization may be an important strategy to overcome those barriers.

9

Figure 1.1: Conceptual Model of Immigrants’ Oral Health, Access to Care, and

Transnational Dental Utilization

SOCIOECONOMICPOSITION

GENDERINCOMEPOVERTY

EDUCATIONDISCRIMINATION

ETHNICITYEMPLOYMENT

STATUS / DENTAL INSURANCE

GLOBALIZATION

PSYCHO-‐SOCIAL-‐BEHAVIOURAL

FACTORS

SOCIAL SUPPORT

ACCULTURATION (I.E. OFFICIAL LANGUAGE

PROFICIENCY)

ORAL HEALTH STATUS

DENTAL HEALTH CARE SYSTEMS IN

CANADA

STRUCTURAL DETERMINANTS INTERMEDIARY DETERMINANTS

SOCIAL AND

POLITICA

L CO

NTEXT

DENTAL CARE EXPERIENCES

ACCESS TO DENTAL CARE (I.E. UNMET DENTAL CARE

NEEDS)

TRANSNATIONAL DENTAL CARE UTILIZATION

LENGTH OF TIME POST-‐IMMIGRATION

MIGRATION

POST-‐IMMIGRATION DENTAL CARE EXPERIENCES

10

1.5. Thesis Outline

This dissertation is organized as follows: Chapter 2 outlines the theoretical framework, drawing

on a review of literature on immigration, immigrants’ health, oral health, post-migration social

determinants of oral health, self-reported oral health, access to dental care and transnational

dental care utilization. Chapter 3 describes methods, data source and statistical analyses.

Chapter 4 addresses objective 1, and presents methods, results, and the policy implications of

changes in immigrants’ oral health over time. Chapter 5 addresses objective 2, and presents

methods, results, and the policy implications of immigrants’ unmet dental care needs. Chapter 6

addresses objective 3 and presents methods, results, and the policy implications of immigrants’

use of transnational dental care. Finally, Chapter 7 presents the main conclusions of this

research, and describes future policy implications and research directions.

11

Chapter 2

Literature Review

2.1. Understanding International Migration: Global and Canadian Contexts

Currently, international migration movements are closely intertwined with the broader processes

of economic integration that have been shrinking the world, in a phenomenon referred to as

globalization. Places that are integrated to one another by flows of goods, capital, commodities,

and information are also integrated by increased flows of people. In 2010, approximately 214

million immigrants left their country of origin and migrated to an international destination; by

2050, it is estimated that this number will double and reach 405 million annually (UNDESA,

2009). These immigrants are differentially distributed in many regions and sub-regions across

the world. In 2010, they accounted for 16.8% and 14.2% of the total population of Oceania and

North America, in contrast to Asia and Latin America percentages, respectively of, 1.5% and

1.3% (United Nations Department of Economic and Social Affairs [UNDESA], 2009). The US

remains the top migrant destination country in the world, with 42.8 million migrants, 13.8% of

the total population in 2010 (UNDESA, 2009).

Although the 2008 global financial crisis slowed down migratory flows, there were no

staggering reversals in the patterns of movement, and thus, the global stock of migrants, built up

over the course of several decades, was hardly affected (International Organization for

Migration, 2011). Immigration from Mexico, India, Russia and China, the top four emigrating

countries, continued even after the crisis (World Bank, 2011). In addition, immigrants from

India, China, Mexico, and the Philippines, the top remittance-receiving countries, continued to

send money to their relatives in their country of origin (World Bank, 2011).

12

Many reasons have motivated human migration, including the search for: 1) new places for

settling; 2) food; 3) security; 4) adventure and entrepreneurship; and 5) forced labour. Massey et

al. (1993) proposed a variety of theoretical models, employing different concepts, assumptions

and frames to explain international migration movements. These theoretical models include: 1)

neoclassical economics: macro-theory - where international migration is caused by geographic

differences in the supply of and demand for labour; 2) neoclassical economics: micro-theory -

where international migration is driven by individuals’ choices, and their cost-benefit analyses;

3) the new economics of migration - where migration decisions are made by families or

households’ cost-benefit analyses; 4) the dual labour market - where international migration

stems from pull factors in receiving countries (a constant need for foreign workers); and 5) the

world systems - where increased market globalization creates mobile populations (Massey et al.,

1993).

Most recently Massey (2003) and Massey and Taylor (2004) have proposed the synthethic

theoretical international migration theory, in which international migration is described as a

synthesis of all previous theories. Multiple theories may explain current migration movements,

and nations may belong to multiple migratory systems. A complex interplay of mechanisms

determined by the new economics of labour migration, social capital theory, segmented labour

market theory, world systems theory, and neoclassical economics determine contemporary

migration movements. Once initiated, a web of interpersonal networks and informal institutions

supports these migration flows.

Overall, migrants are important global economic forces. They contribute significantly to the

total work force in many high-income countries, filling their demands for unpleasant, unstable

and low-wage jobs. At the same time, migrant remittances and savings affect incomes of

migrant-sending households, increasing their liquidity, and enabling productive investments

(UNDESA, 2009). Thus, immigration is a contemporary social issue and an inextricable part of

economic globalization.

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2.2. Understanding International Migration: The Canadian Context

Immigrants represent a large and increasing proportion of Canada’s entire population. Almost

20% of the Canadian population is foreign-born (Statistics Canada, 2006). In addition,

Citizenship and Immigration Canada estimates indicate that between 2001 and 2010, the country

admitted approximately 250,000 immigrants per year, distributed among economic, family

reunification and refugee immigration categories (Citizenship and Immigration Canada, 2009).

A result of the historical shifts in Canadian immigration policies, this large population of

immigrants has produced demographic, social and economic changes to Canada.

Simon (1999) described the development of Canadian immigrant policies in three historical

phases. In the first phase (1850-1962), Canada’s immigration policy focused on recruiting

Europeans and their families to fulfill an increased demand for workers. “The system was

ethnocentric and racist” (Simon, 1999, p.41). In the second phase (1962-1989), with the end of

the Second World War, Canada emerged as an international peacekeeping and anti-racist nation,

and in 1962, the country abolished the ethnic preference immigration system, in favour of the

point system. For Simon (1999), the Canadian immigration point system was created in

response to: 1) a decrease in the supply of qualified European immigrants; 2) a rise in labour

demand for an increasingly industrialized country; and 3) the country’s increasing appreciation

for multiculturalism. In the third phase (1989-present), immigration policies have been devoted

to maximizing economic interests and reducing welfare burden. In this context, an increased

proportion of highly skilled or capital immigrants, with excellent English/French skills, have

been selected to the detriment of family class immigrants and refugees. The preference for

economic class immigrants is based on the assumption that they will likely contribute to higher

national productivity, with less welfare support for settlement. However, this assumption is

flawed, since a large proportion of economic immigrants have been facing numerous barriers to

social and economic integration, as will be detailed in the following paragraphs (Simon, 1999).

Currently, the proportion of immigrants arriving in Canada from Asia, Africa and Latin

America, also referred to as visible minority immigrants, has increased steadily. According to

estimates from the 2001 Census of Canada, of those entering the country during 1991-2001,

14

nearly three-quarters (74%) were members of visible minority groups, with Chinese and South

Asian groups predominating (Boyd, 2006, 2010). These immigrants are concentrated in the

three largest cities in Canada: Toronto, Vancouver and Montreal (Boyd, 2006).

In addition, a large proportion of skilled immigrants have been recruited. Since 1996, skilled

worker immigrants have comprised more than half of all entering immigrants. This cohort is

significantly more educated than their non-visible minority counterparts (Basavarajappa &

Frank, 1999) and than immigrants arriving in earlier decades (Boyd, 2010). However, their

earnings are not commensurate with their educational skills. Indeed, several studies have shown

decrease in earnings and increase in employment gaps for immigrants arriving in the late 1990s

in comparison to earlier cohorts and the overall Canadian population (Aydemir & Skuterud,

2005; Frenette & Morissette, 2005; Heisz, Bordt, Das, Sudip, & Larochelle-Côte, 2005; Picot &

Hou, 2003). In addition, low-income cut off (LICO) rates have risen among immigrants, and in

2000, immigrants’ LICO rates were 2.5 times higher than the Canadian-born population (Picot

& Hou, 2003). In general, these immigrants have experienced higher rates of unemployment and

underemployment, while performing jobs that Canadian-born populations have shunned (Picot

& Hou, 2003; Boyd 2006; 2010).

Boyd (2006, 2010) suggests several explanations for recent arrivals’ lower labour force

participation and high un/under employment rates: 1) the changing composition of immigrants;

2) prolonged time to settle; 3) language difficulties; 4) unfamiliarity with Canada’s labour

system; 5) decreasing returns for foreign experience; 6) poor economic conditions for new

labour market entrants as a whole; and 7) employer-based discrimination against those lacking

Canadian experience. Other authors have emphasized that Canadians are much better educated

than in the past, and this might play against current immigrants, making them less competitive

than in the past (Alboim, Finnie, & Ming, 2005; Reitz, 2001). There is also evidence of

discounting of foreign degrees by employers (Alboim et al., 2005), and of discriminatory

practices against immigrants in the working environment (Pendakur & Pendakur, 1998; 2011;

Yoshida & Smith, 2008).

15

Overall, current immigration policies are entrepreneurial in character. These policies are

formulated on the basis that immigrants should be self-sufficient, and self-responsible for their

economic and social adjustment, reducing state costs related to settlement and language

proficiency programs. However, current immigration trends have suggested that recent arrivals

are not doing as well economically as earlier cohorts. These economic and social disadvantages

have potential consequences for immigrants’ health and oral health. Details on general

immigrants’ health and oral health will be provided in the following sections, with particular

emphasis on the case of immigrants to Canada.

2.3. Immigrants’ Health

The Canadian immigration point system selects most immigrants based on education, job

experience and age, all traits related to human capital and its potential to produce economic

growth. Health is also an integral part of human capital, as once immigrants have their health

compromised they cannot fully realize their economic and social potential (Beiser, 2005).

Therefore, in addition to socio-economic criteria, a comprehensive medical screening also

ensures that immigrants, except refugees, are healthy at the time they enter the country. As a

result of this practice, recent immigrants are, on average, healthier than Canadian residents

(Beiser, 2005; De Maio, 2010; De Maio & Kemp, 2010; Dunn & Dyck, 2000; Newbold, 2005,

2009; Newbold & Danforth, 2003; Vissandjee, et al., 2004; Smith et al., 2007).

The effects of resettlement on the health of immigrant populations are unclear and complex.

Research conducted with immigrant communities has identified that experience post-migration

serves as both risk (Frisbie, Cho, & Hummer, 2001; Hazuda, Haffner, Stern, & Eifler 1998;

Marmot & Syme, 1976) and protector factors (MacLean, 1998). Beiser’s (2005) review on

immigrant and refugee health in Canada summarizes the two main explanatory models to

immigrants’ health patterns: the sick immigrant paradigm and the healthy immigrant effect.

The sick immigrant paradigm prevailed in the middle of the 20th century. This paradigm

endorsed the idea that immigrants carry infectious diseases, and therefore threaten Canada’s

public health and its publicly funded social and health services (Beiser, 2005). The sick

immigrant paradigm has been surpassed, since comprehensive medical screenings became a

16

mandatory criterion for admission in Canada. The health-related criteria guarantee admissibility

mostly for healthy immigrants and for immigrants with history of treatable diseases (e.g.,

inactive TB, syphilis).

The medical exclusion criteria gave rise to a new immigrant health paradigm, namely “the

healthy immigrant effect”, proposed by several scholars (De Maio, 2010; De Maio & Kemp,

2010; Newbold, 2005, 2009; Newbold & Danforth, 2003). This new paradigm suggests that

immigrants are healthy and even healthier than their Canadian counterparts; but that their health

tends to deteriorate within five to ten years of residency in the new country (Newbold, 2009).

Proponents of the healthy immigrant effect have also articulated a wide variety of reasons

related to affirming that long term exposure to post-migration stressors is the reason for

immigrants’ health decline (Anderson, Blue, Holbrook, & Ng, 1993; Bentham, Hinton,

Hayners, Lovett, & Bestwick, 1995; Deinar & Dunnigan, 1987; Hazuda et al., 1998).

Prior studies suggest two potential pathways to explain the healthy immigrant effect: the

convergence explanation (Dunn & Dyck 2000; Frisbie et al., 2001; Hazuda et al., 1988; Kagan

et al., 1974; Marmot et al., 1975; Marmot & Syme, 1976; Worth, Kato, Rhoads, Kagan, &

Syme 1975) and resettlement stress (Beiser, 2005; Beiser, Hou, Hyman & Tousignant, 2002).

The first premise suggests that the health outcomes of immigrants, when they are exposed to

risk factors that affect Canadians, converge to the overall Canadian level, or even worse. Key

epidemiological studies assessing cardiovascular disease (CVD), breast cancer, suicide rates, in

the US and Canada (Dunn & Dyck 2000; Frisbie et al., 2001; Hazuda et al., 1988; Kagan et al.,

1974; Klierwer & Smith, 1995; Kliewer & Ward, 1988; Marmot et al., 1975; Marmot & Syme,

1976; Worth et al., 1975) are consistent with the convergence explanation. While behavioural

risk factors are at the center of immigrants’ convergence trends, the resettlement stress

explanation emphasizes that the root causes for immigrants’ health deterioration rely on the

effect of the amplified stress associated with the process of resettlement (Beiser, 2005; Beiser et

al., 2002). Immigrants are more likely to experience unemployment (Aydemir & Skuterud,

2005; Frennete & Morissette, 2005; Heisz et al., 2005; Newbold & Danforth, 2003; Picot &

Hou, 2003), poverty (Beiser et al., 2002; Picot & Hou, 2003) and barriers to accessing health

services (Klierwer & Smith, 1995) than native-born populations. Immigrants’ increased

17

structural barriers result in increased stress and ultimately health deterioration. The links

between low social position, chronic stress and health deterioration can be explained by the

allostatic load concept (McEwen, 2008). The over time accumulation of social, physical and

material stressors, resulting from low social position, may produce a chronic overuse of the

brain’s stress response that affects several physiological systems in the body including

cardiovascular, metabolic and immune systems. In other words, “the wear and tear from chronic

overactivity of systems that protect the body by responding to internal and external stress,

including the autonomic nervous system, the hypothalamic-pituitary-adrenal (HPA) axis and

cardiovascular, metabolic, and immune systems” (McEwen, 2008, p.171).

Overwhelmingly, cross-sectional and longitudinal analyses have continued to demonstrate that

immigrants are healthier than the native-born population at the time of arrival in the country, an

advantage lost over the years post-migration (De Maio, 2010; De Maio & Kemp, 2010; Fuller-

Thompson, Noack, & George, 2011; Kim, Carrasco, Muntaner, Mckenzie, & Noh 2013;

Newbold, 2009; Setia, Quesnel-Vallee, Abrahamowicz, Tousignant, & Lynch, 2009; Singh-

Setia, Lynch, Abrahamowicz, Tousignant, & Quesnel-Vallee, 2011). With a few exceptions, this

pattern has been confirmed in studies of self-assessed health status (De Maio & Kemp, 2010;

Fuller-Thompson et al., 2011; Kim et al., 2013; Newbold, 2009; Setia et al., 2011), presence of

diagnosis of diabetes and heart disease (Creatore et al., 2010; Veenstra, 2009), overweight and

obesity (McDonald & Kennedy. 2005; Ng, Wilkins, Gendron, & Berthelot, 2005), mental health

(De Maio & Kemp, 2010; Smith et al., 2005; Stafford, Newbold, & Ross 2011) and birth

outcomes (Auger, Luo, Platt, & Daniel, 2008; Moore, Daniel, & Auger, 2009; Ray, Vermeulen,

Schull, Singh, Shah, & Redelmeier, 2007). These studies have demonstrated that not only has

the health of immigrants been declining, but also, at the population level, health inequalities are

produced between immigrants and non-immigrants. Attempting to move beyond individualistic,

behavioural and cultural explanations for these health inequalities, political economy and social

determinants of health perspectives have been applied (De Maio, 2010; De Maio & Kemp,

2010; Dunn & Dyck, 2000, Shahidi, 2011). Some authors have even proposed that immigration

is pathogenic by itself (De Maio, 2010), and migration is a social determinant of health (Dunn &

Dyck, 2000; Vissandjee et al., 2004). Others have examined immigrants’ health disadvantages

as an effect of racism (Hyman, 2009), discrimination (De Maio & Kemp, 2010) and oppression

18

(Spitzer, 2012). These perspectives highlight that health inequalities within immigrant groups,

as well as the decline in immigrants’ health, are ultimately a result of shortcomings in public

policy (De Maio, 2010).

2.4. Immigrants’ Oral Health

In contrast to research on immigrants’ general health, the study of the effects of immigration on

oral health has gained attention only in recent decades. Ismail and Szpunar’s (1990) publication

on the oral health status of Mexican-Americans marked the first study on the oral epidemiology

of immigrant communities. Since then, interest has grown in the oral epidemiology of

immigrants. However, this field lacks a systematic theoretical and explanatory approach.

Therefore, an appraisal of the dental literature was conducted by adapting Beiser’s (2005)

medical explanatory models of immigrant health, which was described in the previous section.

In the first paradigm, new immigrants have worse oral health outcomes than the native born

populations. They are included among high-risk groups for oral diseases along with aboriginal

communities, racial, ethnic minorities and medically compromised populations (Lawrence &

Leake, 2001). This idea is consistent with Beiser’s (2005) sick immigrant paradigm. Most oral

epidemiology research has supported this assumption that immigrant groups carry a

disproportionate burden of oral disease (Ahluwalla & Sadowsky, 2003; Almerich-Silva &

Montiel-Company, 2007; Locker et al., 1998), because many of them come from low/middle

income countries that might suffer from barriers to dental care, lack of preventive programs, and

fluoridated water supplies or other sources of fluoride. Following their arrival in the new

country, their oral health would tend to improve with higher levels of acculturation (Bower &

Newton, 2007; Cruz et al., 2004; Cruz et al., 2009; Gao & McGrath 2011; Mariño et al., 2001)

and longer residency in the new, high-income country (Cruz, Chen, Salazar, karloopia, & Le

Geros, 2010; Gao & McGrath 2011)

However, three main methodological limitations in the dental literature provide a basis for

caution in inferring immigrants’ oral disease vulnerability. First, studies that support this

paradigm have grouped different immigrant populations in the same homogenous category

(Ahluwalia & Sadowsky, 2003; Almerich-Silva & Montiel-Company, 2007; Cruz et al., 2009;

19

Locker at al., 1998), neglecting to note anthropological and sociological differences in health

(Chemtob, Leventhal, & Ravell-Weiler, 2003) and oral health (Cruz, Galvis et al., 2001; Vered

et al., 2009). Second, the dental literature has often used acculturation as a proxy measure of the

effect of post-migration factors in care-seeking behaviour, specifically associating higher

acculturation levels with improvement in oral health outcomes (Bower & Newton, 2007; Cruz et

al., 2004; Cruz et al., 2009; Gao & McGrath, 2010; Ismail & Szpunar, 1990; Mariño et al.,

2001). Although acculturation provides plausible explanations for immigrants’ health behaviour

change at the individual level, studies on acculturation and oral health lack strong considerations

of the social, political and economic determinants that shape immigrants’ oral health at the

population level. In addition, measuring acculturation is a complex undertaking because of the

lack of standardized acculturation scales/proxy measures and the frequent use of unidimensional

scales (e.g., language preference); (Gao & McGrath, 2011). Third, there is plausible evidence

showing that immigrants’ oral health rates are not always inferior to their host counterparts

(Sgan-Cohen et al., 1992; Vered et al., 2008; Vered et al., 2009; Zini et al., 2009). This

information leads us to the next paradigm.

The second paradigm assumes that immigrants have better oral health outcomes than their host

country counterparts, which over time tend to deteriorate. This idea is similar to the healthy

immigrant paradigm and has been supported by several international studies. For instance, Sgan-

Cohen et al, (1992), William et al (1996), and Cruz, Xue, et al., (2001) have identified fewer

lifetime dental caries among adult immigrants from Ethiopia, Bangladesh, Haiti than among

their counterpart adults in Israel, UK and the US. Vered et al.’s (2008) findings are consistent

with this idea. These authors followed the oral health status of a cohort of Ethiopian immigrants

to Israel from 1999 to 2005 and identified that 70.1% (n=472) of the examinees were caries-free

at baseline, presenting better indices than the Israeli population. Despite Ethiopian immigrants’

superior oral health indicators, their oral health deteriorated after five years of residency in the

country. Assimilation of Western high sugar intake, and the replacement of traditional chewing

and cleaning sticks by modern toothbrushes were pointed out as the reasons for such

deterioration. On the other hand, Zini et al. (2009) compared self-perceived measures with

clinically diagnosed dental and periodontal health status among immigrants to Israel, and

concluded that minority groups should not be prejudicially regarded as less knowledgeable.

20

Although the oral healthy immigrant paradigm has produced plausible findings, underpinned by

the longitudinal follow-up study of newly settled Ethiopian immigrants in Israel, determining

the extent to which this effect applies to all other immigrant groups, including those

immigrating to Canada, constitutes an important research priority.

With regard to the oral health of immigrants in Canada, very little is known. Following a

common international trend, most Canadian studies have assessed the oral health of specific

populations covered by publicly subsidized programs, such as children (Abramson & Heinman,

1997; Locker et al., 1998; Weinstein, Smith, Fraser-Lee, Shimono & Tsubouchi, 1995; Werneck

et al., 2008; Woodward, Leake, & Main, 1996) and elders (Dong et al., 2007; Lai & Hui, 2007),

for many of whom high caries rates (Lai & Hui, 2007; Locker et al., 1998) and low frequency of

dental visiting (Abramson & Heinman, 1997; Lai & Hui, 2007; Locker et al., 1998; Werneck et

al., 2008; Woodward, Leake, & Main, 1996) have been reported. Although these studies have

indicated initial poor oral health outcomes in this population, their oral health would tend to

improve with longer residency in Canada (Locker et al., 1998; Newbold & Patel, 2006). Along

these lines, Ghiabi, Mathews, and Brillant (2014) examined the oral health of a sample of adult

immigrants and refugees in Nova Scotia, and identified that recent adult immigrants to Canada

had higher rates of untreated decay than the overall Canadian population. Importantly, all of

these studies are cross-sectional study designs, posing challenges to understand the effect of the

immigration process on oral health.

While the effects of immigration on the oral health of immigrants remain controversial, a

common ground found in both the sick and the oral healthy immigrant paradigms is their failure

to reflect on upstream structural determinants of oral health; that is, research on immigrants’

oral health has neglected the social, political, and economic factors that determine patterns of

oral health in Canada.

2.5. Post-Migration Determinants of Oral Health

In this section, Solar and Irwin’s (2010) conceptual framework on social determinants of health

is used to explain how post-migration social determinants may impact immigrants’ oral health.

The immigrant oral health literature is rarely considered within the social determinants of health

21

framework. In this regard, many broad determinants influence the health of Canadians,

including gender, income and social status, employment and working conditions, health

practices, social and physical environments, and culture (Raphael, 2009). These social

determinants are more important for immigrants than non-immigrants (Dunn & Dyck, 2000), as

immigrants experience worse socio-economic conditions than their Canadian counterparts

(Dunn & Dyck. 2000). The dimensions of social stratification thought to be influential in oral

health apparently mirror those of general health (Sabbah, Tsakos, Chandola, Sheiham, & Watt,

2007; Watt, 2007); for instance, income and education gradients in oral health are similar to

those of general health (Sabbah et al., 2007).

The determinants of immigrants’ oral health examined in this study are structural and

intermediary determinants. Structural determinants include income, history of social assistance,

education, employment status, gender, discrimination and ethnicity. Intermediary determinants

include social support and acculturation (i.e., official language proficiency).

Income influences health outcomes through the direct effect of material resources. It allows

individuals to: 1) access better quality material resources such as food and shelter; 2) access

services such as health, education and leisure; and 3) improve self-esteem and social standing

and participation in society (Solar & Irwin, 2010). With regard to the effect of income on oral

health, a substantial body of literature has shown that individuals in lower socioeconomic

positions have worse oral health outcomes (Sabbah et al., 2007; Sabbah, Tsakos, Sheiham, &

Watt, 2009a; Sanders, Slade, Turrell, Spencer, & Marcenes, 2006). Immigrants are arguably at

increased risk of poor oral health, as they experience disproportionately higher levels of poverty

compared to their Canadian-born counterparts (Hyman, 2004).

Education affects health through knowledge of healthy lifestyles (Solar & Irwin, 2010). In

addition, education provides formal qualifications that potentially lead to better socio-economic

position, through occupation and income (Solar & Irwin, 2010). In the context of immigrants to

Canada, however, although they tend to be highly educated, the majority experience

underemployment, unemployment and poverty (Aydemir & Skuterud, 2005; Frenette &

Morissette, 2005; Heisz et al., 2005; Picot & Hou, 2003). Thus, for immigrants to Canada,

22

education level might not be a good indicator of socio-economic position (De Maio, 2010). On

the other hand, education may affect immigrants’ health through knowledge of healthy lifestyles

obtained prior and after immigrating. It is known that high level of education is generally

associated with good clinical and self-reported oral health status (Sabbah et al., 2007; Sabbah et

al., 2009a). Moreover, it can also be associated with increased awareness of dental problems

(Locker, Maggirias & Wexler, 2009).

Un- and under-employment are important measures of economic strain among immigrants in

Canada (Dunn & Dyck, 2000; Shahidi, 2011). Immigrants to Canada face increased challenges

to securing permanent full-time employment in Canada’s increasingly racialized labour market,

and once employment is secure, they have lower income earnings than their Canadian

counterparts (Block & Galabuzi, 2011). Employment status may influence immigrants’ oral

health through: 1) the direct relation between material resources and oral health; and 2) better

access to certain privileges such as dental insurance, the most dominant predictor of access to

dental care in Canada (Millar & Locker, 1999; Thompson, Cooney, Lawrence, Ravaghi, &

Quiñonez, 2014). In Canada, employed individuals are more likely to have dental insurance,

which in turn, results in improved access to dental care (Millar & Locker, 1999). Unemployed

individuals are less likely to have dental insurance, even after adjusting for other socio-

demographic factors such as age, income and education (Millar & Locker, 1999).

Sex-disparities often refer to differences in women’s ability to obtain education and to gain

access to respect and well-remunerated forms of employment. In general, immigrant women are

paid lower wages, have less job security, and worse labour market participation than immigrant

men in the Canadian labour market (Shields et al., 2010). This financial disadvantage may put

immigrant women at greater risk to report poor oral health than men. In addition, the

immigration process may lead to differential stress responses in men and women that could be

linked to dental problems. However, stress-mediated explanations on oral health outcomes and

inequalities have yet to be fully understood (Chi & Tucker-Seeley, 2013).

Perceived discrimination can influence health and health behaviour outcomes through: 1) the

effect of physiological stress response on the immune system; 2) the direct effect on health

23

behaviours, such as delays in seeking healthcare, including dental care; and 3) disadvantage in

labour market outcomes and earnings (Solar & Irwin, 2010). Health status and outcomes among

immigrants who experience discrimination are often worse than their counterparts (De Maio &

Kemp, 2010). For instance, De Maio and Kemp’s (2010) analysis of the LSIC identified that

immigrants who reported being discriminated against were more likely to report poor general

health. In the same study, experience of discrimination was also associated with mental health

deterioration. With regard to oral health, no research has examined the effect of self-perceived

discrimination on immigrants’ oral health. In dentistry, the effect of discrimination on

populations’ oral health has been scarcely studied. Only two studies were found examining these

relationships. One examined the role of self-perceived discrimination as a mediator effect

between race and tooth loss in a sample of Brazilian civil servants, and did not find any

statistical association (Celeste, Gonçalves, Eaerstein, & Bastos, 2013). The other by Jamieson,

Steffens, and Paradies (2013) investigated the association between discrimination and dental

visiting behaviours in an Aboriginal Australian birth cohort and found that, after controlling for

other risk factors, those reporting discrimination were 3.8 times more likely to have never

visited a dentist before.

The relation between ethnicity and health is complex, has changed over time, and differs among

countries. Traditionally, researchers have explained ethnic disparities in health as a matter of

socio-economic differences, or of “cultural” or “racial differences” (Smith, 2000). In Canada,

ethnicity has been framed as either birth place or Statistics Canada’s visible minority category

(De Maio, 2010). Recently, notions of racism and discrimination have been incorporated to

explain immigrants’ ethnic disparities in health (Vissandjee et al., 20004). Veenstra (2009) even

calls for the notion of racialized identity to describe groups of people that have been socially and

politically constructed as ‘‘racially’’ distinct. Generally, European, White respondents have

better health outcomes than any racial/cultural group, even after controlling for immigrant

status, socio-economic position and demographics (Veenstra, 2009). These ethnic inequalities

have been attributed to experience of discrimination and racism that can limit opportunities for

high education, good jobs with high salaries, health insurance, and quality care impacting the

health and well-being of those belonging to marginalized ethnic groups (Veenstra, 2009).

Although the majority of self-assessed health studies highlight that non-White immigrants fare

24

worse than “White” immigrants, other studies have found the opposite (Dunn & Dyck, 2000;

Newbold & Danforth 2003; Vissandjee et al., 2004). For instance, Dunn and Dyck (2000),

Newbold and Danforth (2003) as well as Vissandjee et al.’s (2004) respective analyses of the

National Population Health Survey (1994-1995, 1998-1999) and the 2000 Canadian Community

Health Survey revealed that European immigrants were more likely to report poorer self-

reported general health and chronic conditions than non-European immigrants. These findings

were apparently linked to the older profile of European immigrants when compared to other

ethnic groups (Dunn & Dyck, 2000; Newbold & Danforth, 2003; Vissandjee et al., 2004). De

Maio (2010) has outlined that health transition by ethnicity may be dependent on the choice of

measures, and that ethnicity is integral to providing a heterogeneity analysis of the health of

immigrants in Canada. The author concludes that for ethnicity to be fully understood, more

research is needed on its interaction with discrimination.

With regard to oral health, similar ethnic disparities are found. Previous studies conducted with

children, adults and elderly in the US and UK have demonstrated a general trend in which White

populations have better self-reported and clinical oral health outcomes than any other ethnic

minority group (Flores & Lin, 2013; Newton, Corrigan, Gibbons, & Locker, 2003; Sabbah,

Tsakos, Sheiham & Watt, 2009b; Shelley, Russell, Parikh, & Fahs; 2011; Wu et al., 2013).

Several causal pathways have been studied to better understand ethnic differences in oral health.

For instance, Sabbah et al. (2009b) examined the effect of income and education on ethnic

differences in the oral health of US adults, and revealed that socioeconomic position (i.e.,

income and education) only partly explained the ethnic differences in clinical and self-reported

oral health outcomes found in their study. Ethnic disparities were also found in dental service

utilization among children, adults and elderly in the US (Doty & Weech, 2003; Flores & Lin,

2013; Shelley et al., 2011). Again, White groups had better dental care utilization than other

ethnic minorities, including Blacks and Hispanics (Doty & Weech, 2003; Flores & Lin, 2013).

The ethnic disparities in dental care utilization found in these studies were mostly explained by

socioeconomic factors such as income, education, as well as access to dental insurance and

official language proficiency (Doty & Weech, 2003; Shelley et al., 2011).

25

Social support is a feature of social integration (Muntaner, 2004), a measure of immigrants’

participation in family and community networks that may help promote health and welfare

(Solar & Irwin, 2010). Participation in these social networks, for instance, might help

immigrants obtain information on self-care and on how to navigate the dental care system in

Canada. Following the medical literature, dentistry has also referred to social support as a matter

of social cohesion and social capital. Muntaner (2004) has argued that social capital does not

bring a new explanation into how society’s affect health and that social networks, norms of

reciprocity and trustworthiness may as well be referred to as social integration, social cohesion

or social support. Internationally, poor social support (e.g., loneliness, not being married, poor

social interaction with friends and neighbours, poor participation in social activities including

religious services, and increased number of homicides per thousand) have been linked to a

number of oral health outcomes among general populations of children/adolescents and elderly

in Brazil, Sweden, UK, and the US, including caries experience (Patussi, Marcenes, Croucher,

& Sheiham, 2001), dental injury (Patussi, Hardy, & Sheiham, 2006), coronal and root caries

(Avlund, Holm-Pedersen, Morse, Viitanen, & Winblad, 2003), poor self-reported oral health

(McGrath & Bedi, 2002), and poor dental care utilization (Burr & Lee, 2013). In Canada, social

support has been linked to better dental care utilization among elderly Chinese immigrants (Lai

& Hui, 2007). In addition, social capital, measured as engagement for the common good, sense

of belonging, system connections, and family role in community, was correlated with better self-

reported oral health among parents of Arabic children in Toronto, but not with their children’s

oral health status (Al-Rudainy, 2011)

Official language proficiency has often been used as an indicator of immigrants’ level of

acculturation. However, measuring acculturation is a complex undertaking, and the use of a

single measure, such as official language proficiency, does not comprehensively encompass the

cultural context of each immigrant group (Gao & MacGrath, 2011). Nonetheless, English

proficiency at home has been linked to good oral health outcomes in children (Al-Jewair &

Leake, 2010) and better dental care utilization in adult and elderly immigrant groups in Canada

and the US (Amin & Perez, 2012; Graham, Tomar, & Logan, 2005; Jaramillo, Thornton-Evans,

& Griffin, 2009; Shelley et al., 2011). In contrast, Newbold and Patel’s (2006) analysis of the

Canadian National Population Health Survey found that immigrants aged 12 years and older,

26

who spoke a language other than English or French, were more likely to have used a dentist

within the past year, which suggests that language may not be a barrier to dental care in this

country.

Time since immigration may be relevant for immigrants’ oral health and access to dental care.

Locker et al., (1998) reported that those recent adolescent immigrants who had been in Canada

for six or more years had better oral health outcomes (e.g., less proportion of calculus, less

proportion of decayed teeth, less dental treatment needs) than those who resided in Canada for

less than two years. However, improvements in the oral health of adolescents were apparently

due to the influence of dental public health programs targeting specific populations such as

children and adolescents (Locker et al., 1998). Length of immigration was also correlated with

better dental care utilization among immigrants in Quebec (Bedos et al., 2004). For instance,

Bedos et al. (2004) identified that immigrants living in the country less than ten years had lower

dental care utilization than those residing in Canada for more than ten years. Consistently,

Newbold and Patel (2006) showed that immigrants residing in Canada for less than four years

were less likely to have visited a dentist in the past year than those who resided in the country

for more than five years. Further, recent analyses of the CHMS (2007-2009) demonstrated that a

higher proportion of immigrants living in Canada less than ten years, reported avoiding a dental

professional due to cost than those living in Canada greater than ten years (Thompson, 2012).

Overall, there is an agreement that the oral health and access to dental care of recent

immigrants’ is worse than longer-term residents. However, it remains unclear when

improvements occur, if the improvement pattern is linear over time, or if there is any time

threshold for this improvement. It is also unclear how the oral health of immigrants evolves in

the first five years after settlement. These limitations are related to the cross-sectional nature of

the large majority of immigrants’ oral health and access to dental care studies, which prevents

an observation of time trends.

27

2.6. Post-Migration Determinants of Oral Health: The Canadian Dental Care System

In this section, a very brief overview will be provided on historical and current developments in

the Canadian dental care system. This overview provides a context to understand the dental care

opportunities and barriers available for landed immigrants.

Dental care in Canada is predominantly privately financed. Information from the Canadian

Institute for Health Information (2010) reveals that approximately 95% of total dental care

expenditures are privately paid, of which 44% are paid through out-of-pocket expenditures and

51% through employment-based insurance. The remaining 5% consists of public financing

targeting socially marginalized groups, and is delivered in the private sector through public

forms of third party financing (Quiñonez et al., 2007).

Overall, publicly financed dental care is distributed in the following way: 1) the federal

government finances care for state recognized groups such as Aboriginal populations, the

Armed forces, and refugees, the latter through the Interim Federal Health Program (IFHP); 2)

the provinces finance dental care delivered in-hospitals and for groups such as low-income

children and social assistance recipients, and in addition, through costs sharing agreements with

the provinces, municipalities finance care for low-income children and social assistance

recipients, and independently for groups such as low-income seniors (Quiñonez et al., 2007).

Among immigrant groups, only refugees are eligible for basic care services and supplementary

coverage, including emergency dental, vision, and pharmaceutical care, through the IFHP.

These benefits are funded on a temporary basis to ensure refugees’ health coverage while their

permanent resident status is processed. Eligibility for IFHP benefits expires after a specified

period (no longer than 12 months), but is renewable (Gagnon, 2002). Although legally insured,

refugees face several barriers to accessing their health care benefits, including dental care. These

barriers are related to: many providers’ unwillingness to process IFHP forms or their lack of

knowledge on how to bill for services; processing difficulties at the IFHP office, including pre-

authorization for certain conditions and late reimbursement to providers; and absence of

coverage for certain dental care conditions (Gagnon, 2002). Currently, many cuts have been

28

applied to the IFHP, and all refugee groups except government-assisted refugees have lost

access to several health care benefits, including dental care (Sheikh, Rashid, Berger & Hulme,

2013; Citizenship and Immigration, 2012).

Within the current dental care system, immigrants will remain individually responsible to ensure

their oral health and access to dental care. Their ability to ascend in the social position ladder,

find high paid, permanent jobs opportunities that will ensure access to dental insurance, will

potentially determine their oral health status over the years post-migration.

29

Chapter 3

Methods

3.1. Data Source

Quantitative data analysis was conducted using the Longitudinal Survey of Immigrants to

Canada (LSIC) (Statistics Canada, 2007a) primarily to determine immigrants’ oral health,

access to dental care and transnational dental care utilization. The LSIC was completed by

Statistics Canada and Citizenship and Immigration Canada (Statistics Canada, 2005) to examine

the first four years of immigrants’ settlement in Canada. This survey was designed to investigate

the process of settlement of recent immigrants over a period of time and to identify factors that

hinder or assist adjustment to Canada (Statistics Canada, 2005).

The LSIC target population consist of Canada’s foreign-born that: 1) arrived in Canada between

October 1, 2000 and September 30, 2001; 2) are aged 15 or older at the time of landing; and 3)

“landed” from abroad, and applied through a Canadian Mission abroad. In total, the LSIC

includes three “waves”, collected at six months (Wave 1), two years (Wave 2) and four years

(Wave 3) after arrival.

The survey collected information in more than 15 languages on socioeconomic status, housing,

language skills, values and social attitudes, social support, health status, access and utilization.

While measures of self-reported oral health were collected along the three waves of the survey,

access to care and transnational dental care utilization questions were asked only at wave 2 and

3. A two-stage stratified sampling method was used to select the survey respondents. The first

30

stage involved the selection of an immigrant unit (individual, couples or families) from the

administrative database of Citizenship and Immigration Canada. The second stage involved the

selection of one member from the immigrant unit, aged 15 years or older at the time of landing,

and who landed from abroad. Asylum seekers and individuals who applied for any type of

permament residency within Canada were excluded from the survey. Interviews were conducted

in person and by telephone. Most interviews at all three waves were conducted in person, and a

minority was conducted over the telephone mainly because limitations related to the place of

interview and specific language needs (Statistics Canada, 2005).

Among the 250,000 people admitted to Canada within this time period, the survey determined a

target population of 169,400 immigrants. The survey population of interest consisted of those

immigrants in the target population who still reside in Canada at the time of a given wave.

During the survey period, the initial target number of target population was reduced because

some immigrants left Canada to return to their home country or for another country and were

thus excluded from the survey. At Wave 1, this population was estimated at approximately 164

200 immigrants, at Wave 2, the size of the population of interest was estimated to be 160,800,

and at wave 3,157,600 immigrants (Statistics Canada, 2005). A total of 7,716 respondents

completed the three waves of interviews.

This study’s target population consisted of non-refugee immigrants, with no previous experience

of migration, aged 20-60 at baseline who answered questions on oral health, access to dental

care and transnational dental care utilization.

Statistics Canada data is collected by experienced professional and trained researchers who

follow standardized protocols, keeping up with the agency high standard procedures. The LSIC

data was accessed from Statistics Canada’ s Research Data Centre (RDC) at the University of

Toronto. Due to confidentiality rules, specified by Statistics Canada, descriptive analysis that

produced small cell sizes (<10) were not released from the RDC This study analysis was

conducted at Statistics Canada Research Data Center in Toronto, during 2012-2014.

31

3.2. Variables

3.2.1. Outcome Variables

For objective 1, the outcome variable used was dental problem occurrence. This study outcome

was obtained using the answers to the following question: “Since you came to Canada have you

had a dental problem?” (Yes/No). This question was asked at six months (wave 1), two (wave 2)

and four (wave 3) years after arrival for each respondent. Thus, the outcome was categorized as

“yes” if immigrants reported having dental problems and “no” otherwise.

For objective 2, the outcome variable used was self-reported unmet dental care needs. This

study outcome was obtained using the answers to the following survey question: “Since your

last interview, have you had any dental problems for which you did not receive dental care?”

(yes /no). This question was asked at wave 2 and wave 3. Since we were interested in assessing

predictors of unmet dental care needs over the years, we developed a summary outcome variable

by composing the responses at wave 2 and 3. Thus, the outcome was categorized as “yes” if

immigrants reported having any unmet dental care needs over a three point five year period

(either in wave 2 or wave 3) and “no” otherwise.

For objective 3, the outcome variable was transnational dental care utilization, which was

obtained using the answers to the following survey question: “Since your last interview have

you received dental care outside Canada?” (yes/no). This question was asked at wave 2 and

wave 3. Since we were interested in assessing predictors of transnational dental utilization over

a three point five year period, we developed a summary outcome variable by composing the

responses at wave 2 and 3. This outcome was assessed as “Yes” if respondents had received any

dental care outside Canada over a three point five year period (i.e., at least one “yes” for the

survey question in wave 2 or wave 3) and “No”, otherwise.

3.2.2. Independent Variables

The independent variables used in this study were socio demographics, socioeconomic, official

language proficiency, social support, and self-reported dental problems variables.

32

Sociodemograohic variables included age, sex, marital status and ethnicity. Age was categorized

in the following groups: 20-29, 30-39, 40-49 and ≥ 50. Information on marital status was

collected as married, common-law, widow/widower, separated, divorced. To obtain a similar

proportion for categories in marital staus variable, consequently improving the quality of the

models, we categorized this variable as not married vs. married. Ethnicity was obtained on the

basis of ethnic origin, as defined by Statistics Canada (Statistics Canada, 2004). This variable

was categorized as: 1= Arabic, African and Middle Eastern (Arabic world, African continent

and Middle East Asia); 2=South Asian (India, Pakistan, and Sri Lanka); 3= Chinese (Mainland

China, Taiwan, Hong Kong); 4= East Asian (Korean, Japanese and other East Asian countries);

5= Latin American and Caribbean (Caribbean, Mexico, Central and South America).

Socioeconomic variables included level of education, history of social assistance, self-perceived

discrimination, income, and employment status. Level of education was collected as the highest

level of education and coded as college/university and more vs. high school and less. History of

social assistance was coded as a binary variable (yes/no). This variable was selected to capture

the self-reported oral health status of one of the poorest groups in society, those who typically

fall well below the Statistics Canada Low-Income Cut-Offs (National Council of Welfare,

2000).

Perceived discrimination was assessed as a binary response to the following question: “Since

your arrival in Canada, have you experienced discrimination or been treated unfairly by others

because of your ethnicity, culture, race or skin color, language or accent, or religion?” (yes/no).

Discrimination is associated with a range of adverse health effects (Krieger, 2000) and was

included in our study to capture the effect of social exclusion on self-reported oral health status.

This independent variable was included only at research objective 1

Information on income was collected as annual household income from all sources. In the

research paper objective 1 (Chapter 4), we included the variable income as a time varying

variable. Because the initial exploration of the income variable shown that almost 90% of

respondents reported earning less than $40,000 a year and a total household income of <

$40,000 approximates the average earning of the working poor in Canada (Human Resources

33

and Social Development Canada, 2006), the income variable at wave 1 was classified as ≤

$40,000 vs. > 40,000. Employment status was recoded as employed full time, employed part-

time, self-employed and unemployed. This categorization captures the influence of employment

status on self-reported oral health.

In the research papers objectives 2 and 3 (Chapters 5 and 6), the variable income and

employment status were classified differently to adapt for the cross-sectional analysis approach.

Employment status and average household income were the only two variables that varied

across time. Thus, we created summary variables that accounted for time variability and

reflected the cross-sectional nature of the analysis. Employment status was categorized as

always being employed vs. always/sometimes unemployed over the period of the survey. The

summary of the household income variable was derived in the following way. First, we created

a variable containing the average income across the three waves, and then we calculated the

mean and standard deviation of this variable. Since the standard deviation rounded about

$20,000 a year, and $40,000 a year is a good proxy for the threshold income of the working

poor in Canada (Human Resources and Social Development Canada, 2006), we created four

categories for the income variable that included: ≥$60,000; $40,000-$60,000; $20,000-40,000;

≤$20,000.

Official language proficiency was measured based on self-reported proficiency in writing,

reading, and speaking in English or French (cannot write/speak/read, poorly, fairly well, well,

very well). We recoded responses to these questions as poor, moderate and good/very good.

To assess social support, we used three variables: having relatives in Canada (yes/no), social

group membership (yes/no), and frequency of visiting relatives in Canada (monthly and less,

weekly and daily). These independent variables were included only in the analysis for research

objective 1.

Self-reported dental problems as an independent variable was included only at research

objective 3. This independent variable was derived from the following question: “Since you

came to Canada have you had dental problems?”.

34

3.3. Statistical Analysis

Weighted frequency distributions were computed. We calculated frequency distributions for

socio demographic, socio economic, social support and official language variables across the

three waves. We identified that the distribution of total household income, employment status,

and frequency of visiting relatives varied across time. Bivariate descriptive statistics were

calculated in relation to each specific outcome.

For objective 1, a generalized estimation equation (GEE) approach (Zeger, Liang, & Albert,

1988) was used to estimate the probability of reporting dental problems among immigrants,

while taking into consideration individual heterogeneity and controlling for the individual stock

of independent variables. We used the Quasi-likelihood under independence model criterion

(QIC) (Pan, 2001) to compare the fit of models and select the best subset of covariates.

For objective 2 and 3 multiple logistic regressions were conducted for each dependent variable

to identify the strongest predictors of reporting unmet dental care needs and transnational dental

care utilization over time. Before estimating multiple logistic regression models, we examined

collinearity amongst and between each of the variables, using variance inflation factor (VIF).

Only those variables with a VIF equal to, or less than three, were entered into the model. This

criteria was used in consistency with previous studies examining access to dental care and dental

treatment needs of a national mixed sample of native and foreign-born Canadians (Thompson,

2012; Ramraj 2012; Ramraj et al., 2012). We used the Akaike Information Criteria (AIC) to

compare the fit of models while accounting for additional variables in the models (Akaike,

1974). Sample and bootstrap weights were used, as specified by Statistics Canada, in all

statistical analysis using STATA 12 (Stata Corp. College Station, Texas, US). Statistical

significance was interpreted at the 5% level (p = 0.05).

35

Chapter 4

Does “the Healthy Immigrant Effect”

Apply to Oral Health? An Analysis of the

Longitudinal Survey of Immigrants to

Canada

In this chapter, we addressed the first objective of this study. In this analysis, we examined

whether the self-reported oral health of immigrants changed over time, and the socio-

demographic (including ethnicity) and economic factors associated with this change. We used

three waves of the LSIC and used the generalized estimating equation approach to estimate

changes in immigrants’ self-reported oral health over the four-year period. This chapter is

organized in a manuscript format in the following sequences: 1) Manuscript (Abstract,

Introduction, Methods, Results, Discussion, Policy Implications and Conclusion); 2) Tables; 3)

Figures.

36

Abstract

Objective: To examine the “healthy immigrant effect”, or the effect of immigration on the self-

reported oral health of immigrants to Canada over a four year period.

Design and participants: The study used Statistics Canada’s Longitudinal Survey of

Immigrants to Canada (LSIC 2001-2005). The target population comprised 3,976 non-refugee

immigrants to Canada, aged 20-60 years old, with no previous migration history. The dependent

variable was self-reported dental problems. The independent variables were: age, sex ethnicity,

income, education, perceived discrimination, history of social assistance, social support and

official language proficiency. A generalized estimation equation approach was used to assess

the association between dependent and independent variables.

Results: After two years, the proportion of immigrants reporting dental problems more than

tripled (32.6%), and remained approximately the same at four years after immigrating (33.3%).

Over time, immigrants were more likely to report dental problems (OR=2.77; 95% CI 2.55-

3.02). An increase in self-reported dental problems over time was associated with sex, history of

social assistance, total household income, and self-perceived discrimination.

Conclusion: There was an increased likelihood of reporting dental problems over time,

suggesting that the healthy immigrant effect applies to oral health. Immigrants should arguably

constitute an important focus of public policy and programmes aimed at improving immigrants’

oral health and access to dental care.

37

4.1. Introduction

Immigrants represent a large and increasing proportion of Canada’s population. Almost 20% of

the Canadian population is foreign-born (Statistics Canada, 2006) and approximately 250 000

immigrants are admitted to the country each year (Citizenship and Immigration Canada, 2009).

Currently, most immigrants to Canada come from Asia and Pacific Rim countries (49%), Africa

and the Middle East (24%) (Citizenship and Immigration Canada, 2011). With the introduction

of the immigration point system, immigrants to Canada are selected based on their education

level, job skills and health status. The premise behind the selection criteria is to maximize

immigrants’ contributions to the Canadian economy with minimal financial burden on the health

and welfare system.

Prior to immigrating, immigrants undergo a comprehensive medical screening that helps ensure

they are healthy at the time of arrival. In fact, the literature has consistently shown that recent

immigrants to Canada enjoy better health than the general Canadian population (De Maio, 2010;

De Maio & Kemp, 2010; Hyman, 2001; Newbold, 2009; Newbold & Danforth, 2003; Smith et

al., 2005; Vissandjee et al., 2004). However, over the years after immigration, their health

deteriorates to levels equal or worse than native-born Canadians in a phenomenon called the “

healthy immigrant effect” (De Maio, 2010; De Maio & Kemp, 2010; Hyman, 2001; Newbold,

2009; Newbold & Danforth, 2003; Smith et al., 2005; Vissandjee et al., 2004). Although

empirical studies overwhelmingly support “the healthy immigrant effect”, it remains unclear

what contributes to changes in immigrants’ health over time. Some reviews on the health and

determinants of health of Canadian immigrants suggest that immigrants’ initial better health

status is an effect of the immigration self-selection process (Hyman, 2001). Over time, changes

in environment and living conditions, especially related to the amplified pressure associated

with poverty, marginalization, class inequity, and lack of services (Hyman, 2001), may lead to

health deterioration. While there is a large body of literature examining the health of immigrants

to Canada, very little is known about the oral health of adult immigrants, and there is no

evidence that “the healthy immigrant effect” applies to oral health.

Very few studies have examined the oral health of immigrants in Canada, and most have

focused on the oral health of children/adolescents (Locker et al., 1998; Werneck et al., 2008)

38

and elderly (Dong et al., 2007). These studies suggest that immigrants have a higher rate of oral

disease, a pattern that improves with longer residency in Canada (Locker et al., 1998; Werneck

et al., 2008). Internationally, evidence on the effect of immigration on oral health remains

controversial. Some studies have shown that immigrants carry a disproportionate burden of oral

disease that tends to improve with longer residency in the new country (Gao & MacGrath,

2011), whereas other studies have found that immigrants have better oral health outcomes that

deteriorate over time (Vered et al., 2008). Importantly, the large majority of these published

studies are cross-sectional study designs, posing challenges to inferences on the impact of the

immigration process on oral health.

Using longitudinal data, the present study aims to examine changes in adult immigrants’ oral

health status over a four-year period. We hypothesized that on average immigrants’ self-

reported oral health status declines over the years. Our secondary hypothesis is that changes in

immigrants’ self-reported oral health over time vary according to socio-demographic and

economic factors.

4.2. Methods

4.2.1. Data Source

This study used data from the Longitudinal Survey of Immigrants to Canada (LSIC) to examine

transitions in the oral health status of immigrants to Canada. The LSIC was a three-wave

longitudinal survey, conducted by Statistics Canada (2001-2005), in which the first four years of

immigrant settlement was examined. The survey collected information in more than 15

languages on socioeconomic status, housing, language skills, values and social attitudes, social

support, health status, access and utilization. Self-reported measures of oral health status and

dental utilization were included in the LSIC Health Module. Data were collected at six months

(wave 1), two years (wave 2) and four years (wave 3) after immigration, from a sample of

immigrants who arrived in Canada between October 2000 and September 2001. A two-stage

stratified sampling method was used to select the survey respondents. The first stage involved

the selection of an immigrant unit (individual, couples or families) from the administrative

database of Citizenship and Immigration Canada. The second stage involved the selection of one

39

member from the immigrant unit, aged 15 years or older at the time of landing, and who landed

from abroad. Interviews were conducted in person and by telephone. A total of 7,716

respondents completed the three waves of interviews (Statistics Canada, 2005). From this

longitudinal sample of 7,716 (3,819 men and 3,897 women), we excluded individuals using the

following criteria: 1) immigrants who had previously lived in Canada; 2) immigrants who had

lived in a third country prior to immigrating; 3) immigrants less than 20 years and more than 60

years of age at baseline. After applying the study sample selection criteria, no missing data were

found for the dependent variable across the three data time points. Thus, our final study sample

comprised 3,976 immigrants, 1,870 men and 2,106 women (approximately 51.5% of the

baseline sample of respondents in the third wave of the survey). Figure 4.1 shows details of the

sample selection.

4.2.2. Indicators and Variables

4.2.2.1. Self-reported Oral Health

Self-reported oral health is the outcome of interest, and was measured using a single-item

question: “Since you came to Canada have you had a dental problem?” (Yes/No). This question

was asked at six months (wave 1), two (wave 2) and four (wave 3) years after arrival. Some

researchers have raised questions regarding the validity and reliability of self-reported oral

health measures (Liu et al., 2010). However, it is generally agreed that these measures are useful

indicators to assess oral health outcomes and needs, to evaluate outcomes of dental care, and to

understand oral health related behaviours in large population surveys (Gilbert et al., 2002; Jones

et al., 2001; Locker et al., 2009). In addition, self-reported oral health measures are strongly

correlated to non-clinical and clinical oral health outcomes, including perceived mouth dryness,

worry about teeth (Mathias et al., 1995), oral pain and discomfort, and oral functional decline

(Locker, 2002), dentition status, numbers of missing teeth (Locker et al., 2005), coronal caries,

mobile teeth (Jones et al., 2001), and decayed teeth (Locker et al., 2005).

40

4.2.2.2. Socio Demographic Variables

Socio demographic variables included age, sex, marital status and ethnicity. Age was classified

in the following groups: 20-29, 30-39, 40-49, and ≥ 50. Marital status was dichotomized as

married or not married (single, divorced, widow). Ethnicity was obtained on the basis of ethnic

origin, as defined by Statistics Canada (Statistics Canada, 2004). This variable was categorized

as: 1= Arabic, African and Middle Eastern (Arabic world, African continent and Middle East

Asia); 2=South Asian (India, Pakistan, and Sri Lanka); 3= Chinese (Mainland China, Taiwan,

Hong Kong); 4= East Asian (Korean, Japanese and other East Asian countries); 5= Latin

American and Caribbean (Caribbean, Mexico, Central and South America).

4.2.2.3. Socio Economic Variables

Socio economic variables included income, level of education, history of social assistance,

employment status, and self-perceived discrimination. Total household income was coded as ≤

$40,000 vs. > 40,000. A total household income of $40,000 approximates the average earning

of the working poor in Canada (Human Resources and Social Development Canada, 2006). In

2005, a household of four would be classified as a working poor family if its after-tax income

was below $32,556 (Statistics Canada, 2007b). Level of education was coded as

college/university and more vs. high school and less. History of social assistance was coded as a

binary variable (yes/no). This variable was selected to capture the self-reported oral health status

of one of the poorest groups in society, those who typically fall well below the Statistics Canada

Low-Income Cut-Offs (National Council of Welfare, 2000).

Employment status was recoded as employed full time, employed part-time, self-employed and

unemployed. This categorization captures the influence of employment status on self-reported

oral health status.

Perceived discrimination was assessed as a binary response to the following question: “Since

your arrival in Canada, have you experienced discrimination or been treated unfairly by others

because of your ethnicity, culture, race or skin color, language or accent, or religion?” (yes/no).

41

Discrimination is associated with a range of adverse health effects (Krieger, 2000) and was

included in our study to capture the effect of social exclusion on self-reported oral health status.

4.2.2.4. Social Support and Official Language Proficiency Variables

To assess social support, we used three variables: having relatives in Canada (yes/no), social

group membership (yes/no), and frequency of visiting relatives in Canada (monthly and less,

weekly and daily). Social support has been associated with good health and oral health status

among immigrant populations (McGrath & Bedi, 2002).

Official language fluency was measured based on self-reported proficiency in writing, reading,

and speaking in English or French (cannot write/speak/read, poorly, fairly well, well, very well).

We recoded responses to these questions as poor, moderate and good/very good. Official

language proficiency has also been linked to good self-reported oral health outcomes among

immigrant groups (Gao & McGrath, 2011).

4.2.3. Data Analysis

Univariate descriptive statistics were computed. We calculated frequency distributions for socio

demographic, socio economic, social support and official language variables across the three

waves. We identified that the distribution of total household income, employment status, and

frequency of visiting relatives varied across time. Thus, these variables were classified as time

varying and were entered as repeated measures in the longitudinal model.

The LSIC is a longitudinal data set consisting of very large cross-sectional micro-units, which

include thousands of observations at three time periods that are nested within individuals. A

generalized estimation equation (GEE) approach (Zeger et al., 1988) was used to estimate the

probability of reporting dental problems among immigrants, while taking into consideration

individual heterogeneity and controlling for the individual stock of independent variables. This

approach allows the inclusion of time invariant (e.g., ethnicity, sex) and time varying variables

in the same model, and is appropriate to estimate population average differences between

groups.

42

The trend over time was examined by modelling year as a continuous variable. However,

exploration of the proportion of self-reported dental problems over time showed continuous

change only between the first two years and stagnation between the second to fourth years of

immigration. Thus, since changes in self-reported dental problems were not continuous over

time, a piecewise model was fitted to test for the change in self-reported dental problem trends

between year 2 and year 4 (wave 3). This sudden change in trend was represented by a dummy

variable denominated increment (equals to 1, if observation year = 4; 0, otherwise).

The models were built in the following sequence: 1) unadjusted models that examined the

association between various independent variables and self-reported dental problems; 2) a

multivariable adjusted model including independent variables that showed significance at the

bivariate analysis. Lastly, we estimated a series of multivariate models testing time interactions

on variables that were statistically significant in the adjusted model. These models showed that

for each selected variable initial differences in self-reported dental problems remained

significant over time (data not shown).

Sample and bootstrap weights were also used, as specified by Statistics Canada, in all statistical

analysis using STATA 12 (Stata Corp. College Station, Texas, US). We used the Quasi-

likelihood under independence model criterion (QIC) (Pan, 2001) to compare the fit of models

and select the best subset of covariates. Statistical significance was interpreted at the 5% level (p

= 0.05).

4.3. Results

Table 4.1 shows selected weighted and bootstrapped baseline sample characteristics (wave 1).

The study sample consisted of similar weighted proportions of men (47%) and women (53%).

Immigrants of South Asian (27.8%) and Chinese (25.6%) origin represented more than 50% of

the total weighted sample, whereas immigrants from Latin America and the Caribbean

corresponded to only 5% of the sample. Although the large majority of immigrants have college,

university degree and more (82.4%), 42.9% were unemployed and almost 90% earned less than

$40,000 a year at baseline. Almost half of immigrants rated their language fluency

(English/French) at baseline as moderate (43.1%).

43

Significant increases in self-reported dental problems were noted within two years post-arrival.

Six months after arrival, only 9.4% (95% CI 8.6%-10.3%) of immigrants reported having dental

problems since immigration. After two years the proportion of immigrants reporting dental

problems since immigration more than tripled (32.6%; 95% CI 31.6%-33.5%), a statistically

significant increase, and remained approximately the same at four years after immigrating

(33.3%; 95% CI 31.9%-34.9%) (Figure 4.2). These proportions are equivalent to the average

prevalence of dental problems in the following periods: 0-6 months (9.4%), 6 months-2yrs

(32.6%), 2-4yrs (33.3%).

Table 4.2 presents the unadjusted and adjusted association of individual socio demographic and

economic factors associated with self-reported dental problems. In the unadjusted model, the

odds of immigrants having self-reported dental problems increased over the first two years

(OR= 2.84; 95% CI 2.59-3.12). However, from year 2 (wave 2) to year 4 (wave 3), a slight

decrease in odds of reporting dental problems was observed (OR=0.13; 95% CI 0.10-0.16).

Similarly, in the adjusted model (Table 4.2, model 1), the odds of reporting dental problems

increased within the first two years (OR=2.77; 95% CI 2.55-3.02), and decreased between year

2 (wave 2) to year 4 (wave 3) (OR=0.13; 95% CI 0.10-0.16). Age was also significantly

associated with an increase in self-reported dental problems [(OR age 40-49= 1.22; 95% CI

1.02-2.00) (OR age ≥ 50 =1.42; 95% CI 1.01-1.50)]. Thus, overall, at any given time, older

immigrants were more likely to report dental problems. Interestingly, the unadjusted model

showed that immigrants with high school and less (OR=0.81; 95% CI 0.72-0.91), and the

unemployed (OR= 0.65; 95% CI 0.58-0.72) were less likely to report dental problems.

However, these differences were not found in the adjusted model.

The adjusted model showed that women were more likely to report dental problems than men

(OR 1.34; 95% CI 1.20-1.50). Immigrants with a history of social assistance (OR= 1.28; 95% CI

1.07-1.53) and that reported always being discriminated against (OR= 1.25; 95% CI 1.05-1.50)

were more likely to report dental problems. Surprisingly, immigrants with a total household

income of less than or equal to $40,000 had lower odds of reporting dental problems (OR=0.82;

95% CI 0.73-0.92). Non-European immigrants from Arabic/ African/ Middle Eastern (OR=0.77;

95% CI 0.63-0.94), South Asian (OR=0.38; 95% CI 0.30-0.47), Chinese (OR= 0.60; 95% CI

44

0.49-0.73), East Asian (OR=0.38; 95% CI 0.31-0.48) and Latin American/Caribbean (OR=

0.54; 95% CI 0.40-0.72) were less likely to report dental problems than Europeans.

4.4. Discussion

Our study provides the first insight into the self-reported oral health transitions of immigrants to

Canada over a four-year period after immigrating. It has produced four main findings: 1) the

healthy immigrant effect may be applied to oral health; 2) immigrant women were more likely

to report dental problems than men; 3) immigrants in the highest and lowest social position had

increased likelihood of reporting dental problems; and 4) ethnicity and experience of

discrimination were linked to immigrants’ self-reported dental problems.

4.4.1. Does “the Healthy Immigrant Effect” Apply to Oral Health?

Only 9.4% of immigrants reported dental problems at wave 1. A rapid increase in self-reported

dental problems occurs within two years after arrival. After four years of arrival, the proportion

of immigrants reporting dental problems tripled, increasing from 9.4% to 33.3%. Self-reported

dental problems have been correlated to poor self-reportred oral health measures (Locker et al.,

2009). Thus, the over time, increase of dental problems may denote a decline in immigrants’

oral health status, and suggest that the healthy immigrant effect may be applied to oral health.

However, this finding must be interpreted with caution. First, there is great variability in the

meaning of self-reported oral health, because this measure is highly influenced by individuals’

cultural and subjective views. Increase in self-reported dental problems over time may denote

decline in oral health and/or increase in oral health self-awareness. Self-reported dental

problems may also refer to an individual treatment needs and histories, tooth loss and denture

wearing (Locker et al., 2009). Second, we could not compare our results with the Canadian-born

population for the same time period. Nevertheless, comparing the prevalence of dental problems

among young adult immigrants (aged 20-39 yrs) found in the LSIC (2001-2005) with a similar

prevalence (i.e., prevalence of poor self-reported oral health because of problems with their oral

health) and age group of foreign-born and native-born Canadians found in the CHMS (2007-

2009) (Health Canada, 2010), the following trend is observed. Only 7.2% of immigrants

reported dental problems at baseline compared to 19.3% of the foreign-born and 16.8% of the

45

native born-population. Over a four-year period, however, immigrants’ prevalence of dental

problems (25.1%) surpassed the foreign (19%) and native-born (17%) Canadian population.

Thus, although there are limitations in making a direct comparison, apparently the self-reported

oral health of immigrants quickly deteriorates to levels worse than the overall Canadian

population. Likewise, recent research by Vered et al. (2008) supports “the healthy immigrant

effect” on oral health. Using clinical measures, these authors identified that despite 70.1%

(n=472) of immigrants to Israel being caries-free at baseline, presenting better indices than the

local population, their oral health deteriorated after five years of residency in the country.

4.4.2. The Role of Socio-demographic and Economic Factors Explaining Immigrants’ Self-reported Dental Problems

Immigrant women had increased likelihood of reporting dental problems than their male

counterparts. Consistent with our findings, Newton et al., (2003) identified that female members

from White, Indian, Chinese and Black Caribbean community groups in England, were more

likely to report oral and facial symptoms and impact upon activities of daily living in

comparison to male respondents. There are two potential explanations for gender disparities in

immigrants’ self-reported oral health. The first is gender differences in economic status.

Research has identified that immigrant woman are paid lower wages, have less job security, and

worse labour market participation than men in the Canadian labour market (Shilelds et al.,

2010). This financial disadvantage may put immigrant women at greater risk to report dental

problems than men. The second potential explanation is that the immigration process may lead

to differential stress responses in men and women that could be linked to dental problems.

However, stress mediated explanations on oral health inequalities have yet to be fully

understood (Chi & Tucker-Seeley, 2013).

Interestingly, immigrants with a total household income of more than $40,000 a year were more

likely to report dental problems than those earning less than or equal to $40,000 a year. Albeit

contradictory, this finding is consistent with previous published literature on immigrants non-

oral health related outcomes (Smith et al., 2005). Also, immigrants on social assistance had

higher odds of reporting dental problems than those with no history of social assistance. Thus,

both study immigrants in the highest (i.e., total household income >$40,000) and in the poorest

46

social position in society (ie., social assistance recipients) were more likely to report dental

problems. This suggests a non-linear social gradient relationship that may be explained by the

direct effect of socio economic position in self-reported oral health. It is possible that higher

income may be correlated to increased perception of dental problems. A similar pattern was

found in relation to education (Locker et al., 2009). In a mixed sample of immigrants and

Canadian-born respondents, Locker et al., (2009) found that better-educated respondents were

more likely than their counterparts to report dental problems. Conversely, social assistant

recipients’ greater economic needs and high prevalence of oral disease (Bedos et al., 2003) may

lead to increase likelihood of reporting dental problems than non recipients of such benefit.

Ethnicity was correlated with initial self-reported oral health status. Immigrants of European

origin were more likely to report dental problems than non-European immigrants. Most studies

assessing self-reported oral health status among ethnic groups have demonstrated that White

European immigrants have better self-reported oral health outcomes than other ethnic groups

(Newton et al., 2003). There are several possible explanations for this discrepancy. First,

European immigrants may be more aware of their dental problems than other immigrant groups.

This increased awareness might be an effect of Europeans’ longer history of access to

preventive dental care and fluoridated water supplies (Widström & Eaton, 2004). Alternatively,

our results may be due to differences in immigrants’ settlement experiences. It is known that

non-European immigrants face greater challenges to economically integrate in Canada (Block &

Galabuzi, 2011; Pendakur & Pendakur, 2011). This disadvantage might influence their lower

perception of dental problems in face of greater hardships in their lives. In other words, greater

competing socioeconomic needs may cause non-European immigrants to pay less attention to

their oral health.

Self-perceived experience of discrimination was another socio economic factor related to self-

reported dental problems. Immigrants who experienced discrimination were more likely to

report dental problems. Similarly, De Maio and Kemp (2010), using the LSIC, identified that

immigrants who experienced discrimination had higher odds of experiencing a worsening self-

reported mental health and self-assessed general health, after controlling for confounders. We

speculate that experience of discrimination seems to affect immigrants’ oral health through

47

disadvantage in the labour market outcomes, and earnings (Solar & Irwin, 2010) that have a

direct impact in their oral health and ability to access care. However, further research is needed

to better understand the effect of self-perceived discrimination on immigrants’ oral health.

4.4.3. Policy Implications

This study suggests that the “healthy immigrant effect” may be applied to oral health, leading to

several implications for immigration and oral health policies in Canada. An increase in self-

reported dental problems over time is potentially related to challenges in being able to access

dental care. Since in Canada, dental care is mostly financed through employment-based private

dental insurance and/or out-pocket expenditures (Locker et al., 2011; Millar & Locker, 1999),

immigrants’ increase in self-reported dental problems demonstrates that public policies in

Canada are likely potentially failing to provide access to dental care and/or adequate

employment resettlement opportunities for immigrants.

Another implication for policy is that although immigrants are selected to maximize the

Canadian economy, without burdening the welfare and health care system, failing to provide

dental care for this group may actually produce additional unforeseen social and health care

burdens in the form of work and school days lost, and increased visits to hospital emergency

rooms due to dental problems (Quiñonez, Ieraci, & Guttman, 2011). Not only the current policy

is shortsighted from an economic viewpoint, it also raises significant ethical issues in selecting

highly educated and healthy immigrants to boost the Canadian economy, and then denying them

access to opportunities and resources for them to maintain their oral health.

As a policy option, increased access to dental care for all immigrants in Canada should: 1)

reduce the social and economic impact of dental problems in Canada, 2) mitigate further strains

in the Canadian health care system, 3) improve immigrants’ oral health status and opportunities

to succeed in the new country. Specific attention should be paid to immigrant women who were

at greater risk to report dental problems than men.

Lastly, to inform policy development, future national oral health surveys should include details

on the immigration experience (e.g., experience of discrimination, ethnicity, social class

48

indicators). This information will be valuable in the study of oral health inequalities in this

population. Moreover, there is a need to investigate these oral health inequalities stratified by

gender, an aspect that was not fully addressed in our study.

4.4.4. Limitations

This study is not without limitation. Firstly, although self-reported oral health status measures

raise validity and reliability concerns (Liu et al., 2010), this measure is arguably a very useful

general indicator of oral conditions and treatment needs in population based samples (Jones et

al., 2001; Locker et al., 2009). Secondly, our results were also limited to information available

on the LSIC. This survey did not provide information on dental insurance coverage across

waves; thus, we were severely limited in exploring the effect of dental insurance on immigrants’

self-reported oral health transitions. The LSIC also did not provide information on some cultural

oral health related behaviours including oral hygiene and diet. Thus, we were limited to explore

whether changes in those practices had an an effect on immigrants’ increased self-reporte dental

problems over time. Thirdly, our findings are representative of the cohort of immigrants who

immigrated in 2001; immigrant cohorts have grown and are known to change in terms of home

country over time.

4.5. Conclusion

This study suggests that “the healthy immigrant effect” may be applied to oral health.

Immigrant women were more likely to report dental problems than men. European immigrants

were more likely to report dental problems than any other immigrant ethnic group. In addition,

we found a non-linear social economic gradient on immigrants’ self-reported dental problems,

potentially explained by variations in the links between socio-economic position, and self-

reported dental problems.

4.6. What this Study Adds

• Using a longitudinal analysis, this study has suggested that the “healthy immigrant effect”

applies to oral health.

49

• Immigrant women were more likely to report dental problems than men. Also, a non-linear

social gradient in oral health was found, in which the immigrants in the highest and in the

lowest socio economic position were more likely to report dental problems. This evidence

suggests a link between socio-economic position and immigrants’ perception of dental

problems.

50

Table 4.1: Baseline Sample Characteristics and Weighted Proportions from the

Longitudinal Survey of Immigrants to Canada (2001-2005)*

Total (%) Sex Male 47.0 Female 53.0 Age 20-29 30.8 30-39 45.5 40-49 17.2 ≥ 50 6.4 Marital Status Married/common-law 86.3 Single/not married 13.7 Highest level of education outside Canada College, University and more 82.4 High school and less 17.5 Total household Income > $40,000 7.4 ≤ $40,000 92.6 Employment status Employed full-time 40.1 Employed part-time 7.8 Self-employed 9.2 Unemployed 42.9 History of social assistance No 89.9 Yes 11.1 Discrimination experience Never 54.4 Sometimes 28.5 Always 17.1 Ethnicity European origins 15.7 Arabic/African/Middle Eastern 11.7 South Asian 27.8 Chinese 25.6 East Asian 14.2 Latin American and Caribbean 5.0 Official language fluency (English/French) Poor 44.3

51

Moderate 43.1 Good/very good 12.6 Participation in social religious groups Yes 21.4 No 78.6 Presence of relatives in Canada Yes 53.8 No 46.2 Frequency meeting relatives in Canada Monthly and less than monthly 15.7 Weekly 57.2 Daily 27.1

*Sample size = 3,976

52

Table 4.2: Unadjusted and Adjusted Associations between Self-reported Dental Problems

and Socio-demographics, Socio-economic and Other Independent Variables from a

Sample of Immigrants: Longitudinal Survey of Immigrants’ to Canada, 2001-2005

Model unadjusted, OR (95%CI)

Model 1 adjusted, OR (95%CI)

Year 2.84 (2.59-3.12) 2.77 (2.55-3.02) Increment 0.13 (0.10-0.16) 0.13 (0.10-0.16) Ethnicity European origins (Ref) 1.00 1.00 Arabic/African 0.86 (0.75-1.00) 0.77 (0.63-0.94) South Asian 0.44 (0.37-0.51) 0.38 (0.30-0.47) Chinese 0.59 (0.52-0.67) 0.60 (0.49-0.73) East Asian 0.47 (0.40-0.55) 0.38 (0.31-0.48) Latin American/Caribbean 0.64 (0.50-0.60) 0.54 (0.40-0.72) Age 20-29 (Ref) 1.00 1.00 30-39 1.13 (1.00-1.27) 1.05 (0.93-1.47) 40-49 1.16 (1.00-1.34) 1.22 (1.02-2.00) ≥ 50 1.04 (0.87-1.24) 1.42 (1.01-1.50) Sex Male (Ref) 1.00 1.00 Female 1.23 (1.13-1.34) 1.34 (1.20-1.50) Marital status Married (Ref) 1.00 1.00 Not married 0.84 (0.73-0.97) 0.89 (0.72-1.10) Highest level of education College/University (Ref) 1.00 1.00 High school and less 0.81 (0.72-0.91) 0.91 (0.78-1.06) Employment status Employed full time (Ref) 1.00 1.00 Employed part-time 1.08 (0.94-1.24) 1.13 (0.92-1.37) Self-employed 1.13 (1.00-1.28) 1.02 (0.87-1.20) Unemployed 0.65 (0.58-0.72) 0.97 (0.83-1.12) Total household Income > $40,000 (Ref) 1.00 1.00 ≤ $40,000 0.48 (0.44-0.52) 0.82 (0.73-0.92) History of social assistance No (Ref) 1.00 1.00 Yes 1.49 (1.25-1.77) 1.28 (1.07-1.53)

53

Discrimination Never (Ref) 1.00 1.00 Sometimes 1.10 (1.00-1.21) 1.15 (0.98-1.33) Always 1.18 (1.05-1.33) 1.25 (1.05-1.50) Official language fluency Poor (Ref) 1.00 1.00 Moderate 1.10 (1.00-1.23) 1.09 (0.93-1.28) Good/very good 1.72 (1.49-1.99) 1.20 (1.00-1.43) Social support No social group membership (yes) 0.93 (0.82-1.05) 0.86 (0.73-1.00) No relatives in Canada (yes) 1.12 (1.01-1.25) 0.90 (0.79-1.02) Frequency meeting relatives in Canada Monthly (Ref) 1.00 1.00 Daily 0.96 (0.83-1.11) 1.09 (0.89-1.33) Weekly 1.00 (0.89-1.13) 0.93 (0.80-1.08) QIC 1,260.00

54

Figure 4.1: Sample Size – Self-reported Dental Problems Model (Longitudinal Survey of

Immigrants to Canada, 2001-2005)

Sample for all the three waves: 7,716 immigrants (3,819 males

and 3,897 females)

Excluded 648 immigrants (8.4%) who lived in Canada before

Sample: 7,068 immigrants (3,474 males and 3,594 females)

Excluded 2,208 immigrants (31.2%) who lived in a third country


Excluded 444 immigrants (9.1%) younger than 18 yrs. and 205

immigrants (4.2%) older than 60 yrs.


Excluded 235 immigrants (5.6%) who had refugee status

Final sample for the present analysis: 3,976 immigrants

(1,870 males and 2,106 females)

55

Figure 4.2: Average Prevalence of Self-reported Dental Problems among Adult

Immigrants (Longitudinal Survey of Immigrants to Canada, 2001-2005)

8.6%

31.6%31.9%

9.4%

32.6% 33.3%

10.3%

33.5%34.9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5Yrs after immigration

CI - Lower Proportion CI - Upper

Wave 3Wave 2Wave 1

56

Chapter 5

Predictors of Unmet Dental Care Needs

among Immigrants: Analysis of the

Longitudinal Survey of Immigrants to

Canada

In this chapter, we addressed the second objective of this study. In this analysis, we examined

predictors of immigrants’ unmet dental care needs, an indicator of barriers to dental care, over a

three-point-five-year period. We used two waves of the LSIC and used multiple logistic

regression analysis. This chapter is organized in a manuscript format in the following sequences:

1) Manuscript; 2) Tables; 3) Figure.

57

Abstract

Objective: To examine the determinants of unmet dental care needs over a three-point-five-year

period among a sample of adult immigrants.

Method: A secondary data analysis was conducted on the Longitudinal Survey of Immigrants to

Canada (LSIC). Sampling and bootstrap weights were applied to make the data nationally

representative. Simple descriptive analyses were conducted to describe the demographic

characteristics of the sample. Bivariate and multiple logistic regression analyses were applied to

identify factors associated with immigrants’ unmet dental care needs over time.

Results: Approximately 32% of immigrants reported unmet dental care needs. Immigrants

lacking dental insurance (OR= 2.63; 95% CI: 2.05-3.37), and those with an average household

income of $20,000 to $40,000 per year (OR=1.62; 95% CI: 1.01-2.61), and lower than $20,000

(OR=2.25; 95% CI: 1.31-3.86), were more likely to report unmet dental care needs than those

earning more than $60,000 per year. In addition, South Asian (OR= 1.85; CI: 1.25-2.73) and

Chinese (OR=2.17; CI: 1.47-3.21) immigrants had significantly higher odds of reporting unmet

dental care needs than Europeans.

Conclusions: Lack of dental insurance and low income predicted unmet dental care needs over

a three-point-five-year period in a sample of immigrants to Canada. Ethnic disparities in

immigrants’ unmet dental care needs over time were also found.

58

5.1. Introduction

Over the last several decades, Canada has become an increasingly multicultural society.

Approximately 250,000 immigrants enter Canada each year, arriving from Asia and Pacific Rim

countries (49%), Africa and the Middle East (24%), the United Kingdom and Europe (13%),

South and Central America (11%), and the United States (3%) (Statistics Canada, 2006). Canada

selects immigrants based on education, job skills, health status and age, all traits linked to an

immigrant’s ability to contribute to the Canadian economy.

In this regard, oral health is an integral part of overall health, and fundamental to an immigrant’s

ability to fulfill their human capital. Oral disease can reduce work productivity (Hayes,

Azarpazhooh, Dempster, Ravaghi, & Quiñonez, 2013), employability (Glied & Neidell, 2010),

quality of life (Naito et al., 2006), and systemic health (Simpson, Needleman, Wild, Moles, &

Mills, 2010). Yet unfortunately, there is very limited information on the oral health of adult

immigrants in Canada. Previous cross-sectional studies have suggested that, in general,

immigrants have poorer oral health status than the Canadian population (Dong et al., 2007;

Locker et al., 1998; Werneck et al., 2008). Recently, a longitudinal analysis has suggested that

although immigrants have good oral health status at arrival, post-migration, their oral health

deteriorates to levels worse than the Canadian population (Calvasina, Muntaner, & Quiñonez,

2013). Among the possible explanations for immigrants’ poor oral health status and its potential

decline is poor access to dental care.

Access to care is a multidimensional concept that has often been defined as the ability to obtain

needed health care (Aday, 1975). The inability to obtain needed care is referred to as an ‘unmet

health care need,’ a concept commonly used in the health service research to indicate barriers to

care (Newacheck et al., 2000). In dentistry, unmet dental care needs have been correlated to

poor oral health and poor dental service utilization (Thompson, 2012; Ramraj et al., 2012). It

has also been used to measure difficulties to access dental care due to service costs, or lack of

insurance in many studies in the US (Jeffrey & Newacheck, 2006; Kenney et al., 2005; Lewis et

al., 2005). Therefore, in this study, unmet dental care needs is used as an indicator of barriers to

accessing dental care.

59

In turn, very little is known about immigrants’ access to dental care in Canada. Earlier studies

have provided equivocal findings. For instance, whereas Bedos et al. (2004) reported lower rates

of dental service utilization among immigrants in comparison to Canadian-born populations,

Newbold and Patel (2006) demonstrated that immigrants have a higher rate of dental utilization

than Canadian-born populations. However, the latter also reported that, compared to native-born

Canadians, immigrants were more likely to consult a dentist for treatment rather than for

preventive reasons (Newbold & Patel, 2006). Recently, analysis of the Canadian Health

Measure Survey (CHMS 2007-2009) revealed that immigrants have a higher risk of reporting

various negative outcomes associated with poor oral health and access to dental care (Health

Canada, 2010; Ramraj, 2012; Thompson, 2012). For instance, immigrants had a higher

prevalence of self-reported untreated dental conditions (Health Canada, 2010), a lower

prevalence of dental insurance coverage (Health Canada, 2010), and were more likely to have

untreated periodontal disease (Ramraj, 2012). In addition, immigrants had higher odds of

reporting cost barriers to dental care than those born in Canada (Thompson, 2012). Cost barriers

such as a lack of income and dental insurance are known to be the dominant predictors of access

to care in the predominantly private fee-for service Canadian dental care system (Quiñonez et

al., 2007), especially because they help to eliminate the upfront cost of care (Locker et al., 2011;

Millar & Locker, 1999).

Other factors associated with immigrants’ access to dental care include language and cultural

barriers (Akresh, 2009; Shelley et al., 2011) or unfamiliarity with the health care system. Also,

access to dental care can vary across different ethnic groups (Bierman et al., 2010). A recent

report on access to health care in Ontario revealed that over half of non-European immigrants

had not visited a dentist in the previous 12 months compared to less than 35% of Europeans

(Biermen et al., 2010).

Understanding immigrants’ to Canada unmet dental care needs is important to plan effective

policy interventions aimed at eliminating potential barriers to care, thus offering opportunities

for immigrants to fully realize their potential in the country. This study examines predictors of

unmet dental care needs, among a sample of recent immigrants to Canada over a three-point-

five-year period.

60

5.2. Methods

5.2.1. Data Source

This study uses three waves of Statistics Canada’s Longitudinal Survey of Immigrants to

Canada (LSIC) to study immigrants’ unmet dental care needs. The survey collected information

in more than 15 languages on socio-economic status, housing, language skills, values and social

attitudes, social support, health status, access and utilization. Measures of access to, and

utilization of dental services were included in the LSIC Health Module. Data were collected at

six months (wave 1), two years (wave 2) and four years (wave 3) after immigration. The LSIC

target population was derived from a sample of immigrants: 1) who arrived in Canada between

October 2000 and September 2001; 2) were aged 15 years or older at time of landing; and 3)

landed from abroad, and applied through a Canadian Mission abroad. A two-stage stratified

sampling method was used to select the survey respondents. The first stage involved the

selection of an immigrant unit (individual, couples or families) from the administrative database

of Citizenship and Immigration Canada. The second stage involved the selection of one member

from the immigrant unit, aged 15 years or older at the time of landing. Interviews were

conducted in person and by telephone. A total of 7,716 respondents completed the three waves

of interviews, representing a cohort of 157,600 immigrants (Statistics Canada, 2005). From this

longitudinal sample of 7,716 (3,819 men and 3,897 women), we excluded individuals using the

following criteria: 1) immigrants who previously lived in Canada; 2) immigrants who previously

lived in a third country; 3) immigrants with less than 20 years and more than 60 years of age at

baseline; 4) immigrants with refugee status; 5) immigrants who did not report dental problems

across the waves. Thus, our final study sample comprised 2,126 immigrants. Figure 5.1 shows

details of the sample selection criteria.

5.2.2. Study Variables

Self-reported unmet dental care needs was used as a proxy for barriers to accessing dental care.

This study outcome was obtained using the following survey questions: “Since your last

interview, have you had any dental problems for which you did not receive dental care?” (yes

/no). Similarly to previou studies (Jeffrey & Newacheck, 2006; Kenney et al., 2005; Lewis et

61

al., 2005), we assumed that respondents who had a dental problem for which they did not

received dental care, had an unmet dental care need.This question was asked at wave 2 and

wave 3. Since we were interested in assessing predictors of unmet dental care needs over the

years, and since there was no over-time variation on the proportion of unmet dental care needs

across waves, we developed a summary outcome variable by adding the responses at wave 2 and

3. Thus, the outcome was categorized as “yes” if immigrants reported having any unmet dental

care needs over a three-point-five-year period and “no” otherwise.

Covariates examined in bivariate and logistic regression analyses for their relationship to unmet

dental care needs over time were selected based on: 1) information collected and available in the

LSIC; and 2) variables that have been previously explored in the dental literature on

immigrants’ access to dental care in Canada (Bedos et al., 2004; Newbold & Patel, 2006). Thus,

three categories of independent variables were considered: 1) socio-demographic; 2) socio-

economic; and 3) official language proficiency.

5.2.2.1. Socio-demographic Variables

Socio-demographic variables included age, sex, marital status and ethnicity. Age was classified

in the following groups: 20-29, 30-39, 40-49, and ≥ 50. Marital status was dichotomized as

married or not married (single, divorced, widow). Ethnicity was obtained on the basis of ethnic

origin, as defined by Statistics Canada (Statistics Canada, 2004). We selected this variable to

capture ethnic disparities in immigrants’ access to dental care in Canada. This variable was

categorized as: 1= Arabic, African and Middle Eastern (Arabic world, African continent and

Middle East Asia); 2=South Asian (India, Pakistan, and Sri Lanka); 3= Chinese (Mainland

China, Taiwan, Hong Kong); 4= East Asia (Korean, Japanese and other East Asian countries);


5.2.2.2. Socio-economic Variables

Socio-economic variables included education, history of social assistance, dental insurance

coverage, employment status and average household income. Education was categorized as

having college, university degree and more vs. high school diploma or less. History of social

62

assistance was categorized as yes/no. Dental insurance coverage was asked only at year four

(wave 3), and categorized as yes/no.







mean and standard deviation of this variable. Since the standard deviation rounded $20,000 a

year, and $40,000 a year is a good proxy for the threshold income of the working poor in

Canada (Human Resources and Social Development Canada, 2006), we created four categories

for the income variable that included: ≥$60,000; $40,000-$60,000; $20,000-40,000; ≤$20,000.

5.2.2.3. Official Language Proficiency Variable

Official language proficiency was assessed through self-reported proficiency in writing, reading,

and speaking in English or French (cannot write/speak/read, poorly, fairly well, well very well).

We recoded responses to these questions as poor, moderate and good/very good.

5.2.3. Statistical Analysis

Simple descriptive analyses were conducted to describe the demographic characteristics of the

sample of immigrants. Bivariate analyses were performed to examine the relationship between

each socio-demographic, socio-economic and official language variables and unmet dental care

needs. Statistical significance was set at the 0.05 level. Before estimating multiple logistic

regression models, we examined collinearity amongst and between each of the variables, using

variance inflation factor (VIF). Only those variables with a VIF equal to or less than three were

entered into the model. This criteria was used in consistency with previous studies examining

access to dental care and dental treatment needs of a national mixed sample of native and

foreign-born Canadians (Ramraj et al., 2012; Thompson, 2012). Multiple logistic regression

analyses were conducted to assess the independent association between unmet dental care needs

63

and the socio-demographic, socio-economic and official language variables. Two logistic

regression models were than estimated. In model 1, we entered education, income, history of

social assistance, and employment status on unmet dental care needs controlling for age, sex,

ethnicity, marital status and official language proficiency. In model 2, we entered the dental

insurance variable into model 1, in order to explore the effect of lack of dental insurance in the

odds ratio of the other variables and the outcome variable. We used Akaike Information Criteria

(AIC) to compare the fit of models while accounting for additional variables in the models

(Akaike, 1974). Sample weights and 1,000 bootstrap weights, as specified by Statistics Canada

were applied in all statistical analysis. We performed all analysis using STATA version 12

(Stata Corp. College Station, Texas, US).

5.3. Results

The final sample included 2,126 participants, representing almost 47, 050 immigrants to Canada

when weighted, out of 157,600 immigrants who resided in Canada from 2001 to 2005 (29).

Table 5.1 shows that the sample consisted of a majority of women (55.9%), married (87.5%),

aged between 30-39 years (47.1%). South Asian and Chinese immigrants represented more than

50% of the total sample, whereas immigrants from Latin American and Caribbean countries

corresponded to 5% of the total sample. Although the majority of immigrants were highly

educated, with college or university degrees and beyond, more than 65% reported an average

household income of less than $40,000 a year. Approximately 43% of the sample rated their

official language proficiency (English/ French) as fair, and around 40% rated their language

proficiency as poor. Almost two-thirds of immigrants reported having dental insurance at year

four. Approximately 32.3% of immigrants reported unmet dental care needs over a three-point-

five-year period of observation.

In the bivariate analysis, immigrants with less than high school (OR=1.72; 95% CI: 1.35-2.20),

an average household income of less than $20,000 (OR=3.96; 95% CI: 2.56-6.11), with a

history of social assistance (OR= 1.47; 95% CI: 1.09-1.98), experience of unemployment (OR=

1.78; 95% CI: 1.44-2.21), and lacking dental insurance (OR= 3.21; 95% CI: 2.63-3.92), were

more likely to have had an unmet dental care need. Very good/good official language

proficiency was inversely correlated with unmet dental care needs over time (OR=0.61; 95% CI:

64

0.45-0.81). Other correlates of unmet dental care needs included age and ethnicity (Table 5.2).

Sex and marital status were not independently associated with unmet dental care needs over

time.

In model 1 of the multiple logistic regression analysis, average household income, level of

education, ethnicity and age remained statistically significant after controlling for all covariates

(Table 5.3). In model 2, with the inclusion of the dental insurance variable, the odds ratio of age

became not significant and in general, there was a reduction in the odds ratio of the other

significant variables from model 1. Model 2 shows that a lack of dental insurance (OR= 2.63;

95% CI 2.05-3.37) was strongly correlated with unmet dental care needs (Model 2). Also,

immigrants with an average household income between $20,000 to $40,000 (OR=1.62; 95% CI:

1.01-2.61), and lower than $20,000 (OR= 2.25; 95% CI: 1.31-3.86), were more likely to report

unmet dental care needs than those earning more than $60,000. Moreover, immigrants from

South Asian (OR= 1.85; 95% CI: 1.25-2.73) and Chinese (OR= 2.17; 95% CI: 1.47-3.21) ethnic

origins were more likely to report unmet dental care needs than Europeans over time.

5.4. Discussion

This study is the first to explore the issue of unmet dental care needs, an indicator of barriers to

dental care, using a longitudinal, representative sample of immigrants to Canada. Our findings

suggest that approximately 32.3%, roughly fifteen thousand immigrants had at least one unmet

dental care needs over time. This finding reflects those of Thompson (2012), who found that

31.2% of immigrants living in Canada less than ten years reported avoiding a dental

professional due to cost, a proportion significantly higher than the proportion of immigrants

living in Canada greater than ten years (17.5%).

After controlling for all independent variables, a lack of dental insurance and an average

household income lower than $40,000 a year were the main predictors of unmet dental care

needs. Importantly, a lack of dental insurance was the strongest predictor of immigrants’ unmet

dental care needs (i.e., access). Those who lacked dental insurance had, on average, a higher risk

of reporting unmet dental care needs than immigrants with a household income between

$20,000-$40,000 and lower than $20,000.

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In addition, the provision of dental insurance for immigrants with an average household income

between $20,000-$40,000 and lower than $20,000 significantly reduced the odds of reporting

unmet dental care needs. For instance, for immigrants with dental insurance the odds of

reporting unmet dental care needs was 0.38 (OR=1/2.63=0.38), while the odds of immigrants

with a household income between $20,000-$40,000 was 1.65, and lower than $20,000 was 2.25.

Consequently, providing dental insurance for immigrants in the former and latter income groups

reduced their odds of reporting unmet dental care needs to 0.62 (OR=1.65*0.38=0.62) and 0.86

(OR=2.25*0.38=0.86), respectively. Thus, dental insurance may contribute significantly to

eliminating income disparities in immigrants’ unmet dental care needs. This finding

corroborates those of Ramraj et al., (2012) and Thompson et al., (2014), whose analyses of the

CHMS, which included immigrants, found that dental insurance was a more important

determinant of having unmet dental care needs than income. Our finding is also consistent with

Newbold and Patel (2006), who identified that having dental insurance was a predictor of

immigrants’ dental service utilization. The present study adds further support to the fundamental

role of dental insurance in mitigating access to dental care in Canada.

Ethnicity was significantly associated with unmet dental care needs over the time of observation

for some, but not all groups. When compared with Europeans, Chinese and South Asian

immigrants were more likely to report unmet dental care needs. This finding is consistent with

previous Canadian literature showing that European respondents report higher dental care

utilization than other non-ethnic groups, including Asian and South Asian immigrants (Biermen

et al., 2010; Newbold & Patel, 2006). One possible explanation for Europeans’ potentially better

access to dental care is related to evidence showing that European immigrants have higher

earnings than other ethnic immigrant groups in Canada (Pendakur & Pendakur, 2011), an

advantage that likely improves their ability to access dental care. Moreover, South Asian and

Chinese immigrants are among the most disadvantaged in the Canadian labour market

(Pendakur & Pendakur, 2011). For instance, analysis of the 2006 Census indicates that Chinese

and South Asian immigrants whose employment status is matched to White immigrants earned

8% and 30% less, respectively, than their White counterparts. These differences in employment

earnings may reflect forms of racial discrimination in the Canadian labour market, that force

racialized (i.e., non-european) immigrants to precarious employment, low earnings, and poverty

66

(Block & Galabuzi, 2011), all aspects that potentially explain ethnic disparities in unmet dental

care needs found in this study.


Our findings suggest that financial barriers, in particular dental insurance, represent the

predominant factors in explaining immigrants’ overall unmet dental care needs over time.

Although financial barriers are also significant determinants of access to dental care among the

general Canadian population, it is clear that immigrants experience greater cost-prohibitive

barriers to accessing dental care than non-immigrant Canadians (Thompson, 2012). Thus, our

findings underscore the need for improving immigrants’ dental insurance coverage through the

expansion of public programs that would ensure subsidized/free of charge access to dental care

for adult immigrants in Canada. This option would arguably reduce immigrants’unmet dental

care needs, and improve oral health equity for the overall Canadian population. Another

competing alternative would be to develop programs that would direct immigrants to permanent

employment that includes dental insurance coverage. These two policy interventions may

constitute important components of efforts to improve immigrants’ access to dental care.

Specific attention should also be paid to South Asian and Chinese immigrants who were found

to be at greater risk of unmet dental care needs.

5.4.2. Limitations

This study has several limitations. Firstly, the data did not allow us to perform a longitudinal

analysis because: 1) we did not have information on unmet dental care needs at wave 1; and 2)

there was no significant change in the proportion of immigrants who reported unmet dental care

needs between waves 2 and 3. Thus, we performed a cross-sectional analysis, which prevented

causal determination. However, cross-sectional studies offer an optimal exploratory analysis of

factors influencing access to dental care in Canada in a population about whom very little is

known. Secondly, our results rely on immigrants’ self-reports of unmet dental care needs rather

than on direct observation. Self-reports have been found to provide different assessment from

those of clinically determined standards (Liu et al., 2010; Ramraj, 2012). However, it is often an

underestimation of clinically determined treatment needs (Ramraj, 2012). Thus, it is possible

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that more than 32.3% of immigrants in the survey had clinically relevant unmet dental care

needs. Thirdly, limitations on the survey did not allowed us to explore other potential reasons

for immigrants’ unmet dental care needs including anxiety of potential pain, and concerns about

being judged by dentists for their poor oral condition (Bedos et al., 2005; Muirhead et al., 2009).

Besides that, some additional conclusions may have been obtained if a detailed analysis of the

proportions of immigrants’ unmet dental care needs across time was performed. However, our

initial exploration of this proportion did not shown variation; thus, we focused on the analysis of

predictors of unmet dental care needs over a three-point-five-year period. Finally, our results are

based on a sample of immigrants who immigrated in 2001. While the immigrant population in

Canada has grown tremendously since that time, this study still reflects the most recent and

accurate estimate of unmet dental care needs among a representative sample of the immigrant

population in Canada.

5.5. Conclusion

Our research identified that financial barriers were associated with immigrants’ unmet dental

care needs over time. Immigrants lacking dental insurance and with low income were more

likely to have unmet dental care needs compared to their counterparts. In addition, Chinese and

South Asian immigrants had higher odds of reporting unmet dental care needs than Europeans.


• Use of unmet dental care as an indicator of barriers to dental for immigrants in Canada.

• Reinforce the role of dental insurance as the strongest predictor of unmet dental care needs

over a three point five period among immigrants’ to Canada.

• Ethnic disparities on unmet dental care needs were found. Chinese and South Asian

immigrants were more likely to report unmet dental care needs than Europeans. These ethnic

disparities are apparently explained by ethnic differences in the Canadian labour market.

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Table 5.1: Sample Characteristics - Unmet Dental Care Needs Model (Weighted

Proportions)*

(%) Sex Male 44.1 Female 55.9 Age 20-29 28.9 30-39 47.1 40-49 18.1 ≥ 50 5.8 Ethnicity European 20.5 Arabic/African/Middle Eastern 14.2 South Asian 22.6 Chinese 25.1 East Asian 12.5 Latin American/Caribbean 5.0 Marital Status Married 87.5 Not married 12.5 Highest level of education College, university degree and more 64.9 High school and less 15.1 Average household income ≥ $60,000 10.2 $40,000- $60,000 24.1 $20,000-$40,000 45.1 ≤ $20,000 20.7 History of social assistance No 87.7 Yes 12.3 Official language proficiency (English/French) Poor 41.4 Moderate 43.1 Good/very good 15.5 Employment status Always employed 35.9 Always/sometimes unemployed 64.1

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Unmet dental care needs Yes 32.3 No 67.7 Dental insurance Yes 61.1 No 38.9

* Sample size = 2,126

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Table 5.2: Unadjusted Associations with Unmet Dental Care Needs among Adult

Immigrants: Longitudinal Survey of Immigrants to Canada, 2001-2005 (Weighted

Proportions)

Unmet dental care needs

Yes (n=686, 32.3%)

No (n=1440, 67.7%)

OR 95% CI

Sex Male (Ref) 293 (31.3%) 644 (68.7%) 1.00 Female 393 (33.0%) 796 (67.0%) 1.08 0.89-1.32 Age 20-29 (Ref) 169 (27.5%) 446 (72.5%) 1.00 30-39 323 (32.3%) 679 (67.7%) 1.25 0.99-1.58 40-49 138 (35.8%) 248 (64.2%) 1.47 1.11-1.94 ≥ 50 55 (44.7%) 68 (55.3%) 2.12 1.43-3.17 Ethnicity European (Ref) 84 (19.7%) 342 (80.3%) 1.00 African/ Arabic/Middle Eastern 104 (35.4%) 190 (64.6%) 2.23 1.58-3.16 South Asian 175 (37.3%) 294 (62.6%) 2.43 1.81-3.26 Chinese 229 (44.0%) 292 (56.0%) 3.20 2.36-4.33 East Asian 53 (20.4%) 207 (79.5%) 1.05 0.70-1.57 Latin American 24 (23.5%) 80 (76.5%) 1.25 0.74-2.12 Marital status Married (Ref) 607 (32.6%) 1,253 (67.3%) 1.00 Not married 79 (29.6%) 184 (70.4%) 0.87 0.64-1.18 Highest level of education outside Canada

College/University degree and more (Ref) 547 (30.3%) 1,256 (69.7%) 1.00

High school or less 138 (42.8%) 184 (57.2%) 1.72 1.35-2.20 Average household income ≥ $ 60,000 (Ref) 38 (18.3%) 169 (81.7%) 1.00 $40,000- $60,000 101 (20.7%) 388 (79.3%) 1.17 0.75-1.83 $20,000-$40,000 327 (35.7%) 589 (64.3%) 2.49 1.65-3.74 ≤ $20,000 197 (46.9%) 223 (53.1%) 3.96 2.56-6.11 History of social assistance No (Ref) 506 (31.2%) 1,115 (68.8%) 1.00 Yes 91 (40.0%) 136 (60.0%) 1.47 1.09-1.98 Official language proficiency (English/French)

Poor (Ref) 316 (39.4%) 487 (60.6%) 1.00

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Moderate 244 (29.1%) 593 (70.8%) 0.63 0.51-0.78 Good/very good 85 (28.3%) 216 (71.7%) 0.61 0.45-0.81 Employment status Always Employed (Ref) 187 (24.5%) 577 (75.53%) 1.00 Unemployed once or more 449 (36.6%) 863 (63.4%) 1.78 1.44-2.21 Dental insurance Yes (Ref) 289 (22.29%) 1,007 (77.71%) 1.00 No 396 (47.96%) 430 (52.04%) 3.21 2.63-3.92

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Table 5.3: Multiple Logistic Regression Analyses of Factors Associated with Unmet Dental

Care Needs among Adult Immigrants: Longitudinal Survey of Immigrants to Canada,

2001-2005

Model 1

OR (95% CI) Model 2

OR (95% CI) Sex Male (Ref) 1.00 1.00 Female 1.05 (0.82-1.35) 1.08 (0.83-1.40) Age 20-29 (Ref) 1.00 1.00 30-39 1.17 (0.88-1.57) 1.22 (0.91-1.64) 40-49 1.53 (1.07-2.18) 1.39 (0.96-2.01) ≥ 50 1.62 (0.93-2.81) 1.12 (0.63-2.00) Ethnicity European origins (Ref) 1.00 1.00 Arabic/African/ West Asian 1.29 (0.83-1.99) 1.21 (0.77-1.91) South Asian 1.93 (1.31-2.83) 1.85 (1.25-2.73) Chinese 2.12 (1.45-3.12) 2.17 (1.47-3.21) East Asian 1.10 (0.67-1.80) 1.11 (0.67-1.83) Latin American/Caribbean 0.95 (0.49-1.83) 0.91 (0.46-1.77) Marital status Married (Ref) 1.00 1.00 Not married 1.01 (0.68-1.51) 1.04 (0.69-1.57) Highest level of education College, University and More (Ref) 1.00 1.00 High school and less 1.64 (1.15-2.32) 1.53 (1.07-2.20) Average household income ≥ $ 60,000 (Ref) 1.00 1.00 $40,000 - $60,000 0.89 (0.54-1.48) 0.90 (0.54-1.50) $20,000 - $40,000 1.81 (1.13-2.89) 1.62 (1.01-2.61) ≤ $ 20,000 2.83 (1.67-4.79) 2.25 (1.31-3.86) History of social assistance No (Ref) 1.00 1.00 Yes 1.17 (0.76-1.81) 1.11 (0.71-1.74) Official language proficiency Poor (Ref) 1.00 1.00 Moderate 0.83 (0.63-1.09) 0.96 (0.72-1.27) Good/very good 0.90 (0.58-1.39) 0.98 (0.63-1.53) Employment status

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Always employed (Ref) 1.00 1.00 Always/ sometimes unemployed 1.30 (0.98-1.71) 1.19 (0.90-1.58) Dental insurance Yes (Ref) 1.00 No 2.63 (2.05-3.37) AIC 1,868.97

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Figure 5.1: Sample Size – Unmet Dental Care Needs Model (Longitudinal Survey of

Immigrants to Canada, 2001-2005)


and 3,897 females)










Excluded 1,850 (46.5%) who did not report dental problems

Final sample for the present analysis: 2,126 immigrants (938

males and 1,188 females)

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Chapter 6

Predictors of Transnational Dental Care

Utilization among Immigrants: Analysis

of the Longitudinal Survey of Immigrants

to Canada

In this chapter, we addressed the third objective of this study. In this analysis, we examined the

determinants of immigrants’ transnational dental care utilization. We hypothesized that financial

barriers, more specifically lack of dental insurance, determine immigrants’ transnational dental

care utilization; that is, the use of dental services outside Canada. We used two waves of the

LSIC, and used multiple logistic regression analysis to estimate factors associated with

immigrants’ transnational dental care utilization over a three-point-five-year period. This

chapter is organized in a manuscript format in the following sequences: 1) Manuscript (Abstract,

Introduction, Methods, Results, Discussion, Limitations, Policy Implications, and Conclusion;

2) Tables; 3) Figures.

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Abstract

Background: Information on transnational dental care utilization, or the use of dental services

outside Canada by immigrants, has never been available. This study examines predictors of

transnational dental care utilization over a three-point-five-year period among immigrants to

Canada.

Methods: Data from the Longitudinal Survey of Immigrants to Canada (LSIC, 2001-2005) was

used. Sampling and bootstrap weights were applied to make the data nationally representative.

Simple descriptive analyses were conducted to describe the demographic characteristics of the

sample. Bivariate and multiple logistic regression analyses were applied to identify factors

associated with immigrants’ transnational dental care utilization over time.

Results: Approximately 13% of immigrants received dental care outside Canada over a period

of a three-point-five-year. Immigrants lacking dental insurance (OR=2.05; 95% CI: 1.55-2.70),

those reporting dental problems (OR=1.45; 95% CI: 1.12-1.88), who were female (OR=1.59;

95% CI: 1.22-2.08), aged greater than or equal to 50 years old (OR=2.30; 95% CI: 1.45-3.64)

and who were always unemployed (OR=1.70; 95% CI: 1.20-2.39) were more likely to report

transnational dental care utilization. History of social assistance was inversely correlated with

the use of dental services outside Canada (OR=0.48; 95% CI: 0.28-0.83). South Asian

immigrants were less likely to use transnational dental care than Europeans (OR=0.48; 95% CI:

0.31-0.74).

Conclusions: It is estimated that roughly 11,500 immigrants have used dental care outside

Canada over a three-point-five-year period. Although transnational dental care utilization may

serve as an individual solution for immigrants’ initial barriers to accessing dental care in

Canada, it demonstrates weaknesses to in-country efforts at providing publicly funded dental

care to socially marginalized groups. Policy reforms should be enacted to expand dental care

coverage among immigrants to Canada.

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6.1. Introduction

Over the last several decades, Canada has become an increasingly multicultural society.

Approximately 250,000 immigrants enter Canada each year, arriving from Asia and Pacific Rim

countries (49%), Africa and the Middle East (24%), the United Kingdom and Europe (13%),

South and Central America (11%), and the United States (3%) (Statistics Canada, 2006). Canada

selects immigrants based on their education, job skills, health status and age, all traits linked to

an immigrant’s ability to contribute to the Canadian economy. Ensuring immigrants access to

resources so that they can maintain their health and thus fulfill their human capital is important.

However, research has suggested that immigrants to Canada encounter increased challenges to

accessing dental care than the overall Canadian population, which are related to cost (Thompson

et al., 2014), (i.e., lack of dental insurance and low income), language and cultural barriers

(Dong et al., 2011; MacEntee et al., 2012). In Canada, dental care is predominantly financed and

delivered in the private sector (Quiñonez et al., 2007). In this context, immigrants are largely

responsible for financing their own dental care through out-of-pocket payments or employment-

based dental insurance, the two dominant forms of financing dental care in the country (Locker

et al., 2011; Millar & Locker, 1999; Quiñonez et al., 2007; Quiñonez & Grootendorst 2011).

Immigrants experiencing barriers to accessing dental care in Canada use different strategies to

obtain care. They may visit emergency room departments (Magalhaes, Carrasco & Gastaldo,

2010), access the dental services black market (Campbell, 2011; Keung, 2011), or use

transnational health care strategies (Dong et al., 2011; MacEntee et al., 2012). The literature on

transnational health care has often focused on “medical tourism” to describe the experience of

wealthy native-born residents from high-income countries who seek less expensive options in

resource constrained countries (Johnston et al., 2010; Labonté et al., 2013). Medical tourism is a

globalized health care service industry (Johnston et al., 2010; Labonté et al., 2013). It involves

the intentional purchase and arrangement of elective treatments by patients across borders

(Johnston et al., 2010; Labonté et al., 2013). Although the magnitude of dental tourism is

unclear, it is speculated that dental procedures are the dominant type of medical tourism,

accounting in some countries for 60% of medical tourism revenue (Cohen & Rogers, 2012).

Within the transnational health care framework, other authors have specifically studied the

experience of immigrants returning home for the sole purpose of obtaining health care, naming

this experience “medical returns” (Horton & Cole, 2011). In this study, transnational dental care

78

is described as the experience of immigrants seeking dental care outside Canada, which can

involve immigrants’ participation in dental tourism and/or dental returns, as well as

opportunistic dental visits while travelling to their country of origin.

No definitive research exists on Canadian immigrants’ transnational dental care utilization.

Much of what is known is based on anecdotes (Kaufman, 2013; Rothe, 2007), brief reports

(Turner, 2009), and two qualitative studies (Dong et al., 2007; MacEntee et al., 2012). The US

provides comprehensive evidence on immigrants’ use of health care services, including dental

care, in Mexico (Bastida et al., 2008; Brown 2008; De Jesus & Xiao, 2013; Wallace et al.,

2009). These studies suggest that cost, convenience, lack of health insurance, and cultural

preferences for the health care of their country of origin motivate Mexican immigrants to seek

health care in Mexico (Bastida et al., 2008; Brown 2008; De Jesus & Xiao, 2013; Wallace et al.,

2009).

To the best of our knowledge, this is the first study in Canada investigating immigrants’ use of

dental care services outside the country. Using a longitudinal survey, the present study examines

predictors of transnational dental care utilization over a three-point-five-year period among a

nationally representative sample of immigrants. We hypothesized that a lack of dental insurance

in Canada is associated with immigrants’ transnational dental care utilization.

6.2. Methods

6.2.1. Study Design

This study uses Statistics Canada’s Longitudinal Survey of Immigrants to Canada (LSIC, 2001-

2005) (Statistics Canada, 2005) to examine predictors of transnational dental care utilization

among a sample of immigrants to Canada. The LSIC target population consists of Canada’s

foreign-born who: 1) arrived in Canada between October 1, 2000, and September 30, 2001; 2)

were aged 15 or older at the time of landing; and 3) “landed” from abroad, and applied through

a Canadian Mission abroad. In total, the LSIC included three “waves”, collected at six months

(wave 1), two years (wave 2) and four years (wave 3) after arrival. Among the 250,000

immigrants admitted to Canada from 2000 to 2001, it was estimated that at wave 1 the

population of interest was approximately 164,200 immigrants; at wave 2; 160,800; and at wave

3, 157,600 immigrants (Statistics Canada, 2005). The survey collected information in more than

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15 languages on socioeconomic status, language skills, values and social attitudes, social

support, health, access and utilization. Amongst the many factors collected in the survey,

information on oral health status and dental utilization was included. By the final wave, 7,716

(3,819 men and 3,897 women) respondents completed the three waves of interviews (Statistics

Canada, 2005). For this study, we used a weighted sample of 3,976 immigrants. We restricted

our sample to non-refugee respondents aged 20-60 years old at baseline, with no previous

history of migration, who answered questions on dental care utilization outside Canada. Figure

6.1 shows details of the sample selection criteria.

6.2.2. Study Variables

The dependent variable was transnational dental care utilization, which was assessed using the

following survey question: “Since your last interview have you received dental care outside

Canada?” (yes/no). This question was asked at wave 2 and wave 3. Since we were interested in

assessing predictors of transnational dental utilization over a three-point-five-year period, and

since there was no over-time variation on the proportion of immigrants receiving dental care

outside Canada, we developed a summary outcome variable by adding the responses at wave 2

and 3. This outcome was assessed as “Yes” if respondents had received any dental care outside

Canada over a three-point-five-year period (i.e., at least one “yes” for the survey question in one

of the waves) and “No”, otherwise. The independent variables were based on 1) information

collected and available in the LSIC, and 2) variables that have been previously explored in the

literature on immigrants’ transnational health care utilization (Bastisda et al., 2008; Brown

2008; De Jesus & Xiao, 2013; Wallace et al., 2009). Thus, four categories of independent

variables were considered: 1) self-perceived dental problems; 2) socio-demographics; 2) socio-

economic position and 3) official language proficiency.

6.2.2.1. Self-perceived Dental Problems

Self-reported dental problem was assessed using the following question: “Since you came to

Canada have you had dental problems?” (yes/no).

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6.2.2.2. Socio-demographic Variables

Socio-demographic variables included age, sex, marital status and ethnicity. Age was classified

in the following groups: 20-29, 30-39, 40-49, and ≥ 50 years. Marital status was dichotomized

as married or not married (single, divorced, widow). Ethnicity was obtained on the basis of

ethnic origin, as defined by Statistics Canada (Statistics Canada, 2004). This variable was

categorized as: 1= Arabic, African and Middle Eastern (Arabic world, African continent and

Middle East Asia); 2=South Asian (India, Pakistan, and Sri Lanka); 3= Chinese (Mainland

China, Taiwan, Hong Kong); 4= East Asia (Korean, Japanese and other East Asian countries);


6.2.2.3. Socio-economic Variables

Socio-economic variables included education, history of social assistance, dental insurance

coverage, employment status and average household income. Education was categorized as

having college, university degree and more vs. high school diploma or less. History of social

assistance was categorized as yes/no. Dental insurance coverage was asked only at year four

(wave 3), and categorized as yes/no.







mean and standard deviation of this variable. Since the standard deviation rounded $20,000 a

year, and $40,000 a year is a good proxy for the threshold income of the working poor in

Canada (Human Resources and Social Development Canada, 2006), we created four categories

for the income variable that included: ≥$60,000; $40,000-$60,000; $20,000-40,000; ≤$20,000.

6.2.2.4. Official Language Proficiency Variable

Official language proficiency was assessed through self-reported proficiency in writing, reading,

and speaking in English or French (cannot write/speak/read, poorly, fairly well, well, very well).

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We recoded responses to these questions as poor (i.e., cannot write/speak/read and poorly),

moderate (i.e., fairly well) and good/very good (i.e., well, very well).

6.2.3. Statistical Analysis

Weighted frequency distributions for categorical demographic and socioeconomic

characteristics were calculated. Bivariate (unadjusted) weighted logistic regression analysis was

applied to identify factors having a significant relationship with transnational dental care

utilization. Statistical significance was set at the 0.05 level. Before estimating multiple logistic

regression models, we examined collinearity amongst and between each of the variables, using

variance inflation factor (VIF). Only those variables with a VIF equal to, or less than three, were

entered into the model. This criteria was used in consistency with previous studies examining

access to dental care and dental treatment needs of a national mixed sample of native and

foreign-born Canadians (Ramraj et al., 2012; Thompson 2012). We used Akaike Information

Criteria (AIC) to compare the fit of models while accounting for additional variables in the

models (Akaike, 1974). Sample weights and 1,000 bootstrap weights, as specified by Statistics

Canada, were applied in all statistical analysis. All analyses were conducted using STATA

version 12 (Stata- Corp, College Station, Texas, US).

6.3. Results

The final sample included 3,976 immigrants, representing approximately 89,100 immigrants

when weighted, out of a cohort of 157,600 immigrants residing in Canada between 2001 and

2005. Table 6.1 shows selected weighted and bootstrapped baseline sample characteristics. The

study sample consisted of similar weighted proportions of men (47%) and women (53%).

Immigrants of South Asian (27.8%) and Chinese (25.6%) origin represented more than 50% of

the total weighted sample, whereas immigrants from Latin America and the Caribbean

corresponded to only 5% of the sample. Although the large majority of immigrants have college,

university degree and more (82.4%), 42.9% had been unemployed during the first four years

after immigration, and roughly 45% had an average household income of less than $40,000 per

year. Almost half of immigrants rated their language proficiency (English/French) as moderate

(43.1%). Almost two-thirds of immigrants reported dental problems at four years post-migration

(33.3%). Most of the sample had not received dental care outside Canada (87.2%).

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In the bivariate analysis, immigrants who lacked dental insurance were more likely to have

received dental care outside Canada (OR=2.42; 95% CI: 1.96-2.98) than their counterparts.

Those who reported dental problems were more likely to receive dental care outside Canada

(OR=1.48; 95% CI: 1.21-1.81) than those without. Other correlates of transnational dental care

include average household income of less than $20,000 (OR=2.11; 95% CI: 1.53-2.92), being

female (OR=1.69; 95% CI 1.37-2.08), aged 40-49 (OR=1.40; 95% CI: 1.05-1.86) and aged

greater than or equal to 50 (OR= 2.20; 95% CI: 1.57-3.08) years at baseline, having an

education of high school or less (OR=1.34; 95% CI: 1.07-1.69), and being unemployed

(OR=2.54; 95% CI: 2.01-2.21). Moderate language proficiency was inversely associated with

transnational dental care (OR= 0.65; 95% CI 0.53-0.81) (Table 6.2)

Table 6.3 shows the results of the final multiple logistic model. After controlling for all

independent variables, the association between dental insurance, self-reported dental problems,

sex, unemployment, age and transnational dental care remained statistically significant. Lack of

dental insurance remained the strongest financial predictor of receiving dental care outside

Canada. Immigrants with no dental insurance were around 2.1 times more likely to have

received dental care outside Canada than those with dental insurance. In the same model, being

female (OR=1.59; 95% CI: 1.22-2.08), those aged greater than or equal to 50 years (OR=2.30;

95% CI: 1.45-3.64) and those who had always been unemployed (OR=1.70; 95% CI: 1.20-2.39)

were also more likely to receive dental care outside Canada. Interestingly, after adjustments,

history of social assistance and marital status became statistically significant. Those immigrants

receiving social assistance were less likely to have received dental care outside Canada

(OR=0.48; 95% CI: 0.28-0.83). Ethnic disparities were found among immigrants who received

dental care outside Canada; that is, in comparison to Europeans, South Asian immigrants were

less likely to have received dental care outside the country (OR=0.48; 95% CI: 0.28-0.83).

6.4. Discussion

Almost 11,500 immigrants to Canada received dental care outside the country over a three-point

five-year period post-immigration. Of those, approximately 11% reported dental problems and

almost 20% did not have dental insurance. These findings suggest that after three-point-five-

years post-migration, transnational dental care remains an important strategy for immigrants to

obtain care, especially for those facing affordability issues.

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Lack of dental insurance was the strongest financial predictor of transnational dental care

utilization. This finding is consistent with Dong et al. (2007) and MacEntee et al. (2012), who

identified that financial barriers among elderly Chinese immigrants in Canada, including lack of

dental insurance, prompted these immigrants to seek dental treatment in China, where costs are

20-30% lower than in Canada (MacEntee et al., 2012). Similarly, in the US, lack of dental

insurance was an important predictor of Mexican immigrants seeking and receiving

medical/dental care in Mexico (Bastisda et al., 2008; Brown 2008; De Jesus & Xiao, 2013;

Wallace et al., 2009). Further, our findings highlight that over a three-point-five-year period,

uninsured Canadian immigrants were much more likely than the insured to have received dental

care outside Canada. A similar over time effect of lack of dental insurance was found among

Mexican American immigrants in the US seeking dental care in their country of origin (Bastisda

et al., 2008).

Overall, this study suggests that for uninsured Canadian immigrants, it is cheaper to receive

dental care outside Canada, possibly in their country of origin, than to pay for dental care

expenses inside Canada. In many low/medium income countries, the source countries of the

majority of immigrants to Canada, “lower labour and living costs, the availability of inexpensive

pharmaceuticals and the low cost or absence of malpractice insurance allow these countries to

offer some dental procedures at 10 percent of the American price, including airfares” (MacEntee

et al., 2012, p.11). In China, for instance, dental implants can cost seven times less than the

Canadian price (MacEntee et al., 2012)

History of social assistance and unemployment were also associated with transnational dental

care utilization. Immigrants with a history of social assistance were less likely to have received

dental care outside the country. It is possible that for the poorest groups of immigrants, the costs

of travelling abroad offset the financial savings of this travel. However, in Canada, those

receiving social assistance often receive public subsidies, or dental insurance coverage

(Quiñonez et al., 2007), an enabling resource that facilitates access to care inside the country.

Those that were unemployed were also more likely to have received dental care outside Canada.

Again, a lack of dental insurance seems to explain the association between immigrants’

unemployment and use of dental care services abroad. The effect of employment status on

facilitating access to dental care in Canada is mostly due to the increasing probability of having

dental insurance (Millar & Locker, 1999). In Canada, unemployed individuals are less likely to

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have dental insurance, even after adjusting for other socio-demographic factors such as age,

income and education (Millar & Locker, 1999). Thus, lack of dental insurance among

unemployed immigrants may propel them to look for cost-saving alternatives outside Canada.

In addition, women were more likely to have received dental care outside Canada than men.

One possible explanation for this finding is related to sex differences in the labour market. In

Canada, immigrant women are less likely to have job security, and have worse labour market

participation than immigrant men (Shields et al., 2010). Since access to dental insurance is

contingent on immigrants’ participation in the labour market within secure, well-paid jobs with

benefits, immigrant women are potentially less likely to have dental insurance coverage than

men. Indeed, data from the Canadian Health Measure Survey (CHMS), which included

immigrants, indicated that on average women had lower dental insurance coverage than men

(Health Canada, 2010). Another possible explanation may rely on sex disparities in the use of

dental care services. Immigrant women may be more likely to seek dental care outside Canada

than men because, in general, they are more likely to report need for dental treatment (Calvasina

et al., 2013) and more likely to use dental services than men (Newbold & Patel, 2006).

Interestingly, South Asian immigrants were less likely to report transnational dental care than

European immigrants. Cultural and economic differences in perception of dental treatment

needs may help explain this ethnic difference. For instance, in comparison to Europeans, South

Asian immigrants are less likely to report having dental problems (Calvasina et al., 2013), and

less likely to have used dental services in Canada (Newbold & Patel, 2006). We speculate that

South Asian immigrants’ overall lower perception of need would also make them less prone to

seek dental care outside Canada. Another possible explanation lies in the socio-economic

disparities between these two groups. Generally, South Asian immigrants in Canada earn less

than Europeans (Pendakur & Pendakur, 2011). Cost and inconvenience of travel increase as

individuals fly longer distances. Thus, for South Asian immigrants the compound costs of long

distance travel and dental treatment could offset the advantages of receiving dental care outside

the country. By contrast, in many European countries some dental treatments remains publicly

funded (Widström & Eaton, 2004), which may encourage European immigrants to go back to

their country for publicly subsidized care.

85


Although transnational dental care utilization may remedy immigrants’ individual dental care

barriers in Canada, it demonstrates weaknesses to in-country efforts at providing publicly

funded dental care to socially marginalized groups, and also diminishes the impetus to advocate

for expansion of publicly subsidized health care coverage in the country (Johnston et al., 2010;

Labonté et al., 2013). Also, in case of complications after dental treatment, public resources in

the form of emergency room visits may be used to remedy failure of treatment privately

purchased abroad (Johnston et al., 2010; Labonté et al., 2013). Immigrants represent an

important economic, social and demographic asset to the Canadian economy, and it is equally

important for the government to ensure that recent immigrants can benefit reciprocally. To the

extent that accessibility to dental services for immigrants in Canada may help them maintain

their oral health, and thus fully participate in Canadian society, this study suggests that public

access to dental care among immigrants should be considered as an important public policy

issue. Also, given that the lack of dental insurance was the main determinant of transnational

dental care utilization over a three-point-five-year period, and access to dental insurance is

associated with permanent employment (Quiñonez & Grootendorst, 2011), policy makers

should also focus on developing programs to direct immigrants to permanent employment

opportunities.

6.4.2. Limitations

The limitations of this study include its cross-sectional analysis, which prevented us from

establishing a causal pathway. However, our results provide information on the determinants of

transnational dental care over a three-point-five-year period. We were also unable to assess the

effect of immigrants’ cultural preference for care. However, this effect apparently had no

significance, since official language proficiency, an indicator of communication and cultural

barriers to care, was not associated with transnational dental care after controlling for other

factors. This finding supports our initial hypothesis that socio-economic, not cultural, factors are

the most important determinant for the use of transnational dental care among immigrants to

Canada. Besides that, some additional conclusions may have been obtained if a detailed analysis

of the proportions of immigrants’receiving dental care ouside Canada across time was

performed. However, our initial exploration of this proportion did not shown variation; thus, we

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focused on the analysis of predictors of transnational dental care over a three-point-five-year

period. Lastly the survey only provides information on whether immigrants received dental care

outside Canada or not. Additional information on location, type of treatment received, and

method of payment would allow us to better characterize immigrants’ use of transnational dental

care.

6.5. Conclusion

This study revealed that lack of dental insurance was the most important predictor of over time

transnational dental care utilization among immigrants to Canada. Female immigrants and those

who were unemployed were more likely to report receiving dental care outside Canada. Self-

perception of dental problems was also associated with use of transnational dental care among

immigrants. Overall, our study findings indicate that immigrants may continue to use dental

services abroad unless policy reforms are initiated to promote: 1) greater immigrants’

accessibility to dental care in Canada; and 2) better labour market integration of immigrants in

Canadian society.


• This is the first study in Canada investigating immigrants’ transnational dental care

utilization.

• Over a three-point-five-year period, lack of dental insurance was associated with

immigrants’ transnational dental care utilization. Immigrants women; those unemployed and

were more likely to use transnational dental services than their counterparts.

• Although transnational dental care utilization may serve to the purpose of remedy individual

dental care barriers in Canada, it raises critical considerations. Increase engagement in this

type of service may lead to loss of impetus to advocate for expansion of publicly subsidized

dental care coverage in Canada, at the same time that it may increase use of public resources

in the form of emergency room visits to remedy failure of treatment privately purchased

abroad.

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Table 6.1: Sample Characteristics – Transnational Dental Care Utilization Model* (%) Sex Male 47.0 Female 53.0 Age 20-29 30.8 30-39 45.5 40-49 17.2 ≥ 50 6.4 Marital status Married 86.3 Not married 13.7 Highest level of education College, university and more 82.4 High school and less 17.5 Total household income ≥$60,000 24.7 $40,000-60,000 30.2 $20,000-40,000 33.8 ≤$20,000 11.3 Ethnicity European 15.7 Arabic/African/West Asian 11.7 South Asian 27.8 Chinese 25.6 East Asian 14.2 Latin American and Caribbean 5.0 History of social assistance No 89.9 Yes 11.1 Official language fluency (French and English) Poor 44.3 Moderate 43.1 Good/very good 12.6 Employment status Always employed 54.1 Always unemployed 20.7 Sometimes unemployed 25.2 Dental insurance Yes 57.6 No 42.4

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Dental Problems (wave 3) No 66.7 Yes 33.3 Dental care outside Canada No 87.2 Yes 12.8

* Sample size = 3,976

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Table 6.2: Unadjusted Associations with Transnational Dental Care Utilization among

Adult Immigrants: Longitudinal Survey of Immigrants to Canada, 2001-2005 (Weighted

Proportions)

Received dental care outside Canada

Yes

(n=509, 12.8%) No

(n=3467, 87.2%) OR (95%CI)

Sex Male (Ref) 183 (9.8%) 1,684 (90.2%) 1.00 Female 327 (15.5%) 1,780 (84.5%) 1.69 (1.37-2.08) Age 20-29 (Ref) 146 (11.9%) 1,080 (88.1%) 1.00 30-39 197 (10.9%) 1,612 (89.1%) 0.91 (0.72-1.15) 40-49 109 (15.9%) 576 (84.1%) 1.40 (1.05-1.86) ≥ 50 58 (22.9%) 196 (77.1%) 2.20 (1.57-3.08) Ethnicity European (Ref) 80 (13.1%) 530 (86.9%) 1.00 African/Arabic/Middle Eastern 70 (15.4%) 384 (84.6%) 1.20 (0.83-1.74) South Asian 98 (9.1%) 980 (90.9%) 0.66 (0.46-0.92) Chinese 143 (14.4%) 853 (85.6%) 1.11 (0.82-1.51) East Asian 82 (14.8%) 471 (85.2%) 1.15 (0.81-1.64) Latin American 26 (13.2%) 170 (86.8%) 1.01 (0.60-1.69) Marital status Married (Ref) 428 (12.5%) 3,003 (87.5%) 1.00 Not married 82 (15.2%) 462 (84.8%) 1.25 (0.95-1.65) Highest level of education outside Canada

College/University degree and more (Ref) 401 (12.2%) 2,876 (87.8%) 1.00

High school or less 109 (15.7%) 585 (84.2%) 1.34 (1.07-1.69) Average household income ≥ $ 60,000 (Ref) 96 (10.1%) 852 (89.9%) 1.00 $40,000- $60,000 135 (11.6%) 1,028 (88.4%) 1.17 (0.87-1.57) $20,000-$40,000 168 (12.9%) 1,333 (87.1%) 1.32 (1.00-1.76) ≤ $20,000 84 (19.2%) 352 (80.8%) 2.11 (1.53-2.92) History of social assistance No (Ref) 351 (11.6%) 2,673 (88.4%) 1.00 Yes 35 (10.6%) 301 (89.4%) 0.90 (0.61-1.31) Official language fluency (English/French)

Poor (Ref) 992 (83.5%) 196 (16.5%) 1.00 Moderate 1,697 (88.5%) 220 (11.5%) 0.65 (0.53-0.81)

90

Good/very good 455 (86.8%) 69 (13.1%) 0.76 (0.55-1.07) Employment status Always employed (Ref) 208 (9.7%) 1,943 (90.3%) 1.00 Always unemployed 176 (21.4%) 645 (78.6%) 2.54 (2.01-3.21) Sometimes unemployed 126 (12.6%) 876 (87.4%) 1.34 (1.05-1.71) Dental problem No (Ref) 300 (11.3%) 1,115 (84.1%) 1.00 Yes 210 (15.9%) 2,350 (88.7%) 1.48 (1.21-1.81) Dental insurance Yes (Ref) 197 (8.6%) 2,086 (91.4%) 1.00 No 312 (18.6%) 1,369 (81.4%) 2.42 (1.96-2.98)

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Table 6.3: Multiple Logistic Regression Analyses of Factors Associated with Transnational Dental Care Utilization: Longitudinal Survey of Immigrants to Canada, 2001-2005

OR (95% CI) Dental insurance Yes (Ref) 1.00 No 2.05 (1.55-2.70) Average household income ≥ $ 60,000 (Ref) 1.00 $40,000 - $60,000 1.12 (0.79-1.59) $20,000 - $40,000 0.96 (0.66-1.38) ≤ $ 20,000 1.29 (0.79-2.10) Dental Problems No (Ref) 1.00 Yes 1.45(1.12-1.88) Sex Male (Ref) 1.00 Female 1.59 (1.22-2.08) Age 20-29 (Ref) 1.00 30-39 0.97 (0.72-1.31) 40-49 1.39 (0.94-2.05) ≥ 50 2.30 (1.45-3.64) Marital status Married (Ref) 1.00 Not married 1.64 (1.12-2.38) Highest level education College, university and more (Ref) 1.00 High school and less 0.96 (0.67-1.36) Ethnicity European (Ref) 1.00 Arabic/African/Middle Eastern 1.04 (0.67-1.70) South Asian 0.48 (0.31-0.74) Chinese 0.73 (0.48-1.11) East Asian 0.74 (0.46-1.19) Latin American/ Caribbean 1.22 (0.64-2.33) History of social assistance No (Ref) 1.00 Yes 0.48 (0.28-0.83) Official language fluency Poor (Ref) 1.00 Moderate 0.87 (0.63-1.18) Good/very good 0.90 (0.57-1.42) Employment status Always employed (Ref) 1.00 Always unemployed 1.70 (1.20-2.39) Sometimes unemployed 1.04 (0.77-1.41)

92

AIC 45,456.77

93

Figure 6.1: Sample Size – Transnational Dental Care Utilization Model (Longitudinal

Survey of Immigrants to Canada, 2001-2005).


and 3,897 females)









Final sample for the present analysis: 3,976 immigrants

(1,870 males and 2,106 females)

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Chapter 7

Conclusions

7.1. Final Concluding Remarks

The present study added several innovations to the current knowledge on immigrants’ oral

health. First, it used a social determinants of oral health framework to examine immigrants’ self-

reported oral health, access to dental care, and transnational dental care utilization. In contrast,

previous literature has mainly emphasized the role of culture in the oral health of immigrants.

Second, it is the first to conduct a longitudinal analysis and examine the oral health transitions

of immigrants to Canada over a four-year period. It used a generalized estimating equation

approach that considered individual heterogeneity. Heterogeneity was also accounted for

through the ethnic group variable. Third, it is the first study to examine immigrants’ unmet

dental care needs and transnational dental care utilization as a way to examine barriers to dental

care access and dental care utilization over time. Fourth, it examined the effect of self-perceived

discrimination on immigrants’ self-reported oral health. This variable has scarcely been studied

in relation to oral health outcomes.

Findings from this study suggest that “the healthy immigrant effect” may be applied to oral

health. Although immigrants to Canada were apparently healthy at six months post-migration, a

rapid increase in self-reported dental problems was observed as early as two years after arrival,

and maintained after four years.

Although there are some limitations in making direct comparisons, results from the LSIC (2001-

2005) and the CHMS (2007-2009), demonstrate that, in fact, an overshooting phenomenon

seems to occur. In other words, analysis of the two surveys indicates that after two years,

immigrants’ oral health deteriorates to levels worse than the overall Canadian population. This

95

finding is particular important to counter the perception that immigrants always have poorer oral

health than their host country populations.

Lack of dental insurance was the dominant predictor of immigrants’: 1) barriers to accessing

dental care (i.e., unmet dental care needs), and 2) transnational dental care utilization over a

three-point-five-year period. Although financial barriers are also significant determinants of

access to dental care among the general Canadian population, immigrants experience greater

cost-prohibitive barriers to accessing dental care than non-immigrant Canadians (Thompson,

2012). Amongst those immigrants experiencing financial barriers, particularly lack of dental

insurance, it is cheaper to receive dental care outside Canada, possibly in their home country,

than to pay for dental care expenses inside Canada. These findings add further support to the

role of dental insurance in mitigating financial barriers to accessing dental care in Canada.

Other socio-economic factors, such as unemployment and history of social assistance, were

associated with immigrants’ transnational dental care utilization. While immigrants with a

history of social assistance were less likely to receive dental care outside Canada, unemployed

immigrants were more likely to receive transnational dental care. Again, access to dental

insurance may help explain these findings. In Canada, while unemployed individuals have no

access to dental insurance (Millar & Locker, 1999), social assistance recipients receive public

dental insurance that ensures them access to basic dental care (Quiñonez et al., 2005). Also,

among the poorest groups in society (i.e., social assistance recipients), the costs of travelling

abroad offset the financial savings of this travel.

The next set of analyses also demonstrated some interesting findings. This study found that

immigrants in the highest (i.e., total household income >$40,000) and in the poorest social

position in society (i.e., social assistance recipients) were more likely to report dental problems

than their counterparts. This suggests a non-linear social gradient relationship that may be

explained by the different effects of socio-economic position in the perception of dental

problems. For instance, it may be the case that for those immigrants in higher socio-economic

position, increased self-reported dental problems over time may represent increased awareness

of their oral health while for immigrants in the lower socio-economic position, who generally

96

have greater economic needs and higher prevalence of oral disease, increased self-reported

dental problems over time may represent oral health deterioration.

Sex and ethnic disparities were associated with immigrants’ oral health outcomes. For instance,

we found that immigrant women were more likely to report dental problems, and to use

transnational dental care as a way to overcome in-country access barriers. These oral health and

dental care utilization inequalities may be explained by sex differences in economic status, since

it is known that immigrant women are paid lower wages, and have less job security and worse

labour market participation than immigrant men (Shields et al., 2010). Interestingly, sex

differences were not found in relation to immigrants’ unmet dental care needs.

Non-European immigrants were less likely to report dental problems, and more likely to report

unmet dental care needs (ie., Chinese and South Asians) than European groups. These findings

may be explained by ethnic differences in immigrants’ labour market experiences. It is known

that, in the Canadian labour market, European immigrants have higher earnings than non-

European immigrants (Block & Galabuzi, 2011; Pendakur & Pendakur, 2011). Non-European

immigrants’ greater economic disadvantage may lead them to pay less attention to their oral

health, and may increase their odds of having poor access to dental care, and subsequently more

unmet dental care needs.

Another interesting finding in this study refers to the association of self-perceived

discrimination and official language proficiency with immigrants’ oral health outcomes. It was

found that immigrants who reported being discriminated against were more likely to report

dental problems over a four-year period. This association may be explained by links between the

experience of discrimination and disadvantages in labour market earnings that have a direct

impact on their oral health and ability to access dental care. After controlling for socio-

economic factors, official language proficiency, a variable often used as a proxy for

acculturation, did not predict any of the outcomes examined in this study. This finding supports

the idea that socio-economic factors are apparently the dominant determinant of immigrants’

oral health and access to dental care in Canada.

97

7.2. Policy Implications

Several policy implications can be discussed from this study’s results. Immigrants’ increase in

self-reported dental problems over time may be related to poor access to dental care. Since in

Canada, dental care is mostly financed through employment-based dental insurance and/or out-

of-pocket expenditures (Locker et al., 2011; Millar & Locker, 1999), immigrants’ increase in

self-reported dental problems demonstrates that public policies in Canada are potentially failing

to provide publicly funded access to dental care and/or permanent employment resettlement

opportunities for immigrants. In addition, immigrants’ increased dental problems over time may

produce additional unforeseen social and health care burdens in the form of work and school

days lost, and increased visits to hospital emergency rooms due to dental problems (Quiñonez et

al., 2011). Not only is the current national dental policy shortsighted from an economic

viewpoint, it also raises ethical issues in selecting highly educated and healthy immigrants to

boost the Canadian economy, and then denying them access to opportunities and resources for

them to maintain their oral health.

Lack of dental insurance was the strongest predictor of immigrants’ barriers to dental care (i.e.,

unmet dental care needs) in Canada and transnational dental care utilization. Although

transnational dental care utilization may remedy individual dental care barriers in Canada, it

further demonstrates the weakness of in-country efforts at providing publicly funded dental care

to socially marginalized groups. Other negative implications of the use of transntional dental

care to overcome in-country access barriers include: 1) reduction of the impetus to advocate for

expansion of publicly subsidized health care coverage in the country; 2) increased use of public

resources, in the form of emergency room visits, to remedy the failure of treatment privately

purchased abroad (Johnston et al., 2010; Labonté et al., 2013). Thus, while Runnels, Packer,

Labonté, and Deonandan (2013) argue that this type of practice serves a purpose, governments

should arguably be responsible for the health of their population, especially for those who have

been welcomed to contribute to the Canadian social fabric, namely immigrants.

With this background, this research proposes increasing access to dental care for all immigrants

in Canada through two competing policy options, the first being best known to improve equity:

1) expansion of publicly funded dental programs in Canada to all immigrant groups; and/or 2)

98

employment policies directed at resettling immigrants into permanent employment, a common

source of dental insurance.

7.3. Future Research

Several research questions originate from our study limitations:

1) Clinical and self-reported longitudinal analysis of immigrants and non-immigrants

oral health. Once longitudinal clinical data are available, it would be interesting to compare

immigrants vs. non-immigrants’ oral health, access to dental care (i.e., unmet dental care

needs) and transnational dental care utilization over time. This question would allow us: 1)

to strengthen our hypothesis of immigrants’ oral health deterioration over time; and 2) to

examine whether oral health deterioration is caused by poor access to dental care. Trends in

immigrants’ access to dental care and transnational dental care utilization over time could

also be examined in the future.

2) Economic impacts of immigrants’ increased self-reported dental problems over time.

An economic analysis would provide more detailed information regarding the societal costs

of immigrants’ increased dental problems over time, in terms of time loss from work, from

school or from normal activities. Similarly to Hayes et al. (2013), an exploratory analysis of

the Canadian Health Measure Survey (CHMS) could be used to quantify time loss due to

dental problems, and to provide information regarding the economic impacts of these issues,

comparing these results between recent vs. old cohorts of immigrants residing in Canada.

Another interesting economic analysis would quantify and compare the use and associated

costs of emergency room visits due to dental problems among recent vs. long term

immigrants (e.g., less than 5 yrs vs. more than 5 yrs). This analysis could also be stratified

by sex, ethnicity and immigrant category.

3) Implement qualitative studies exploring strategies used by immigrants to overcome

access barriers. Qualitative research is needed to better understand immigrants’ use of

transnational dental care, a strategy used by immigrants to overcome barriers to dental care.

This will provide further clarity to some questions raised in this study: What types of

99

transnational dental care strategies do immigrants use most often? Dental tourism or dental

returns? What is the purpose of those visits and what forms of payment are used? What are

the main reasons for those visits? Are those visits made only because of lack of dental

insurance or because of a cultural preference of care? Are those visits a reflection of lack of

integration in Canada? Anecdotal reports have indicated that immigrants have turned to

black market dental services to overcome access barriers. A qualitative study could map

those services, quantify the volume of patients, and interrogate the main reasons behind the

supply and demand for this market.

4) Further examine Canadian involvement in transnational dental care utilization. Future

research could compare immigrants’ vs. non-immigrants’ use of dental tourism, location, the

form of payment, and differences in price relative to Canada. Trends on immigrants’ vs.

non-immigrants’ use of transnational dental care over time could also be examined. Such a

study would help determine the volume of Canadians (immigrants and non-immigrants) who

use this strategy and the impact of this strategy in both low/middle and high-income

countries. For instance, increased use of transnational dental care strategies, such as dental

tourism, could increase global economic inequalities and undermine efforts to expand

universal dental care systems across the globe.

5) Study examining the oral health transitions of other groups of immigrants. Children

and refugees are two groups of immigrants who are entitled to publicly funded dental

programs. These studies could help us better understand the impact of access to dental

benefits on immigrants’ self-reported dental problems over time. The LSIC offers interesting

information on immigrants’ children and refugees’ self-reported oral health and access to

dental care over time. The study of refugees’ oral health trends and access to dental care is a

timely research question, since the Canadian government has recently cut dental benefits to

the large majority of refugees (Citizenship and Immigration, 2012; Sheikh et al., 2013).

6) Explore the effect of pre-migration and post-migration factors on immigrants’ change

in self-reported dental problems over time. Three possible research questions could be

implemented examining the association of pre-and post-migration factors on immigrants’

100

self-reported dental problems: 1) the effect of immigrants’ changes in socio-position in their

self-reported oral health over time; 2) the effect of immigrants’ home and host country

welfare regimes and dental care systems on immigrants’ oral health transitions over time; 3)

the effect of diet changes on immigrants’ self-reported dental problems over time.

7) Identify pathways linking discrimination to oral health deterioration. This study

identified that discrimination was associated with decreased in self-reported dental problems

over time. However, it is still unclear how self-perceived discrimination is linked to

increases in self-reported dental problems. We speculated that this association occurs

through disadvantages in the labour market that force immigrants into precarious and low

paid jobs, which in turn, would affect their oral health and ability to access dental care.

However, the LSIC did not ask where the episode of discrimination occurred. It merely

asked if since arrival in Canada, immigrants have experienced discrimination or unfair

treatment by others because of their ethnicity, culture, race or skin colour, language or

accent, or religion? Thus, further research is needed to test our hypothesis.

101

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