Evidence-based clinical guidelines for immigrants and refugees

Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, Narasiah L, Kirmayer LJ, Ueffing E, Macdonald NE, Hassan G, McNally M, Khan K, Buhrmann R, Dunn S, Dominic A, McCarthy AE, Gagnon AJ, Rousseau C, Tugwell P; Canadian Collaboration for Immigrant and Refugee Health, Assayag D, Barnett E, Blake J, Brockest B, Burgos G, Campbell G, Chambers A, Chan A, Cheetham M, Delpero W, Deschenes M, Dharamsi S, Duggan A, Durand N, Eyre A, Grant J, Gruner D, Harris S, Harris SB, Harvey E, Heathcote J, Heidebrecht C, Hodge W, Hone D, Hui C, Hum S, Janakiram P, Jivani K, Jurcik T, Keystone J, Kitai I, Krishnamurthy S, Kuhn S, Kutcher S, Laroche R, Logie C, Martin M, Massenat DE, Matthews D, Maze B, Menzies D, Munoz M, Murangira F, Nolen A, Plourde P, Sandoe A, Sears J, Rousseau H, Ryder AG, Schwartzman K, Stauffer W, Thombs BD, Topp P, Toren A, Torres S, Ullah A, Varghese S, Vissandjee B, Welt M, Wobeser W, Wong D, Zelkowitz P, Zhong J, Zlotkin S. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011 Jul 27.


There are more than 200 million international migrants worldwide, and this movement of people has implications for individual and population health. The 2009 United Nations Human Development Report suggested that migration benefits people who move, through increased economic and education opportunities, but migrants frequently face barriers to local health and social services. In Canada, international migrants are a growing and economically important segment of the population (Table 1A).

Immigrants to Canada are a heterogeneous group. Upon arrival, new immigrants are healthier than the Canadian-born population, both because of immigrant-selection processes and policies and because of sociocultural aspects of diet and health behaviours. However, there is a decline in this “healthy immigrant effect” after arrival. In addition, compared with the Canadian-born population, subgroups of immigrants are at increased risk of disease-specific mortality; for example, Southeast Asians from stroke (odds ratio [OR 1.46, 95% confidence interval [CI] 1.00–1.91), Caribbeans from diabetes mellitus (OR 1.67, 95% CI 1.03–2.32) and infectious diseases (e.g., for AIDS, OR 4.23, 95% CI 2.72–5.74), and immigrant men from liver cancer (OR 4.89, 95% CI 3.29–6.49). The health needs of newly arriving immigrants and refugees often differ from those of Canadian-born men, women and children. The prevalence of diseases differs with exposure to disease, migration trajectories, living conditions and genetic predispositions. Language and cultural differences, along with lack of familiarity with preventive care and fear and distrust of a new health care system, can impair access to appropriate health care services. Additionally, patients may present with conditions or concerns that are unfamiliar to practitioners.

Many source countries have limited resources and differing health care systems, and these differences may also contribute to health inequalities among migrants. In these guidelines, we refer to low-and middle-income countries as “developing.”

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