Housing and Health of Recent Immigrants in Canada: A Narrative ...

Housing and Health of Recent Immigrants in Canada: A Narrative Review Abdullahel Hadi, PhD1 Ronald Labonté, PhD1

1 Institute of Population Health, Ottawa, Ontario

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Table of Content

Abstract Acknowledgements 1. 1.1 1.2

Introduction Background Objectives of the review

2. 2.1 2.2 2.3 2.4 2.5

Methods Review approach Data sources and search strategy Inclusion/exclusion criteria Data abstract, quality assessment and synthesis Limitations

3. 3.1 3.2 3.3

Synthesis of Results Canadian housing policy: formation and change Housing and health concerns of recent immigrants Effect of housing on immigrants’ health

4. 4.1 4.2 4.3

Discussion and Policy Implications Shift in Canadian housing policy Cost effectiveness of housing investment Strategic priorities: housing for new immigrants

5.

References

Housing and the Health of Immigrants

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Abstract

Introduction: Effects of housing conditions on health have been extensively reviewed among major population sub-groups in Canada. Despite growing interest in immigrant access to affordable housing, very few studies have attempted to assess the effects of housing on immigrant health. This review assesses the evidence base for the effects of housing on immigrant health with reference to, or inferences concerning, recent immigrants in Canada.

Methods: Electronic databases of medical and social sciences were searched from January 1991 through August 2010 that analyzed both qualitative and quantitative studies on immigrant housing status, and its association with health. A total of 44 studies met inclusion criteria for this review.

Results: Over the time period studied, Canada experienced a shift in policy from providing

affordable housing to relying on market mechanisms. Research evidence shows that this policy shift has made housing less accessible for recent immigrants with low incomes. Conclusion: Federal and provincial governments should re-examine existing housing policy and identify strategic priorities to provide affordable housing for new immigrants in Canada. A number of policy directions are suggested by the review.

Keywords: Housing, policy, immigrant, health, Canada Résumé Introduction : Les conséquences des conditions de logement sur la santé, les interactions sociales, les activités économiques et le bien-être général ont été considérablement étudiées pour des sousgroupes d’importantes populations au Canada. Malgré un intérêt croissant de l’accès des immigrants à des logements abordables, très peu d’études ont été faites pour essayer d’évaluer les effets du logement sur la santé des immigrants. Cette étude évalue la base évidente des effets de la situation actuelle du logement sur la santé et le bien-être des immigrants récents au Canada. Méthodes : Les bases de données électroniques des sciences médicales et sociales ont été examinées de janvier 1991 à la fin août 2010. Celles-ci analysaient des études qualitatives et quantitatives sur la situation du logement des immigrants et son lien à leur santé et leur bien-être. Quarante-quatre études au total ont satisfait aux critères d’inclusion pour cette étude. Résultats : Le changement de politique du logement au Canada de « fournir un logement abordable» à « compter sur les mécanismes du marché » correspond aux derniers changements économiques mondiaux. Cette étude a montré que ce changement de politique a rendu les logements inaccessibles aux derniers immigrants ayant de faibles revenus. Le manque d’accès { des logements abordables augmente le risque de problèmes de santé pour eux. Conclusions : Les autorités fédérales et provinciales devraient réexaminer la politique existante sur le logement et identifier leurs priorités stratégiques pour fournir des logements abordables aux nouveaux immigrants au Canada. Mots clés : Logement, politique, immigrant, santé, bien-être, action, Canada

Working Papers Volume 2, Number 5. August 2011

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Corresponding Author Abdullahel Hadi Institute of Population Health 1 Stewart Street Ottawa ON K1N 6N5 Tel: (613) 562-5800 ext. 1252 Email: [email protected]

Acknowledgements For useful comments on earlier drafts: Toba Bryant, Vivien Runnels, Michelle Payne and two anonymous PHIRN reviewers INTRODUCTION 1.1

Background

The concept that poor housing has health consequences is not recent, as public health officials in the UK in Victorian times were aware of the link between poor housing conditions and the spread of disease (Dunn 2000a). Recent epidemiological studies similarly find relationships between poor housing conditions and various respiratory and chronic health conditions in both children and adults (Strachan 1988; Strachan and Elton 1986). Using a longitudinal approach, Marsh et al. (1999) found housing deprivation to be associated with infectious diseases, respiratory conditions and overall ill health, even after controlling for standard of living and genetic, social, and behavioural factors. Shaw (2004) considers housing a key social determinant of health and argues that housing conditions can influence health at individual-household as well as area-neighbourhood levels. Other researchers consider housing condition to be an important indicator of quality of life, as it can affect health, social interaction, economic activity, and general well-being (Engeland and Lewis 2005). Correlation between housing and health status, as found in many studies, does not mean that ill health is necessarily caused by poor housing (Wilkinson 1999; Carter and Polevychok 2004). For example: although low-income people with chronic illness generally are more likely to live in poor housing, the causal pathway can go in both directions. Some researchers argue that the cause-effect relationships between poor housing and poor health are not well established (Jacobs et al. 2010), although others contend that the weight of evidence indicates that housing conditions are important determinants of health (Carter and Polevychok 2004). Several studies from a variety of countries have demonstrated housing related health effects arising from exposure to physical, biological and chemical hazards (Dunn 2002a; Jacobs et al. 2010). Of particular concern is that Canada’s housing market in recent decades has become increasingly inaccessible to low-income individuals and households, resulting in inequities in housing accessibility, affordability and adequacy (Hulchanski 2007; Hulchanski 2004). As one indicator of this, Shapcott (2008) reports a 22% increase in the number of shelter beds in one year in 2007. The need to revisit existing Canadian housing policies has been widely expressed. As a 2009 Senate Committee Report on cities stated, ‘... the existing (municipal) policies and programs entrap people in poverty, creating unintended perverse effects which make it virtually impossible for too many people


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to escape reliance on income security programs and even homeless shelters.’ (Senate Canada 2009: p5). Interest in housing and its effects on population sub-groups (that is, apart from the generic category of ‘low-income’) has grown only recently in Canada (Bryant 2003). Compared to ethnic and other minority communities, housing experiences and homelessness among recent1 immigrants to Canada have not been well explored (Chambon et al. 1997; Murdie et al. 2006). One study on immigrant population in Calgary found that poor housing had negative health effects, jeopardized children’s’ education and impaired family life (Danso and Grant 2001). Using Survey on Labour and Income Dynamics (SLID), Fluery (2007) estimated about 20.4% new immigrants with low-income to live in over-crowded 2 housing conditions in 2004 in Canada. A recent US study, which may have some relevance to the Canadian experience, reports that 54–70% of immigrants compared to only 7% of the general population do not have access to adequate housing (Tillett 2006). For new immigrants, access to adequate and suitable housing with security of tenure is an important facilitator of integration into a new society (Murdie et al. 2006; Ley et al. 2001). Good housing not only reduces the length of resettlement for immigrants, but also reduces long-term costs to society in other areas such as health, education, social assistance and employment insurance (Thompson at al. 2001; Jacobs et al. 2009; Carter and Polevychok 2004; Dunn 2000a; Ambrose 2001). Immigrants, compared to native-born Canadians, have better health status when they arrive in Canada (Dean and Wilson 2010; Chiu et al. 2009; Perez 2002), partly because persons with serious health problems are screened in the immigration process (Ali et al. 2004). Over time, the health status of immigrants declines to that of the average native-born population (Dean and Wilson 2010). How much of this decline might be attributed to poor housing has not been systematically reviewed; and only a few Canadian studies have attempted to assess specifically the effects of housing on migrant health (Murdie et al. 2006; Mattu 2002). This lack of research may be partly explained by inadequate information on immigrant communities and other marginalized populations experiencing limited housing choice (including homelessness) in major databases in Canada (Murdie et al. 2006).

1.2

Objectives of the review

The objective of this project is to assess the evidence base for the effects of housing on the health and well-being of recent immigrants to Canada. Specific objectives are to: review the changes to housing policies that might have created inequities in housing affordability among Canadian populations, generally; 1

By ‘recent,’ and following common usage in the immigration literature, we refer to immigrants who have arrived in their new country within the past ten years. 2

According to CMHC, a house is not considered crowded if it has one bedroom for each: cohabiting adult couple; unattached household member 18 years of age and over; same-sex pair of children under age 18; and additional boy and/or girl in the family, unless there are two opposite sex siblings under 5 years of age.


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Hadi & Labonté examine the accessibility of recent immigrants to adequate and affordable housing compared to other Canadians; assess the effects of housing provisions on the health of recent immigrant communities; and identify policy options that can promote adequate and affordable housing for new immigrants, thereby reducing housing-related health inequities in Canada.

METHODS Review approach This narrative review adopted a systematic approach comprised of the following sequence of activities (see Table 1): determine the synthesis questions, conduct a mapping exercise, refine the search strategy, appraise and classify evidence, synthesize selected evidence, adapt findings to the Canadian context, and summarize potential policy implications of the findings. Using key concepts of housing, strategy, immigrant, inequality, employment, poverty, ethnicity, affordability, health, illness, and mortality identified in the mapping exercise, a search strategy was developed that included search terms, data sources, inclusion-exclusion criteria, data extraction process, quality assessment, synthesis of evidence, and reporting. Table 1: Main Steps in Evidence Review Review Question: What is known about the effects of the current state of housing on the health and well-being of recent immigrants in Canada? Mapping and search strategy development: A quick mapping exercise (non-systematic search) for peer-reviewed journal articles and grey literature identified 31 citations Six citations provided data and analysis relevant to the review question and allowed refinement of the search strategy Searching and reviewing literature: Refinement of search strategy, repetition of search and selection of studies Classification of studies (journal articles and grey literature) and extraction of findings Assessing quality of studies and synthesizing findings: Appraisal of the quality of evidence Synthesis of findings to answer sub-questions: a. How does housing condition as a key determinant of health differ between recent immigrants and other Canadians? b. What are the potential effects of housing condition on the health of immigrants? Reporting evidence: Highlight the key outcomes of synthesis and their applicability in modifying policy and programs.


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Data sources and search strategy We adopted a strategy that involved searching for evidence through different sources including electronic databases, reference lists, and hand-searching of key journals. The searches for relevant literature were undertaken in August at the Health Science Library of the University of Ottawa. The primary databases were Medline, Embase and Web of Science (SSCI). Other databases such as Google Scholar, GreyNet International, ISI Webknowledge and Scopus were also searched. We also reviewed reference lists of the relevant studies on housing and health that met the inclusion/exclusion criteria. Keywords used were “housing”, “shelter”, “housing policy”, “immigrant”, “newcomer”, “settlement”, “health”, “equity” and “well-being”.

2.3

Inclusion/exclusion criteria

The inclusion and exclusion criteria used to select studies were as follows: • Articles/reports that addressed housing and health of immigrants • Reports/papers published in English • Qualitative and quantitative studies • Relevance to Canadian context • The reference period was from 1991 to 2010 The final search provided 318 citation titles and abstracts. The citation titles included original articles, review papers and grey literature (such as unpublished research reports, commissioned reports, evaluation studies, etc.). The process of identification and screening of citations/reports is shown in the flow chart (Figure 1). A total of 77 articles/reports met the inclusion criteria and are included in this review (see ‘List of reports used in this review’). Additional references are cited for the historical, policy-oriented and general housing/health relationships they describe.


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Figure 1: Flow chart of the identification and selection of studies 318 potentially relevant citations identified and screened for retrieval

217 citation titles retained for the next step

101 ineligible citations excluded on the basis of title

14 citation titles excluded for duplication

203 abstracts or executive summaries of studies retrieved

143 abstracts or executive summaries excluded

62 full-text articles read for eligibility

22 full-text articles excluded

40 articles or reports retained

64 additional articles identified

104 potentially appropriate studies found for review

27 studies excluded as results presented were not relevant

Total 77 articles included for final review Source: Adopted from Liberati A, Altman DG, Tetzlaff J et al. (2009)

2.4

Data abstraction, quality assessment and synthesis

Basic characteristics of all selected studies were summarized in a data abstraction form under different headings such as “participants”, “research methods”, “setting”, “sample sizes”, “interventions”, “outcomes”, “evidence of changes”. These characteristics were then organized, documented, reviewed and analyzed thematically to respond to the review questions. A rigorous appraisal module similar to that used in systematic reviews was initially developed to assess the quality and comprehensiveness of evidence. The diversity of studies identified by the initial search and secondary reference searching, however, led to a simpler categorization of studies based upon whether they provided new empirical evidence, offered policy analyses or provided commentary only. Findings discussed in this review paper focus on the first two article categories.


2.5

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Limitations

The review used both peer reviewed published articles and grey literature. As a result, the quality of reported studies has not been uniform. Explanations of some of the findings were inadequate and incomplete. Numerous studies have documented the relationship between poor housing and ill health although findings are sometimes contradictory or weak in terms of causality (Wilkinson 1999). While strongly suggestive, existing research remains limited in definitively arguing how and to what extent housing investment would be an effective strategy for health improvement (CSIP 2010). Nonetheless, sufficient evidence exists to suggest housing policy reforms that are more likely to lead to improved health for recent immigrants. As well, several of the studies on housing and health, generally, and housing and immigrant health specifically, are not Canadian, limiting somewhat the inferences such studies might have for recent immigrants in Canada.

SYNTHESIS OF RESULTS 3.1

Canadian housing policy: formation and change

The following section highlights key Canadian government housing initiatives and the political and economic context under which housing policies have been developed or changed. While more recent housing policy decisions are of immediate importance to the findings from this review it is useful to understand the development of (and retreat from) governments’ active participation in affordable housing within a larger historical trajectory. Doing so can provide clues into the socioeconomic and ideological contexts that, at least in part, motivate particular government policy choices.

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First federal initiative

Unlike many developed nations, Canada never had a national comprehensive housing policy. It has, however, enacted several measures to support the housing system and promote homeownership (CHRA 2009). The federal government first entered into the public housing sector in 1920 by providing funds to rebuild houses for those who lost homes in the Halifax explosion (Chisholm 2003). At the same time, the federal government approved a scheme of providing loans for new housing, primarily to create jobs for the veterans of World War I (Chisholm 2003).

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Dominion Housing Act of 1935 and aftermath

During the Great Depression of the 1930s, the federal government passed the Dominion Housing Act in 1935 as part of economic recovery measures and to assist municipalities to provide housing for the poor (Chisholm 2003; Dupuis 2003). Soon after, the National Housing Act of 1938 was introduced to promote private market housing (Dupuis 2003; Bryant 2004) and subsequently the federal government itself became involved in providing social housing (Chisholm 2003; Bryant 2004).

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World War II and federal housing policy

Responding to the pressure from the municipalities to improve urban slum areas, the federal government formed Wartime Housing Limited in 1941, which constructed about 26,000 new rental Working Papers Volume 2, Number 5. August 2011

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housing units (Chisholm 2003). At the end of the War, the Central Mortgage and Housing Corporation (CHMC) (forerunner of Canada Mortgage and Housing Corporation) was established in 1945 to assist the private housing market, promote the construction trades and increase employment (Belec 1984). Such involvement in the private housing market had dual purposes: to provide housing assistance for War veterans; and to help the growing middle class with disposable income to invest in building their own homes (Belec 1984).

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Supporting provincial authorities in housing

In 1949, the federal government amended the National Housing Act (NHA) to help share housing deficits between the federal and provincial governments, as mortgage support was not enough to provide housing for those in low-income households (Chisholm 2003). A second amendment to the NHA was made in 1956 primarily to correct market imperfections. The NHA was revised again in 1964 to add a new public housing program. To promote low cost housing for the poor, provincial housing authorities and non-profit community groups were given the opportunity to apply for lowinterest loans (Chisholm 2003). One explanation for such direct government involvement was its rising financial capacity and motivation to reduce inequalities in the standard of living among Canadians (Dupuis 2003). In the 1970s, the focus of CMHC gradually shifted to improving housing conditions of low-income families in poor neighbourhoods by enabling them to buy their own homes. The housing strategy supported private sector involvement in providing affordable rental housing through tax deduction and Assisted Rental Program of CMCH (Chisholm 2003).

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Conflict and cooperation between the federal and provincial policies

In the late 1960s, the federal government was criticised for its inaction in meeting the needs of the urban poor and supporting the building of ‘ghettos of the poor’ in urban areas (Chisholm 2003). In response to these criticisms, the government created a separate Ministry of State for Urban Affairs (MSUA) in 1971 to focus on mortgage and housing issues in urban areas. However, federal involvement in housing and urban issues was not unanimously appreciated by provincial governments, as the provinces have jurisdiction over housing policy (Chisholm 2003; Bryant 2004). Provincial criticisms over the role of the federal government in housing policy ultimately led to the elimination of the Ministry in 1978.The role of the federal government in housing was effectively relinquished by the Charlottetown Accord of 1992, which clarified the provinces’ exclusive authority over and responsibility for housing policy (Chisholm 2003).

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De-emphasizing social housing

In the early 1980s, the federal government supported social housing, provided funds for lowincome households and shared the cost of housing projects with the provinces (Dupuis 2003). During the 1990s, the federal government increasingly de-emphasized social housing, did not increase its financial support for social housing, and stopped long-term funding commitments for housing except for First Nations reserves (Chisholm 2003). This shift away from social housing was partly a result of the federal government decision to focus on eliminating budget deficits and reducing the accumulated public debt. Some argue that this shift was also consistent with the federal government’s adoption of neoliberal economic policies dominant at the time, which emphasized a reliance on markets and the private sector in areas such as housing provision (Bryant 2004). As a result, the federal government in 1993 cancelled several housing projects, many of which had severe financial implications for low-income households (Chisholm 2003). Compounding the federal retreat from affordable housing were shifts in provincial policies. In 1995, for example,


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the Ontario provincial government imposed a moratorium on new social housing and amended legislation to permit landlords to use income criteria to screen potential tenants, severely reducing access of the low-income population to housing (Bryant 2004).

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Re-emergence of a federal role in “Affordable Housing Supply”

Responding to the growing public concerns about the rise of homelessness, the lack of social housing since the early 1990s, and the rise in rents after deregulation, the federal government reentered the sector to provide support for affordable housing in the late 1990s (Dupuis 2003). In 2001, the federal, provincial and territorial authorities agreed to adopt the Affordable Housing Framework Agreement where the provinces and territories must have matching funds to receive federal grants (CMHC 2010; Wellesley Institute 2010). Under this framework, each provincial or territorial housing authority was to design and implement its own housing program. As part of the Affordable Housing Initiative (AHI), the federal government provided $680 million to provincial and territorial housing authorities in 2001 (CMHC 2010). Two years later, in 2003, an additional $320 million was allocated and targeted to low-income households under this agreement (Chisholm 2003). The federal government continued its support for housing for low-income Canadians. In 2008, it announced that it would invest $1.9 billion over five years – part of which would be used for the Affordable Housing Initiative that would run from 2008 until 2011 (CMHC 2010). ●

The Government of Ontario’s recent initiatives in housing for low-income households

Some provincial governments have re-entered social housing provision. In Ontario, for example, the Planning Act was amended in in 2006 to enhance the ability of Municipalities to plan for mixed and integrated neighbourhoods (MoMAH 2010). Under the Delivering Opportunities for Ontario Renters (DOOR) program, the government in 2007 provided $127 million to create or rehabilitate affordable rental housing units. In 2008, it provided $100 million to the municipalities to repair nearly 4,000 social housing units. In 2009, Ontario invested $622 million to match the federal funding to generate about $1.2 billion that would be spent to rehabilitate 50,000 social housing units and to build 4,500 new housing units for low income Canadians (MoMAH 2010). The accountability framework of Ontario’s Long-Term Affordable Housing Strategy includes an annual progress report on housing using a set of performance indicators, although it does not have any commitment to reducing homelessness nor any integrated approach for social housing, rent subsidy for those who are in need, or housing supports for disabled people (SRAC 2010).

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Towards creating a national housing strategy

Although the Affordable Housing Framework Agreement in 2001 was considered a major step toward creating a national housing plan, little progress has been visible to date. In 2009, the United Nations Human Rights Council (UNHRC) expressed its concerns about rising homelessness in Canada and reminded the federal government of the nation’s commitment to address poverty and housing issues (Wellesley Institute 2010). A Senate Committee of the federal government, after reviewing poverty and housing conditions, also recommended financial provision to support affordable housing (Senate Canada 2009). In response to these criticisms, the federal government proposed a new initiative in 2009 that would require it to consult all relevant stakeholders (including provinces, territories, municipalities, Aboriginal groups, and the non-profit and private sectors) in developing a national housing strategy (Wellesley Institute 2010). A new parliamentary Bill (C-304) was introduced to Working Papers Volume 2, Number 5. August 2011

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ensure secure, adequate and affordable housing for Canadians. It is expected to be before Parliament at the end of 2011 for its final reading. In parallel, the federal, provincial, and territorial authorities are expected to continue to work on a national housing framework. Summary The policy review indicates that Canada has never had a constitutionally mandated housing policy at the federal level. Federal housing policy initiatives developed and evolved primarily to respond to the needs of the Canadian economy, and only marginally to achieve the social goal of ensuring equitable access to housing.

3.2

Housing and health concerns of recent immigrants

Since 2001, more than 220,000 people enter Canada each year as immigrants (Wayland 2007). While Europe has long been the primary source of immigration to Canada, most recent immigrants (those who have entered the country within the past ten years) have come from East and South Asia followed by the Middle East and Africa. This is changing the traditional mosaic of ethnic groups, particularly in large metropolitan centres (Wayland 2007). Although recent immigrants are better educated and skilled than their earlier counterparts, they experience extreme difficulties in the job market (Statistics Canada 2005) largely because of the lack of Canadian experiences and skills (Wayland 2007). Evidence indicates that people with nonCanadian education earned 30% less than those with a Canadian education (Alboim et al. 2005). Also, overseas labour market experience is associated with between 25 to 50% reduced earnings relative to comparable Canadian experience (Alboim et al. 2005; Aydemir and Skuterud 2004). The overall slower growth of the Canadian economy in recent decades is also considered an employment-related barrier for newcomers (Wayland 2007). Recent immigrants, therefore, have tended to rent rather than own their homes. Housing “careers” also differ by the ethnicity of the new immigrants. Immigrants from Southern Europe in the past and China in recent years have been the most successful in becoming homeowners while Caribbean and the South Asian immigrants have experienced difficulties in affording homes (Wayland 2007). Regardless of their country of origin, most recent immigrants settle in one of three large metropolitan areas: Toronto, Vancouver and Montreal (Wayland 2007). There is growing concern that Canada’s capacity and performance in providing adequate housing for newcomers has diminished over the past several decades, resulting in increased inequity in housing access among its population sub-groups (Hulchanski 2007). This section reviews the housing conditions of recent immigrants and their accessibility to adequate housing in Canada.

3.3

Effect of housing on immigrants’ health

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Poverty and housing inequity

Recent immigrants are generally poorer compared to earlier immigrants and native-born Canadians; and the income gap between recent immigrants and other Canadians has been increasing (Picot 2004). Poverty and poor economic standing, in turn, are associated with limited access to housing and other needed services (Reid et al. 2008). CMHC (2010) estimates that about


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55% of lowest-income renters were in core housing need in urban Canada in 2007. In a study on changes in housing affordability and Toronto’s rental market, Murdie (2003) found that recent immigrants with low income had very limited access to affordable housing, paid a large share of their income on housing, and were unlikely to have enough money to spend on food, clothing, transportation and educational supplies. This resulted in less ability to improve their quality of life. Opportunities in the labour and housing markets, the study notes, have worsened substantially for recent immigrants compared to earlier immigrants to the area. Other studies have found that most new immigrants spend more than 30% of household earnings for accommodation (Carter et al. 2008) while a small proportion spend 50% of their incomes in rent (CMHC 2004). On average, new immigrants have to spend 6.3% more of their income for housing than other Canadians, while the average income of new immigrants was 18.9% less (CMHC 2004; Wachsmuth 2008). Unsurprisingly, a study of early settlement experiences found that 31% of recent immigrants identified high housing cost as the greatest problem they encountered (Statistics Canada 2005). Compared to the Canadian average, only a small proportion of new immigrants have been successful in owning homes in recent years (CMHC 2004). This situation is largely a result of the large share of income new immigrants spend on rent, preventing them from saving for such a purpose (Wachsmuth 2008). Barriers, discrimination and challenges in the housing market in Canada by ethnicity are well known (Murdie et al. 2006; Wachsmuth 2008; Teixeira 2008). Immigrants with minority identities have greater difficulties finding appropriate housing (Wachsmuth 2008) than whites, and nonwhites (notably blacks) are generally treated differently in housing markets (Danso and Grant 2001; Hulchanski 1997). Using the housing experience of Black African immigrant communities in Calgary, Danso and Grant (2001) identified various forms of difficulties in the employment market and ethnicity-based discrimination in the housing market. Another Canadian study found that immigrants face serious discrimination in the private housing market, especially if they are women, black, or single with children (Wachsmuth 2008). A well-publicized study on the rental experiences of Jamaican, Polish and Somali new immigrant groups in Toronto suggests that Poles, being white, had the least problems, Jamaican and Somalis, being black, had problems, while Somalis had the greatest difficulties in renting a house (Dion 2001; also cited by Murdie 2003; Wachsmuth 2008). These findings suggest the existence of racial inequity that reinforces residential inequalities by ethnicity (Dion 2001). Canada has been accused of replicating earlier US practices that deny ‘access for black and other minorities to housing in white neighbourhoods’ in its large metropolitan centres (Danso and Grant 2001). Gender differences in housing access also persist. Lone (or unattached) women generally face housing affordability problems: 52% of them pay more than 30% of income for their accommodation (Farha and Goba 2002). Although not distinguishing between native-born and immigrant populations, one study

estimated that one in four homeless people living on the streets in Canada is female, however, the proportion of homeless women may be much higher since they are less likely to be visibly homeless due to the additional risks they face. These risks include sexual assault or, if they have children, losing their children to welfare agencies (CERA2002). The poverty rate is higher among recent immigrant households with children (36.4%) than among their Canadian counterparts (13.3%), which can have a potential negative effect on immigrant children’s health (Beiser et al. 2002). High poverty rates can also have severe negative effects on the learning outcomes of children (Wachsmuth 2008). Studies conducted in the USA show that children of recent immigrant households have inadequate food, live in substandard housing (Capps


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et al. 2004) and experience higher incidences of illnesses (Litt et al. 2009). Another US study found that unaffordable housing forced low-income households to spend a larger share of their income on rent, which compromised their ability to have adequate healthy food, medical care and other basic necessities (Child Health Impact Working Group 2005). Finally, poor housing leads to slow integration of new immigrants, restricts their spatial mobility and access to community support networks, and limits their educational and employment opportunities (Carter and Osborne 2009; Carter and Polevychok 2004; Wachsmuth 2008). Conversely, access to affordable housing provides a sense of security and confidence that helps new immigrants to interact with neighbours and to integrate into communities more easily (Danso and Grant 2001; Wachsmuth 2008). It also helps to improve their social mobility, productivity and earning capacities (Danso and Grant 2001). A US study showed that affordable housing reduces stress and increases the resources available for better food and health care, which in turn can improve overall health and quality of life (Cohen 2007).

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Housing inequity and immigrant health

Associations between housing and health outcomes have been extensively studied (Dunn 2000b; Bryant 2003; Stewart and Roden 2006; Miles and Jacobs 2008; NCHH 2009). Rudolf Virchow, in the mid 19th century, identified poor sanitation, crowding, and inadequate ventilation as risk factors of infectious diseases (Krieger and Higgins 2002). Poor housing conditions affect various dimensions of health. Krieger and Higgins (2002), in their review, synthesize evidence that shows how overcrowding with poor ventilation increases interior moisture, how exposure to organic compounds such as lead can cause asthma, how exposure to deteriorating insulation can cause lung cancer, how dirty carpeting contains dust and allergens, and how toxic substances can result in allergic, respiratory, neurological and haematological illnesses, and chronic health problems. The WHO in a review of housing and health (2004) found poor housing (with potential exposure to toxins, lead, asbestos or carbon monoxide) to be associated with higher incidence of asthma, respiratory and skin allergies, and lung diseases. Several studies in UK found that poor environmental conditions such as dampness and exposure to asbestos and radon led to higher prevalence of asthma and meningitis, hypothermia, skin and eye irritation, and coronary heart disease (Harker 2006; CSIP 2010). In a literature review of over 100 research studies undertaken in the UK, bad housing, defined by homelessness, overcrowding, and poor physical condition, was found to be associated with a higher incidence of childhood accidents, poor health status in children, poor performance at school, and increased behavioural problems in childhood (Harker 2006). Using a longitudinal approach, a study in the UK shows that the experience of living in substandard housing3 during childhood can have longer-term health implications during adult life (Marsh 1999). Although Canadian children generally experience better housing conditions in owner-occupied, single family dwellings compared to many developed countries, it has been

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Sub-standard housing was measured using the following variables: homelessness, dissatisfaction with the area they live in, dissatisfaction with present accommodation, accommodation has had serious problems of damp or mould, overcrowding (more than one person per room), front door of the accommodation on or above the third floor of the building, living in non self-contained accommodation (rooms, caravans, etc), not having sole access to a bath, not having sole access to a kitchen, and lacking or having to share an indoor toilet (Marsh 1999).


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estimated that nearly 15% of Canadian children were in ‘core housing need’4 in 1996 (Jackson and Roberts 2001). Overcrowding,5 generally associated with poverty, can aggravate existing health problems (Murphy 2006; Australian Indigenous HealthINFONET 2008) and increase the transmission of viral and bacterial infections (Goux and Maurin 2005). A number of studies have linked overcrowding to skin infections, meningitis, respiratory infections, childhood tuberculosis and poor mental health (Harker 2006; Murphy 2006). The reduction of overcrowding would, therefore, reduce the risk factors for infectious diseases and improve physical and mental health (Cohen 2007; Goux and Maurin 2005). Few studies on the health effects of recent immigrant housing in Canada exist. Preston (2009) reports poor quality of housing among the homeless and new immigrants in the Greater Toronto region but without referencing health outcomes. A US study reports that most recent immigrants were living in adverse environmental conditions that included exposure to dampness and mould (44%), pests (28%), poor ventilation (26%) and indoor smoking (16%) (Litt et al. 2009). One British study showed that inequalities in housing and income contributed to greater incidence of mental illness in immigrants than in the native-born population (Silveira and Ebrahim 1998); since the same situation in both factors (housing and income) exist for recent Canadian immigrants one could assume a similar risk exists. In Canada, recent immigrants with low incomes have experienced substantial housing deprivation (such as poor environmental conditions, overcrowding and homelessness) that can have serious health implications (Marsh 1999). Recent immigrants and refugees in Canada are more likely to live in smaller and more crowded homes or in sub-standard conditions than are non-immigrants in Canada (CMHC 2004; Carter et al. 2008), with the attendant health risks. This situation is largely a result of their low incomes and limited ability to afford more space (Fleury 2007). While a quarter of immigrant homes in the USA were overcrowded during 2005-2007 (Litt et al. 2009), the situation in Canada was slightly better for recent immigrants (20.4% in 2004) and has been approaching comparability to other low-income Canadians (7.7%) (Fleury 2007). Hyman (2004) found resettlement stress among Canadian immigrants to be associated with the re-activation of tuberculosis (from their previous infections at the country of origin), diabetes and a decline in mental health; the precise role of housing in this process is not known, however, studies previously cited suggest that housing inadequacy is a major cause of new immigrant stress. The decline of the ‘healthy immigrant effect’ noted earlier has been explained, in part, in a US study by new

Core housing need means that the house is either in need of major repair and/or crowded and/or unaffordable (i.e., 30% or more of pre tax income spent on dwelling costs) and that alternative housing meeting the three standards is not affordable (Jackson and Roberts 2001). 4

A household was considered overcrowded if at least one additional bedroom was needed. The criteria used to assess bedroom requirements included: there should be no more than two persons per bedroom, a household of one unattached individual may reasonably occupy a bed-sit (i.e. have no bedroom), couples and parents should have a separate bedroom, children less than five years of age, of different sexes, may reasonably share a room, children five years of age or over, of different sexes, should not share a bedroom, children less than 18 years of age and of the same sex may reasonably share a bedroom, and single household members aged 18 years or over should have a separate bedroom (Australian Bureau of Statistics 2008) 5


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immigrants’ low incomes and associated poor physical facilities, overcrowding and inappropriate housing environment (Early et al. 2006).

●

Homelessness

Homelessness is a particular instance of housing inequity. Estimates of homelessness in Canada range from nearly 150,000 (or about 0.5%) in 2005 (Laird 2007) to 157,000 in 2009 (Trypuc and Robinson 2009). Although a causal association between homelessness and poor health is difficult to measure (Frankish, Hwang, Quantz 2005), homelessness is found to be a risk factor for such health problems as seizures, chronic pulmonary diseases, musculoskeletal disorders, tuberculosis, skin problems and premature death (Hwang 2001). A longitudinal study of a cohort of 8,769 men in Toronto found a higher risk of mortality and morbidity among homeless men compared to other groups (Hwang 2002). In a US study, homeless children are reported to be particularly vulnerable and at risk for serious medical problems (Grant et al. 2007). Homelessness also has significant negative effects on mental health (Wachsmuth 2008; Bryant 2003), partly as a result of a loss of dignity and a sense of shame experienced by homeless people (Pruegger et al. 2007). A systematic review suggests that access to affordable housing for homeless people and people from slums not only reduces mental depression (Taske et al. 2005) and environmental stress (Ponizovsky and Perl 1997; Lubell et al. 2007) but also improves self-reported physical and mental health (Taske et al. 2005). The risk of being homeless among recent immigrants is particularly high and has been growing. Lack of affordable housing has been identified as the most important predictor of homelessness among immigrants and refugees (Wachsmuth 2008). Recent immigrants and refugees generally opt for the cheapest accommodation available, share rents with others and accept crowding to avoid becoming homeless (Fiedler et al. 2006; Chan et al. 2005). One strategy new immigrants frequently employ is to use their ethnic ties to find low cost temporary accommodation (D’Addario et al. 2007; Chan et al. 2005). Studies suggest that, unlike native-born Canadians, most new immigrants encounter barriers to finding an affordable home, such as low level of income, lack of employment, large family size, and inability to communicate effectively in English or in French (Teixeira 2008). A homeless new immigrant often faces additional burdens in obtaining affordable housing over and above those of Canadian born homeless people, such as discrimination, financial insecurity and having to adapt to a new environment and culture (Pruegger et al. 2007). Cancellation of public housing programs has been reported as accelerating a housing crisis and the risk of homelessness for new immigrant groups in Toronto (Access Alliance 2003). A recent study reported that about 10% of homeowners and 13% of renters among recent immigrants in greater Vancouver were at risk of being homeless as they had to spend more than half of their household income on housing (Hiebert et al. 2008). Any unfortunate event - such as being unemployed or losing work due to illnesses - may lead them to become homeless. A review of healthy housing intervention studies in USA provided sufficient evidence that neighbourhood level interventions such as integrated pest management, radon air mitigation, lead hazard control, smoking ban, and drinking & wastewater treatment could improve the health and well-being of persons living in the neighbours (NCHH 2009). Adequate housing prevents communicable diseases by ensuring supply of safe drinking water, sanitation and waste disposal mechanisms, and safeguard against hazardous substances (Lawrence and Hartig 1998). Cohen (2007) found that affordable housing improve health outcomes by reducing exposure to high risk environmental pollutions, alleviating crowding, stress and related adverse health outcomes, health care expenditures, providing a sense of security, access to neighborhoods of opportunity. The


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extent to which these interventions might apply to housing deficits for recent immigrants to Canada is not known, although several interventions have been suggested for improving housing conditions and are discussed later in this paper (Thompson et al. 2009; Taske et al. 2005).

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Neighbourhood

A review of housing and health conditions in the USA suggests that physical and socioeconomic characteristics of neighbourhoods can exert powerful influences on the health of people who live within them (Robert Wood Johnson Foundation 2008). Recent reviews of research on neighbourhood effects on health, drawing from studies conducted in several different countries, found that poor-quality neighbourhoods with a lack of parks and walking areas and with a sense of un-safety lead to low rates of physical exercise, limited scope to socialize and low rates of community involvement (Shaw 2004; WHO 2004). Households with lower income have limited choice in selecting neighbourhoods and avoiding environments that can lead to poor physical and mental health and limited social support (Stewart and Rhoden 2006). The nature and causes of residential concentration and relocation patterns of immigrant households in Canada are well known (Murdie et al. 2006; Danso and Grant 2001). Traditional urban ecological models suggest that immigrants settle in older neighbourhoods with inexpensive rental housing in inner-city districts (Di Biase and Bauder 2005; Wachsmuth 2008). Most new immigrants in Canada generally live with a relative or friend for some time, and 80% of them move to rental accommodations six months after arrival (Statistics Canada 2005). The majority (76%) live in large cities (CMHC 2004, Carter 2005). Studies report that neighbourhood concentration of immigrants has increasingly pushed relatively poor immigrants into lower rent neighbourhoods with limited community services (Murdie 2003; Wachsmuth 2008). When services are available, immigrant children are less likely to access them because of linguistic and cultural barriers (Kobayashi et al., 1998). Finally, studies further suggest that affordable and safe housing creates a positive environment and stability that can lead to higher physical and mental health (Murphy 2006) while providing a stable basis for new immigrants and refugees to face the challenges of settlement in a new country (Carter et al. 2008). This brings the review to a consideration of policy options that would improve housing options for recent immigrants to Canada.

DISCUSSION AND POLICY IMPLICATIONS A shift in political ideology in the early 1990s had a large role in reshaping the social and economic strategies and practices of the government in producing and distributing goods and services, including those affecting housing. Bryant (2003) shows how this government shift towards a neoliberal political ideology and its emphasis on private markets created the conditions that reduced the affordability of housing. Canada now has the most market-based private housing sector of the developed countries after the USA. This strategy has not only been discriminatory in the way it treats owners and renters (Hulchanski 2007); it has also shifted from providing affordable housing to low-income households to relying on market mechanism to do so.


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4.1

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Shift in Canadian housing policy

The federal government played a significant role during the Great Depression in the 1930s and continued funding for housing for low-income Canadians until the mid-1980s. The federal government modified its housing strategy at that time, withdrawing most of its financial support for housing for the poor and finally ending its support for affordable housing in 1996 (Bryant et al. 2010). Property investment decisions were left primarily to private markets, which in turn were shaped largely by corporate strategic interests where investing for affordable housing has never been a priority (Hulchanski 2007). The housing sector was seen as having a less competitive edge than industrial or commercial sectors in terms of economic returns or aggregate economic growth, while returns on the products of industrial investment, particularly those targeting export markets, were more positively regarded (Pugh 1990). As with many other previously publicly subsidized goods, housing came to be considered by policy makers primarily as a market commodity – not as a public good or human right integral to the wider health and socioeconomic well-being of the country (Pierre 2007).

4.2

Cost effectiveness of housing investment

There has been some academic and research interest in understanding the social and economic returns of housing investment. A decade-old systematic review found that public investment in housing can significantly reduce heating costs and improve physical and mental health (Thompson et al. 2002). A British intervention study - conducted in an overcrowded, poor and inner urban area of West London with a matched control community – showed a seven-fold improvement in health, measured in self-rated illness-days (Ambrose 2001). The intervention consisted of investments to improve the quality of housing over a four-year period by reducing overcrowding, damp and cold conditions, infestations, risk of accidents at home, noise and environmental irritants, and improved indoor and outdoor air quality. This study also estimated the annual healthcare costs per household as seven times lower in the intervention than in the control community after five years. Other studies support the claim that the benefits of public housing investment outweigh the costs. A UK study estimated the cost of homelessness for a person to be thousands of pounds per year and that investing in housing to reduce homelessness produced more benefits than costs (Kenway and Palmer 2003). A US study similarly found that homelessness and poor housing leading to severe negative effects on mental health and developmental well-being of children cost an additional US $6,700 per child (Child Health Impact Working Group 2005). This study did not estimate total familial costs associated with homelessness or poor housing, or the costs of public subsidization of adequate housing. However, a recent Canadian review argues that the ‘cost needed to provide affordable housing’ is much less than the ‘costs required to provide health care, education, and other social services’ for those who would benefit from better housing (Wellesley Institute 2010). This suggests that it may be less affordable over the longer term to avoid the short-term investments required for affordable housing.

4.3

Strategic priorities: housing for new immigrants

Statistics Canada (2005) has reported a mixed “housing career” for the recent immigrants in Canada. Murdie (2006) categorizes them into three groups on the basis of their access to acceptable housing. They are immigrants who: i) face extreme difficulties accessing acceptable housing; ii) struggle, sacrifice and ultimately become homeowners; and iii) are financially well placed to


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become homeowners quickly (Murdie 2006). We suggest a focus on those who experience extreme difficulties finding an affordable home for their families. In this respect, the policy responses differ little from those facing low-income Canadians more generally, albeit with an understanding that recent immigrants now fare worse in housing access than to comparable, low-income native-born Canadians. Policy makers will need to consider several issues in developing an affordable housing strategy for recent immigrants. These issues include the financial viability of such programs, shortand long-term social and economic returns, and political will. This narrative review provides evidence that justifies developing such a strategy. It also argues that provision of affordable housing for new immigrants is cost-effective and would be beneficial to both members of the immigrant communities and society at large. Based on the evidence, several policy priorities for establishing housing strategy for the immigrants are proposed.

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Adopt housing services in the immigrant settlement program

The federally-funded Immigrant Settlement and Adaptation Program (ISAP) currently provides six direct and two indirect capacity building services for new immigrants through a number of different public and non-profit service providers (CIC 2005; Wayland 2007). Housing services consist principally of information to new immigrants seeking housing information (such as types of housing, sources, help lines for tenants and legal assistance if needed) through printed and webbased materials (Wachsmuth 2008).Temporary accommodation and financial and other supports are provided for one year from the date of arrival to government-sponsored refugees (GARs). Tenant supports and access to community information are also provided. Other services provided by ISAP are language and skill training to enter the job market, economic, educational and recreational services, information and tips on banking and shopping, and interpreters or translators (Schmidt 2009). Given that most of these services are provided in English and French only, and many are available through the Internet only, it is likely that new immigrants have limited access to these materials (Wayland 2007). Although the current ISAP policy is comprehensive in scope and designed for a pluralistic integration of immigrants, the policy focuses primarily on immediate needs. The difficulties that newcomers experience in finding affordable accommodation have never been considered in the settlement strategy (Wayland 2007) except for provision of temporary housing for homeless refugees. Front-line settlement workers often have limited knowledge about housing issues as they are not primarily responsible for housing provision for new immigrants (Wayland 2007). Several studies indicated the possibility of linking housing with immigration policy initiatives (Wayland 2007; Wachsmuth 2008) but did not elaborate except to suggest that new immigrants might be given information of relevant service agencies, including housing, at the port of entry to expedite finding appropriate accommodation (Kilbride and Webber 2006). Reitz (1998) observed that immigrant settlement is a long-term process and is influenced largely by wider institutional contexts such as social systems, economic opportunities, educational systems and social assistance (Wayland 2007). Thus, immigrant housing policy should be viewed as one of many social and economic policies required to address the needs of new immigrants, notably poverty and economic insecurity (Carter and Polevychok 2004). These findings suggest that the Immigrant Settlement and Adaptation Program (ISAP) should consider incorporating housing services within its present six basic services. As Kilbride and Webber (2006) suggest, settlement programs should begin at the point of entry and could actively link new immigrants with established agencies to enable them to find appropriate accommodation.


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Such programs could also provide comprehensive information prior to their arrival about the problems that they might face in getting accommodation. This may require front-line settlement workers to have increased knowledge of and responsibility for providing information on affordable housing. As well, recent immigrants should not only be provided with comprehensive information about services but also with information about their rights and responsibilities as tenants or homeowners. Such information should be provided prior to arrival in Canada through websites as well as through support service providers upon their arrival (Wayland 2007). As suggested by Wachsmuch (2008), ethnic and cultural organizations can be involved in the provision of services which search for houses. Discriminatory practices in housing (such as selection of tenants, landlord-tenant disputes, etc.) should be addressed by promoting and enforcing human rights policies.

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Modify immigrant selection criteria to reduce hidden homelessness among recent immigrants

After successful settlement of new immigrants for more than 40 years since World War II, Canada is now experiencing difficulties in integrating immigrants and refugees in the Canadian labour market (Richmond and Shields 2005). The Canadian economy has increasingly been losing its capacity to absorb as large a proportion of recent immigrants as it has done in the past. Unlike native-born Canadians, most new immigrants encounter barriers to finding affordable housing because of their low level of income, lack of employment, large family size, ethnic identity and inability to communicate. Grubel (2005) blames Canadian immigration policy for growing poverty among recent immigrants. Grubel places the responsibility on individuals rather than on markets and government regulation. He argues that the causes of poor economic performance of recent immigrants can be reduced by creating a new immigrant selection process whereby immigrant applicants would receive temporary renewable work visas and would be accepted as immigrants only after they find sustained employment. From the vantage of the single outcome of improving housing for immigrants to Canada, the current immigration selection criteria could be routinely modified based on the projected opportunities in the job markets in Canada. Given that a group of recent immigrants have performed very well, a profile of the capacities and economic potentials for success of new immigrants could be developed and routinely updated. This would reduce potential hidden homelessness among future immigrants by selecting only those persons/families who would perform better in increasingly competitive labour markets and who would be financially better able to avoid living in poor housing conditions. Such a modification to immigration criteria, however, would need to be balanced against other policy objectives associated with maintaining or increasing present levels of immigration; as well as consideration of other policy measures governments can take to improve labour market opportunities and housing affordability/adequacy for new immigrants as well as native-born Canadians.

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Expand and diversify the housing portfolio for new immigrants

There is considerable evidence and argument supporting a call for federal and provincial authorities to revisit the existing housing policy, prioritize the housing needs for new immigrants to Canada and incorporate provision for affordable rental units (Omidvar and Richmond 2003).


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According to one estimate, core housing need6 for recent immigrant households was 35.4% in 2006 (CMHC 2010). Several studies suggest that authorities at all levels of government (federal, provincial and municipal) should increase the supply of affordable housing or increase affordability of existing private rental housing (Wayland 2007). There are several ways to provide supports for recent immigrants who experience difficulties in obtaining affordable housing, such as federal cash transfers for assisted home ownership and a subsidized rental program by the province. An appropriate balance of support between the federal and provincial governments would need to be determined. Evidence suggests that investing in housing reduces health care and welfare costs. Spending on housing programs for marginalized communities can also generate desired social returns in the long run. Housing support to low-income households has already been adopted as a policy tool to de-concentrate poverty (Suttor 2007). Such programs (for example, shelter allowance in Canada and rental voucher programmes in the UK) have been effective in improving household safety and security (Strange 2003; Taske et al. 2005). These programs also offer a wider choice of neighbourhoods in which people can choose to live. Experience of developing mixed-income suburbs in Toronto in the 1960s through the 1980s further suggests that public subsidy for housing for low-income households effectively reduces market-driven concentrated poverty (Sutton 2007). The benefits of providing affordable housing have been recognized by policy makers. For example, in 2009, the Ontario government decided to invest about $1.2 billion (in addition to $622 million from the federal government) to construct affordable housing (MoMAH 2010). The amount, however, is considered to be far below what would be required to adequately address the problems of under-housed populations as a large proportion of the nearly 150,000 homeless Canadians (Laird 2007) live in Ontario. If poor housing conditions are to be prevented several policy directions are suggested by the available evidence, including: i) the provision of rental subsidies, including a targeted subsidy for recent immigrants in need; ii) consideration to reinstatement of rent control by provincial governments affecting all population groups experiencing difficulty in accessing affordable housing; and iii) a needs-based share of the current stock of affordable housing dedicated to recent immigrants. Protecting existing subsidized rental housing units that are closer to job growth areas could further reduce the tendency of new immigrants to locate in low income neighbourhoods that provide fewer services or transport access. This policy option could also de-concentrate poverty and promote equity by providing low-income recent immigrants better choices to disperse across the city or region where affordably priced private housing units are available. One short-term solution to increase the stock of affordable housing might also be to loosen temporarily criteria under the Ontario Planning Act for basement rentals, although with such rental units still being subject to minor modification. As recent immigrants generally pay a large share of their income for housing, more generous income support would be needed to raise the minimum wage to ensure a living wage for immigrants with low household incomes (Wayland 2007; Carter and Polevychok 2004). Calls for

6

Core housing need refers to families which are unable to afford housing that meets adequacy, suitability and affordability standards. Affordability is defined as a maximum of 30% of the family income spent on housing (Available at http://www.cmhc-schl.gc.ca/en/corp/faq/faq_002.cfm).


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such ‘living wage’ increases are not restricted to recent immigrants, and a fuller analysis of their implications is the topic of a separate narrative review (forthcoming). Provision of low interest credit to recent immigrants to meet rental housing needs could be an alternative to public subsidies, similar to the Canada Student Loans Program. Recipients would be expected to pay back the loan at low (or zero) interest once they are employed and earning at a certain level. This policy option could be managed through the tax system and, if adopted, should be extended to all eligible low-income Canadians facing difficulties in obtaining affordable housing. Finally, recent immigrants are different than their predecessors in terms of the country of origin, ethnicity and cultural background. The family size of recent immigrants, coming mostly from Asia and Africa, is generally higher than those of earlier immigrants who primarily came from Europe (Murdie 2006). As a result, their housing requirements (in terms of size) may be different than most of the available homes in Canada. Housing initiatives for recent immigrants should recognize the needs for larger accommodation for extended families.

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Promote an integrated approach to housing

It is increasingly recognized that housing policy alone cannot guarantee affordable housing for recent immigrants in need (Carter 2004). A successful housing policy is only one component of a broader policy framework and must be integrated with other policy areas including health, education and social assistance (Carter 2004). Available studies explicitly or implicitly call for coordinated policy responses by establishing coordinating committees between housing departments and settlement agencies at all levels and acting under a common policy framework (Wayland 2007). Studies report limitations of the non-profit sector in delivering settlement services as a result of reduced funding and restructuring of their role (Omidvar and Richmond 2003). It has also been reported that no single department is clearly assigned to help access employment and housing (Richmond and Shields 2005). A lack of integrated planning and service coordination to provide employment training, health care, housing and welfare services for new immigrants was also identified (Mwarigha 2002). These findings imply that housing services for recent immigrants should be better integrated with other service provisions affecting their health, such as investment for job creation and enhancing educational attainment for children. Such integration should occur at both policy and provider levels. 5.0

Summary

This review has examined evidence of the current state of housing for recent immigrants in Canada and its association with their health. It suggests that a reliance on market mechanisms, and a retreat from the public provision of affordable housing (at least until Ontario’s recent investment in new housing public housing stock), has and will continue to have detrimental effects on the health of recent immigrants to Canada by decreasing the availability of affordable housing for this population. The lack of affordable housing compounds other stresses (such as higher rates of poverty, and stresses of settlement) that affect recent immigrants’ health. Some studies further suggest that the medium and long-term health costs of inadequate housing could be greater than the costs of ensuring affordable housing in the short-term.


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What is already known on this topic The effect of housing conditions on health is well established, although the context of housing policy changes and its effects on the well-being of disadvantaged population sub-groups (such as recent immigrants) have not been well explored What this study adds 77 studies that examined the transformation of housing policy, housing conditions and their links with the health and well-being of recent immigrants in Canada were reviewed Canadian housing policy has shifted in recent decades from providing affordable housing to relying on market mechanisms Most recent immigrants to Canada are experiencing difficulties in finding affordable homes because of their low income, lack of employment, large family size, ethnic identity and inability to communicate effectively in English or French Federal and provincial authorities should re-examine their existing housing policies and establish provisions to provide more public housing and financial support for affordable rental units as part of settlement policy for newcomers to Canada

List of reports used in the review Access Alliance 2003. Best Practices for Working with Homeless Immigrants and Refugees. A Community-Based Action-Research Project Phase I: Research. Toronto: Access Alliance Multicultural Community Health Centre. Alboim N, Finnie R, Meng R 2005. The Discounting of Immigrants’ Skills in Canada. Evidence and Policy Recommendations. IRPP Choices 11, 2: 1-26. Australian Indigenous Health INFONET 2008. REVIEW OF THE IMPACT OF HOUSING AND HEALTHRELATED INFRASTRUCTURE ON INDIGENOUS HEALTH. Retrieved from http://www.healthinfonet.ecu.edu.au/determinants/physical-environment/reviews/our-review Aydemir A, Skuterud M 2004. Explaining the Deteriorating Entry Earnings of Canada’s Immigrant Cohorts: 1966-2000. Economics Working Paper, Labour and Demography Series, Statistics Canada. Beiser M, Hou F, Hyman I, Tousignant M 2002. Poverty, Family Process, and the Mental Health of Immigrant Children in Canada. Am J Public Health. 2002;92:220–227. Belec J 1984. Origins of State Housing Policy in Canada: The Case of the Central Mortgage Bank. Canadian Geographer 28(4):377-382. Bryant T 2003. The Current State of Housing in Canada as a Social Determinant of Health. Policy Options March:52-56. Bryant T 2004. How Knowledge and Political Ideology Affects Rental Housing Policy in Ontario, Canada: Application of a Knowledge Paradigms Framework of Policy Change. Housing Studies 19(4):635–651. Capps R et al. 2004. The Health and Well-being of Young Children of Immigrants. Washington DC: Urban Institute.


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Carter T, Polevychok C 2004. Housing is Good Social Policy. Ottawa: Canadian Policy Research Networks Inc. (CPRN). Carter T 2005. The Influence of Immigration on Global City Housing Markets: The Canadian Perspective. Urban Policy and Research 23(3):265 – 286. Carter et al. 2008. The Housing Circumstances of Recently Arrived Refugees: The Winnipeg Experience. Edmonton: Prairie Metropolis Centre. Carter TS, Osborne J 2009. Housing and Neighbourhood Challenges of Refugee Resettlement in Declining Inner City Neighbourhoods: A Winnipeg Case Study. Journal of Immigrant & Refugee Studies 7(3):308— 327. CERA 2002. Women and Housing in Canada: Barriers to Equality. Centre for equality Rights in Accommodation. Women’s Housing Program. [http://www.equalityrights.org/cera/docs/CERAWomenHous.htm#_ftnref3] Chan S, Hiebert D et al. 2005. The Profile of Absolute and Relative Homelessness Among Immigrants, Refugees, and Refugee Claimants in the GVRD. Final Report. MOSAIC, May 2005. Child Health Impact Working Group 2005. Affordable Housing and Child Health: A Child Health Impact Assessment of the Massachusetts Rental Voucher Program. Boston: Child Health Impact Working Group. Chisholm S 2003. Affordable housing in Canada’s urban communities: A literature review. Ottawa: Canada Mortgage and Housing Corporation. CHRA 2009. An Affordable Housing Policy for Canada. Ottawa: Canadian Housing and Renewal Association. CMHC 2004. 2001 Census Housing Series: Issue 7 Revised—Immigrant Households. Socio-economic Series 04-042. December 2004. Ottawa: Canada Mortgage and Housing Corporation. CMHC 2010. 2010 Canadian Housing Observer. Ottawa: Canada Mortgage and Housing Corporation. Cohen R 2007. The Positive Impacts of Affordable Housing on Health: A Research Summary. Center for Housing Policy, USA. CSIP 2010. Good housing and good health? A review and recommendations for housing and health practitioners. Sector Study. Care Services Improvement Partnership, UK. Department of Health. Retrieved from http://www.healthimpactproject.org/resources/document/Good_housing_and_good_health.pdf D’Addario S, Hiebert D, Sherrell K 2007. Restricted Access: The Role of Social Capital in Mitigating Absolute Homelessness among Immigrants and Refugees in the GVRD. Refuse 24(1):107-115. Danso R, Grant M 2001. Access to Housing as an Adaptive Strategy for Immigrant Groups: Africans in Calgary. Canadian Ethnic Studies 32(3): 19-43.


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Di Biase S, Bauder H 2005. Immigrant Settlement in Ontario: Location and Local Labour Markets. Canadian Ethnic Studies Vol. 37, No. 3: 114-135. Dion KL 2001. Immigrants' Perceptions of Housing Discrimination in Toronto: The Housing New Canadians Project. Journal of Social Issues 57(3):523-539. Dunn J 2000b. Housing and Health Inequalities: Review and Prospects for Research. Housing Studies 15(3):341–366. Dupuis J 2003. Federal Housing Policy: An Historical Perspective. Parliamentary Research Branch, Library of Parliament, Canada. Early J et al. 2006. Housing Characteristics of Farmworker Families in North Carolina. Journal of Immigrant and Minority Health, Vol. 8, No. 2):173-184. Farha L, Goba R 2002. Access Denied: Canada’s Housing Crisis. Habitat Debate 8(4). UN-Habitat [http://ww2.unhabitat.org/hd/hdv8n4/cases.asp ] Fiedler R, Schuurman N, Hyndman J 2006. Hidden homelessness: An indicator-based approach for examining the geographies of recent immigrants at-risk of homelessness in Greater Vancouver. Cities 23(3):205–216. Fleury D 2007. A Study of Poverty and Working Poverty among Recent Immigrants to Canada. Final Report. Ottawa: Human Resources and Social Development Canada. Frankish CJ, Hwang SW, Quantz D 2005. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005 96 Suppl 2:S23-9. Goux D, Maurin E 2005. The effect of overcrowded housing on children’s performance at school. Journal of Public Economics 89 (2005):797– 819. Grant R et al. 2007. The Health of Homeless Children Revisited. Advances in Pediatrics 54 (2007) 173– 187. Harker L 2006. Chance of a lifetime: The impact of bad housing on children’s lives. Edinburgh: Shelter. Hiebert DJ, Mendez P, Wyly E 2008. The Housing Situation and Needs of Recent Immigrants in the Vancouver Metropolital Area. Working Paper Series No. 08-01. Metropolis British Columbia: Centre of Excellence for Research on Immigration and Diversity. Hulchanski JD 1997. Immigrants and Access to Housing: How Welcome are Newcomers to Canada? Metropolis Year II Conference. The Development of a Comparative Research Agenda. Hulchanski JD 2007. Canada’s Dual Housing Policy. Assisting Owners, Neglecting Renters. Research Bulletin # 38, Centre for Urban and Community Studies, University of Toronto.


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Hwang SW 2001. Homelessness and health. CMAJ 164(1):229-33. Hwang SW 2002. Is homelessness hazardous to your health? Obstacles to the demonstration of a causal relationship. Can J Public Health. 93(6):407-10. Hyman I 2004. Setting the Stage: Reviewing Current Knowledge on the Health of Canadian Immigrants. What Is the Evidence and Where Are the Gaps? Canadian Journal of Public Health 95(3):1-4. Jackson A, Roberts P 2001. Physical Housing Conditions and the Well-Being of Children. Ottawa: Canadian Council on Social Development. Kobayashi A, Moore E, Rosenberg M 1998. Healthy Immigrant Children: A Demographic and Geographic Analysis. Hull: Human Resources Development Canada. Krieger J, Higgins D 2002. Housing and Health: Time Again for Public Health Action. Am J Public Health. 2002;92:758–768. Laird G 2007. SHELTER: Homelessness in a growth economy: Canada’s 21st century paradox. A Report for the Sheldon Chumir Foundation for Ethics in Leadership [Available: http://www.chumirethicsfoundation.ca/files/pdf/SHELTER.pdf] Lawrence R, Hartig T 1998. Housing, health, and well-being: Revising the research and policy agendas', Housing: Theory and Society 15(4):266 — 270. Litt JS, Goss C, Diao L, Allshouse A, Diaz-Castillo S, Bardwell RA, Hendrikson E, Miller SL, Diguiseppi C 2009. Housing Environments and Child Health Conditions Among Recent Mexican Immigrant Families: A Population-Based Study. J Immigrant Minority Health May 18, 2009. Lubell J, Crain R, Cohen R 2007. Framing the Issues – the Positive Impacts of Affordable Housing on Health. Center for Housing Policy, USA. Marsh A 1999. Housing and health: the nature of the connection. Radical Statistics 72: Marsh A, Gordon D, Pantazis C and Heslop P 1999. Home sweet home? The impact of poor housing on health. Bristol: Policy Press. Miles R, Jacobs DE 2008. Future Directions in Housing and Public Health: Findings From Europe With Broader Implications for Planners. Journal of the American Planning Association 74(1):77-89. MoMAH 2010. Housing. Toronto: Ontario Ministry of Municipal Affairs and Housing. Available: http://www.mah.gov.on.ca/Page7101.aspx Murdie RA 2003. Housing Affordability and Toronto’s Rental Market: Perspectives from the Housing Careers of Jamaican, Polish and Somali Newcomers. Housing, Theory and Society; 20: 183–196. Murdie R, Preston V, Ghosh S, Chevalier M 2006. Immigrants and Housing: A Review of Canadian Literature from 1990 to 2005. Canada Mortgage and Housing Corporation.


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