Montréal, Montréal, Canada b Centre de recherche du CHU Sainte-Justine, Montréal, Canada

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1 This article was downloaded by: [Universite de Montreal] On: 16 August 2011, At: 11:32 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Ethnicity & Health Publication details, including instructions for authors and subscription information: The influence of poverty and social support on the perceived health of children born to minority migrant mothers Andraea Van Hulst a b, Louise Séguin a c d, Maria-Victoria Zunzunegui a c d, Maria P. Vélez a b & Béatrice Nikiéma a c a Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada b Centre de recherche du CHU Sainte-Justine, Montréal, Canada c Institut de recherche en santé publique de l'université de Montréal (IRSPUM), Montréal, Canada d Centre de recherche Léa-Roback sur les inégalités sociales de santé, Montréal, Canada Available online: 12 Apr 2011 To cite this article: Andraea Van Hulst, Louise Séguin, Maria-Victoria Zunzunegui, Maria P. Vélez & Béatrice Nikiéma (2011): The influence of poverty and social support on the perceived health of children born to minority migrant mothers, Ethnicity & Health, 16:3, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan, sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings,

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3 Ethnicity & Health Vol. 16, No. 3, June 2011, The influence of poverty and social support on the perceived health of children born to minority migrant mothers Andraea Van Hulst a,b *, Louise Séguin a,c,d, Maria-Victoria Zunzunegui a,c,d, Maria P. Vélez a,b and Béatrice Nikiéma a,c a Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada; b Centre de recherche du CHU Sainte-Justine, Montréal, Canada; c Institut de recherche en santé publique de l Université de Montréal (IRSPUM), Montréal, Canada; d Centre de recherche Léa-Roback sur les inégalités sociales de santé, Montréal, Canada (Received 12 May 2010; final version received 20 January 2011) Objective. Poverty and low social support are common among minority migrant families. Little is known about their impact on the health of children of minority migrants to Canada. This study examined the associations between maternal perception of child s health and migration status, and examined the specific role of poverty and low social support in these associations. Design. Data from the first two rounds of the Quebec Longitudinal Study of Child Development (QLSCD) were analysed. The sample included 1990 children at 17 months of age, classified according to their mother s migration status: children of minority migrant mothers (n 165) and Canadian-born mothers (n 1825). Maternal perception of child s health status and social support were measured at 17 months, household income was measured at 5 and 17 months. Multivariable logistic regressions were performed; interactions of migration status with poverty and social support were tested. Results. Poverty and low social support were more common among minority migrant mothers than among Canadian-born mothers. Children of minority migrant mothers who were never poor and reported high levels of social support were perceived in better health (OR 0.42; 95% confidence interval (CI): ) than children of Canadian-born mothers (reference group). In contrast, children of minority migrant mothers who were always poor and reported low social support were perceived in worse health (OR 6.32; 95% CI: ) compared to the reference group. Conclusion. In Quebec, economic hardship and lack of social support are common realities among minority migrants with young children. Combined exposure to poverty and low social support is most detrimental to the perceived health of children of minority migrants. Keywords: emigration and immigration; child health; poverty; social support; birth cohort Background In 2006, immigrants represented 19.8% of the Canadian population and 11.5% of the population in the province of Quebec (Statistics Canada 2007b). With the growing importance of migration to Canada, there are increasing numbers of children born in *Corresponding author. a.van.hulst@umontreal.ca ISSN print/issn online # 2011 Taylor & Francis DOI: /

4 186 A. Van Hulst et al. Canada to immigrant parents. One in four children born in Quebec in 2006 has at least one parent who immigrated to Canada (Institut de la statistique du Québec 2009). Since the 1980s, immigrants to Canada and Quebec increasingly originate from non-european and developing countries. Among immigrants received in Quebec in 2006, 30% were born on the African continent, 30% in Asia, and 18% in South and Central America (Ministère de l Immigration et des Communautés Culturelles 2009). In contrast, 20% of immigrants received in the same year were born in Europe, 2% in the USA, and less than 1% in Oceania. Mirroring changes in patterns of immigration, children born to immigrant parents in Quebec represent increasingly diverse ethnocultural backgrounds. Factors that are likely to have strong influences on migrants and their children s health include social determinants of health, such as poverty and social isolation (Dunn and Dyck 2000, Caritas Europa 2006, WHO Commission on Social Determinants of Health 2008). Studies consistently find strong associations between early childhood poverty and adverse health on multiple measures (Aber et al. 1997, Séguin et al. 2003, 2007). Poverty can be transient or chronic; although both are associated with poor health, chronic poverty appears to have more deleterious effects on children s health, thus supporting the use of longitudinal measures of poverty (Aber et al. 1997, Séguin et al. 2007). National statistics show that between 1980 and 2000, the proportion of low income among immigrants to Canada has increased, particularly among recent immigrants, with the highest augmentation seen in immigrants from Africa and South, East, and Western Asia (Picot and Hou 2003). Additionally, immigrants from non-european source countries and new immigrants to Canada are more likely to report having lower social support compared to the Canadian-born population (Dunn and Dyck 2000, Sword et al. 2006). Social support can provide the material, emotional, and social resources needed to cope with life stressors. The lack of social support experienced by immigrants as they resettle into a new country may have negative health impacts. For example, among migrants, lower social support has been associated with increased likelihood of maternal depression (Dennis et al. 2004, Sword et al. 2006) and poorer neonatal health outcomes (Battaglini et al. 2000). Although immigrants are more likely to be poor and have low social support, they are usually found to have better health outcomes in adulthood compared to the Canadian-born population (Chen et al. 1996, Dunn and Dyck 2000, Newbold and Danforth 2003). Similar findings are reported in relation to neonatal health outcomes such that newborns of immigrant mothers have health advantages despite higher maternal exposure to adverse socio-economic conditions during pregnancy and post-birth (Cervantes et al. 1999, Guendelman et al. 1999). However, fewer studies have examined the impact of poverty and low social support on the health of children born to migrant mothers after the neonatal period, and it is not clear whether similar health advantages are found during early childhood (Mendoza 2009). Some studies report better overall health among children born to immigrant mothers, with a lower prevalence of asthma, better mental health outcomes, and fewer hospitalisations (Beiser et al. 1998, Hernandez and Charney 1998, Klinnert et al. 2003, Guttmann et al. 2004, Nikiéma et al. 2008, Vaage et al. 2009), yet others found them to do less well particularly in terms of developmental health (Schulpen 1996, To et al. 2004). One hypothesis is that exposure to poverty and low maternal

5 Ethnicity & Health 187 social support may have negative effects on the health of children born to immigrant mothers and attenuate or reverse their neonatal health benefits (Mendoza 2009). We examined differences in children s health status at 17 months of age, as perceived by their mother, of children born to minority migrant mothers compared with children born to Canadian-born mothers, while exploring the specific contributions of social support and a longitudinal measure of poverty on perceived child health. We relied on a conceptual model developed by Denton et al. (2004) where authors proposed two hypotheses that could account for observed differences in health between distinct groups. The differential exposure hypothesis suggests that one group may be in worse health than the other due to exposure to more conditions that have negative influences on health. Accounting for the differences in exposure to poverty and low social support between children of immigrant and those of Canadian-born mothers would thus explain observed differences in health. The differential vulnerability hypothesis suggests that differences in health occur because the groups react differently when exposed to conditions that influence health. The latter hypothesis implies effect modification whereby children born to immigrant mothers and those born to Canadian-born mothers are expected to show different levels of risk depending on their level of exposure to poverty and low social support. Methods Study population Data were available in the Quebec Longitudinal Study of Child Development (QLSCD), a birth cohort of children followed annually since the age of 5 months. The Quebec Master Registry of Live Births was used to sample the cohort for which the target population was representative of 95% of all single births in the province between 1997 and 1998 (Jetté and Groseilliers 2000). Children of mothers living in Northern Quebec, Cree or Inuit territories, and Indian reserves were excluded (2.1%) because of the remoteness of these regions. Also excluded were children for whom the period of gestation was unknown and those whose gestation lasted less than 24 or more than 42 weeks (1.4%). Within the target population, a random sample of 2940 infants was initially selected of which 265 families were either not found (65%) or excluded from the study because they were not proficient in either study languages (French or English) (30%), or due to prolonged absence from or temporary residence within the province (5%) (Figure 1). A total of 2223 families agreed to participate in the first round of the study (83% participation) of which a random sample of 2120 was kept for the longitudinal follow-up (Jetté and Groseilliers 2000). Baseline nonparticipants were more likely to speak languages other than French or English at home and to report lower levels of education. In 1999, when children were 17 months old, the sample included 2045 children representing 97% of baseline participants; participation in the second round was lower for minority migrant families (86%) than for Canadian-born families (98%) (Jetté 2002). Overall, participants lost between rounds one and two were more likely to be poor and to have a mother with low education and worse self-rated health at baseline. Migration status was determined at baseline according to the mother s country of birth. Mothers born in Canada were defined as Canadian-born (n 1825) and those born in countries different from the USA, Australia, New Zealand, or the European

6 188 A. Van Hulst et al. QLSCD*Target population n= 2940 Not eligible n=265 Did not consent n=452 Baseline at 5 months of age n= 2223 Randomly excluded after completion of baseline n=103 Considered for longitudinal follow-up n= 2120 Follow-up at 17 months of age n= 2045 Study population n= 1990 Children born to minority migrant mothers n= 165 Losses to follow-up n=75 Excluded from study n=55 Children born to Canadian-born mothers n=1825 Figure 1. Flow chart of study participants. *Quebec Longitudinal Study of Child Development; $ Not found (n 172), Not proficient in either study languages (n 80), Temporary residence (n 13); % Non-minority migrants (n 53), Missing mother s country of birth (n 2). continent were defined as minority migrants (n 165). Immigrant mothers born in the USA, Australia, New Zealand, or Europe (n 53) were excluded from analyses. This was done because previous studies reported important differences between immigrants from minority and majority countries, particularly with respect to income level and social support (Chen et al. 1996, Dunn and Dyck 2000). Similar differences were also found in the QLSCD, suggesting that these two groups of immigrants differ in term of their socio-economic characteristics and should therefore be examined as distinct groups. However, due to their small sample size in the QLSCD, they could not be examined separately and were thus excluded from all analyses. This resulted in a final sample size of 1990 children and their mothers, as two cases had missing data on mother s country of birth. Information on father s country of birth was available; however, paternal immigration status was not considered in this study due to the much lower overall response to the father s selfadministered questionnaire.

7 Ethnicity & Health 189 Data collection Data were collected through home-based interviews with the person most knowledgeable about the child, who in 98% of cases was the child s mother. Questionnaires were administered by trained interviewers in either French or English. Since the QLSCD was not initially designed to study migrants, questionnaires were not translated to other languages and translators were not available during home visits. Information related to neonatal health problems including prematurity, low birth weight, and congenital malformations was retrieved from hospital birth files. The study received ethics approval from the Faculty of Medicine, University of Montreal. Study variables Child s overall health status was measured as the mother s perception of her child s health at 17 months of age ( In general, would you say your child s health is...? Excellent, very good, good, fair, or poor ). This variable was then dichotomised according to whether the child s health was perceived as excellent or not, a categorisation that has been used in previous studies with the same cohort of children (Séguin et al. 2003, Monette et al. 2007). This measure was found to be strongly associated with maternal reports of specific health problems experienced by the child in the preceding 3 months, including a variety of acute and chronic health problems and hospitalisations among 17-month-old children of the QLSCD for both Canadian-born and immigrant families (Monette et al. 2007). Mother s perception of her child s health thus represents a reliable indicator of the child s global health in the study population. Poverty was defined using a household income adequacy indicator based on lowincome cut-offs (LICO) established in 1998 by Statistics Canada (1998). The lowincome cut-off corresponds to the level of income at which a household must allocate on average a 20% greater share of its pre-tax income to food, clothing, and shelter than that allocated to these expenses by the average family. This measure takes the household s size and the level of urbanisation of the residence location into account to distinguish households with adequate incomes (above the LICO) from households with inadequate incomes (below the LICO). Using this categorisation, a longitudinal measure of poverty was computed with data from the first and second rounds of the QLSCD, when children were 5 and 17 months old, respectively. Participants below the LICO in both the first and second rounds were categorised as always poor, participants below the LICO in either round but not in both were categorised as sometimes poor, and those above the LICO in both rounds were categorised as never poor. Maternal level of social support was measured in the second round of the QLSCD with three items drawn from the Social Provision Scale ( I have family and friends who help me feel safe, secure and happy, There is someone I trust whom I would turn to for advice if I were having problems, and There are people I can count on in an emergency (Cutrona and Russell 1987). Mothers were asked to rate these items on a four-point scale (strongly agree to strongly disagree), those who answered either disagree or strongly disagree on at least one of the three items were categorised as having a low social support. Additional covariates that were considered were selected based on their previously reported associations with child health or migration status. They include

8 190 A. Van Hulst et al. the following characteristics of children: sex, age in months, birth rank (first, second, third or more), neonatal health (preterm birth, low birth weight, and congenital malformations), duration of breastfeeding (never, B3 months, ]3 months) and type of child care (in child s home, in another home, in a daycare centre). Maternal characteristics include age at the birth of the index child (B20 years, 2034 years, ]35 years), language usually spoken at home (French and/or English, other), length of time since immigrated to Canada (B5 years, 59 years, ]10 years), level of education (some college or university studies, high school or vocational or trade school diploma, no high school diploma), presence of a partner, and maternal smoking during pregnancy and at 17 months. Lastly, depressive symptomatology according to the CES-D 12-item scale using a cut-point of ]12 (Poulin et al. 2005) and maternal self-reported health (very good, less than very good) were measured in the first and second rounds of the QLSCD. Similar longitudinal measures as described previously for the longitudinal measure of poverty were computed for maternal depressive symptomatology and self-reported health. Statistical analysis Descriptive analyses were stratified according to migration status to compare children born to minority migrant and Canadian-born mothers. Chi-square tests were used to compare proportions for characteristics of the children and mothers. Subsequently, multivariable logistic regressions were constructed to assess the association of migration status with perceived child health. Covariates were considered as follows: potential confounders were entered one by one into the model with maternal migration status; if their inclusion into the equation produced a change of more than 10% in the coefficient for perceived child health by maternal migration status, they were retained as control variables for the final model (Rothman 2002). Two covariates satisfied this condition: maternal self-reported health and symptoms of depression. Additional adjustment variables which were thought to play an important role in relation to the main independent variable and/ or health outcome were further controlled for by adding them to the final model. Odds ratios and 95% confidence intervals were calculated. Cases with missing data were excluded listwise from multivariable analyses (n 60). Of the 60 cases, 51 had missing data on the longitudinal measure of poverty, among which nine were categorised as minority migrants. Multiplicative interactions in the association between migration status and mother s perception of child s health were assessed using cross-product terms for exposure to poverty and social support. Interactions were tested one at a time, and significant interactions were included in the final models. Analyses were conducted using SPSS software, version Results The distribution of characteristics of the children and mothers is presented in Tables 1 and 2, respectively. Overall, children of minority migrant mothers were more likely to be perceived in less than excellent health compared to children of Canadian-born mothers. Children of minority migrants were slightly older, more likely to be third or more in birth rank, to have been breastfed for more than 3 months, and to attend a daycare centre. No statistically significant differences were found in child s sex,

9 Ethnicity & Health 191 Table 1. Characteristics of children from the Quebec Longitudinal Study of Child Development (QLSCD) born to minority migrant and Canadian-born mothers. Minority migrant mothers, N 165 Canadian-born mothers, N 1825 Total, N 1990 % % % Chi 2 p-value Health as perceived by mothers Excellent Less than excellent Child s sex Female Male Child s mean age in (0.56)** (0.56)** (0.56)** 0.041* months Birth rank First Second Third or more Premature birth (B37 weeks) No Yes Low birth weight (B2500 g) No Yes Congenital malformation No Yes Duration of Breastfeeding Never breastfeed B 3 months B0.001 ] 3 months Type of child care In child s home In a home other than child s home In a daycare centre Source: Direction santé Québec de l Institut de la statistique du Québec. *t-test p-value. **Standard deviation. premature birth, low birth weight, and congenital malformations (Table 1). Minority migrant mothers were more likely to be older at the birth of the index child, to speak a language other than French or English at home, to be always poor, to report lower levels of social support, to not live with a partner, to refrain from smoking

10 192 A. Van Hulst et al. Table 2. Maternal characteristics of children born to minority migrant and Canadian-born mothers from the Quebec Longitudinal Study of Child Development (QLSCD). Minority migrant mothers, N 165 Canadian-born mothers, N 1825 Total, N 1990 % % % Chi 2 p-value Age of mother at birth of child Less than 20 years years B years or more Language spoken at home by mother French and/or English B0.001 Other Length of time since migration Less than 5 years years years or more 39.4 Maternal level of education Partial or completed college or university studies High school or vocational or trade school diploma No high school diploma Poverty at 5 and 17 months Never poor Sometimes poor B0.001 Always poor Maternal level of social support High social support B0.001 Low social support Presence of a partner at 17 months Lives with a partner Lives without a partner Maternal smoking during pregnancy No B0.001 Yes Maternal smoking at 17 months No or occasionally B0.001 Yes Maternal depression at 5 and 17 months Never depressed

11 Ethnicity & Health 193 Table 2 (Continued ) Minority migrant mothers, N 165 Canadian-born mothers, N 1825 Total, N 1990 % % % Chi 2 p-value Sometimes depressed B0.001 Always depressed Maternal self-reported health at 5 and 17 months Always very good or excellent Sometimes less than very B0.001 good Always less than very good Source: Direction santé Québec de l Institut de la statistique du Québec. during the pregnancy and at 17 months, and to report more symptoms of depression and lower self-rated health at 5 and 17 months (Table 2). No difference in the level of education was found. Among migrants, 23% immigrated to Canada less than 5 years ago, 38% immigrated 59 years ago, and 39% immigrated 10 years or more ago. Length of time since migration was associated with duration of poverty: while more than 75% of mothers who immigrated less than 5 years ago were always poor, this proportion decreased to approximately 50% with increasing time in Canada, but did not nearly reach the levels seen among Canadian-born mothers (14%) even after more than 10 years since immigration. Low social support was more common among mothers who immigrated less than 10 years ago (18%); however, this proportion decreased to similar levels as seen in Canadian-born mothers with longer duration since immigration (]10 years) (3%). Results from multivariable logistic regressions are presented in Table 3. A statistically significant interaction was found between poverty, social support, and migration status (chi 2 p-value 0.003). Odds ratios (OR) presented in Table 3 are therefore stratified for these variables with, as reference group, children of Canadian-born mothers who were never poor and reported high social support. Overall, 75% of Canadian-born compared with 29% of minority migrants belonged to the most favourable subgroup ( never poor and high social support). The least favourable subgroup ( always poor and low social support) was composed of 1% of Canadian-born compared with 10% of minority migrants mothers. After adjusting for birth rank, type of child care, maternal age, maternal selfreported health, and symptoms of depression, child s health status as perceived by Canadian-born mothers did not vary significantly by level of social support or by poverty status. Contrary to expectations, Canadian-born mothers who were always poor and had low social support perceived their children to be in better health (OR 0.24; 95% CI: ). Among minority migrant mothers, perception of their child s health status varied according to levels of social support and poverty. Minority migrant mothers who were never poor and reported high social support

12 194 A. Van Hulst et al. Table 3. Mother s perception of child s health status in the Quebec Longitudinal Study of Child Development (QLSCD) stratified by maternal migration status, level of social support, and poverty. Child s health status perceived by mother as less than excellent Migration status Social support (n) Poverty (n) Crude OR (95% CI) Adjusted OR* (95% CI) Canadian-born mothers Minority migrant mothers High level Never poor 1 1 (1708) (1325) Sometimes poor 1.17 ( ) 1.05 ( ) (162) Always poor (221) 1.53 ( ) 1.36 ( ) Low level (68) Never poor (44) 1.25 ( ) 1.09 ( ) Sometimes poor 1.99 ( ) 1.28 ( ) (4) Always poor (20) 0.35 ( ) 0.24 ( ) High level Never poor (44) 0.51 ( ) 0.42 ( ) (134) Sometimes poor 2.16 ( ) 1.68 ( ) (25) Always poor (65) 1.93 ( ) 1.56 ( ) Low level (20) Never poor (3) 1.00 ( ) 0.67 ( ) Sometimes poor 1.99 ( ) 1.31 ( ) (2) Always poor (15) 7.96 ( ) 6.32 ( ) Source: Direction santé Québec de l Institut de la statistique du Québec. *Adjusted for birth order, maternal age, type of child care, maternal self reported health, and maternal depression. perceived their children to be in better health than comparable Canadian-born mothers (OR 0.42; 95% CI: ); however, when reporting low social support and being always poor children of minority migrants were perceived in worse health (OR 6.32; 95% CI: ) compared to the reference group. Adjusting for length of time since migration did not change estimates in the final model; however, it led to a decrease in the precision of estimates and was therefore not retained in the model. In secondary analyses, we compared children born to minority migrant mothers with those of Canadian-born mothers within comparable levels of social support and poverty status, by redefining the reference group in five additional logistic regression analyses (Table 4). Compared to Canadian-born mothers who are always poor and have low social support, minority migrant mothers with similar characteristics (i.e., always poor and low social support) were more likely to perceive their children in worse health (OR 26.31; 95% CI: ). Except for the measure of association

13 Ethnicity & Health 195 already presented for minority migrant mothers compared to Canadian-born mothers in the most favourable sub-group (high social support and never poor), other measures of association in these secondary analyses were not statistically significant. Discussion In this study we examined the associations between mother s migration status and the perceived health status of their 17-month-old child while considering the specific role of poverty and low social support in explaining differences in perceived health. In bivariate analyses, we found that, on average, children of minority migrant mothers were more often perceived in less than excellent health compared to children of Canadian-born mothers. Exposure to sustained poverty (two consecutive years) and low social support at 17 months were more common among minority migrants than among Canadian-born mothers. However, accounting for these differences in exposure did not explain differences in perceived child health. We also found differences according to migration status in the associations of the combined exposure to low social support and sustained poverty with child s health status. These findings support the vulnerability hypothesis whereby children of minority migrant mothers are perceived in worse health when they are exposed to both low social support and sustained poverty. This was true when compared to children of Canadian-born mothers in most favourable conditions (high social support and never poor) and to children of Canadian-born mothers in least favourable conditions (low social support and always poor). However, when in most favourable conditions (high social support and never poor ), children of minority migrant mothers were perceived in better health than children of Canadian-born mothers with similar conditions. Table 4. Mother s perception of child s health status in the Quebec Longitudinal Study of Child Development (QLSCD), comparing children of minority migrants to those of Canadian-born mothers within similar conditions of social support and poverty. Social support Poverty Migration status Adjusted OR* (95% CI) High level Never poor Minority migrant mothers 0.42 ( ) Canadian-born mothers 1 Sometimes poor Minority migrant mothers 1.54 ( ) Canadian-born mothers 1 Always poor Minority migrant mothers 1.19 ( ) Canadian-born mothers 1 Low level Never poor Minority migrant mothers 0.66 ( ) Canadian-born mothers 1 Sometimes poor Minority migrant mothers 1.07 ( ) Canadian-born mothers 1 Always poor Minority migrant mothers ( ) Canadian-born mothers 1 Source: Direction santé Québec de l Institut de la statistique du Québec. *Adjusted for birth order, maternal age, type of child care, maternal self-reported health, and maternal depression.

14 196 A. Van Hulst et al. Previous studies report a concentration of poverty and lower levels of social support among immigrants, and particularly among minority and recent migrants (Battaglini et al. 2000, Dunn and Dyck 2000, Sword et al. 2006). Potential explanations for these observations include discrimination and racism in workplaces as well as barriers experienced by immigrants in the recognition of skills and qualifications obtained in foreign countries. Our finding supports previous evidence that poor, socially marginalised migrants and their families experience worse health than the host country s population (Caritas Europa 2006). Low social support seems to be detrimental for children born to minority migrant mothers particularly when combined with sustained poverty. Raising a child in a new country while also having to adapt to a new culture is likely to be highly stressful for immigrants. Social support from family networks has been found to be most important, yet often lacking for immigrant women with young children (Battaglini et al. 2000, Ward 2003). One study reported that minority migrants were more likely to report both lower practical and emotional support compared to Australian-born mothers of 6- month-old infants (Bandyopadhyay et al. 2010). Another study found that the type of social support related to health differs by migration status (Dunn and Dyck 2000). For immigrants, not having somebody to make them feel loved was associated with poor self-reported health while for non-immigrants not having somebody to count on in a crisis was associated with poor self-reported health. This suggests that certain types of social support may be more important for minority migrant mothers with young children; however, our measure of social support did not allow us to examine the impact of different types of social support on perceived child health. Sustained poverty and reports of low social support decreased among minority migrants with increasing time since migration. The proportion of minority migrants reporting low social support reached those of Canadian-born mothers after more than 10 years since migration. However, sustained poverty remained significantly higher for minority migrants even after 10 years since migration. Time since migration may thus serve as a proxy for increased social support among minority migrants; however, it is an imperfect proxy for improved socio-economic conditions over time with increased duration in a host country. Time since migration has been identified as an important predictor of perinatal health (Gagnon et al. 2010) and has been used as an indicator of level of acculturation (Hunt et al. 2004). Our findings suggest that, at least for minority migrants, poverty combined with low social support may be a more important determinant for perceived child health than duration since immigration. The unanticipated finding among Canadian-born mothers with low social support and sustained poverty deserves further attention. This finding could be related to cultural differences in the correlates of self-reported health such that poor socio-economic conditions are more strongly related to poorer self-reported health among immigrants than among non-immigrants (Lindström et al. 2001). Alternatively, it might be related to random error since it was obtained from a small subgroup of children born to Canadian-born mothers who may not represent the group of children living in deprivation in the baseline population. This explanation is supported by previous studies using QLSCD data which reported that low household income and low social support were associated with poorer overall health regardless of migration status (Séguin et al. 2003, 2007).

15 Ethnicity & Health 197 This study, however, has some limitations that need to be taken into account when interpreting the results. First, the limited sample size of children born to minority migrant mothers resulted in imprecise estimates. Second, differences in baseline participation between immigrant and non-immigrant families are probable. Although information on baseline non-participants immigration status was not available, families who did not consent to participate were more likely to speak neither official language at home (Jetté and Groseilliers 2000). Also excluded by design from the baseline study population were families who were not sufficiently fluent in either study language. In Quebec, approximately 43% of immigrant families speak a language other than French or English in their home (Statistics Canada 2007a) and, upon admission to Quebec, approximately 23% do not speak either official language (Institut de la statistique du Québec 2009). Baseline nonparticipants are thus more likely to include immigrant families and may include most socially disadvantaged immigrant families due to language barriers. Similarly, losses to follow-up between the study s first and second rounds resulted in further differences between participants and non-participants, particularly with respect to migration status and socio-economic characteristics. Thus, particularly among immigrants, non-participation at baseline and losses to follow-up are expected to be higher for those who are most vulnerable with respect to socio-economic factors (i.e., social isolation due to language barriers, low income, low education). However, lower participation among socio-economically deprived families would only result in a selection bias if participation was also related to child health. In this case, lower participation among families whose child is in poorer health would result in an underestimation of measures of effect while lower participation among families whose child is in better health would result in an overestimation of measures of effect. Although there is no way to verify this information, we believe that the former is more likely. Lastly, the QLSCD did not include a measure of discrimination, which may be a potential confounder in the associations examined (De Maio and Kemp 2009). On the other hand, strengths of this study include that data of the QLSCD were collected prospectively using questionnaires previously validated in the National Longitudinal Study of Children and Youth (Jetté and Groseilliers 2000). Additionally, the initial sample was representative of the province s singleton life births, and the first two rounds of the QLSCD had overall high response rates. In the second round of the study, 11% of participating children were born to an immigrant mother, which is comparable to the province-wide proportion of children born to immigrant mothers at that time (12% in 1995 and 16% in 2000) (Institut de la statistique du Québec 2009). Finally, the inclusion of important longitudinal measures, including for poverty, in the current study allowed us to measure the impact of different levels of severity for these factors. Sustained poverty and low social support prevail among minority migrant families with young children residing in Quebec, Canada. Our findings reveal the importance of addressing these circumstances to avoid potential immediate and long-term adverse consequences on the well-being of children born to minority migrant mothers. More research using larger samples is needed to replicate our findings and to describe differences on other measures of health as well as on changes in health status over time as children of immigrant mothers become older. Findings also confirm the need for resources, both economic and social, to support

16 198 A. Van Hulst et al. immigrant families with young children, especially those originating from countries of non-french and non-english ancestry. Key messages (1) Exposure to both low social support and sustained poverty was more common among minority migrant families than among Canadian-born families with young children. (2) Compared to children of Canadian-born mothers, children of minority migrants were perceived in worse health when mothers reported low social support and sustained poverty but were perceived in better health when mothers reported high social support and not being poor. (3) Findings suggest that children of minority migrants are not equally vulnerable in terms of health risks: they form a heterogeneous group depending on their exposure to social determinants of health. Acknowledgements This study was funded by the Canadian Institute of Health Research (CIHR) Grant Number 00309MOP and by the Institut de la Statistique du Québec, Direction Santé Québec, which was responsible for the study s data collection. The Institut de recherche en santé publique de l Université de Montréal (IRSPUM) is funded by the Fonds de la Recherche en Santé du Québec (FRSQ) and the Centre Léa-Roback is funded by the FRSQ and the CIHR. AVH is supported by a CIHR Training Grant in Population Intervention for Chronic Disease Prevention: A Pan-Canadian Program. References Aber, J.L., et al., The effects of poverty on child health and development. Annual Review of Public Health, 18, Bandyopadhyay, M., et al., Life with a new baby: how do immigrant and Australianborn women s experiences compare? Australian and New Zealand Journal of Public Health, 34 (4), Battaglini, A., et al., Les mères immigrantes: Pareilles pas pareilles! Facteurs de vulnérabilité propres aux mères immigrantes en période périnatale [online]. Direction de la santé publique, Régie régionale de la santé et des services sociaux de Montréal-Centre. Available from: [Accessed 1 June 2008]. Beiser, M., et al., Growing up Canadian, a study of new immigrant children. Ottawa: Applied Research Branch, Strategic Policy, Human Resources Development Canada. Caritas Europa, Migration, a journey into poverty? A Caritas Europa study on poverty and exclusion of immigrants in Europe [online]. Available from: module/filelib/poverty2006enweb.pdf [Accessed 1 June 2008]. Cervantes, A., Keith, L., and Wyshak, G., Adverse birth outcomes among native-born and immigrant women: replicating national evidence regarding Mexicans at the local level. Maternal and Child Health Journal, 3 (2), Chen, J., Ng, E., and Wilkins, R., The health of Canada s immigrants in Health Reports, 7 (4), Cutrona, C.E. and Russell, D.W., The provisions of social relationships and adaptation to stress. In: W.H. Jones and D. Perlman, eds. Advances in personal relationships. Greenwich, CT: JAI Press, 3767.

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