Immigrant youth are at high risk of experiencing discrimination, harassment, aggression, physical violence, and sexual violence in their destination country.1 These risks affect youth who are refugees or asylum seekers as well as those who experience voluntary or planned migration. The potential risk for harm after immigration demonstrates a clear need for research to inform prevention and intervention efforts to protect the safety and security of immigrant youth.
In this context, the study by Saunders and colleagues2 on the risk of experiencing violent injury among immigrant and refugee youth in Canada is timely and important. Canada is a leader in the Americas in accepting immigrant families, and immigrants to Canada constitute nearly one-quarter of the population.3 The study by Saunders et al2 included nearly 23 million person-years for youth aged 10 to 24 years between 2008 and 2016 and found that rates of violent injuries—those requiring acute care (ie, an emergency department visit or hospitalization) or resulting in death—to be 51% lower among immigrant youth compared with Canadian-born youth after adjusting for age, sex, neighborhood income, and rurality.2 Rates of injuries were particularly low among immigrants from South and East Asia, Canada’s largest intake countries. Saunders et al2 explain that Canada accepts a relatively high proportion of immigrants in socioeconomic classes that place them at lower risk of experiencing violence. Additionally, Saunders et al2 posit that other factors, such as the type of social support, family cohesion, and living in communities with other immigrants, may be protective against experiencing violence among immigrant youth.4
However, this study found that refugee status was associated with higher risk of experiencing violent injuries compared with nonrefugee status, while both groups had lower rates of assault than nonimmigrants. This difference in risk may reflect a difference between the experience of arriving in Canada following forced displacement compared with voluntary and planned migration. In addition, refugee and immigrant groups may experience differential rates of xenophobia, discrimination, and harassment. Somali youth were the only immigrant youth who experienced higher rates of violent injuries compared with nonimmigrants. This finding amplifies recent efforts by community-led organizations, such as Youth LEAPS5 in Toronto, Ontario, to raise awareness and address the large burden of violence and homicide—often associated with racism and Islamophobia—that Somali youth face. For example, although Somali people constitute 1% of the population, in 2014, 16% of homicide victims in Toronto were Somali.
The ability of Saunders et al2 to link health and administrative data sets (ie, health insurance registry, emergency department visits, hospitalizations, deaths, residence information, and immigration status) fills an important gap in scholarship on violence against immigrant youth. The size of the study sample allowed the authors to evaluate the risk of experiencing violent injury at the level of country of origin. This level of granularity beyond the regional level is unique in population health and critical in understanding health disparities. In a context in which data on immigration status are often scarce, the study by Saunders et al2 provides a blueprint for other researchers on how to use health and administrative data to examine the associations of immigrant and refugee status with a variety of health outcomes.
This study also draws attention to several important themes researchers of violence and immigration are grappling with: first, the importance of examining discrimination; second, who may be missing in data; and third, how sociopolitical context is associated with health outcomes. First, while the large sample allowed the data to be evaluated to a more granular level to include country of origin for immigrant groups, it did not include race or ethnicity data. It was not possible to compare the rates of violent experiences between immigrants and nonimmigrants with the same race or ethnicity. This is especially important given that the authors found higher rates of violent injury among Somali immigrant youth than among nonimmigrant youth.2 Research to determine whether Somali immigrant youth have similar rates of experiencing violent injury compared with other individuals categorized as the same race who would have similar experiences of racism may help inform ongoing efforts to address this disparity in experiencing violent injury.
Second, as Saunders et al2 note, there were important exclusions in the data: individuals who were included were only those with the most severe violent injuries who reached a hospital and not those who experienced bullying or discrimination, which are also generally acknowledged as harmful to health. Immigration status was only available for permanent residents, so the sample of youth did not include undocumented or temporary residents, asylum seekers, and those who had not yet obtained permanent residency. There are a number of barriers that may make immigrants less likely to seek care within the health care system, including language barriers, limited familiarity with the systems,6 or the sensitive nature of their injury (eg, intimate partner violence or child abuse).
Third, research on immigrant health occurs within a sociopolitical context. In 2012, the Canadian federal government instated cuts to the Interim Federal Health Program (IFHP) limiting access to comprehensive health care for refugees and refugee claimants in Canada.7 Although some of these provisions were reinstated after a 2014 court ruling that deemed these cuts a violation of Canada’s Charter of Rights and Freedoms, the IFHP was only fully reversed in 2016 by a new administration.7 Therefore, during the study years when the IFHP was reduced, a higher proportion of refugees may have been excluded from care and would not have been included in this study. The sociopolitical context that allowed the IFHP cuts to move forward in 2012 may also have placed youth at increased risk of violent injury.
This large study of youth in Ontario, Canada,2 is important foundational work for understanding the association of immigration status and with experiencing violent injury. It will be critical for future studies in the field to examine the associations of social exclusion, racism, xenophobia, Islamophobia, and other forms of discrimination with risk of experiencing violent injury. Elucidating the role of the explanatory factors that Saunders et al2 posit may be protective (ie, education level, language proficiency, trauma history, social support, and family cohesion) will require new approaches to data and measurement. Future studies should also evaluate specificity in the types of violence experienced by youth (eg, child abuse, hate crimes, or youth, intimate partner, gang, or bystander violence). Families and communities affected by violence should inform research approaches via community-based participatory research, which could both generate critical insights and further inform efforts to use and improve population data. Additionally, research on how the sociopolitical determinants of health can shape the immigrant experience will be particularly important to inform policy and hold governments accountable for their responsibility in protecting immigrant health and rights.
Published: March 4, 2020. doi:10.1001/jamanetworkopen.2020.1456
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Adhia A et al. JAMA Network Open.
Corresponding Author: Avanti Adhia, ScD, Harborview Injury Prevention and Research Center, University of Washington, Box 359960, 325 Ninth Ave, Seattle, WA 98104 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Adhia A, Bhatia A, Dawson-Hahn E. Violence Against Immigrant Youth in Canada: Why More Research Is Needed. JAMA Netw Open. 2020;3(3):e201456. doi:10.1001/jamanetworkopen.2020.1456
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