BACKGROUND

Resettled refugees land in Canada through 3 sponsorship models with similar health insurance and financial supports but differences in how resettlement is facilitated. We examined whether health system utilization, costs, and aggregate 1-year morbidity differed by resettlement model.

METHODS

Population-based matched cohort study in Ontario, 2008 to 2018, including pediatric (0–17 years) resettled refugees and matched Ontario-born peers and categorized refugees by resettlement model: (1) private sponsorship (PSRs), (2) Blended Visa Office-Referred program (BVORs), and (3) government-assisted refugee (GAR). Primary outcomes were health system utilization and costs in year 1 in Canada. Multivariable logistic regression was used to test the associations between sponsorship model and major illnesses.

RESULTS

We included 23 287 resettled refugees (13 360 GARs, 1544 BVORs, 8383 PSRs) and 93 148 matched Ontario-born. Primary care visits were highest among GARs and lowest in PSRs (median visits [interquartile range], GARs 4[2–6]; BVORs 3[2–5]; PSRs 3[2–5]; P <.001). Emergency department visits and hospitalizations were more common among GARs and BVORs versus PSRs (emergency department: GARs 19.2%; BVORs 23.4%; PSRs 13.8%; hospitalizations: GARs 2.5%; BVORs 3.2%; PSRs 1.1%, P <.001). Mean 1-year health system costs were highest among GARs (mean [standard deviation] $1278 [$7475]) and lowest among PSRs ($555 [$2799]; Ontario-born $851 [9226]). Compared with PSRs, GARs (adjusted odds ratio 1.63, 95% confidence interval 1.47–1.81) and BVORs (adjusted odds ratio 1.52, 95% confidence interval 1.26–1.84) were more likely to have major illnesses.

CONCLUSIONS

Health care use and morbidity of PSRs suggests they are healthier and less costly than GARs and BVOR model refugees. Despite a greater intensity of health care utilization than Ontario-born, overall excess demand on the health system for all resettled refugee children is low.

What’s Known On This Subject:

Globally, the number of pediatric refugees is increasing. Along with Canada’s government-assisted refugee resettlement program, open to families with medically and socially complex needs, Canada has a unique refugee resettlement program in which private citizens are responsible for early settlement support.

What This Study Adds:

Pediatric refugees who come to Canada through private sponsorship are healthier with lower health system utilization compared with government-assisted and other resettlement models. Across all refugee groups, compared with Ontario-born, the excess demand on the health system is minimal.

In recent years, there has been an unprecedented level of global migration as families flee persecution and violence and seek refuge outside of their native homes.1  Many countries, including Canada, have opened their doors to refugees, welcoming tens of thousands of children and their parent(s) every year. Canada has consistently been among the top per capita receiving countries worldwide for resettled refugees.2,3  Canada has unique refugee resettlement streams, in which private citizens are responsible for early settlement support through (1) entirely private sponsorship (private sponsorship of refugees program [PSR]) or (2) blended sponsorship (Blended Visa Office-Referred program [BVOR]) models. These programs have been the subject of international interest with efforts underway through the Global Private Sponsorship Initiative to spread the models to other countries.4  The relatively large Canadian commitment to resettling Syrian refugees leveraged both private sponsorship models.

There are important knowledge gaps around how consistently private sponsorship meets refugee resettlement needs, especially as compared with more traditional and common government-assisted refugee (GAR) programs. Details of Canada’s refugee system and supports are available elsewhere with key differences and similarities outlined in Table 1.2,3  Broadly, the assignment to each of the PSR, BVOR, and GAR groups is nonrandom, with the most socially and medically complex refugees in the GAR program.3  Refugees in all models are immediately eligible for provincial health care with additional limited supplemental health insurance benefits for the first year from the Interim Federal Health Program for prescription drug coverage and limited dental services.57  Health system navigation is facilitated through respective sponsors. Refugee children and youth typically arrive in receiving countries with substantial disease burdens, often related to infection or malnutrition.812 

TABLE 1

Brief Overview of the 3 Main Refugee Resettlement Programs in Canada

PSRsGARsBVORs
Identification of potential refugees The Refugee and Humanitarian Resettlement Program helps refugees who are outside of Canada and their country of origin and who need protection. The UNHCR and Private Sponsors identify refugees for resettlement. A person cannot apply directly to Canada for resettlement. All resettled refugees are eligible for provincial health insurance upon arrival to Canada. 
Proportion of resettled refugees (2010–2014)a 46% 53% 1% 
Knowledge of English/Frencha 38% 26% 14% 
Top 3 countries of citizenshipa Iraq, Eritrea, Ethiopia Iraq, Bhutan, Somalia Myanmar, Eritrea, Iran 
Sponsors Permanent residents of Canada or Canadian citizens who are from faith communities, ethnic groups, families, charitable organizations Government of Canada Permanent residents of Canada or Canadian citizens who are from faith communities, ethnic groups, families, charitable organizations 
Financial support 12 mo, provided by Private Sponsor. Funds raised or use personal income to provide support for the first year 12 mo, provided by Government of Canada 6 mo, provided by Government of Canada AND 6 mo by Private Sponsor 
Start-up costs/settlement plan Private sponsor. Refugees also connected with settlement worker who supports settlement services and access to support services. Government of Canada including reception at port of entry, temporary accommodation, assistance finding permanent accommodation, basic orientation, links to settlement programing and federal and provincial programs provider through a service provider organization Private sponsor. Refugees also connected with settlement worker who supports settlement services and access to support services 
Social/emotional support during sponsorship period Private sponsor Service provider organization Private sponsor 
Referral Incorporated organizations that have signed a sponsorship agreement with Immigration, Refugees and Citizenship Canada or through small groups of residents that will act as guarantors. United Nations Refugee Agency or another designated referral organization. Emphasis on selecting Government Assisted Refugees on the basis of protection needs rather than ability to establish in Canada. United Nations Refugee Agency submits profiles to government of Canada for consideration, including eligibility and admissibility assessment. Profiles then matched to private sponsors. 
PSRsGARsBVORs
Identification of potential refugees The Refugee and Humanitarian Resettlement Program helps refugees who are outside of Canada and their country of origin and who need protection. The UNHCR and Private Sponsors identify refugees for resettlement. A person cannot apply directly to Canada for resettlement. All resettled refugees are eligible for provincial health insurance upon arrival to Canada. 
Proportion of resettled refugees (2010–2014)a 46% 53% 1% 
Knowledge of English/Frencha 38% 26% 14% 
Top 3 countries of citizenshipa Iraq, Eritrea, Ethiopia Iraq, Bhutan, Somalia Myanmar, Eritrea, Iran 
Sponsors Permanent residents of Canada or Canadian citizens who are from faith communities, ethnic groups, families, charitable organizations Government of Canada Permanent residents of Canada or Canadian citizens who are from faith communities, ethnic groups, families, charitable organizations 
Financial support 12 mo, provided by Private Sponsor. Funds raised or use personal income to provide support for the first year 12 mo, provided by Government of Canada 6 mo, provided by Government of Canada AND 6 mo by Private Sponsor 
Start-up costs/settlement plan Private sponsor. Refugees also connected with settlement worker who supports settlement services and access to support services. Government of Canada including reception at port of entry, temporary accommodation, assistance finding permanent accommodation, basic orientation, links to settlement programing and federal and provincial programs provider through a service provider organization Private sponsor. Refugees also connected with settlement worker who supports settlement services and access to support services 
Social/emotional support during sponsorship period Private sponsor Service provider organization Private sponsor 
Referral Incorporated organizations that have signed a sponsorship agreement with Immigration, Refugees and Citizenship Canada or through small groups of residents that will act as guarantors. United Nations Refugee Agency or another designated referral organization. Emphasis on selecting Government Assisted Refugees on the basis of protection needs rather than ability to establish in Canada. United Nations Refugee Agency submits profiles to government of Canada for consideration, including eligibility and admissibility assessment. Profiles then matched to private sponsors. 

This does not include refugees from the In-Canada Asylum Program where claimants make a claim to the Immigration, Refugee Board of Canada (IRB).

a

Immigration, Refugees and Citizenship Canada. Evaluation of the resettlement programs (GAR, PSR, BVOR, and RAP). Available at: https://www.canada.ca/content/dam/ircc/migration/ircc/english/pdf/pub/resettlement.pdf

Although GARs are known to have greater medical and social complexity than PSRs and BVORs based on the selection criteria of each resettlement program,3  the degree of medical complexity and the extent to which each group uses the health system early after arrival is largely unknown. These data are important for provinces, given that, although immigration policy is federal jurisdiction, provinces are largely responsible for health care, education, and social services. The objectives of this study are to report the demographic and health status characteristics of pediatric resettled refugees in Ontario, Canada by resettlement model and to examine health care use and costs in the first year after landing in Ontario. We present data on Ontario-born children and youth to contextualize utilization and resource intensity. In addition, with this study, we examine differences in standardized measures of morbidity across groups of resettled refugees and across refugees from different countries and distinct resettlement commitments. We hypothesize that GARs will have higher use of health care services and greater intensity of resource utilization as reflected by health system costs in the first year after arrival in Canada compared with PSRs.

We conducted a population-based matched cohort study among resettled refugee and Ontario children eligible for provincial health insurance using health administrative datasets linked at ICES (formerly Institute for Clinical Evaluative Sciences), a not-for-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health data without consent in Toronto, Canada. Ontario, Canada’s most populous province (population ∼14 million) receives ∼50% of Canada’s refugees each year, of which >98% settle in urban areas.13 

We included all resettled refugee children aged 0 to 17 years who landed in Ontario between April 1, 2008 and March 31, 2017. We did not include undocumented immigrants or refugees from the In-Canada Asylum Program,14  in which refugee applications are made by those already in Canada. We excluded those without a full year of publicly funded provincial health insurance coverage from the landing date and those without a valid health card number. We further excluded children with a missing census metropolitan area. Resettled refugees were matched 1:4 with Canadian-born children on birth date (+/− 30 days), sex, income quintile, and census metropolitan area. Refugees who could not be matched were excluded from analyses. Matched Ontarians were assigned an index date corresponding to their refugee match’s landing date. For greater context, Supplemental Table 5 shows characteristics of the matched Ontario-born population and the general population of Ontario children and youth.

We used multiple health and demographic databases available and linked at ICES. Individual person-level records were linked by using a unique encoded identifier, derived from the health card number of Ontario residents eligible for provincial health insurance, including resettled refugees. The Ontario portion of the Immigration, Refugees and Citizenship Canada Permanent Resident database contains demographic information on those who landed in Ontario since 1985 with permanent residency status (those granted the right to live, stay, and work in Canada).15  We used this database to ascertain refugees’ resettlement model, country of citizenship, world region of origin, and landing date. Refugees were also grouped into “pre-Syrian” era (before November 2015) and “Syrian” era (November 2015 onward) time periods that delineated Canada’s large and specific commitments to resettle Syrian refugees.16  Linkage of Immigration, Refugees and Citizenship Canada data to the Registered Persons Databases, the provincial health insurance registry, has been validated with linkage rates of 86%.17  The Ontario Health Insurance Plan physician billings database captured outpatient visits to primary care physicians and specialists. We ascertained visits to physicians and nurse practitioners in community health centers (CHC) using the CHC dataset. CHCs are nonprofit, community-based health organizations that provide primary health care, health promotion, and disease prevention services to those facing barriers.18  The Canadian Institute for Health Information Discharge Abstract Database and Same Day Surgery Databases identified hospitalizations and surgeries, whereas the National Ambulatory Care Reporting System identified emergency department (ED) discharge data. We used the Ontario Marginalization material deprivation index, a census-based measure, to categorize neighborhood-level marginalization closest to the year of landing.19  Such neighborhood measures of socioeconomic status have been associated with health outcomes and health system utilization.20  Individual-level measures of marginalization and income are not available in linked datasets. The Registered Persons Database was used for demographic characteristics (age, sex, postal code, and residence).

Our main exposure was the refugee resettlement model in 1 of 3 programs: (1) GAR, (2) PSR, or (3) BVOR (a program started in 2013).3  Under all 3 programs, resettled refugees are immediately eligible for provincial health care. GARs are assigned a case worker who helps them navigate health card applications and facilitates access to health care services. Both BVORs and PSRs are resettled by private citizens who take responsibility for this role.

Our secondary exposure was country of citizenship. Country of citizenship categories were chosen because of specific and large resettlement commitments by the federal government during the study period: Afghanistan, Iraq, Iran, Syria, Bhutan, Myanmar, Somalia, Eritrea, Congo, other African countries, and “other” countries.2123 

Health Services Utilization

We compared health care utilization among resettled refugees and matched Ontario-born children in the first year after landing. Primary care visits included those to a family physician, nurse practitioner, or pediatrician, and specialist visits included both overall and to pediatric subspecialists. We described ED visits by acuity level (high, low) and hospitalizations by type (medical vs surgical and elective vs nonelective) and facility type (pediatric academic, nonpediatric academic, and community). We enumerated the most common visit diagnoses across all settings using the International Classification of Diseases 10th Revision chapter and compared them across resettlement categories.

Health Care Costs

We described health care costs overall, by sector (eg, outpatient, hospitalizations), and by resettlement model as a proxy for health system resource intensity. Outpatient health care costs were based on unit costs of services provided to patients during an episode of care, paid by provincial insurance (Ontario Health Insurance Plan) to eligible health care providers. We calculated hospitalization, same-day surgery, and ED visit costs using case-mix methodology, in which the cost of a patient encounter is based on the intensity of resources used during the episode of care.24  Costs do not include primary care visits within CHCs.

Year 1 Morbidity

We measured aggregate morbidity at 1 year after arrival in Canada using the Johns Hopkins Adjusted Clinical Group (ACG) System aggregated diagnosis groups (ADGs) case-mix adjustment system. Case-mix assignment is based on several factors, including age, sex, and diagnoses received through outpatient and inpatient care settings, over a 1-year period. This measure predicts an individual’s morbidity and long-term health care needs and has been validated for use with health administrative data in pediatric populations.2529  We grouped ADGs into (1) any or 2+ major illnesses (using the ACG System ADGs of time-limited major; chronic medical, unstable; psychosocial, recurrent, persistent or unstable; progressive or likely to recur; or malignancy) and (2) minor (using the ACG System ADGs such as those with minor adverse effects, signs, and symptoms, and less likely to recur).

Analysis

We calculated frequencies and percentages to describe baseline characteristics of refugee groups and Ontario residents and used standardized differences to compare between groups.30  An imbalance in groups was defined as an absolute value >0.10. For health care utilization and costs, we used P values from a 1-way ANOVA, median (interquartile range) from the Kruskal-Wallis test, and, for categorical values, we used χ2 test. Multivariable logistic regression tested the relationship between having at least 1 major ADG and resettlement model among resettled refugees, adjusted for age, sex, and neighborhood level of material deprivation. As a secondary analysis, we compared aggregate morbidity across country cohorts using all resettled refugees as a referent group.

Ethics Approval

The Research Ethics Board at The Hospital for Sick Children, Toronto, Ontario approved this study.

From April 1, 2008 to March 31, 2017, 23 450 resettled refugee children and youth landed in Ontario. After exclusions, the cohort consisted of 23 287 resettled refugees and 93 148 matched Ontario-born children (Supplemental Fig 3). Among resettled refugees, there were 13 360 (57.4%) GARs, 1544 (6.6%) BVORs refugees, and 8383 (36.0%) PSRs (Table 1). Compared with the general population of Ontario-born children, refugees and the matched Ontario-born cohort had greater proportions of individuals in the lowest income quintile, highest material deprivation quintile, and urban settings (Supplemental Table 5).

Baseline demographic characteristics of resettled refugees and matched Ontario-born children are shown in Table 1. PSRs were older than BVOR refugees, and GARs and had equal proportions of males and females. The proportion of youth living in the lowest income quintile was highest among GARs (57.3%) and lowest among BVOR refugees (43.4%). Almost all (>99%) resettled refugees resided in urban locations, with exception of BVOR refugees, in which a proportion lived in rural areas (12.3%). PSRs were mainly from Iraq (31.6%), Syria (27.6%), and Afghanistan (12.1%), whereas a higher proportion of GARs and BVORs refugees were from Syria (42.2% and 79.8%, respectively). The majority (59.8%) of PSRs landed in the pre-Syrian era5  and almost all (93.8%) BVOR refugees arrived during the Syrian era.

Health care use in the first year of landing differed among resettled refugees (Table 2). Primary care visits were high among resettled refugees compared with matched Ontario-born children (median visits [interquartile range], GARs 4 [2–6]; BVORs refugees 3 [2–5]; PSRs 3 [2–5]; Ontario-born 2 [1–4]) with a similar distribution for any outpatient visits to all providers. The proportion of children with an outpatient visit to a physician or nurse practitioner for mental health concerns was similar between resettled refugees (10.5%) and matched Ontario-born children (11.3%) but was lower in PSRs (6.0%) compared with GARs (13.1%) and BVOR refugees (12.1%) (P <.001).

TABLE 2

Baseline Demographic Characteristics of Resettled Refugees Aged 0 to 17 y Who Landed in Ontario Between April 1, 2008 and March 31, 2017 and Matched Ontario-Born Youth, by Resettlement Model

VariableGARsBVORsPSRsStandardized DifferenceMatched Ontario-Born
GARs vs PSRsBVORs vs PSRs
n (%) 13 360 (57.4) 1544 (6.6) 8383 (36.0)   93 148 
Age, mean ± SD 8.19 ± 4.87 7.34 ± 4.67 8.66 ± 5.01 0.10 0.27 8.30 ± 4.92 
Age group, n (%)       
 <1 y 528 (4.0) 78 (5.1) 253 (3.0) 0.05 0.10 3390 (3.6) 
 1–4 y 3120 (23.4) 418 (27.1) 1907 (22.7) 0.01 0.01 21 859 (23.5) 
 5–12 y 6609 (49.5) 791 (51.2) 3925 (46.8) 0.03 0.04 45 296 (48.6) 
 13–17 y 3103 (23.2) 257 (16.6) 2298 (27.4) 0.01 0.04 22 603 (24.3) 
Sex, n (%)       
 Female 6430 (48.1) 736 (47.7) 4037 (48.2) 0.00 0.01 44 808 (48.1) 
 Male 6930 (51.9) 808 (52.3) 4346 (51.8) 0.00 0.01 48 340 (51.9) 
Neighborhood income quintile, n (%)      
 Q1 (lowest) 7658 (57.3) 670 (43.4) 4474 (53.4) 0.08 0.20 51 208 (55.0) 
 Q2 2455 (18.4) 356 (23.1) 1551 (18.5) 0.00 0.11 17 448 (18.7) 
 Q3 2143 (16.0) 225 (14.6) 1054 (12.6) 0.10 0.06 13 688 (14.7) 
 Q4 948 (7.1) 180 (11.7) 893 (10.7) 0.13 0.03 8084 (8.7) 
 Q5 (highest) 156 (1.2) 113 (7.3) 411 (4.9) 0.22 0.10 2720 (2.9) 
Material deprivation quintile, n (%)      
 Missing 8 (0.1) — — — — 149 (0.2) 
 Q1 (lowest) 301 (2.3) 106 (6.9) 385 (4.6) 0.13 0.10 6862 (7.4) 
 Q2 287 (2.1) 152 (9.8) 694 (8.3) 0.28 0.05 8722 (9.4) 
 Q3 2050 (15.3) 237 (15.3) 1026 (12.2) 0.09 0.09 11 328 (12.2) 
 Q4 3433 (25.7) 404 (26.2) 1732 (20.7) 0.12 0.13 17 842 (19.2) 
 Q5 (highest) 7281 (54.5) 645 (41.8)a 4546 (54.3)a 0.01 0.26 48 245 (51.8) 
Rurality, n (%)       
 Missing 6 (0.0) — — — — 0 (0.0) 
 Urban 13 331 (99.8) 1354 (87.7)a 8320 (99.2)a 0.08 0.48 91 946 (98.7) 
 Rural 23 (0.2) 190 (12.3) 63 (0.8) 0.09 0.48  
Census metropolitan area, n (%)      
 Toronto 4042 (30.3) 425 (27.5) 5173 (61.7) 0.67 0.73 38 560 (41.4) 
 Ottawa, Gatineau 2197 (16.4) 195 (12.6) 780 (9.3) 0.21 0.11 12 688 (13.6) 
 Hamilton 1985 (14.9) 83 (5.4) 473 (5.6) 0.31 0.01 10 164 (10.9) 
 Kitchener, Cambridge 1490 (11.2) 140 (9.1) 468 (5.6) 0.20 0.13 8392 (9.0) 
 London 1574 (11.8) 65 (4.2) 384 (4.6) 0.27 0.02 8092 (8.7) 
 Windsor 1612 (12.1) 26 (1.7) 475 (5.7) 0.23 0.21 8452 (9.1) 
 Other 460 (3.4) 610 (39.5) 630 (7.5) 0.18 0.81 6800 (7.3) 
Country of origin, n (%)      
 Afghanistan 491 (3.7) 0 (0.0) 1012 (12.1) 0.32 0.52 — 
 Other African countries 456 (3.4) 37 (2.4) 164 (2.0) 0.09 0.03 — 
 Bhutan 442 (3.3) — 0 (0.0) 0.26 — — 
 Congo 664 (5.0) 26 (1.7) 116 (1.4) 0.21 0.02 — 
 Eritrea 138 (1.0) 57 (3.7) 604 (7.2) 0.31 0.16 — 
 Ethiopia 156 (1.2) — 201 (2.4) 0.09 0.19 — 
 Iran 350 (2.6) 12 (0.8) 41 (0.5) 0.17 0.04 — 
 Iraq 2804 (21.0) 80 (5.2) 2648 (31.6) 0.24 0.73 — 
 Myanmar 511 (3.8) 63 (4.1) 73 (0.9) 0.20 0.21 — 
 Somalia 988 (7.4) 0 (0.0) 311 (3.7) 0.16 0.28 — 
 Syria 5644 (42.2) 1231 (79.8)a 2315 (27.6) 0.31 1.21 — 
 Other 716 (5.4) 38 (2.5) 898 (10.7) 0.20 0.34 — 
World region of origin, n (%)      
 Africa 2403 (18.0) 124 (8.0) 1398 (16.7) 0.03 0.27 — 
 Americas 186 (1.4) 15 (1.0) 62 (0.7) 0.06 0.03 — 
 Asia and Pacific 1631 (12.2) 65 (4.2) 1485 (17.7) 0.15 0.44 — 
 Europe and USA 94 (0.7) — 36 (0.4) 0.04 — — 
 Middle East 8980 (67.2) 1340 (86.8)a 5202 (62.1) 0.11 0.58 — 
 Stateless and missing 66 (0.5) — 200 (2.4) 0.16 — — 
Era of resettlement, n (%)       
 Pre-Syrian era 6818 (51.0) 96 (6.2) 5015 (59.8) 0.18 1.39 — 
 Syrian era 6542 (49.0) 1448 (93.8) 3368 (40.2) 0.18 1.39 — 
VariableGARsBVORsPSRsStandardized DifferenceMatched Ontario-Born
GARs vs PSRsBVORs vs PSRs
n (%) 13 360 (57.4) 1544 (6.6) 8383 (36.0)   93 148 
Age, mean ± SD 8.19 ± 4.87 7.34 ± 4.67 8.66 ± 5.01 0.10 0.27 8.30 ± 4.92 
Age group, n (%)       
 <1 y 528 (4.0) 78 (5.1) 253 (3.0) 0.05 0.10 3390 (3.6) 
 1–4 y 3120 (23.4) 418 (27.1) 1907 (22.7) 0.01 0.01 21 859 (23.5) 
 5–12 y 6609 (49.5) 791 (51.2) 3925 (46.8) 0.03 0.04 45 296 (48.6) 
 13–17 y 3103 (23.2) 257 (16.6) 2298 (27.4) 0.01 0.04 22 603 (24.3) 
Sex, n (%)       
 Female 6430 (48.1) 736 (47.7) 4037 (48.2) 0.00 0.01 44 808 (48.1) 
 Male 6930 (51.9) 808 (52.3) 4346 (51.8) 0.00 0.01 48 340 (51.9) 
Neighborhood income quintile, n (%)      
 Q1 (lowest) 7658 (57.3) 670 (43.4) 4474 (53.4) 0.08 0.20 51 208 (55.0) 
 Q2 2455 (18.4) 356 (23.1) 1551 (18.5) 0.00 0.11 17 448 (18.7) 
 Q3 2143 (16.0) 225 (14.6) 1054 (12.6) 0.10 0.06 13 688 (14.7) 
 Q4 948 (7.1) 180 (11.7) 893 (10.7) 0.13 0.03 8084 (8.7) 
 Q5 (highest) 156 (1.2) 113 (7.3) 411 (4.9) 0.22 0.10 2720 (2.9) 
Material deprivation quintile, n (%)      
 Missing 8 (0.1) — — — — 149 (0.2) 
 Q1 (lowest) 301 (2.3) 106 (6.9) 385 (4.6) 0.13 0.10 6862 (7.4) 
 Q2 287 (2.1) 152 (9.8) 694 (8.3) 0.28 0.05 8722 (9.4) 
 Q3 2050 (15.3) 237 (15.3) 1026 (12.2) 0.09 0.09 11 328 (12.2) 
 Q4 3433 (25.7) 404 (26.2) 1732 (20.7) 0.12 0.13 17 842 (19.2) 
 Q5 (highest) 7281 (54.5) 645 (41.8)a 4546 (54.3)a 0.01 0.26 48 245 (51.8) 
Rurality, n (%)       
 Missing 6 (0.0) — — — — 0 (0.0) 
 Urban 13 331 (99.8) 1354 (87.7)a 8320 (99.2)a 0.08 0.48 91 946 (98.7) 
 Rural 23 (0.2) 190 (12.3) 63 (0.8) 0.09 0.48  
Census metropolitan area, n (%)      
 Toronto 4042 (30.3) 425 (27.5) 5173 (61.7) 0.67 0.73 38 560 (41.4) 
 Ottawa, Gatineau 2197 (16.4) 195 (12.6) 780 (9.3) 0.21 0.11 12 688 (13.6) 
 Hamilton 1985 (14.9) 83 (5.4) 473 (5.6) 0.31 0.01 10 164 (10.9) 
 Kitchener, Cambridge 1490 (11.2) 140 (9.1) 468 (5.6) 0.20 0.13 8392 (9.0) 
 London 1574 (11.8) 65 (4.2) 384 (4.6) 0.27 0.02 8092 (8.7) 
 Windsor 1612 (12.1) 26 (1.7) 475 (5.7) 0.23 0.21 8452 (9.1) 
 Other 460 (3.4) 610 (39.5) 630 (7.5) 0.18 0.81 6800 (7.3) 
Country of origin, n (%)      
 Afghanistan 491 (3.7) 0 (0.0) 1012 (12.1) 0.32 0.52 — 
 Other African countries 456 (3.4) 37 (2.4) 164 (2.0) 0.09 0.03 — 
 Bhutan 442 (3.3) — 0 (0.0) 0.26 — — 
 Congo 664 (5.0) 26 (1.7) 116 (1.4) 0.21 0.02 — 
 Eritrea 138 (1.0) 57 (3.7) 604 (7.2) 0.31 0.16 — 
 Ethiopia 156 (1.2) — 201 (2.4) 0.09 0.19 — 
 Iran 350 (2.6) 12 (0.8) 41 (0.5) 0.17 0.04 — 
 Iraq 2804 (21.0) 80 (5.2) 2648 (31.6) 0.24 0.73 — 
 Myanmar 511 (3.8) 63 (4.1) 73 (0.9) 0.20 0.21 — 
 Somalia 988 (7.4) 0 (0.0) 311 (3.7) 0.16 0.28 — 
 Syria 5644 (42.2) 1231 (79.8)a 2315 (27.6) 0.31 1.21 — 
 Other 716 (5.4) 38 (2.5) 898 (10.7) 0.20 0.34 — 
World region of origin, n (%)      
 Africa 2403 (18.0) 124 (8.0) 1398 (16.7) 0.03 0.27 — 
 Americas 186 (1.4) 15 (1.0) 62 (0.7) 0.06 0.03 — 
 Asia and Pacific 1631 (12.2) 65 (4.2) 1485 (17.7) 0.15 0.44 — 
 Europe and USA 94 (0.7) — 36 (0.4) 0.04 — — 
 Middle East 8980 (67.2) 1340 (86.8)a 5202 (62.1) 0.11 0.58 — 
 Stateless and missing 66 (0.5) — 200 (2.4) 0.16 — — 
Era of resettlement, n (%)       
 Pre-Syrian era 6818 (51.0) 96 (6.2) 5015 (59.8) 0.18 1.39 — 
 Syrian era 6542 (49.0) 1448 (93.8) 3368 (40.2) 0.18 1.39 — 
a

Small cell sizes <6 suppressed as per institutional policy and number rounded to prevent back-calculation.

—, Cell size suppressed as per institutional policy with values added to largest group.

ED visits were more common among GARs and BVOR refugees compared with PSRs (GARs 19.2%; BVORs refugees 23.4%; PSRs 13.8%, P <.001). The proportions hospitalized in the first year between resettled refugees and matched Ontario-born children were similar (2.0% and 1.8%, respectively) with marked differences by groups (GARs 2.5%; BVORs refugees 3.2%; PSRs 1.1%). GARs had the greatest proportion admitted to pediatric academic hospitals compared with PSRs (67.8% vs 43.2%). Few resettled refugees required hospitalization in an ICU (61 patients, 0.3%). Reasons for visiting the ED and hospitalizations were similar between refugee resettlement groups and matched Ontario-born children, with visits most commonly for injuries and respiratory tract illness (Supplemental Tables 6 and 7). Specialist visits for GARs were most often for infectious diseases and neurodevelopmental concerns, both common among PSRs and BVOR refugees. For Ontario-born children, specialist visits were most often for behavioral and mental health concerns (Supplemental Tables 8 and 9).

Mean health system costs (Fig 1, Table 2) were higher among resettled refugees (mean [SD]: $1009 [$6068]) than in matched Ontario-born youth (mean [SD]: $852 [$9227]), and significantly higher among GARs (mean [SD]: 1278 [7475]) versus other resettled refugees (P <.001). Across all groups, outpatient visits were the highest contributor to costs.

FIGURE 1

Average health care costs among youth aged 0 to 17 years, inclusive, among resettled refugees that landed in Ontario between April 1, 2008 and March 31, 2017 and matched Ontario-born youth, by resettlement model.

FIGURE 1

Average health care costs among youth aged 0 to 17 years, inclusive, among resettled refugees that landed in Ontario between April 1, 2008 and March 31, 2017 and matched Ontario-born youth, by resettlement model.

Close modal

The odds of a major illness, as measured by 1 or more major ADG, in the first year since landing was highest among GARs (10.0%), followed by BVOR refugees (9.8%) and PSRs (6.6%) (GARs adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.47–1.81; BVORs refugees aOR 1.52, 95% CI 1.26–1.84) (Tables 3 and 4). In comparing morbidity by country cohort, children and youth from Syria had greater odds of having at least 1 major illness (aOR 1.36, 95% CI 1.23–1.50), whereas those from Eritrea (aOR 0.58, 95% CI 0.43–0.79) and Myanmar (aOR 0.69, 95% CI 0.50–0.95) had lower odds of having at least 1 a major illness compared with the overall population of resettled refugees (Fig 2, Supplemental Table 9).

FIGURE 2

Odds of having any major ADG among resettled refugees that landed in Ontario between April 1, 2008 and March 31, 2017 by country cohort (ref: average effect, all refugees).

FIGURE 2

Odds of having any major ADG among resettled refugees that landed in Ontario between April 1, 2008 and March 31, 2017 by country cohort (ref: average effect, all refugees).

Close modal
TABLE 3A

Health Care Use Among Youth Aged 0 to 17 y, Inclusive, Among Resettled Refugees Who Landed in Ontario Between April 1, 2008 and March 31, 2017 and Matched Ontario-Born Youth, by Resettlement Model

VariableGARsBVORsPSRsPAll Resettled RefugeesMatched Ontario-Born
n 13 360 1544 8383  23 287 93 148 
Primary care visits       
 Any PC visit, n (%) 12 205 (91.4) 1337 (86.6) 6764 (80.7) <.001 20 306 (87.2) 62 935 (67.6) 
 No. PC visits, median ± IQR 4 (2–6) 3 (2–5) 3 (2–5) <.001 4 (2–6) 2 (1–4) 
Outpatient visits       
 Any outpatient visit, n (%) 12 462 (93.3) 1381 (89.4) 6997 (83.5) <.001 20 840 (89.5) 67 907 (72.9) 
 No. outpatient visits, median ± IQR 5 (3–8) 4 (2–6) 3 (2–5) <.001 4 (2–7) 3 (1–5) 
Outpatient visits, mental health       
 Any visit, mental health, n (%) 1745 (13.1) 187 (12.1) 507 (6.0) <.001 2439 (10.5) 10 541 (11.3) 
 No. visits, mental health, median ± IQR 1 (1–2) 1 (1–2) 1 (1–2) .111 1 (1–2) 2 (1–3) 
Specialist visits       
 Any specialist visit, n (%) 5197 (38.9) 516 (33.4) 1933 (23.1) <.001 7646 (32.8) 29 795 (32.0) 
 No. specialist visits, median ± IQR 2 (1–3) 2 (1–3) 2 (1–3) <.001 2 (1–3) 2 (1–3) 
Pediatric subspecialist visits       
 Any subspecialist visit, n (%) 1376 (10.3) 82 (5.3) 306 (3.7) <.001 1764 (7.6) 4999 (5.4) 
 No. subspecialist visits, median ± IQR 1 (1–3) 2 (1–3) 1 (1–2) <.001 1 (1–2) 1 (1–2) 
ED visits, all-cause       
 Any ED visit, n (%) 2563 (19.2) 362 (23.4) 1160 (13.8) <.001 4085 (17.5) 20 942 (22.5) 
 No. ED visits, median ± IQR 1 (1–2) 1 (1–2) 1 (1–1) <.001 1 (1–2) 1 (1–2) 
High-acuity ED visits       
 Any high-acuity ED visit, n (%) 1796 (13.4) 229 (14.8) 748 (8.9) <.001 2773 (11.9) 13 817 (14.8) 
 No. high-acuity ED visits, median ± IQR 1 (1–1) 1 (1–2) 1 (1–1) .007 1 (1–1) 1 (1–2) 
Low-acuity ED visits       
 Any low-acuity visit, n (%) 1113 (8.3) 179 (11.6) 530 (6.3) <.001 1822 (7.8) 10 347 (11.1) 
 No. low-acuity ED visits, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .42 1 (1–1) 1 (1–1) 
ED visits, mental health       
 Any ED mental health visit, n (%) 50 (0.4) ≤5 (0.3) 10 (0.1) .002 64 (0.3) 621 (0.7) 
 No. ED mental health visits, median ± IQR 1 (1–1) 1 (1–2) 1 (1–2) .883 1 (1–1) 1 (1–1) 
Same-day surgery       
 Any SDS visit, n (%) 387 (2.9) 93 (6.0) 135 (1.6) <.001 615 (2.6) 1785 (1.9) 
 No. of SDS visit, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .048 1 (1–1) 1 (1–1) 
Hospitalizations, all-cause       
 Any all-cause hospitalizations, n (%) 328 (2.5) 50 (3.2) 95 (1.1) <.001 473 (2.0) 1659 (1.8) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .221 1 (1–1) 1 (1–1) 
Hospitalizations, medical       
 Any medical hospitalization, n (%) 246 (1.8) 36 (2.3) 64 (0.8) <.001 346 (1.5) 1245 (1.3) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .35 1 (1–1) 1 (1–1) 
Hospitalizations, surgical       
 Any surgical hospitalization, n (%) 115 (0.9) 18 (1.2) 38 (0.5) <.001 171 (0.7) 475 (0.5) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .355 1 (1–1) 1 (1–1) 
Hospitalizations, mental health       
 Any mental health hospitalization, n (%) 17 (0.1) ≤5 (0.2) ≤5 (0.0) .023 22 (0.1) 221 (0.2) 
ICU admissions       
 Any ICU admission, n (%) 48 (0.4) 6 (0.4) 7 (0.1) <.001 61 (0.3) 126 (0.1) 
Hospital type       
 Pediatric academic, n (%) 219 (67.8) 27 (56.3) 41 (43.2) <.001 287 (61.6) 811 (50.2) 
 Academic, n (%) 11 (3.4) — —  17 (3.6) 63 (3.9) 
 Community/small, n (%) 93 (28.8) 18–23 (37.5) 51–55 (53.7)  162 (34.8) 741 (45.9) 
Medical complexity       
 Major illness (2+ ADGs), n (%) 193 (1.4) 22 (1.4) 50 (0.6) <.001 265 (1.1) 647 (0.7) 
 Major illness (any major ADG), n (%) 1332 (10.0) 152 (9.8) 555 (6.6) <.001 2039 (8.8) 7142 (7.7) 
 Minor illness, n (%) 1503 (11.3) 125 (8.1) 438 (5.2) <.001 2066 (8.9) 6022 (6.5) 
VariableGARsBVORsPSRsPAll Resettled RefugeesMatched Ontario-Born
n 13 360 1544 8383  23 287 93 148 
Primary care visits       
 Any PC visit, n (%) 12 205 (91.4) 1337 (86.6) 6764 (80.7) <.001 20 306 (87.2) 62 935 (67.6) 
 No. PC visits, median ± IQR 4 (2–6) 3 (2–5) 3 (2–5) <.001 4 (2–6) 2 (1–4) 
Outpatient visits       
 Any outpatient visit, n (%) 12 462 (93.3) 1381 (89.4) 6997 (83.5) <.001 20 840 (89.5) 67 907 (72.9) 
 No. outpatient visits, median ± IQR 5 (3–8) 4 (2–6) 3 (2–5) <.001 4 (2–7) 3 (1–5) 
Outpatient visits, mental health       
 Any visit, mental health, n (%) 1745 (13.1) 187 (12.1) 507 (6.0) <.001 2439 (10.5) 10 541 (11.3) 
 No. visits, mental health, median ± IQR 1 (1–2) 1 (1–2) 1 (1–2) .111 1 (1–2) 2 (1–3) 
Specialist visits       
 Any specialist visit, n (%) 5197 (38.9) 516 (33.4) 1933 (23.1) <.001 7646 (32.8) 29 795 (32.0) 
 No. specialist visits, median ± IQR 2 (1–3) 2 (1–3) 2 (1–3) <.001 2 (1–3) 2 (1–3) 
Pediatric subspecialist visits       
 Any subspecialist visit, n (%) 1376 (10.3) 82 (5.3) 306 (3.7) <.001 1764 (7.6) 4999 (5.4) 
 No. subspecialist visits, median ± IQR 1 (1–3) 2 (1–3) 1 (1–2) <.001 1 (1–2) 1 (1–2) 
ED visits, all-cause       
 Any ED visit, n (%) 2563 (19.2) 362 (23.4) 1160 (13.8) <.001 4085 (17.5) 20 942 (22.5) 
 No. ED visits, median ± IQR 1 (1–2) 1 (1–2) 1 (1–1) <.001 1 (1–2) 1 (1–2) 
High-acuity ED visits       
 Any high-acuity ED visit, n (%) 1796 (13.4) 229 (14.8) 748 (8.9) <.001 2773 (11.9) 13 817 (14.8) 
 No. high-acuity ED visits, median ± IQR 1 (1–1) 1 (1–2) 1 (1–1) .007 1 (1–1) 1 (1–2) 
Low-acuity ED visits       
 Any low-acuity visit, n (%) 1113 (8.3) 179 (11.6) 530 (6.3) <.001 1822 (7.8) 10 347 (11.1) 
 No. low-acuity ED visits, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .42 1 (1–1) 1 (1–1) 
ED visits, mental health       
 Any ED mental health visit, n (%) 50 (0.4) ≤5 (0.3) 10 (0.1) .002 64 (0.3) 621 (0.7) 
 No. ED mental health visits, median ± IQR 1 (1–1) 1 (1–2) 1 (1–2) .883 1 (1–1) 1 (1–1) 
Same-day surgery       
 Any SDS visit, n (%) 387 (2.9) 93 (6.0) 135 (1.6) <.001 615 (2.6) 1785 (1.9) 
 No. of SDS visit, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .048 1 (1–1) 1 (1–1) 
Hospitalizations, all-cause       
 Any all-cause hospitalizations, n (%) 328 (2.5) 50 (3.2) 95 (1.1) <.001 473 (2.0) 1659 (1.8) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .221 1 (1–1) 1 (1–1) 
Hospitalizations, medical       
 Any medical hospitalization, n (%) 246 (1.8) 36 (2.3) 64 (0.8) <.001 346 (1.5) 1245 (1.3) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .35 1 (1–1) 1 (1–1) 
Hospitalizations, surgical       
 Any surgical hospitalization, n (%) 115 (0.9) 18 (1.2) 38 (0.5) <.001 171 (0.7) 475 (0.5) 
 No. hospitalizations, median ± IQR 1 (1–1) 1 (1–1) 1 (1–1) .355 1 (1–1) 1 (1–1) 
Hospitalizations, mental health       
 Any mental health hospitalization, n (%) 17 (0.1) ≤5 (0.2) ≤5 (0.0) .023 22 (0.1) 221 (0.2) 
ICU admissions       
 Any ICU admission, n (%) 48 (0.4) 6 (0.4) 7 (0.1) <.001 61 (0.3) 126 (0.1) 
Hospital type       
 Pediatric academic, n (%) 219 (67.8) 27 (56.3) 41 (43.2) <.001 287 (61.6) 811 (50.2) 
 Academic, n (%) 11 (3.4) — —  17 (3.6) 63 (3.9) 
 Community/small, n (%) 93 (28.8) 18–23 (37.5) 51–55 (53.7)  162 (34.8) 741 (45.9) 
Medical complexity       
 Major illness (2+ ADGs), n (%) 193 (1.4) 22 (1.4) 50 (0.6) <.001 265 (1.1) 647 (0.7) 
 Major illness (any major ADG), n (%) 1332 (10.0) 152 (9.8) 555 (6.6) <.001 2039 (8.8) 7142 (7.7) 
 Minor illness, n (%) 1503 (11.3) 125 (8.1) 438 (5.2) <.001 2066 (8.9) 6022 (6.5) 

IQR, interquartile range; PC, primary care

P values of <.05 were considered statistically significant.

TABLE 3B

Health Care Costs Among Resettled Refugees 1 Year After Arrival by Resettlement Model, Compared With Ontario-Born Youth, $CAD

VariableGARsBVORsPSRsAll Resettled RefugeesMatched Ontario-Born
n 13 360 1544 8383 23 287 93 148 
Total cost, mean ± SD 1277.93 ± 7475.29 1146.00 ± 5253.29 555.13 ± 2799.16 1008.98 ± 6068.26 851.95 ± 9226.88 
Total cost, median (IQR) 396 (197–770) 313 (127–691) 202 (78–435) 316 (133–642) 234 (101–575) 
Hospitalization cost, mean ± SD 379.93 ± 5301.64 365.60 ± 3504.30 106.34 ± 2048.89 280.49 ± 4297.31 167.90 ± 3080.97 
Hospitalization costs, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
Same day surgery cost, mean ± SD 48.77 ± 315.74 106.80 ± 494.31 28.17 ± 266.18 45.20 ± 315.04 28.78 ± 232.66 
Same day surgery cost, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
ED cost, mean ± SD 61.04 ± 199.09 68.93 ± 188.95 37.63 ± 133.42 53.13 ± 177.91 67.60 ± 190.98 
ED cost, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
Outpatient cost, mean ± SD 546.40 ± 1139.41 444.61 ± 978.42 295.38 ± 515.98 449.29 ± 958.12 320.62 ± 7574.09 
Outpatient cost, median ± SD 338 (167–593) 225 (90–480) 170 (62–360) 268 (111–508) 131 (40–342) 
Other cost, mean ± SD 290.57 ± 1890.09 266.86 ± 1371.65 115.79 ± 675.24 226.08 ± 1531.39 295.83 ± 2872.07 
Other cost, median (IQR) 4 (0–44) 5 (0–86) 0 (0–13) 1 (0–25) 35 (0–129) 
VariableGARsBVORsPSRsAll Resettled RefugeesMatched Ontario-Born
n 13 360 1544 8383 23 287 93 148 
Total cost, mean ± SD 1277.93 ± 7475.29 1146.00 ± 5253.29 555.13 ± 2799.16 1008.98 ± 6068.26 851.95 ± 9226.88 
Total cost, median (IQR) 396 (197–770) 313 (127–691) 202 (78–435) 316 (133–642) 234 (101–575) 
Hospitalization cost, mean ± SD 379.93 ± 5301.64 365.60 ± 3504.30 106.34 ± 2048.89 280.49 ± 4297.31 167.90 ± 3080.97 
Hospitalization costs, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
Same day surgery cost, mean ± SD 48.77 ± 315.74 106.80 ± 494.31 28.17 ± 266.18 45.20 ± 315.04 28.78 ± 232.66 
Same day surgery cost, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
ED cost, mean ± SD 61.04 ± 199.09 68.93 ± 188.95 37.63 ± 133.42 53.13 ± 177.91 67.60 ± 190.98 
ED cost, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 
Outpatient cost, mean ± SD 546.40 ± 1139.41 444.61 ± 978.42 295.38 ± 515.98 449.29 ± 958.12 320.62 ± 7574.09 
Outpatient cost, median ± SD 338 (167–593) 225 (90–480) 170 (62–360) 268 (111–508) 131 (40–342) 
Other cost, mean ± SD 290.57 ± 1890.09 266.86 ± 1371.65 115.79 ± 675.24 226.08 ± 1531.39 295.83 ± 2872.07 
Other cost, median (IQR) 4 (0–44) 5 (0–86) 0 (0–13) 1 (0–25) 35 (0–129) 

IQR, interquartile range; SD, standard deviation

P values of <0.05 were considered statistically significant.

P <.001 for all comparisons within resettled refugees.

TABLE 4

Odds of Having Any Major ADG Among Resettled Refugees That Landed in Ontario Between April 1, 2008 and March 31, 2017 by Sponsorship Model (ref: PSRs)

VariableaOR (95% CI)
Sponsorship model (ref: PSR)  
 GAR 1.63 (1.47–1.81) 
 BVOR 1.52 (1.26–1.84) 
Sex (ref: male)  
 Female 0.81 (0.74–0.89) 
Age group (ref: 13–17 y)  
 <1 y 1.14 (0.89–1.46) 
 1–4 y 1.21 (1.06–1.38) 
 5–12 y 1.07 (0.95–1.20) 
Material deprivation quintile (ref: Q5)  
 Q1 (highest) 1.12 (0.88–1.44) 
 Q2 1.51 (1.24–1.84) 
 Q3 0.77 (0.67–0.89) 
 Q4 0.91 (0.81–1.02) 
VariableaOR (95% CI)
Sponsorship model (ref: PSR)  
 GAR 1.63 (1.47–1.81) 
 BVOR 1.52 (1.26–1.84) 
Sex (ref: male)  
 Female 0.81 (0.74–0.89) 
Age group (ref: 13–17 y)  
 <1 y 1.14 (0.89–1.46) 
 1–4 y 1.21 (1.06–1.38) 
 5–12 y 1.07 (0.95–1.20) 
Material deprivation quintile (ref: Q5)  
 Q1 (highest) 1.12 (0.88–1.44) 
 Q2 1.51 (1.24–1.84) 
 Q3 0.77 (0.67–0.89) 
 Q4 0.91 (0.81–1.02) 

In this population-based matched cohort study, we observed that ambulatory care utilization, including primary care, was high across all resettled refugee groups, with the highest use observed among GARs. PSRs consistently used acute care services less than other resettled refugee and Ontario-born peers, whereas BVOR refugees’ use of acute care was highest. Among refugees, PSRs had the lowest 1-year aggregate morbidity and used fewer resources. Compared with all resettled refugees, refugees from Eritrea and Myanmar had the lowest aggregate 1-year morbidity, with the highest morbidity observed among refugees from Syria. Although BVOR refugees and GARs generally had greater morbidity and health system utilization than PSRs, at the current levels of Canadian resettlement, refugee children and youth do not place substantial demands on the health care system above and beyond utilization by their Ontario-born peers, even in the first year of resettlement.

GARs, PSRs, and BVOR refugees have access to health care services and either formal or informal settlement support services after arrival in Canada. How refugees are guided through the health and social systems differs by resettlement model (Table 1). The differences in the orientation to health services after settlement and the subsequent ability of refugees to navigate and understand health care services may contribute to our findings. Compared with standalone clinics often accessed by PSRs, integrated community-based primary care with partnerships between dedicated refugee health clinics, local reception centers, and community providers available to GARs may improve timely access to care and better match referrals with needs and services.31  Such care integration may have been a factor in observed high utilization, including for subspecialty care, among GARs. Although observed differences may be, at least in part, related to differences in assistance with health system navigation, our data also indicate that GARs have higher morbidity and more medical complexity than BVOR refugees or PSRs. Others have reported that GARs from Syria have a 2.6 higher odds of unmet health care needs up to 12 months after resettlement compared with PSRs.32  This implies that the magnitude of quality resources required to meet the needs of GARs may actually be greater than our data suggest. This also highlights that there may be inequitable health service responses for different populations based on need.

Reports of refugee children indicate they have high medical needs, mostly related to communicable diseases, including tuberculosis, hepatitis B, and malaria,8,10,12  micronutrient deficiencies,33,34  and dental problems.11,35,36  Because such illnesses are often manageable in primary care, early engagement is essential.9  Our results reveal that almost all resettled refugees have at least 1, and often more, visits to primary care within their first year in Canada, with a larger proportion of GARs seeing subspecialists for infection-related concerns. Connecting refugees to services for noncommunicable disease assessments is also important, especially for children with neurodevelopmental concerns. For all resettled refugee groups, besides infections, neurodevelopmental concerns were one of the top reasons for subspecialty visits. In contrast, for Ontario-born children, specialist visits were most often for behavioral and mental health concerns. Despite the well-described trauma and mental distress many refugees have experienced5,3740  and self-reported unmet mental health care needs,41  the provision of mental health care in this study was low, especially for PSRs. For some, psychological support may come from community resources, although others may have an unmet need.42  Measuring physician visits alone likely underestimates the true need for mental health services for refugees.32,43,44 

For acute care visits, we report Ontario-born children and resettled refugees have similar diagnoses, including high proportions of visits for respiratory tract illnesses and injuries. Others have also reported similar visit reasons in refugee children with comparable proportions visiting the ED in the early resettlement period.8,45  The low proportion of low-acuity visits among refugees, and especially among PSRs, suggests access to primary care may be adequate. The higher number of hospitalizations observed in GARs and BVOR refugees compared with PSRs suggests there may be greater morbidity in these populations.

There are important limitations to this study. We included resettled refugees with immediate access to provincial health care coverage; however, refugees may still use the Interim Federal Health Program until a provincial health card number is issued.5  Although likely infrequent, we may have missed some early health care use. Our data do not have measures of community and social support (eg, housing, settlement workers) or allied health (eg, psychologists, social workers), so underestimates may have been made in total health care costs. Health information before migration is not available and, therefore, we have no measures of baseline health status. This study does not measure unmet health care needs, and we are unable to measure the quality of care received. There are differences in refugees’ settlement models in terms of social supports provided and the presettlement experience that may be associated with health system utilization that were not captured in available data and are an important consideration for contextualizing findings.5 

Canada has a unique refugee resettlement model and resettles among the highest per capita number of refugees. Pediatric refugees who come to Canada through private sponsorship have lower aggregate morbidity with lower health system utilization in the first year after arrival compared with refugees arriving through the GAR and BVOR models. While refugees in these latter 2 models have a greater intensity of health care utilization than those resettling through private sponsorship and Ontario-born, the overall excess demand on the health system for all resettled pediatric refugees is minimal. Resettled refugees in Canada are similar to those in other countries. Taken together, these findings can assist health system planners and immigration ministries from countries across the globe to understand optimal models of refugee resettlement and facilitate planning for how best to support the early health care needs of pediatric refugees.

Dr Saunders conceptualized and designed the study, interpreted the results, drafted the initial manuscript, and revised the manuscript; Dr Guttmann, Ms Gandhi, Dr Stukel, and Dr Wanigaratne conceptualized and designed the study, interpreted the results, and revised the manuscript; Drs Glazier and Rayner interpreted the results and revised the manuscript; Dr Lu had access to and analyzed the data, interpreted the results and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-059255.

FUNDING: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOH is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI) and Immigration, Refugees Citizenship Canada (IRCC). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHI or IRCC. Geographical data are adapted from Statistics Canada, Postal Code Conversation File + 2011 (Version 6D) and 2016 (Version 7B). This does not constitute endorsement by Statistics Canada of this project. Funding for this study was provided by the Canadian Institutes of Health Research grant number PJT 155917 (Dr Guttmann). Dr Guttmann is funded by a Tier 1 Canada Research Chair. The other authors received no additional funding.

CONFLICT OF INTEREST DISCLOSURES: Natasha Saunders reports receiving an editorial honorarium from Archives of Diseases in Childhood and an honorarium from MSI Foundation outside the submitted work. The other authors have no conflicts of interest relevant to this article to disclose.

aOR

adjusted odds ratio

ADG

aggregated diagnosis group

CHC

community health centers

CI

confidence intervals

BVOR

Blended Visa Office-Referred program

ED

emergency department

GAR

government-assisted refugee

PSR

privately sponsored refugee

1
United Nations
.
World migration report 2020
.
Available at: https://www.un.org/sites/un2.un.org/files/wmr_2020.pdf. Accessed September 19, 2022
2
Government of Canada
.
#WelcomeRefugees: key figures
.
3
Government of Canada
;
Immigration, Refugees and Citizenship Canada
.
Evaluation of the resettlement programs (GAR, PSR, BVOR and RAP)
.
4
Global Refugee Sponsorship Initiative
.
Global Refugee Sponsorship Initiative
.
Available at: https://refugeesponsorship.org/. Accessed July 13, 2020
5
Hansen
L
,
Huston
P
.
Health considerations in the Syrian refugee resettlement process in Canada
.
Can Commun Dis Rep
.
2016
;
42
(
Suppl 2
):
S3
S7
6
Government of Canada
.
Interim federal health program – information for health-care professionals
.
7
Interim Federal Health Program
.
Summary of benefits
.
Available at: www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp. Accessed November 13, 2015
8
Watts
DJ
,
Friedman
JF
,
Vivier
PM
, et al
.
Health care utilization of refugee children after resettlement
.
J Immigr Minor Health
.
2012
;
14
(
4
):
583
588
9
Pottie
K
,
Janakiram
P
,
Topp
P
,
McCarthy
A
.
Prevalence of selected preventable and treatable diseases among government-assisted refugees: implications for primary care providers
.
Can Fam Physician
.
2007
;
53
(
11
):
1928
1934
10
Lifson
AR
,
Thai
D
,
O’Fallon
A
, et al
.
Prevalence of tuberculosis, hepatitis B virus, and intestinal parasitic infections among refugees to Minnesota
.
Public Health Rep
.
2002
;
117
(
1
):
69
77
11
Hayes
EB
,
Talbot
SB
,
Matheson
ES
, et al
.
Health status of pediatric refugees in Portland, ME
.
Arch Pediatr Adolesc Med
.
1998
;
152
(
6
):
564
568
12
Meropol
SB
.
Health status of pediatric refugees in Buffalo, NY
.
Arch Pediatr Adolesc Med
.
1995
;
149
(
8
):
887
892
13
Colizzi
M
,
Lasalvia
A
,
Ruggeri
M
.
Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care?
Int J Ment Health Syst
.
2020
;
14
:
23
14
Colizzi
M
,
Sironi
E
,
Antonini
F
, et al
.
Psychosocial and behavioral impact of COVID-19 in autism spectrum disorder: an online parent survey
.
Brain Sci
.
2020
;
10
(
6
):
E341
15
Soglin
LF
,
Ragavan
MI
,
Li
JC
,
Soglin
DF
.
A validated screening instrument for identifying intimate partner violence in South Asian immigrant women
.
J Interpers Violence
.
2021
;
36
(
13–14
):
NP7027
NP7044
16
Government of Canada
.
Canada’s Syrian commitments
.
17
Chiu
M
,
Lebenbaum
M
,
Lam
K
, et al
.
Describing the linkages of the immigration, refugees and citizenship Canada permanent resident data and vital statistics death registry to Ontario’s administrative health database
.
BMC Med Inform Decis Mak
.
2016
;
16
(
1
):
135
18
Refaeli
T
,
Levy
D
,
Ben-Porat
A
, et al
.
Personal and environmental predictors of depression among victims of intimate partner violence: comparison of immigrant and Israeli-born women
.
J Interpers Violence
.
2019
;
34
(
7
):
1487
1511
19
Matheson
F
,
Dunn
J
,
Smith
KWL
, et al
.
Ontario Marginalization Index User Guide. Version 1.0
.
Toronto, Canada
:
Centre for Research on Inner City Health
;
2012
20
Moss
JL
,
Johnson
NJ
,
Yu
M
, et al
.
Comparisons of individual- and area-level socioeconomic status as proxies for individual-level measures: evidence from the Mortality Disparities in American Communities study
.
Popul Health Metr
.
2021
;
19
(
1
):
1
21
Global Affairs Canada
.
Canada and Iraq relations
.
22
Government of Canada
.
Canada announces plans to resettle more Bhutanese refugees
.
23
Prakash
N
,
Prevot
J
,
Kola
B
,
Wood
SK
.
Improving health outcomes for immigrant families through IPV screening: resources and recommendations for pediatric health care providers
.
Curr Probl Pediatr Adolesc Health Care
.
2019
;
49
(
1
):
7
15
24
Wodchis
WP
,
Bushmeneva
K
,
Nikitovic
M
,
McKillop
I
;
University of Toronto
.
Guidelines on person-level costing using administrative databases in Ontario
.
Available at: https://tspace.library.utoronto.ca/handle/1807/87373. Accessed December 2, 2020
25
Rosenbaum
PL
.
Exploring the Johns Hopkins Aggregated Diagnosis Groups in administrative data as a measure of child health
.
Int J Child Health Hum Dev
.
2017
;
10
(
1
):
19
26
Starfield
B
,
Weiner
J
,
Mumford
L
, %
Steinwachs
D
.
Ambulatory care groups: a categorization of diagnoses for research and management
.
Health Serv Res
.
1991
;
26
(
1
):
53
74
27
Austin
PC
,
van Walraven
C
,
Wodchis
WP
, et al
.
Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada
.
Med Care
.
2011
;
49
(
10
):
932
939
28
Siedner
MJ
,
Kraemer
JD
,
Meyer
MJ
, et al
.
Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis
.
BMJ Open
.
2020
;
10
(
10
):
e043763
29
Reid
R
,
MacWilliam
L
,
Roos
NP
, et al
.
Measuring Morbidity in Populations: Performance of the Johns Hopkins Adjusted Clinical Group (ACG) Case-Mix Adjustment System in Manitoba
.
Manitoba, Canada
:
Manitoba Centre for Health Policy and Evaluation
;
1999
30
Austin
P
.
Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research
.
Commun Stat Simul Comput
.
2009
;
38
(
6
):
1228
1234
31
McMurray
J
,
Breward
K
,
Breward
M
, et al
.
Integrated primary care improves access to healthcare for newly arrived refugees in Canada
.
J Immigr Minor Health
.
2014
;
16
(
4
):
576
585
32
Oda
A
,
Hynie
M
,
Tuck
A
, et al
.
Differences in self-reported health and unmet health needs between government assisted and privately sponsored Syrian refugees: a cross-sectional survey
.
J Immigr Minor Health
.
2019
;
21
(
3
):
439
442
33
Geltman
PL
,
Brown
MJ
,
Cochran
J
.
Lead poisoning among refugee children resettled in Massachusetts, 1995 to 1999
.
Pediatrics
.
2001
;
108
(
1
):
158
162
34
Geltman
PL
,
Radin
M
,
Zhang
Z
, et al
.
Growth status and related medical conditions among refugee children in Massachusetts, 1995-1998
.
Am J Public Health
.
2001
;
91
(
11
):
1800
1805
35
Cote
S
,
Geltman
P
,
Nunn
M
, et al
.
Dental caries of refugee children compared with US children
.
Pediatrics
.
2004
;
114
(
6
):
e733
e740
36
Quach
A
,
Laemmle-Ruff
IL
,
Polizzi
T
, %
Paxton
GA
.
Gaps in smiles and services: a cross-sectional study of dental caries in refugee-background children
.
BMC Oral Health
.
2015
;
15
:
10
37
Betancourt
TS
,
Abdi
S
,
Ito
BS
, et al
.
We left one war and came to another: resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families
.
Cultur Divers Ethnic Minor Psychol
.
2015
;
21
(
1
):
114
125
38
Guruge
S
,
Butt
H
.
A scoping review of mental health issues and concerns among immigrant and refugee youth in Canada: looking back, moving forward
.
Can J Public Health
.
2015
;
106
(
2
):
e72
e78
39
Beiser
M
,
Simich
L
,
Pandalangat
N
, et al
.
Stresses of passage, balms of resettlement, and posttraumatic stress disorder among Sri Lankan Tamils in Canada
.
Can J Psychiatry
.
2011
;
56
(
6
):
333
340
40
Lustig
SL
,
Kia-Keating
M
,
Knight
WG
, et al
.
Review of child and adolescent refugee mental health
.
J Am Acad Child Adolesc Psychiatry
.
2004
;
43
(
1
):
24
36
41
Oda
A
,
Tuck
A
,
Agic
B
, et al
.
Health care needs and use of health care services among newly arrived Syrian refugees: a cross-sectional study
.
CMAJ Open
.
2017
;
5
(
2
):
E354
E358
42
Herati
H
,
Meyer
SB
.
Mental health interventions for immigrant-refugee children and youth living in Canada: a scoping review and way forward. [published online ahead of print September 11, 2020]
J Ment Health
.
doi:10.1080/09638237.2020.1818710
43
Tuck
A
,
Oda
A
,
Hynie
M
, et al
.
Unmet health care needs for Syrian refugees in Canada: a follow-up study
.
J Immigr Minor Health
.
2019
;
21
(
6
):
1306
1312
44
Barwick
M
,
Urajnik
D
,
Sumner
L
, et al
.
Profiles and service utilization for children accessing a mental health walk-in clinic versus usual care
.
J Evidence-Based Soc Work
.
2013
;
10
(
4
):
338
352
45
Darwish
W
,
Muldoon
L
.
Acute primary health care needs of Syrian refugees immediately after arrival to Canada
.
Can Fam Physician
.
2020
;
66
(
1
):
e30
e38

Supplementary data