Health of international students in Canada (2013–2024): a scoping review of peer-reviewed and grey literature

Abstract

Objectives

This scoping review explores the health of international students (IS) in Canada by focusing on publicly funded healthcare eligibility, health outcomes and healthcare services, and the social and structural determinants of health (SSDOH).

Design

We registered a protocol and followed scoping review guidance. A search strategy was developed by a librarian, and Google Advanced Search was used for grey literature. Two reviewers screened peer-reviewed studies and one reviewer screened grey literature.

Data sources

Government websites were searched to understand healthcare eligibility. Six databases were searched for peer-reviewed studies. Grey literature sources included news media and websites of educational institutions and non-profits.

Eligibility criteria

We included peer-reviewed and grey literature on IS published between 2013 and 2024. We excluded non-English language studies, protocols and abstracts.

Data extraction and synthesis

Two reviewers extracted data for peer-reviewed studies, produced descriptive statistics and narrative summaries. One reviewer conducted these for grey literature sources.

Results

Most IS in Canada are ineligible for publicly funded healthcare. Among 282 peer-reviewed studies, 26 met our inclusion criteria. Mental health (MH) was the most frequently mentioned, while grey literature also emphasised violence and mortality. Studies focusing on MH generally found better outcomes among IS compared with domestic students. Qualitative studies reported on the SSDOH more than quantitative studies, highlighting that the social environment contributed to MH challenges.

Conclusions

Public healthcare eligibility for all IS may improve access. Differing cultural understandings of MH may have influenced how IS reported experiences. Culturally safe MH supports and large representative studies are needed.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• There are concerns about the numerous challenges faced by international students in Canada; however, no published reviews on the health of temporary migrants in Canada have included studies on this growing population.

WHAT THIS STUDY ADDS

• Despite a ‘universal’ healthcare system, the majority of international students in Canada are ineligible for publicly funded healthcare. Mental health was the most frequently mentioned outcome with several social and structural determinants of health contributing to mental health challenges.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Culturally safe mental health supports and large-scale representative studies are needed.

Introduction

Worldwide, international students (IS) increased from 2.2 to over 6 million between 2001 and 2021.¹ IS physically cross an international border to participate in education in the country of destination.² Students’ motivation to study abroad is multifaceted and may include limited local educational opportunities, economic or political instability in their countries of origin, quality of education abroad, better career prospects and work opportunities during study.^{3 4} In Canada, IS are considered ideal immigrants to transition to permanent residents and citizens, given their local training and anticipated compatibility within the labour market.⁵

Most IS permits each year are issued in Ontario, followed by British Columbia and Québec (figure 1A). While IS originate from nearly 180 countries, in the last decade, approximately 45%–56% have been from India and China.⁶ IS admissions more than doubled between 2015 and 2024 (from 219 035 to 471 785),⁶ constituting 21% of 2022–2023 college and university enrolments in Canada.⁷ The rise in IS admissions has been attributed to stagnant government funding,⁸ leading postsecondary institutions to bolster revenue with higher IS tuition fees.⁹ In 2022, IS spent $37.3 billion Canadian Dollars (on tuition, accommodation, non-essentials), equal to 22% of Canada’s exports,¹⁰ which surpassed the value of Canada’s other major exports (e.g., wood and wood products—$25.7 billion Canadian Dollars).¹¹

Figure 1. Provincial and territorial distribution of international student permit holders (2015–2024) (A¹), peer-reviewed literature (B) and grey literature (C). ¹In (A), international student permit holders were summed by year for each province/territory and then the average was calculated. Data from December 2024 were not available and are not included. Data come from the Government of Canada.

Despite considerable economic contributions, infrastructure (eg, housing) for IS has not kept pace with their growing numbers¹² and their presence in Canada has become increasingly politicised, exposing anti-immigrant sentiments among the general public and on campuses.^{13 14} Community organisations^{15 16} and news media have described the numerous struggles IS have faced,15,18 including stress from academic pressures, financial strain and social isolation underscoring the need to understand their health and its’ social and structural determinants.^{19 20}

In recent years, IS made up almost half of temporary residents in Canada; however, no reviews on migrant health have included IS.²¹ Our main objective was to conduct a scoping review to examine the health of IS in Canada. Our questions were: (1) are IS eligible for publicly funded healthcare? (2) what are the characteristics (eg, publication year, study methodology) of peer-reviewed and grey literature examining the health of IS? (3) what aspects of health services and health outcomes are mentioned? (4) what social and structural determinants of health (SSDOH) are mentioned? (5) do IS experience worse outcomes compared with non-IS? (6) do the SSDOH relate to outcomes?

Methods

We developed and registered a protocol²² prior to commencing this scoping review. We followed guidance by the Joanna Briggs Institute²³ and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.²⁴

Patient and public involvement

The founder (MB) and programme manager (PK) of Laadliyan, a non-profit organisation that provides programming to female South Asian IS in Canada, partnered throughout the research process. The review was conceptualised by SW and MB and was motivated by IS’ experiences of adversity shared with Laadliyan.

The remainder of the methods section is divided into three parts. Part 1 summarises the approach to determining public healthcare eligibility (research question i) and parts 2 (peer-reviewed literature) and 3 (grey literature) summarise the inclusion and exclusion criteria, search strategy, screening, data extraction and analyses (addressing research questions ii-vi).

Part 1: healthcare eligibility, access and services covered

All IS in Canada are directed to have healthcare insurance.²⁵ While Canada’s publicly funded provincial healthcare systems are commonly described as both ‘universal’ and ‘equitable’,²⁶ eligibility depends on provincially determined residence requirements.²⁷ We searched provincial and territorial Ministry of Health websites as well as educational institution and immigration-related websites (eg, settlement.org) as needed. One review author (AL) extracted the following data: eligibility for public health insurance, private health insurance requirements, services covered, waiting period, type of study enrolment (eg, full-time, part-time), length of study permit, applicable fees.

Part 2—Peer-reviewed literature and part 3—grey literature

Inclusion and exclusion criteria

Participants: studies and sources were included if the study population included IS, regardless of student’s age, country of origin, education level or programme.

Concepts: the included concepts were related to healthcare access and health outcomes. To identify a manageable number of relevant studies and sources for screening, we specified health outcomes of concern among IS using reports from community organisations and media coverage. A basic search of MEDLINE, CINAHL and Google Scholar was conducted to identify commonly studied health outcomes among IS. The health outcomes of interest specified for the formal searches were mental health (MH) and disorders, occupational injury, oral health, reproductive and sexual health, violence and mortality.

Context: we included studies and sources relevant for the 10 provinces and 3 territories in Canada, published in 2013 until the dates for which searches took place (~10 years, for feasibility and relevance).

We excluded studies and sources in languages other than English. We also excluded protocols, conference abstracts, interventions, conceptual or theoretical papers, studies not focusing on IS or the IS experience.

Part 2: peer-reviewed literature

Search strategy

A reference librarian (JC) developed the search strategy using terms related to participants, health outcome concepts and context summarised above. The following databases were searched: Ovid MEDLINE ALL, Ovid Embase Classic+Embase, Ebsco CINAHL Plus, Clarivate Web of Science Core Collection, Elsevier Scopus and WHO Global Index Medicus. The search was limited to English language articles, published between 2013 and 2024. The search was completed in October 2024 (see online supplemental table 1 for search strategy). Note that the search strategy was developed for a larger study of 10 countries receiving the largest numbers of IS in 2021, which included Canada, as per the study protocol.²²

Evidence screening and selection

Using Covidence, studies with ‘Canada’ or ‘Canadian’ in the title or abstract were identified for the current review. Two reviewers (AL and DB) conducted title and abstract screening for a 25% sample to assess inter-rater reliability using Cohen’s kappa. Full texts of the remaining studies were reviewed by two review authors (DB and AL). We retained studies on health behaviours leading to health outcomes of interest. Studies were excluded if: results were not directly related to IS or the IS experience or had vague references to health. Disagreements for title and abstract screening and full text inclusion were resolved through discussion (AL, DB, SW).

Data extraction

A data charting table was developed by three reviewers (DB, AL, SW) and included study characteristics such as author(s), publication year, title, etc. We extracted data related to the concepts of interest and health outcome subcategories and SSDOH. We structured data extraction related to the SSDOH using terms identified in theoretical or conceptual frameworks,^{28 29} which included but were not limited to education, built environment, employment and income, housing, food security, social environment, language and culture, government policy, institutional policy, racism, gender bias and intersectionality. Data related to SSDOH subcategories were also extracted—eg, for housing, subcategories were adequate housing, affordable housing, exploitation by landlord, tenant rights, eviction and homelessness. To pilot and test data extraction processes, team members (AL, DB, SW) extracted 25% of the articles to ensure accuracy and consistency. Two team members (AL and DB) separately extracted the remaining studies. Data extraction sheets were compared and combined into a single extraction form (AL, DB). At this stage, physical health emerged as an additional outcome.

Data analysis

The frequencies of study and source characteristics (question ii), mentions of healthcare services and health outcomes (question iii) and SSDOH (question iv) were summarised in tables and figures. We narratively summarised findings, which compared outcomes between IS and non-IS (question v) and examined the relationship between SSDOH and outcomes (question vi). We summarised quantitative, qualitative studies and mixed methods studies separately, grouping study results by major outcome, and within outcomes according to province.

Part 3: grey literature

Search strategy

We used Google Advanced Search to identify relevant sources not published in peer-reviewed journals or books. We entered search terms related to participants, concepts and context. We conducted six searches in English, examining each health outcome with its own search. Mortality was added at this stage due to news media coverage at the time of the search.

Evidence screening and selection

Two research team members (AL and SW) conducted separate searches between 17 October and 6 November 2024. The top 20 results from each of the six searches were screened for relevance based on either the text on the Google page or by reading the website. Screened positive records were compiled from both reviewers and duplicates removed.

Data extraction

Relevant peer-reviewed studies (not already identified) were extracted as per part 2 above. AL and SW developed and piloted a grey literature-specific data extraction sheet, which captured author, title, organisation, publication year, type of source, province, health outcomes, health outcomes subcategories, key findings for health outcomes, SSDOH, SSDOH subcategories and key findings for SSDOH. The data extraction sheet was pilot tested to ensure consistency between two authors (AL and SW). This was done separately by extracting 25 per cent of the sources. The remaining sources were extracted by AL. Health behaviours related to the health outcomes of interest were identified and captured.

Data analysis

Frequencies of source characteristics (eg, province, publication year), outcomes related to healthcare access and health outcomes and their subcategories as well as SSDOH and SSDOH subcategories, were reported in tables and figures. Sources which mentioned the concepts of interest and the SSDOH were narratively summarised.

Results

The Results section is organised into the three parts described above. Parts 2 and 3 are organised with the following subheadings (a) study or source characteristics, (b) frequencies of health outcomes and health behaviours, (c) frequencies of SSDOH and (d) narrative summaries which describe results related to outcomes, and where available the relationship between outcomes and the SSDOH. In part 3, identifying instances where outcomes were related to the SSDOH was challenging, so we offer a narrative summary of the SSDOH alone.

Part 1: healthcare eligibility and access by province/territory

Summarising information from 20 websites, we found that IS enrolled in post-secondary institutions are currently eligible for publicly funded health insurance plans in most provinces and territories, apart from Ontario, Manitoba, the Yukon and most IS in Québec (table 1).2530,32 IS in these latter regions must have private healthcare coverage, commonly available through their learning institution.32,35

Table 1. International student healthcare eligibility by each province/territory in Canada.

Province/territory*	Public healthcare insurance					Private healthcare Insurance†
	Eligible	Waiting period	FT enrolment required	Study permit length (months)	Fee
Alberta	Y	N	Y	≥12	--	Y
British Columbia	Y	Until time remaining in month of arrival+2 months	Y	≥6	$75/mo	Y
Manitoba	N	--	--	--	--	Y‡
New Brunswick	Y	--	Y	≥12	--	Y
Newfoundland & Labrador	Y	--	Y	≥12	--	Y
Northwest Territories	Y	--	--	--	--	Y
Nova Scotia	Y	Until first day of 13th month on arrival	Y	≥12	--	Y
Ontario	N	--	--	--	--	Y‡
Prince Edward Island	Y§	N	--	--	--	Y
Québec	Y¶	--	--	--	--	Y
Saskatchewan	Y	Until first day of third month on arrival	Y	--	--	Y
Yukon	N	--	--	--	--	Y‡

^*There are no designated learning institutions in Nunavut.

^†International students attending public universities/colleges are eligible for private (institutionally provided) healthcare insurance to cover healthcare expenses not covered by public health insurance (eg, dental, optometry). International students attending private universities/colleges may not be eligible for institutionally provided healthcare insurance, or their institution may not offer students a healthcare insurance plan. As such, international students would be required to seek private healthcare insurance directly from an insurance provider.

^‡For international students attending public or private universities/colleges in Manitoba, Ontario and the Yukon, institutional coverage or other private coverage is required for medically necessary healthcare services (similar to those provided to international students in other provinces) as well as supplementary services (e.g., dental).

^§International students who have a study permit with eligibility to work off campus are eligible for public healthcare insurance in Prince Edward Island.

^¶International students from Belgium, Denmark, Finland, France, Greece, Luxembourg, Norway, Portugal, Romania, Serbia and Sweden are eligible for public healthcare insurance in Québec.

mo, month; N, no; Y, yes.

On average, among the provinces/territories that offer healthcare insurance to post-secondary IS, some may require a waiting period (up to 12 months), full-time enrolment at a designated learning institute and/or a study permit length of 6–12 months.30,46 There are additional requirements to access public healthcare insurance in British Columbia (a monthly fee),³⁸ Québec (student must be from 1 of 11 European countries)⁴⁴ and in Prince Edward Island (student must have an off-campus work permit).⁴³ In general, provincial/territorial healthcare coverage for IS includes medically necessary hospital visits, family doctor visits, maternity care by a midwife or physician and diagnostic services and tests.2527 40,42 45 Medically necessary dental surgeries may be covered but vary by province/territory. IS who require coverage for non-emergent dental, optometry or other services not covered under public plans may seek out a private insurance either through their institution’s healthcare plan or directly from an insurance provider.

We found minimal information regarding healthcare eligibility for IS enrolled in primary and secondary schools.

Part 2: peer-reviewed literature

The kappa score for title and abstract screening was 0.68 (indicating substantial agreement), and for full-text screening was 0.92 (almost perfect agreement). A total of 26 peer-reviewed studies met our inclusion criteria (see PRISMA in online supplemental figure 1A; see abbreviated peer-reviewed study extraction in online supplemental table 2).

Study characteristics

Table 2 summarises the frequencies of study characteristics. Figure 1B illustrates the provincial distribution of studies.

Table 2. Peer-reviewed study characteristics.

Study type, method, sample size	Total n=26
Qualitative	14 (53.8%)
Interview (number of participants per study)	10 (71.4%)
n=1–10	5 (50.0%)
n=11–20	5 (50.0%)
Autoethnography	1 (7.1%)
Ethnography	1 (7.1%)
Multimethod (interviews and focus groups)	2 (14.3%)
Quantitative	10 (38.5%)
Survey	10 (100.0%)
n=1–100	1 (10.0%)
n=101–200	1 (10.0%)
n=201–300	3 (30.0%)
n=301–400	2 (20.0%)
n=601–700	1 (10.0%)
n=701–800	1 (10.0%)
n=1001–2000	1 (10.0%)
Studies with comparison population(s)	8 (72.7%)
Mixed method (quantitative and qualitative)	1 (3.8%)
Literature review	1 (3.8%)
Year of publication	Total n=26
2023	12 (46.2%)
2024	5 (19.2%)
2022	3 (11.5%)
2021	2 (7.7%)
2020	2 (7.7%)
2016	2 (7.7%)
Year(s) of data collection*	Total n=29
2020–2024	13 (44.8%)
2014–2019	11 (37.9%)
2000–2013	1 (3.4%)
Did not specify	4 (13.8%)
Study level	Total n=26
Undergraduate	6 (23.1%)
Undergraduate and graduate	10 (38.5%)
Graduate	4 (15.4%)
Missing	3 (11.5%)
Secondary	2 (7.7%)
Secondary, undergraduate and graduate	1 (3.8%)
International student origin regions/ethnicity*	Total n=62
East and Southeast Asian origins (eg, Chinese, Filipino)	11 (17.7%)
Black/African origins	10 (16.1%)
South Asian origins (eg, Indian, Sri Lankan)	9 (14.5%)
Latin, Central and South American origins	8 (12.9%)
West Central Asian and Middle Eastern origins (eg, Turkish, Iranian)	7 (11.3%)
European origins	6 (9.7%)
Asian origins	3 (4.8%)
Did not specify	8 (12.9%)

^*The counts for Year(s) of data collection and international student origin/ethnicity do not sum to 26 due to some studies being counted in multiple subcategories.

Frequencies of health outcomes and health behaviours

There were 84 mentions of health outcomes and behaviours, of which 70% (n=58) were for MH/disorders, followed by health services (n=16, 19.0%) and violence (n=7, 8.3%) (table 3 for health outcomes, online supplemental table 3 for health behaviours).

Table 3. Frequency (n, %) of major health outcome categories and subcategories mentioned in the peer-reviewed and grey literature.

Health outcome major category subcategory	Mentions in peer-reviewed studies n=84				Mentions in grey literature n=74
	Quantitative n=41	Qualitative n=36	Mixed methods n=2	Literature review n=5	n=74
1. Mental health/disorders	33 (80.5%)	22 (61.1%)	2 (100%)	1 (20.0%)	27 (36.5%)
Anxiety	7 (21.2%)	3 (13.6%)	0 (0.0%)	0 (0.0%)	2 (7.4%)
Depression	7 (21.2%)	1 (4.5%)	0 (0.0%)	0 (0.0%)	5 (18.5%)
Mental health and/or mental illness	4 (12.1%)	3 (13.6%)	1 (50.0%)	0 (0.0%)	5 (18.5%)
Stress	4 (12.1%)	3 (13.6%)	0 (0.0%)	0 (0.0%)	4 (14.8%)
Isolation	1 (3.0%)	5 (22.7%)	0 (0.0%)	0 (0.0%)	5 (18.5%)
Homesickness	2 (6.0%)	2 (9.1%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Insomnia/difficulty sleeping	3 (9.1%)	1 (4.5%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Loneliness	0 (0.0%)	3 (13.6%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Suicidal thoughts/ideation	2 (6.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (3.7%)
Emotional well-being	1 (3.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (3.7%)
Suicide attempts	1 (3.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Self-harm	1 (3.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Fear (e.g. jeopardising citizenship or residency, falling ill, future)	0 (0.0%)	1 (4.5%)	0 (0.0%)	1 (100.0%)	2 (7.4%)
Addiction to substances	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (7.4%)
Difficulty concentrating	0 (0.0%)	0 (0.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)
Eating disorder	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
2. Health services	5 (12.2%)	9 (25.0%)	0 (0.0%)	2 (40.0%)	15 (20.3%)
Mental health resource access	4 (80.0%)	5 (55.6%)	0 (0.0%)	0 (0.0%)	3 (20.0%)
Health resource access	1 (20.0%)	2 (22.2%)	0 (0.0%)	1 (50.0%)	6 (40.0%)
Mental health resource quality	0 (0.0%)	2 (22.2%)	0 (0.0%)	0 (0.0%)	1 (6.7%)
Health resource quality	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)	3 (20.0%)
Oral health resource access	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (13.3%)
3. Violence	3 (7.3%)	3 (8.3%)	0 (0.0%)	1 (20.0%)	13 (17.6%)
Physical abuse/safety	1 (33.3%)	1 (33.3%)	0 (0.0%)	0 (0.0%)	2 (15.4%)
Verbal abuse	0 (0.0%)	1 (33.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Sexual violence and/or assault	2 (66.7%)	1 (33.3%)	0 (0.0%)	1 (100.0%)	6 (46.2%)
Harassment	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (23.1%)
Threats to jeopardise resources or citizenship/residency	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (15.4%)
4. Reproductive and sexual health	0 (0.0%)	1 (2.8%)	0 (0.0%)	1 (20.0%)	2 (2.7%)
Abortion	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)
Knowledge of sexual violence	0 (0.0%)	1 (100.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Sex work	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)
Sexually transmitted infections/diseases	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)	0 (0.0%)
5. Physical health	0 (0.0%)	1 (2.8%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Physical health and well-being	0 (0.0%)	1 (100.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
6. Mortality*	n/a	n/a	0 (0.0%)	0 (0.0%)	14 (18.9%)
Death	n/a	n/a	0 (0.0%)	0 (0.0%)	8 (57.1%)
Suicide	n/a	n/a	0 (0.0%)	0 (0.0%)	6 (42.9%)
7. Oral health	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (2.7%)
Returning to home country for care	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (100.0%)
8. Occupational injury	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (1.4%)
Injury while working/volunteering	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)

The denominator for the major categories is the column grand total. The denominator for the subcategories is the major category column total.

Bolded rows indicate a major category and non-bolded rows indicate a subcategory of the major category.

^*Mortality was included as a search term in the grey literature search only.

Frequencies of the SSDOH

The SSDOH were mentioned mostly in qualitative studies (n=73, 79.3%). Social environment (n=23, 25.0%), language and culture (n=16, 17.4%), and employment/income (n=9, 9.8%) (see table 4) were mentioned most frequently across all peer-reviewed studies.

Table 4. Frequency (n, %) of major social and structural determinants of health (SSDOH) categories and subcategories mentioned in peer-reviewed and grey literature.

SSDOH major category subcategory	Mentions in peer-reviewed studies n=92				Mentions in grey literature n=57
	Quantitative n=11	Qualitative n=73	Mixed methods n=5	Literature review n=3	n=57
1. Social environment	3 (27.3%)	20 (27.4%)	0 (0.0%)	0 (0.0%)	6 (10.5%)
Support, family	1 (33.3%)	6 (30.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Support, peers/friends/community	0 (0.0%)	6 (30.0%)	0 (0.0%)	0 (0.0%)	1 (16.7%)
Social support	2 (66.7%)	1 (5.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Support, religious organisations	0 (0.0%)	2 (10.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Alienation/isolation from peers	0 (0.0%)	2 (10.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Support, faculty	0 (0.0%)	1 (5.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Support, partner	0 (0.0%)	1 (5.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Support, host family	0 (0.0%)	1 (5.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Social context and community differences	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (50.0%)
Exploitation, peer	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (16.7%)
Safety and threats to safety	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (16.7%)
2. Language and culture	5 (45.5%)	7 (9.6%)	2 (40.0%)	2 (66.7%)	8 (14.0%)
Language barriers	2 (40.0%)	5 (71.4%)	1 (50.0%)	1 (50.0%)	4 (50.0%)
Cultural differences	3 (60.0%)	0 (0.0%)	1 (50.0%)	1 (50.0%)	3 (37.5%)
Cultural similarities	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Multilingualism	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Accessing resources w/ disability	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (12.5%)
3. Employment/income	0 (0.0%)	7 (9.6%)	2 (40.0%)	0 (0.0%)	9 (15.8%)
Financial stability/security	0 (0.0%)	4 (57.1%)	1 (50.0%)	0 (0.0%)	4 (44.4%)
Working hours	0 (0.0%)	2 (28.6%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Working conditions	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	1 (11.1%)
Exploitation, employer	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (33.3%)
Finding employment	0 (0.0%)	0 (0.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)
Wages	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (11.1%)
4. Racism	0 (0.0%)	8 (11.0%)	0 (0.0%)	0 (0.0%)	1 (1.8%)
Interpersonal racism	0 (0.0%)	6 (75.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)
Structural racism	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Institutional racism	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
5. Government policy	0 (0.0%)	7 (9.6%)	0 (0.0%)	1 (33.3%)	9 (15.8%)
COVID-19 policy restrictions, student permit	0 (0.0%)	3 (42.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Working hours	0 (0.0%)	2 (28.6%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Child support	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Citizenship/permanent residency status	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	3 (33.3%)
Exploitation, public institutions	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (33.3%)
Government policy, health insurance	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)	1 (11.1%)
Government policy, work permits	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (11.1%)
Govt oversight on international student enrolment	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (11.1%)
6. Housing	0 (0.0%)	7 (9.6%)	1 (20.0%)	0 (0.0%)	12 (21.1%)
Adequate housing	0 (0.0%)	4 (57.1%)	1 (100.0%)	0 (0.0%)	6 (50.0%)
Exploitation by landlord	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	3 (25.0%)
Tenant rights	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Eviction	0 (0.0%)	1 (14.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Homelessness	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (16.7%)
Affordable housing	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (8.3%)
7. Institutional policy	0 (0.0%)	5 (6.8%)	0 (0.0%)	0 (0.0%)	4 (7.0%)
Financial support, educational institutions	0 (0.0%)	3 (60.0%)	0 (0.0%)	0 (0.0%)	1 (25.0%)
Tuition and fees	0 (0.0%)	2 (40.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Exploitation, private institutions	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (75.0%)
8. Education	2 (18.2%)	2 (2.7%)	0 (0.0%)	0 (0.0%)	2 (3.5%)
Support programmes at educational institutions	2 (100.0%)	2 (100.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Access to education	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)
Exploitation, educational institutions	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)
9. Built environment	0 (0.0%)	3 (4.1%)	0 (0.0%)	0 (0.0%)	1 (1.8%)
Transportation	0 (0.0%)	3 (100.0%)	0 (0.0%)	0 (0.0%)	0
Crime	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)
10. Intersectionality	0 (0.0%)	3 (4.1%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Gender, race	0 (0.0%)	2 (66.7%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Gender, marital, migration	0 (0.0%)	1 (33.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
11. Gender bias	1 (9.1%)	2 (2.7%)	0 (0.0%)	0 (0.0%)	1 (1.8%)
Gender differences	1 (100.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Against single women	0 (0.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)
12. Food security	0 (0.0%)	2 (2.7%)	0 (0.0%)	0 (0.0%)	4 (7.0%)
Food inaccessibility	0 (0.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Cost of food	0 (0.0%)	1 (50.0%)	0 (0.0%)	0 (0.0%)	2 (50.0%)
Food insecurity	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (50.0%)

The denominator for the major categories is the column grand total. The denominator for the subcategories is the major category column total.

Bolded rows indicate a major category and non-bolded rows indicate a subcategory of the major category.

Narrative summaries—quantitative, qualitative and mixed methods

Quantitative studies

There were 11 quantitative studies, all using survey methodology with only 11 mentions of the SSDOH.

MH studies with comparison populations

There were four studies examining MH outcomes and supports, which took place in Ontario, Manitoba and Québec. In Ontario,⁵³ international graduate students (n=1876) compared with non-international ones (n=4809) were less likely to report anxiety (11.5% vs 22.6%), depression (13.9% vs 22.9%) and stress (44.0% vs 67.0%) while being more likely to experience homesickness (30.6% vs 15.9%). They were also less likely to seek MH support (21.0% vs 49.0%) and reported less willingness to do so in the future. Another Ontario study⁵⁴ with 297 international and 2694 non-international undergraduates identified important gender differences. Among females, IS reported better MH than non-IS, with lower rates of anxiety, depression and insomnia, with no significant differences among males. However, male IS had higher rates of self-harm and suicide attempts, while females reported more suicidal thoughts, self-harm and suicide attempts, both compared with their non-IS counterparts. More IS, particularly males, reported lifetime suicide attempts. At university entry, MH treatment rates were lower (3% international vs 9% domestic students). Both domestic and IS faced similar barriers to care, with 36% reporting unmet needs or delays. In Manitoba,⁵⁵ international undergraduate students (n=210) were 3.44 times more likely to report ‘good’ MH and 1.95 times more likely to have ‘flourishing’ MH compared with non-international undergraduates (n=722). Suicide planning or attempts were similar across groups. IS reported fewer coping skills and were less likely to seek support from their social network (eg, partners, parents, friends). Rates of confiding in campus counsellors or therapists were similar for both groups. Finally, a study⁵⁶ of 1200 customer service employees in Québec found that among 358 IS (30% of total study population) compared with 578 Canadian-born and 264 immigrants, clinical insomnia and anxiety levels were highest among immigrants followed by IS while depression levels were the lowest among IS.

MH studies without comparison populations

The two studies with no comparison population focused on MH. An Alberta study⁵⁷ of 338 IS found that 23% of participants had ‘flourishing’ MH, 65% had ‘moderate’ MH and 11% had ‘languishing’ MH. Additionally, 8.3% reported poor MH despite no diagnosis. Female versus male, PhD students versus other students and married versus single individuals had better MH and lower distress. Females perceived more social support and were more likely to seek help and share struggles, contributing to greater resilience than males. Of 198 IS in Ontario⁵⁸ across various education levels, 56.9% had normal depression levels and 55.2% had normal anxiety levels. However, 15.3% experienced severe depression and 20.4% severe anxiety. Depression and stress levels increased with higher education. Female and non-binary students reported higher depression levels than males. Those with lower financial satisfaction experienced higher depression, anxiety and stress. Better physical health was associated with lower levels of depression, anxiety and stress.

Other health outcomes and health behaviour studies with comparison populations

Two studies focused on sexual health outcomes and behaviours and one on physical health behaviours. A Québec study⁵⁹ looked at sexual violence on campus among IS (n=764) and non-IS (n=5790) and found IS experienced higher rates of sexual harassment (30% vs 24%) and unwanted sexual contact (17% vs 12%) than non-IS. IS were more likely to show at least two post-traumatic stress disorder (PTSD) symptoms (12% vs 8%) but less likely to seek any help (10% vs 8%) or psychological support from their university (42% vs 45%) due to concerns of confidentiality and fears that their status would be affected. In a multiprovince study (Ontario, Québec and Manitoba)⁶⁰ including 242 international and 1220 non-international undergraduates, female IS were less likely to be sexually active compared with their non-international counterparts (46.5% vs 71.6%). Female IS (30.0%) were more likely to use the morning-after pill or calendar method but less likely to use birth control pills (28.8% vs 75.1%). In Ontario,⁶¹ female international (n=60) and 914 non-international undergraduate (n=914) experienced sexual violence at similar rates (24.0% vs 23.2%). IS were more likely to use condoms (81.1% vs 27.6%). One study in Ontario⁶² focused on physical health behaviours and found that IS (n=605) engaged in less physical activity compared with domestic students (n=4035).

Other health outcomes and health behaviour studies without comparison populations

A survey with 202 IS from two Ontario post-secondary institutions who received a health education intervention on topics integral to student life (eg, MH, campus resources)⁶³ found significant positive increases in self-rated health knowledge, ability to access school resources, ability to seek help for MH issues and significant positive decreases in self-rated stress.

Qualitative studies

There were 14 qualitative studies included in the review. Almost all studies (n=12) took place during or after the pandemic (2020) (table 2). MH was mentioned 10 times, and one time each for violence, physical health and health behaviours. All studies mentioned the SSDOH, a total of 73 times.

Mental health

Four studies took place in Ontario. The only qualitative study⁶⁴ conducted before the pandemic with 11 Chinese high school students identified experiences of isolation, loneliness, academic pressures, fear of failure, insomnia, homesickness and boredom. A study⁶⁵ with seven undergraduate students reported worsening mental well-being while waiting for campus MH services during high-demand periods during the semester. Limited healthcare service knowledge was a barrier, though peer mentorship systems helped students navigate resources. Students struggled with the high cost of MH-related medications and doctor visits. Financial challenges often led to housing and food insecurity, further affecting MH. Despite these barriers, personal support systems (ie, friends, pastors, family) played a crucial role in coping. Thirteen undergraduate and graduate students⁶⁶ described anxieties concerning their professional, immigration and long-term residency prospects in light of the pandemic. Students depended strongly on their families for emotional and economic assistance. Additionally, government restrictions on IS work permits posed employment challenges for many students, further exacerbating their stress. Finally, six undergraduate and graduate female students⁶⁷ described that pressures to succeed in higher education were compounded by social isolation, economic uncertainty and public anxiety, made even more difficult for students without strong support networks. Racism (ie, online harassment) was a concern, particularly for East Asian students, while others felt ‘protected’ from racism due to limited social interactions during lockdown. The suspension of campus resources worsened feelings of isolation. Students struggled with limited options and language barriers to accessing MH services.

Three studies took place in Alberta. A study⁶⁸ with 30 high school students found that prolonged separation from family (due to travel restrictions, etc) negatively affected their MH. The study highlighted how overlapping factors—such as race, gender, age, the pandemic and representation of Asian populations in the media created complex pressures for some students. A study⁶⁹ with 11 undergraduate students found that the exclusion from government supports exacerbated feelings of isolation and abandonment. However, students sharing similar languages, ethnicities, cultures and experiences helped buffer against culture shock. Many students appreciated the accessibility of the university’s MH services and supports, contributing positively to their mental well-being. A study⁷⁰ with 17 graduate students found that the pandemic significantly impacted their MH, with many reporting increased loneliness, reduced academic productivity and limited social interaction. These feelings intensified among those who already experienced isolation before the pandemic (ie, students of colour, especially Black students). University services were culturally unresponsive and financially inaccessible, with few therapists of colour available, and often failed to meet the needs of diverse students. While some found help through supervisors or community ties, many felt disconnected and unsupported.

Four other studies took place in BC, Manitoba and Saskatchewan. A BC study⁷¹ with six graduate students found that many reported a strong sense of loneliness and isolation, which heightened feelings of anxiety, hopelessness and frustration. To cope with academic stress, all participants relied heavily on their social support systems (in their home countries and Canada). Students whose first language was not English noted that even small, everyday interactions with English-speakers felt stressful due to language and cultural differences. A second BC study⁷² examined MH behaviours with 17 female undergraduate and graduate students. Over time, many students developed greater self-efficacy (eg, cooking, basic self-care), becoming more independent and confident in managing their health. A male student from Ghana in Manitoba⁷³ described loneliness and the stress of adapting to a new environment, worsened by the COVID-19 pandemic. The off-campus work limit added financial stress, making it difficult to pay for tuition and rent and affected his MH. With limited eligibility for financial supports, he borrowed money and accepted donations to cover his tuition and basic needs. In a Saskatchewan study⁷⁴ with 10 Chinese undergraduate and graduate students, women in particular reported that the pandemic intensified their ongoing loneliness, anxiety and stress due to isolation and travel restrictions. Some feared racist comments or attacks, noting a rise in anti-Asian hate on social media. Family connectedness, peer support, friendships and a sense of belonging within their school or community offered positive coping mechanisms.

Physical health and violence

An ethnographic study from Alberta described one student facing difficulties meeting their daily needs, resulting in poor living conditions, malnutrition and a decline in their physical health.⁶⁸ An Ontario study⁷⁵ with 12 Punjabi women, IS found that many experienced gender-based violence in the form of verbal harassment and sexual exploitation. In some extreme cases, students reported exchanging sexual services for rent, and authors underscored how gender, migration status and economic precarity intersect to create abusive and harmful living situations.

Sexual and reproductive health

An Ontario qualitative study (also cited in an included review)^{76 77} (n=95) described sociocultural differences in understanding sexual and reproductive health topics (eg, safe sex, sexual taboos), lack of sexual health knowledge and barriers to accessing sexual health services contributed to poor reproductive and sexual health. Counsellors and campus staff interviewed used language that suggested they viewed themselves as all-knowing professionals whose job it was to educate IS from ‘backward non-Western countries’, reinforcing Western and Canadian cultural ideals related to gender equality and sexual freedom. The study also noted that while campus violence prevention applied ‘intersectional lenses’ for domestic racialised groups, it did not appropriately respond to the experiences of IS. IS’ desire to immigrate to Canada permanently led to avoidance of reporting of violence and subsequent interactions with law enforcement.

Mixed methods

A mixed methods study at a university in Western Canada reported that housing suitability affected IS’ (n=75) MH and physical health.⁷⁸ Respondents struggled to find affordable (n=32), suitable (n=15) or adequate (n=6) housing, and more than half (n=34) did not know where to seek assistance for accommodation.

Part 3: grey literature

Source characteristics

In total, 30 grey literature sources were included (see PRISMA in online supplemental figure 1B; see abbreviated grey literature extraction in online supplemental table 4). See online supplemental table 5 for a summary of the frequencies of grey literature characteristics and figure 1C for an illustration of the provincial distribution of sources.

Frequencies of health outcomes and health behaviours

MH/disorders accounted for over 36% (n=27) of all health outcomes mentioned, followed by health services (n=15, 20.3%) and mortality (n=14, 18.9%) (table 3). Among health service access, the subcategories included general health (n=6, 40.0%) and MH resource access (n=3, 20.0%), and health resource quality (n=3, 20%).

Frequencies of SSDOH

The most frequently reported SSDOHs were housing (n=12, 21.1%), government policy (n=9, 15.8%), employment/income (n=9, 15.8%) and language and culture (n=8, 14.0%) (table 4).

Narrative summary

Mental health

IS were described as less likely to access MH care than their non-IS counterparts due to stigma, language differences and cultural differences.⁶³ Culturally competent on-campus resources (eg, diverse and non-English speaking counsellors) were rarely available but essential for IS to have access to quality healthcare services.⁷⁹

Mortality

National and local journalism sites reported on IS mortality. Multiple sites contained stories from funeral homes in the Toronto area that reported an increased number of repatriations of the bodies of IS to India.^{80 81} Causes of mortality included medical negligence,⁸² suicide^{79 80} and acts of violence.^{83 84} In BC, over a 2-year period, 47 IS from India died from drug overdoses and suicides.⁸⁵ One source described paying exorbitant tuition fees but receiving little support and services in return as exploitation, and connected this to excess IS deaths from drug toxicity and the overdose crisis.⁸⁶

Other health outcomes and health behaviour

Sources mentioned their ability to navigate healthcare systems^{63 76 87 88} and their understanding of cultural norms related to sexual health⁷⁶ were adversely impacted by experiencing challenges related to language and culture. Physical, sexual and mental abuse experienced by IS at the hands of landlords,^{87 89} employers⁸⁷ and others with positions of power⁷⁶ went unreported to authorities because of threats of jeopardising citizenship or residency.

Social and structural determinants of health

Several grey literature sources described striking experiences related to structural exploitation and deception across multiple social determinants (eg, education, housing, employment). While there was no explicit relationship to health outcomes or behaviours described in these sources, we summarise these experiences because they may be critical drivers of MH among IS. Exploitation from employers (n=3), landlords (n=3), public institutions (n=3), private institutions (n=3), educational institutions (n=1) and peers (n=1) was reported. Employers withheld wages by leveraging IS’ temporary immigration status.^{80 89} Landlords required large upfront payments⁹⁰ for ‘substandard, overcrowded and unsafe’ dwellings, exchanged free rent for sex work,^{90 91} and pressured students into sex work by withholding passports.⁹¹ At the institutional level, degrees from unregulated private colleges were deceptively marketed to IS as a means to obtain permanent residency.⁹² Some IS even learnt on arrival to Canada that the school they enrolled in did not exist.¹⁸ Some universities offered immigration consultants a $2000 referral fee, motivating some to falsify English language testing documents to claim the fee, which risked deportation for the student.⁸⁵

Discussion

Summary of evidence

Our findings, aligned with the six key questions of this review, are as follows:

(1) While IS in most provinces/territories are eligible for publicly funded healthcare, more than half of IS in Canada reside in Ontario, Manitoba, the Yukon and Québec, jurisdictions where students are ineligible for provincial healthcare and are required to enrol in plans administered by their educational institution or other private plans.

(2) More than half of the sources and studies identified in this review were published in 2023 and 2024 and ~50% were based in Ontario.

(3) MH was the most prominent health outcome mentioned in both the peer-reviewed and grey literature. In the grey literature, mortality was the third most mentioned health outcome with sources citing medical negligence, suicide and acts of violence as causes.

(4) Twelve major SSDOH categories were mentioned in both peer-reviewed and grey literature, with most captured in qualitative studies. Among grey literature sources, experiences of exploitation related to multiple social determinants (eg, housing, employment) were documented.

(5) Quantitative peer-reviewed studies focusing on MH found better outcomes (eg, anxiety, depression) among international compared with domestic/non-IS; however, one study found both female and male IS had higher rates of self-harm and suicide attempts. Almost all qualitative peer-reviewed studies focused on MH took place during the COVID-19 pandemic.

(6) Students noted that language and cultural differences, racism, financial challenges, housing and food insecurity exacerbated their MH struggles; while support from friends, family and community members, both in their home countries and in Canada, helped to meet their emotional and tangible support needs. Students struggled with limited campus MH supports, experiencing language and financial barriers to healthcare access and a lack of culturally responsive care.

Limitations

We could not identify how primary and secondary IS access healthcare services. For feasibility, the outcome terms used in the library search were based on reports of community organisations, media and a basic library search on the health of IS, thus we may have missed relevant outcomes. Google searches are conditioned on a user’s search history, behaviour and geographic location, as such, the grey literature search may have inadvertently favoured sources based in the greater Toronto area and the province of Ontario.

Conclusions

Despite making considerable contributions to the Canadian economy, well over half of IS who come to Canada, study in provinces where they are ineligible for provincial healthcare insurance. Eliminating provincial inequities in healthcare eligibility may reduce system fragmentation and improve access and outcomes.

IS frequently mentioned the shortcomings of campus MH services. Guidance from local and international sources suggests that institutions provide culturally sensitive MH support for their students, with a particular focus on IS.93,95 Common suggestions include having culturally competent healthcare professionals, ensuring that service providers understand their province’s healthcare system, equipping staff with the training needed to be ‘first responders’ for IS and diversifying beliefs on MH theories and approaches to accommodate the diverse religious and cultural backgrounds (among other identities) of their students.⁹⁶

The quantitative peer-reviewed studies included in this review do not appear to be generalisable to all IS in Canada—most survey populations were small and enrolled at large universities or colleges (see online supplemental table 2) which may be better resourced than smaller institutions who enrol a larger proportion of IS.⁹⁷ Large-scale population-based studies of IS are needed, particularly to understand rarer outcomes such as sexual violence, suicide and mortality.

Given the growth of IS worldwide, it is important to understand and compare how IS are faring in other high-income countries and the role of the SSDOH in these differing contexts. A scoping review examining the health of IS in 10 high-income countries²² is underway.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.