Undocumented Migrants in Canada: A scope literature review on health, access to services, and working conditions

Abstract

It is estimated that there are 30 to 40 million undocumented workers worldwide. Although undocumented migration has become an issue of high international relevance, it has been strikingly understudied in Canada, especially with respect to its impact on health. The purpose of this study is to explore the concept of undocumentedness in Canada through a scoping review of peer-reviewed and grey literature written in English, French, Portuguese and Spanish between 2002 and 2008. The specific aims are to: i) summarize and disseminate current academic and community-based findings on the health, service access and working conditions of undocumented migrants in Canada; ii) examine the sources and use of evidence; iii) identify significant gaps in existing knowledge; iv) set recommendations for policy and research, including considerations on transnationalism, ethics, interdisciplinary approaches, gender differences, resilience, and impact on the children of non-status parents.

INTRODUCTION

Over the past decade, undocumented migration has become the fastest growing form of migration worldwide, non-status workers comprising its largest group, presently estimated at 30 to 40 million people [1]. On a global scale, undocumented workers contribute to approximately $150 billion per year in global remittances [1], which makes undocumented migration an issue of high international relevance, but strikingly understudied in Canada.

“Undocumentedness” in Canada

In this article, undocumented workers are defined as women and men who participate in the Canadian labour force by legally entering the country and (a) not respecting the limits of their visa or (b) over staying their visa permitted time, as well as by illegally entering the country, including those smuggled across the border.

There are no accurate figures representing the number or composition of undocumented immigrants residing in Canada. A guesstimate of about half a million has been proposed nationally [1, 2], but this number varies among other sources which suggest anywhere from 20,000 to 200,000 undocumented workers [3–5]. In 2003, Ontario’s Construction Secretariat purported that there were 76,000 non-status immigrants in Ontario’s construction industry alone, while other sources confirmed that at least 36,000 failed refugee applicants had never been deported, and another 64,000 individuals overstayed their work, student or visitor visas in 2002 [5]. If it is assumed that workers are accompanied by family, the numbers in Ontario would rise to the highest figure previously estimated for all of Canada. With respect to settlement, Vancouver, Montreal, and Toronto have the highest number of undocumented migrants [6], with nearly 50% residing in Toronto alone [7].

Unlike the U.S., where undocumented migration is associated with clandestine border crossing [8], in Canada, the majority of currently undocumented migrants initially entered through authorized legal channels, including refugee claimants, sponsored immigrants, or as individuals with valid student, work, or visitor visas [9–11]. In some cases, immigrants may also pay large sums of money (i.e. $20,000– $50,000 per person) to be smuggled into Canada [3]. Various reasons, including engaging in work while not holding a work permit or changing employer without government authorization, creates undocumented workers. Hence, Canada’s immigration bureaucracy contributes to the “irregularization” of immigrants’ status from authorized to precarious, and insecure [10]. In this study, undocumented migrants are defined as women or men who: (1) legally enter Canada and (a) do not respect the terms and conditions of their visa or (b) over stay the duration of their visa or (c) use fraudulent documentation, or (2) illegally enter Canada, including those smuggled [1].

Becoming undocumented in Canada is therefore a complex process, interwoven by a flawed immigration system [3, 4] and reinforced by gender, racial stratification [10] and discrimination [12]. The obvious mismatch between labour demands and the type of immigrants who qualify for acceptance to Canada, is a major determinant for becoming non-status [3, 12]. In 2006, the construction industry represented 9.5% of Canada’s total GDP, but Ontario and Alberta did not have enough Canadians to fill this labour demand [3]. Many educated and uneducated workers fill this respective labour shortage, but fail to get past Canada’s points based system which favors immigrants with particular occupational experiences, official languages fluency, and university education [3, 5, 12].

Although a majority of undocumented workers contribute to the growth of the Canadian economy and society, their non-status situation leaves them and their families with precarious access to health care, education, social services, and legal rights that are basic to promote and protect their health [13]. The United Nations (UN) has declared health a fundamental human right, yet non-status migrants are not afforded this right due to their place of birth, and other factors such as discrimination, language, and cultural barriers [14]. This is of particular relevance to Canada, as a country with universal health care, and as a high-income nation which has maintained vital segments of its economy through undocumented labour [5, 12].

The Present Study

Given the known dearth of information regarding the health status of undocumented migrants, the purpose of this study is to explore the concept of undocumentedness in Canada and its relation to undocumented migrants’ health, service access, and working conditions. This article is not a systematic review, whose general purpose is to answer a narrowly defined research question and appraise study designs [15]. Rather, by conducting a scoping review of peer-reviewed and grey-literature, which is more appropriate for investigating a relatively unexplored research area like undocumented migrant health [15], the aims of this study are to:

1. Summarize and disseminate current academic and community based findings on the health, service access and working conditions of undocumented migrants in Canada;

2. Examine the sources and use of evidence;

3. Identify significant gaps in existing knowledge; and

4. Set recommendations for policy and research

METHODS

A scoping review was conducted from November 2008 to January 2009 to explore health issues, access to service and the working conditions of undocumented migrants residing in Canada. This review was informed by Arksey & O’Malley’s (2005) methodological framework for conducting scoping studies, and did not appraise retrieved literature.

Search Parameters

An attempt was made to include primary and secondary studies from both peer-reviewed and grey literature relevant to the Canadian context and published between 2002–2008 in English, French, Spanish or Portuguese. Grey literature was defined as documents or materials outside formal academic channels of publication and distribution, which included community-based research reports, discussion papers or reviews, government documents, theses, information guides or unpublished manuscripts. To ensure rigour in this review, news reports (in print or web-based) were excluded, since the information they provide generally vary by source, time, location and they require particular procedures for analysis [16]. However, such material is used in the discussion or for context throughout this paper.

The start date of 2002 was chosen to reflect major events following 9/11. Since this time, Canada’s immigration policies have come under strong criticism and more stringent security measures have been introduced [11]. Racial profiling has also proliferated and the issue of undocumented work has gained increased media attention [6]. We supposed that a greater volume of literature related to undocumentedness has since been produced.

Identification of Literature

To locate peer-reviewed literature, searches on the following electronic databases were employed: MEDLINE, EMBASE, CINAHL, Scielo, Social Citation Index, and Scholars Portal. Hand searching and reference list searching were also employed to locate peer-reviewed and grey literature, while website searches, Google Scholar, and direct requests to community organizations were made to locate additional grey literature.

Search Terms

To ensure a comprehensive search of this definition, search terms were tailored for each query. For instance, when searching MEDLINE, the MeSH terms such as “transients and migrants” were incorporated. However, the main keywords guiding our search were: undocumented, non-status, irregular status, precarious status, alien(s), illegal(s), unauthorized, boat people, wet-back(s), clandestine, forbidden, outsiders, uninsured, informal labour, sans papier(s), sin papeles, sem status, without papers, no-status, non-citizen. These terms were crossed with: Canad(a/ian), work(ers), immigrant(s), migrant(s), newcomer(s), displaced, health, health conditions, health access and work(ing) conditions.

Selection Criteria

Publications that did not address the Canadian context, took an economic or legal analysis exclusively, or only examined documented migrants (e.g. permanent residents), were excluded from this review. In instances where the relevance of the study was unclear from the title or abstract, the full document was reviewed to determine inclusion for analysis. For instance, a MEDLINE query using: immigrants and health and Canada” as keywords, returned 218 hits, of which only 4 were kept for full review after selection based on abstracts.

Data Management and Charting

We utilized Endnote to manage retrieved items and designed an Excel matrix to facilitate data charting. Charting consisted of inputting study characteristics (e.g. citation, study population, location, study aim(s), methodology, and relevant findings) onto the matrix. Although not all literature made this information explicit, the extracted data was charted and formed the basis of our analysis.

Collating and Reporting Relevant Findings

A narrative approach was used to best elicit common themes from literature findings. A process of concept mapping [17], which requires grouping common themes in findings, was carried out separately for peer-reviewed and grey literature to facilitate comparison between these distinct sources of information.

RESULTS

A scoping review of peer-reviewed and grey literature related to health, service access, and the working conditions of non-status migrants in Canada resulted in 24 items (see Table I).

Table 1.

A summary table demonstrating the key features of the 24 included items

Peer-reviewed Literature
Citation	Type of Source	Key Aims & Objectives	Methods	Relevant Findings
Berhard, Goldring, Young, Berinstein & Wilson (2007)	Research study	To investigate various ways in which the uncertain legal status of one or more family members can affect the well-being of the family as a whole, including Canadian citizens	15 semi-structured interviews with individuals living with precarious status and 62 telephone surveys with newcomer agencies	Limited access to services due to status affects the well-being of all family members Pregnant women turned away by a health clinic because no space available Cost of medical treatment impacts health seeking behaviour (e.g. people pray not to get sick) Difficult to find employment especially for women (i.e. asked for SIN or work permit) Time/money spent on legal services took its toll on well-being Precarious status leads to pervasive feelings of fear and isolation (a. domestic violence due to stress about papers, b. isolation by same ethno-racial community c. limited ability to pursue education) According to parents, the family’s uncertain status had a strong impact on children, both Canadian and foreign born (a. inability to access child services (e.g. speech pathologist) because of parent’s status b. inability for children without status to pursue post-secondary education due to high international fees c. challenges in accessing OHIP coverage, baby-bonus for Canadian children born to undocumented parents)
Caulford & Vali (2006)	Discussion paper	To discuss the increasing problem of medically uninsured immigrants, both globally and in Canada	n/a	From 1997–2004, Canada’s IRB adjudicated 228 000 refugee claims, approving only 40% Rejected refugee claimants who continue to reside in Canada lose their eligibility for public insurance, either provincial or federal. Up to 15% of the 29 000 claims backlogged during the same period are abandoned annually because of cost and delay leading to loss of IFH benefits. Studies from other countries suggest that women without health insurance are 19x more likely to receive inadequate prenatal care than foreign born women with insurance. Study from Brussels showed that of pregnant women with no health insurance, 46% received no prenatal care (6x perinatal death rate). Similar findings in a Scarborough clinic Long wait times to receive care where it is available (i.e. CHCs have long waiting lists) Delayed/denied care at emergency dept. due to inability to pay is a common theme Canadian born children/youth sometimes lack coverage because of uninsured parents
Lowry & Nyers (2003)	Roundtable discussion report	To document the experiences of non-status Algerians living in Canada.	Roundtable discussion with non-status Algerians	Non-status Algerians (Montreal) characterize their experiences of living in Canada without formal status, as being degrading, unliveable, and absurd.
Oxman-Martinez, Hanley, Lach, Khanlou, Weerasinghe & Agnew (2005)	Discussion paper	To outline the policy framework that shapes access to health for women with precarious immigration status	n/a	There are very few statistics related to the number, origins, or other characteristics of non-status migrants in Canada The RCMP and CBSA keep their records regarding apprehension of undocumented migrants and intelligence information very classified In a 2000 interview, the RCMP estimated that some 15 000 illegal migrants enter Canada each year, not accounting for those who enter legally and who remain after (since 9/11 CBSA and CIC have stepped up deportation and border control) IME is conducted for those with legal entry but less is known about the health status of illegal/smuggled migrants, particularly “entertainers” (i.e. which includes exotic dancers and massage parlour workers) which could be at higher risk for HIV/AIDS. Smuggled and trafficked women and those with expired papers face the greatest barriers to access to health services (this puts at risk their own health and that of Canadians).
Rousseau, Kuile, Munoz, Nadeau, Quimet, Kirmayer, & Crepeau (2008)	Research study	To determine if further research is warranted to assess the public health impact of undocumented migrants and to better inform clinicians, institutions, and policy-makers	20 semi-structured interviews with health care professionals and individuals working in community organizations	Difficult to estimate the magnitude of the problem of access for non-status people Most health professionals reported feeling increasingly burdened by the number of and the extent of care needed by uninsured vulnerable patients Consensus about high levels of morbidity associated with the problem of access to care (i.e. delayed care lead to shortcomings in treatment, follow-up and worsening mental health) Poor perinatal care and high risk pregnancies were reported (e.g. ectopic pregnancies, eclampsia and a higher number of C-sections) Problems with children/youth (e.g. acute mental health, PTSD, autism treatment, etc) Most health professionals report that there is a disproportionate burden placed on select organizations to offer/provide care for undocumented Frustration with institutional policies that contradict the core values of health professionals Health professionals note that places offering health services may not always be safe (i.e. reinforce distrust) since many have reported undocumented patients to immigration authorities in the past
Simich, Wu & Nerad (2007)	Research study	To explore how living with irregular status affects mental well-being and social integration	5 KI interviews (immigrant, labour, legal and faith-based organizations) and 11 in-depth interviews with undocumented migrants	The majority of undocumented migrants came to Canada to escape violence and poor economic opportunities back home Most have tried to follow correct immigration procedures Most are parents working in low-paying, exploitative jobs Huge lack of social support beyond the immediate family Undocumented migrants show signs of suffering from trauma, depression, chronic stress, family separation, and stress-related physical illnesses Participants expressed self-esteem and utilized personal coping skills but still reported unmet health needs and barriers to help-seeking The greatest impact of living without status was on the family, especially children
Wright (2003)	Discussion paper	To describe, and begin to account for, some of the new directions in the immigrant and refugee rights scene in Canada	n/a	Most undocumented people appear to be clustered in Vancouver, Toronto and Montreal-the cities with the largest immigrant populations and with important and ongoing histories of anti-racist/immigrant rights organizing Montreal is home to the country’s most visible and well-known campaign for legalization Difference in the movement towards legalization in the US/Can. (i.e. Canada has less numbers of undocumented and less demands placed by service agencies etc) Racial profiling has emerged as a result of 9/11
Grey Literature
Citation	Type of Source	Key Aims & Objectives	Methods	Relevant Findings
Access Alliance (2005)	Literature review	To explore available information and identify knowledge gaps with respect to poverty, racialization and health; housing racialization and health; race-based discrimination and mental health; and access to health care for racialized groups	n/a	Lack of status and/or health insurance are major barriers to health care PHAs in Canada could access services at CHCs but experienced multiple barriers due to stretched CHC resources, continuous fear of deportation and a lack of awareness about services Many PHAs were forced underground and accessed health care when very ill or close to death (thereby delaying diagnosis, increasing severity of illness and increasing viral resistance)
Berinstein, McDonald, Nyers, Wright & Zerehi (2006)	Research study	To understand the barriers that non-status immigrants face in accessing city services in Toronto	Individual interviews with non-status immigrants and focus groups discussions with community agency workers, community activists, union activists and academics	Difficulty in accessing services (i.e. most registration forms ask about immigration status) Avoidance of health services unless extremely sick (i.e. non status people rely on network of people for help, rather than formal services) Many services for non-status people are not advertised and therefore access to such service may be determined by how well connected non status people are to the “grapevine” Proximity to services is another barrier (i.e. far away, work schedule vs. service hours, etc). Non status people with disabilities have increased barriers to access health/housing/social services (e.g. wheel trans requires ID, translators do not understand, etc). Long wait lists at centres that offer care Fear of being reported to immigration if services are sought Paying out of pocket for health care expenses is not feasible for many individuals/families The emotional and physical impacts of lack of access (i.e. women having to provide health care for your own children, work injuries that should have gone to the hospital vs. walk-in). Non-status women experiencing male violence rarely reported their experience due to fear that the police would notify immigration authorities (i.e. fear about what would happen to their children if they reported, lack of control).
Boyd (2006)	Discussion paper	To explore how the norms, social relationships and hierarchies associated with gender affect migration. To explore how gender inequalities in destination countries affect the migrant experiences. To outline the steps needed to ensure equal opportunities and outcomes for migrants.	n/a	Illegal migration to Canada is explained in terms of the mismatch between the demands in the economy and the kind of immigrants accepted by Canada’s points based system No solid research in the figures of illegal immigrants (i.e. 20 000– 200 000 or 500 000) Early statistics conclude that women represented about half of the total number of applicants to the “Long term Illegal Program” and 70% are Caribbean. At this time, nearly 2/3 worked in domestics RCMP estimates 800 persons trafficked illegally to Canada/yr (may be higher) Restrictions to health care have special implications for women who are illegal/trafficked. Trafficked women face physical and psychological health risks (i.e. food/sleep deprivation, repeated rape, physical injury such as bruising, broken bones or teeth, mouth injuries, cuts, burns, emotional manipulation including threats and blackmail, persistent sexual exploitation, social marginalization, deteriorating mental health, anxiety, PTSD, depression, suicidality, somaticised symptoms--headaches, body aches, dizziness, nausea, vision disturbances, threats to repro health, STIs, unwanted pregnancies, forced/unsafe abortion, no ob/gyn care, HIV)
Committee for Accessible AIDS Treatment, CAAT (2006)	Literature review	To identify and propose systemic change in order to address barriers and improve access to services for immigrant, refugee and non-status individuals in Canada.	n/a	Access to affordable/insured health care for IRN-PHAs is extremely limited & often n/a The Human Rights Code does afford protection with respect to employment discrimination. The Employment Standards Act, Workplace Safety and Insurance Act, and Occupational Health and Safety Act do not exclude non-status people but they are extremely unlikely to seek protection under these laws for fear of exposure. This results in a number of non-status PHAs working in unsafe/exploitative work without effective protection The Canada Pension Plan and Employment Insurance programs are limited in their availability to those who have valid status to work in Canada. These programs require a valid SIN to make contributions. Some PHAs who have lived without status have contributed to these programs under false SINs for many years are not able to access these benefits Non-status PHAs, are among the most vulnerable because they are ineligible for most forms of social support. They face enormous barriers to services because interaction with officials may result in immigration taking action against them The fear of exposure limits the ability and willingness of non-status individuals to seek a whole range of services, and inhibits victims/witnesses of crime to come forward It is the policy of the Ontario Ministry of Health and Long-Term Care that Canadian-born children are eligible for OHIP, but documentation, including ID for the parent and the child as well as any documentation relating to the parents’ immigration status is required OHIP eligibility will be granted for 1 year (renewable). This process can be very difficult to navigate, and for non-status parents, presents the difficulty of having to identify themselves to a government authority with info related to their presence in Canada without status Advocacy from front-line agencies is often required in these situations, despite clear direction from the Ministry about the eligibility of the child
Committee for Accessible AIDS Treatment, CAAT (2008)	Research study	To build on the needs identified in previous projects. To collect information about the life experiences of Immigrants, Refugees and Non-status People Living with HIV/AIDS (IRN-PHAs) in the GTA, and how the stresses they face affect their mental health	Focus group or individual interview with IRN-PHAs and individual interview or focus group with 37 service providers	For non-status PHAs, not having full legal status limited participant’s ability to fully settle and plan for a future (mental health) Unrest—participants expressed anxiety and difficulty sleeping at night
Community Legal Education Ontario, CLEO (2006)	Information guide	To provide general legal information pertaining to every child’s right to education	n/a	A child under 18 who is claiming refugee status or who has no status in Canada does not need a study permit from Citizenship and Immigration Canada to go to school It is illegal for a school to refuse to admit any child under 18 years of age because the child or the child’s parent or guardian is in Canada without immigration status No child should be refused admission to school solely because of their or their parents’ inability to produce any of the following: proof of immigration status or application for legal immigration status a work permit or a social insurance number health documentation that is different from that required of all there children other documentation not required of other children seeking admission to school Canada has agreed to make primary and secondary education available to all children
Community Social Planning Council of Toronto, CSPC-T & Davenport Perth Neighbourhood Centre (2007)	Information guide	To provide information about community services in Toronto to people without legal immigration status	n/a	The Toronto Police Services Board has adopted a Don’t Ask, Don’t Tell policy (i.e. an officer will not ask a person to divulge their immigration status unless there is a good reason) Non-status peoples are not eligible for social housing, unless they are able to prove they are waiting upon an immigration/refugee decision from the government The TDSB has passed a Don’t Ask, Don’t tell policy which states that all children will be treated equally, even if they (or their parents) have no immigration status, and that they will not disclose this information to any enforcement agency or government body The Ontario Employment Standards Act provides protection for many classifications of workers regardless of immigration status. Whether or not you have full immigration status, you are entitled to receive the money you have earned Non-status people can also file an anonymous complaint under the Occupational Health and Safety Act, if they feel their working conditions are unsafe Food banks will ask for identification or something with your name and address on it Community Health Centres do not require health insurance. Appointments are necessary and you must live in the catchment area and must meet all criteria CHCs have lengthy waiting lists Arrangements to receive prenatal care for women without OHIP can be made, but usually requires a fee. This is usually arranged between the midwife and the patient If you have a child that was born in Canada, or family members that are Canadian citizens or PR, and they have lost their Canadian id, you can contact particular agencies that will help you fill in the forms, order the ID and provide a secure address at which you can receive it
Community Social Planning Council of Toronto, CSPCT (2008)	Research study	To examine the challenges, fear, and safety concerns non-status immigrant families face with respect to accessing the public school system. To document the experiences of these families within the Toronto public education system. To identify barriers and provide recommendations aimed at ensuring access to public education for all children and youth regardless of immigration status	17 non-status participants (15 parents/guardi an and two youths) were interviewed for this study	Enrolment Denied on Basis of Immigration Status: 4 of the adult respondents reported that their children had been denied enrolment into a Toronto District School Board (TDSB) school based on immigration status; 1 of these was refused access by 4 different schools Documentation Requirements: 15 of the 17 respondents stated that immigration status came up during the enrolment process. Participants were asked by the school to provide proof of immigration status, such as passports, refugee papers, visas, or an application pending an immigration decision Two families experienced difficulties enrolling their children in a Toronto Catholic District School Board (TCDSB) school due to religious affiliation Lack of Information Regarding the Right to Education: 8 out of the 15 adult respondents said they were unaware that their children had the legal right to attend school in ON Not all Toronto school staff are aware of the legal rights of non-status students Fear: 6 out of 15 adult respondents indicated that they were hesitant to try to enroll their children in school for fear of being reported to immigration officials by school administrators. Parents also commented on the fear of being reported to officials if their child was not enrolled in school Staying Under the Radar: Many parents needed to explain what having no status in Canada meant, and instructed their children to be extra careful and thus the need for secrecy greatly affected parent and child involvement in school events and activities OHIP Requirements: Schools require students to possess OHIP coverage to take part in field trips. Many children could not participate due to this
Goldring, Berinstein & Bernhard (2007)	Discussion paper	To present an analysis of the institutionalized production of precarious immigration status in Canada	n/a	Canadian immigration policy generates precarious immigration status, including illegality Precarious immigration status is accompanied by precarious access to public services Pathways to precarious status are gendered and racialized This has implications for citizenship, stratification and exclusion in Canada Trends in immigration and refugee policy indicate that the population with precarious status is likely to grow
Khandor, McDonald, Nyers, & Wright (2004)	Research study	To understand the current need for, and the history of, regularization programs for non-status immigrants in Canada	Focus groups and interviews with community activists, union activists and academics in Toronto and Montreal	While almost all non-status individuals work, they are not protected against unfair and dangerous working conditions and are not eligible for workers compensation if they are injured on the job Non-status people are vulnerable to abuse by employers/landlords, exploitation by immigrant consultants/lawyers, and detention, deportation, and surveillance by authorities When speaking about possible medical exclusion criteria (i.e. HIV, TB, etc) most participants argued this was unfair criteria since most non-status people get sick in Canada--often because of the unsafe and dangerous work conditions that they are forced to accept Regularization programs and other immigration policies assume that people’s lives fit into stereotypical nuclear family conceptualizations (i.e. women are left very dependant on their supposed “opposite sex” partner to apply for them, etc) Recent estimates suggest that there are anywhere between 50 000–200 000 people in Canada with less than full legal status, with 50% of these living in Toronto
Omidvar & Richmond (2003)	Discussion paper	To explore the relationship between social inclusion and immigrant settlement.	n/a	The number of undocumented migrants (e.g. failed refugee claimants, visitors or visa over-stayers, etc) is not known and the little information that is known, usually comes from social service and health agencies who provide emergency support to these people without provision for funding for these services These people make silent contributions to our economy, often through exploited labour, while being denied basic social and health services for lack of documentation Many parents of Canadian-born children may be denied the right to schooling and access to health care. All of these vulnerable groups of newcomers are excluded in various ways from access to basic legal protection and economic justice
Oxman-Martinez & Hanley (2004)	Discussion paper	n/a	n/a	Women with precarious status often face language obstacles, social isolation, fear from authorities, live and work in unhealthy/unsafe environments or are vulnerable to abuse The key social determinants that intersect with non status people include: income and SES, social support networks, education and literacy, employment, working conditions, social environments, physical environments, personal health practices and coping skills, health services, gender and culture
Paradis, Novac, Sarty & Hulchanski (2008)	Research study	To obtain a better understanding of the way in which discrimination contributes to homelessness among immigrant and refugee families with children. To inform and improve public policy and programs for immigrant families, thereby reducing family homelessness	3 sets of interviews with immigrant women (legal and non-status) and with Canadian-born women	Little differences between the immigrant and Canadian-born women, but when differentiated between immigration status, certain trends emerged Women without status are extremely vulnerable, often living in conditions of deep poverty, housing instability, danger, and exploitation Non status women have limited access to social assistance, health care, and other social benefits and often rely on underground employment or informal networks to secure housing Pregnancy and birth for these women represent a crisis—making employment impossible, incurring health care costs, and disrupting precarious housing arrangements Most of these non-status women enter family shelters where they are required to try to regularize their status (risking deportation, etc and pay high fees for legal counselling) Non-status women have longer stays at shelters, which shows that they would be better served by a housing program where they could live with their children while undergoing the status regularization process
Parkdale Community Legal Clinic (2005)	Information guide	To provide information on social membership entitlements	n/a	No right to obtain SIN, work permit, study permit No access to OW, ODSP unless makes application for permanent residence on humanitarian and compassionate (H & C) grounds - legal aid sometimes available for this If working without authorization, in danger of exploitation, cannot obtain EI, and although eligible for employment standards and workers compensation, might be afraid of being turned over to immigration, unless they start H & C application Must pay privately for medical care, or private insurance In emergency, must be treated in hospital, but will be billed Might have access to free medical service at Community Health Centre Can enrol minor children in school free of charge (s. 49.1 Education Act) If known to CIC, might be under Canada-wide immigration warrant for removal
Rights of Non-Status Women Network (2006)	Information guide	To provide information on the risks and barriers faced by non-status women in Canada	n/a	Non-status women are at high risk of experiencing violence because: a. they have very limited access to information, counselling, and other social services; b. they cannot call the police in an emergency without putting themselves at risk of deportation, as the police have authority to arrest or detain someone; c. if her partner is charged with assault this could lead to devastating consequences for her; and d. they cannot easily access medical services Women and children also experience the following barriers: a. limited access to education (i.e. ESL and/or public education); b. sexism; c. abuse (physical, sexual, emotional); d. limited/insufficient healthcare; e. language barriers; f. limited/inadequate housing; g. unemployment/underemployment; h. exploitation by employers; i. discrimination, prejudice, racism; j. fear of being deported or accessing 911 services; and k. isolation
Santos (2005)	Discussion paper	To provide a characteristic profile of undocumented workers and provide recommendations for the deportation of non-citizens in Canada	n/a	The number of construction workers in ON who are involved in some form of underground activity is estimated to be 76, 4000 (the majority of these workers are engaged in the residential sector (83%) with the remaining 17% in the non-residential construction sector Undocumented migrants comprise a subset of this large number -estimated to be 5k–15k The points system specifically discriminates against low education labour, and presents a serious obstacle to formal/legal immigration status Undocumented workers are often employed in part-time and seasonal occupations, which are more precarious, making these positions, unattractive to the general population These immigrants earn less money, contribute to insurance funds, health dies, union dues, pension plans, yet have access to none
Soave Strategy Group, SSG (2006)	Research study	To provide a detailed overview of the severity of undocumented work and its impact on economic development, the welfare, health and safety of undocumented workers, and national security	n/a	Numbers of undocumented workers in Canada range between 200 000 and 500 000 They are generally employed as construction workers, caregivers, housekeepers, cooks, cleaners and, performing tasks not considered “career opportunities” among Canadians In the GTA--it is estimated that there are up to 40 000 undocumented workers (of which half--20 000 are employed in the construction industry) Despite popular discourse findings suggest that there are undocumented workers in the residential construction industry who pay taxes, create jobs and wealth Little awareness/sympathy for undocumented workers (i.e. they work for min wage or less, are exploited by employers, work under hospitable and risky conditions, live in fear of deportation, risk engaging in criminal activity

Literature Profile

Peer-reviewed articles comprised 7 out of the 24 retrieved items. Of these, three were qualitative research studies [18–20], three were discussion papers [6, 11, 21], and one was a roundtable discussion report [22]. Two research studies employed individual interviews with undocumented migrants and key informants (i.e. resettlement service agents, community health centre representatives, health care professionals, etc) from Toronto. The third research study only employed interviews with key informants from Montreal. The roundtable discussion report also employed some elements of qualitative methodology, since it conducted a group discussion with non-status Algerians from Montreal. Discussion papers on the other hand, generally reported on secondary data (i.e. immigration policies, literature reviews) or on the experiences of particular agencies, clinics or coalitions who served or lobbied for undocumented migrant rights in Canada.

A total of 17 items were retrieved from grey literature. Of these, six were qualitative research studies [2, 7, 23–26], five were discussion papers [4, 10, 12, 13, 27], two were literature reviews [28, 29], and four were information guides [30–33]. Data collection for research studies included individual interviews or focus groups with undocumented migrants or key informants. Of particular relevance are four studies. One comparatively examined the experiences of Canadian-born, immigrant and non-status migrant women living in shelters [26]. Another examined the experiences of immigrant, refugee and non-status [24]. Another examined the experiences of undocumented parents/guardians and their children in accessing public education in Toronto [25], and the fourth examined the experiences of non-status male construction workers [2]. Discussion papers and literature reviews reported on similar data as peer-reviewed discussion papers.

With the exception of the Simich et al. (2007) study which only interviewed non-status Latin American migrants and Lowry and Nyers’s (2003) roundtable discussion which included only non-status Algerians, no other research study (peer-reviewed or grey literature) examined a non-status group of an exclusive ethno-cultural origin. Also worthy of mention is that all 24 items retrieved were in English, despite the multi-language search we employed.

Peer-reviewed Literature Themes

Overall, four major categories of themes emerged from peer-reviewed literature findings: 1) the effect of status on mental health; 2) barriers to service access; 3) the effect of status on women and children; and 4) the effect of status on service providers. Other less prominent issues included: working conditions and coping strategies.

1. The effect of status on mental health

There was a general consensus that being non-status significantly took its toll on individuals’ mental health through a variety of mechanisms. Non-status Algerians for instance, described their experience as “degrading” and “unlivable” [22] (p. 66). Feeling constant fear over deportation in addition to anxiety over becoming ill and not having the economic means to seek care [18] were commonly reported. In relation to aspects of integration, social exclusion and isolation [18] were cited in addition to a lack of social support beyond the family structure [20]. In the Bernhard et al. (2007) study, non-status migrants reported feeling socially excluded by members of their same ethno-racial community because unlike them, they had gained legal status and frowned upon them. Non-status migrants also present signs of trauma, chronic stress and depression from family separation and physical illnesses associated with stress [20].

2. Barriers to service access

In relation to health service access, peer-reviewed literature purports three barriers that limit or impede non-status individuals’ ability to receive adequate medical attention. The first is delayed care [19, 21] often resulting from community health centres’ (CHCs) long wait lists. The second is denied care, which often occurs at emergency rooms in hospitals [21] or CHCs which lack the space, resources or the policies to provide care for such individuals [18]. The third barrier is a lack of financial resources to pay for emergency hospital fees or doctors visits [21]. In all such cases, delayed care has been noted to result in shortcomings in treatment, poor follow-up, increased morbidity and poor mental health among non-status individuals [19]. A more obvious factor influencing access is that in addition to being excluded from publicly funded health coverage, non-status individuals are also unable to seek private health insurance due to their lack of citizenship status [11]. Non-status individuals have also been noted to experience barriers in accessing education, due to the lack of financial resources and their precarious legal status [18]. Obtaining legal aid is often restricted by their lack of financial resources and time, which is spent working or caring for family members [18].

3. The effect of status on women and children

One of the most profound impacts of being non-status is on family and children [20]. Of particular concern are non-status pregnant women, since it has been reported that such individuals are often denied care due to limited clinic resources [18], and consequently, many do not receive any prenatal care [21]. Currently, concerns are being raised about the number of non-status women with high-risk pregnancies, such as ectopic pregnancies, eclampsia and an increased need for caesarean sections [19]. Non-status women have also been noted to be more vulnerable to domestic violence [18] and in the case of smuggling or trafficking, women are at greater risk of contracting HIV/AIDS or other STIs [11].

Non-status children, as well as Canadian-born children to non-status parents, are also profoundly affected. For instance, non-status children or youth experience barriers in accessing specialized medical services [18], post-secondary education, attention for acute mental health issues, post-traumatic stress disorder (PTSD) or autism treatment [19]. Canadian-born children on the other hand, have the right to access these services, but often experience challenges in getting OHIP coverage, social services or baby bonus, due to their parents status [18, 21].

4. Effect of status on service providers

Health, social service, resettlement and legal service providers have also been directly impacted by the experiences and needs of non-status people. Many feel overburdened by the disproportionate responsibility placed on select organizations to offer care to non-status individuals, which consistently requires negotiating for more resources [19]. There is also a general understanding that the policies governing the provision of care by health institutions, often conflict with the fundamental beliefs and values held by health professionals, which is to provide care for all, irrespective of status [19]. Many providers note that although health institutions which offer care to non-status people are safe places, non-status individuals may exhibit distrust towards such institutions, due to previous cases where reporting to immigration officials has occurred from such locales [19].

Albeit less prominent, peer-reviewed literature also highlighted the importance of coping mechanisms among non-status migrants, including sustained self-esteem [20]. In relation to working conditions, the majority of non-status individuals are generally subject to low wages and exploitation [20].

Grey Literature Themes

In addition to the four themes that emerged from peer-reviewed literature, grey literature revealed an additional category related to the working conditions of non-status migrants.

1. Working conditions

Generally, non-status individuals work in the construction, hospitality and manufacturing industries or in domestics (e.g. housekeepers, cooks, cleaners, caregivers) [2]. These types of employment are often part-time or seasonal, making them increasingly precarious and undesirable to Canada’s general population [12]. Non-status migrants have no legal right to obtain a work permit or social insurance number (SIN) [31], and thus work in the underground economy for low wages, under poor and unsafe work conditions, with no access to workers compensation [7, 31] or publicly funded health care [28], making them extremely vulnerable to dismissal, abuse and exploitation by their employers [2, 7, 32]. Additionally, many non-status individuals who experience serious workplace injuries requiring emergency assistance, fail to seek such attention and preferentially consult walk-in medical services out of fear of exposure to hospital authorities or their inability to pay emergency fees [23].

Fear of exposure has also resulted in the avoidance of seeking legal protection under the Human Rights Code, the Employment Standards Act, Workplace Safety and Insurance Act or the Occupational Health and Safety Act which do not necessarily exclude non-status individuals [29]. For instance, the Ontario Employment Standards Act provides workers, irrespective of immigration status, protection over receiving full payment for what the worker has earned [30]. Under the Occupational Health and Safety Act, non-status migrants are also able to file anonymous complaints regarding unsafe work conditions [30]. What is more striking, is that many undocumented workers create jobs, pay provincial sales tax and goods and services [2], contribute to insurance funds, health and union dues and pension plans, through false SINs [29] but can never access such services [12].

2. The effect of status on mental health

Much like the peer-reviewed literature suggested, the negative effect of being non-status on mental health is pervasive and occurs through various means. Non-status individuals live in constant fear of deportation [2, 23, 24, 28] which consequently contributes to social isolation and anxiety [13, 32], since fear of exposure limits these individuals’ ability to fully participate in society, plan for their future or fully settle [24, 29]. Likewise, this fear of exposure also contributes to non-status individuals’ deferral of health service access, even in cases of high health risk or need [23, 28, 32]. This is also associated with a general distrust in all figures of authority, which drives non-status individuals to rely heavily on a close network of people for assistance rather than formal services [23]. However, in cases where non-status individuals are victims or witnesses of crime, this mistrust and fear of exposure inhibits reporting to police and consequently contributes to greater emotional distress [29].

3. Barriers to service access

Lack of status and thereby lack of formal entitlement to public health insurance is a major barrier to health seeking for non-status individuals [28, 31]. Not only does lack of coverage compound financial burdens by having to pay out of pocket for health care expenses [23, 31], but it also increases the likelihood of avoiding or delaying care due to long wait lists and stringent eligibility criteria (e.g. belonging to a catchment area) imposed by CHCs that offer free care [23]. For non-status migrants living with HIV/AIDS, timely and affordable health care is of the essence, primarily due to the high cost of necessary treatment associated with HIV/AIDS [29]. Avoidance of health service use has been evidenced by increases in the cancellation of appointments and through evidence suggesting that many non-status individuals present themselves at late stages of illness or near death [23, 28]. Fear of exposure to authority is a major contributor to non-status individuals’ avoidance and postponing of health service use, which is augmented by a history of high-profile deportations and the required policy in many locales to disclose status in order to access to services for the uninsured [23]. Delayed care, as mentioned, contributes to delayed diagnosis, increased severity of illness or disease, and in some cases contributes to viral resistance (i.e. HIV/AIDS) [28].

Proximity to available services, lack of knowledge about such services, or having special needs have also been noted to be significant barriers to health care or service access. For instance, many non-status individuals live far from service centres, or have difficulty reaching them due to variable work schedules (e.g. shift work) that often conflict with service hours [23]. Knowledge about such services also depends on the extent of established networks, since these types of services are rarely advertised [23, 28]. In cases where non-status individuals have a particular physical disability or special need, accessing appropriate health, housing or social services are increasingly difficult, due to transportation barriers (i.e. public transport for the disabled requires ID), language barriers, and many other accessibility issues [23]. With respect to housing, non-status migrants are unable to obtain social housing benefits unless they can prove that they are waiting for a government decision regarding their status [30].

Being non-status directly impacts and reinforces individuals’ precarious access to public services [10], yet status also impacts the nature of service provision. For instance, non-status migrants are at increased risk of experiencing exploitation by service providers such as immigration consultants and lawyers [7]. Despite there being a Don’t Ask Don’t Tell policy in place with respect to police services and public education in Toronto, non-status individuals continue to face many forms of exclusion based on status [25, 30, 33]. Under section 49.1 of Canada’s Education Act, non-status parents can enrol their children (under the age of 18) in school, free of charge [31, 33]. Although it is illegal to refuse admittance due to a child’s or parent’s immigration status [33], a study conducted in 2008 by the Community Social Planning Council of Toronto found that undocumented parents continue to be denied enrolment due to status issues, failure to provide documentation or religious affiliation. Lack of information regarding children’s legal right to education from both school staff and parents, was also a major barrier to public education access [25]. Fear of exposure to school administrators also contributed to parents’ hesitance in enrolling their children, and failure to enrol their children thereof also contributed to fear among parents [25].

4. The effect status on women and children

The effects of being non-status are invariably gendered [10]. Non-status women have been noted to be extremely vulnerable to poverty, unemployment, poor and unstable living conditions, danger, exploitation [26], abuse [23, 27], and high-risk or complications during pregnancy [26]. Lack of status limits women’s ability to access information, seek social assistance, counselling or health care [32], which contributes to their reliance on unsafe and underground employment [27] or informal networks to obtain housing [26]. Women who have been trafficked, may face unique physiological (e.g. sexual assault, torture) and mental health concerns (e.g. PTSD, suicide, anxiety), alongside increased risk of sexual exploitation leading to substantial sexual and reproductive health concerns (e.g. STIs, unsafe abortions, etc) [4].

Generally, non-status women have also been noted to experience more language barriers, social isolation, and fear, in addition to lack of control over partner abuse and the effects of this on their children [23, 27, 32]. In relation to policies, regularization programs and other immigration policies have been noted to reinforce dominant power relations that consequently subjugate women as dependants of their opposite sex partners [7]. If seeking refuge at women’s shelters, which is often longer in duration than immigrant or Canadian-born women [26], institutional policies (in some shelters) make it mandatory for non-status women to regularize their status in order to access services, which increases their likelihood of deportation or incurring debt as a result of seeking legal aid [26].

Children of non-status parents, particularly those born in Canada are also profoundly impacted. For instance, Canadian-born children are legally entitled to receive OHIP coverage (i.e. Ontario public health care coverage), but the application process requires that parents issue documentation regarding their own immigration status [29]. Furthermore, OHIP is only granted to Canadian-born children for a one year period, at which time it must be renewed [29]. Barriers associated with navigating these complex application procedures and fear exposure to formal government authorities, makes it increasingly difficult for non-status parents to obtain these benefits for their children [29]. It is common for non-status parents to rely on the assistance of service providers [29], especially since they aid in filling out applications and often provide a secure address to receive benefits [30]. In relation to education, all schools require that students possess health insurance to participate in out-of-school activities [25]. Hence, children who have not been registered for public health coverage are barred from fully participating in school life [25]. Furthermore, many children experience the added responsibility of being both vigilant and secretive about their family’s status, as instructed by their parents from a very young age [25].

5. Effect of status on service providers

There is a general understanding that limited or stretched resources place large demands on CHCs to provide services for non-status individuals [28]. In addition to resource constraints, service providers genuinely express frustration towards the political frameworks that govern their work, including policies that impede their ability to help individuals based on need, rather than on funding allocation or eligibility requirements [23]. In many cases, such restrictions have led community-based agencies to restrict service provision to newcomers with legal permanent or temporary status [30].

DISCUSSION

Sources and use of evidence

As identified through this review, the majority of information pertaining to the health status and needs of undocumented migrants in Canada stems from social service and health agencies, who despite having constrained budgets, continue to provide services for this population [13]. Grey literature took on a more holistic understanding of health and its related determinants by discussing, in greater detail, aspects related to the working conditions, public education access, and gender disparities associated with being non-status. A possible explanation for this content difference is that grey literature may be prompted by the experiences of front line service providers who work with undocumented migrants, and may thereby reflect personal needs/barriers identified by undocumented migrants themselves rather than academic research priorities. This rationale is also supported by the fact that five out of the six qualitative research studies found within grey literature gave voice to undocumented migrants through focus groups or individual interviews. This is unlike peer-reviewed literature which had only three qualitative research studies, of which only two directly gave voice to undocumented migrants, and one roundtable discussion report with non-status Algerians.

Strengths and limitations of the study

The scoping review presented herein is the first of its kind to comprehensively review current knowledge on the health, service access and working conditions of undocumented migrants residing in Canada. More significantly, this review has integrated and contextualized relevant peer-reviewed and grey literature findings, and has employed a multilingual search to increase the thoroughness of the identified literature. Despite the occurrence of undocumented work in most Canadian provinces, there is an absence of information pertaining to undocumented migration in areas other than Toronto, and an absence of French literature altogether. The authors recognize that this limitation may have been due to the fact that this scoping review did not consider grey literature produced by community groups within cities other than Toronto (e.g. Montreal), and did not consider public opinion or media information, which may have revealed additional findings or literature in languages other than English.

Furthermore, the focus of this study on only a few aspects of undocumented migrant health (e.g. service access and working conditions) may have limited our understanding of the challenges faced by undocumented migrants in Canada, and the full spectrum of available services and sources of support. As a much broader limitation of studies focusing on vulnerable populations, we recognize that the impact of extreme forms of exclusion, fear, and stigma, prevent a full exploration of sensitive issues (e.g. delinquency) which may also be relevant to the undocumented population in Canada [34].

Implications of reviewed literature findings

The findings from the reviewed literature has demonstrated that the undocumented migrant experience is multifaceted and intersects with key social determinants of health—namely social support networks, education, employment, income, the physical and social environment, gender, culture, health seeking behavior, coping strategies, and access to health services [27]. Taking social support as an example, international literature [35] affirms that having no-status is a significant form of social exclusion which renders immigrants vulnerable to structural conditions [18]. This marginalized condition can be described as having a domino effect. As identified in this review, undocumented migrants consistently seek anonymity or avoid exposure as a form self-protection, but this may be inadvertently creating additional barriers to their relative integration into the “host” country’s social and economic life, which in turn decreases their ability to develop a social network and increases their vulnerability [9]. Social isolation, depression, fear, anxiety, and stress are pervasive outcomes associated with status, and there is reason to suggest that alcohol and substance abuse may also be a relevant issue among undocumented individuals [18].

More importantly, issues of access also contribute to poor continuity of care, which is of particular importance in cases where non-status individuals require treatment for chronic conditions or life-saving health care [36]. In a recent news report, CHC physicians expressed concern over the public health implications of delayed or deferral of service use due to fear of exposure [37]. Providers urged immediate service provision for non-status individuals since they are highly vulnerable to infectious diseases such as, malaria, tuberculosis, and HIV [37]. Additionally, in the case of undocumented immigrant women, lack of prenatal care has been correlated with low birth weight, and myriad of other perinatal and neonatal concerns [8]. Anecdotal evidence also suggests that Canadian-born children to non-status parents experience heightened barriers if they have special needs requiring expensive equipment or therapy [38]. A lack of information regarding the exact number of children in these situations makes it difficult to assess the impact of these conditions on their health, and likewise makes it difficult to pressure the Canadian government to address this accessibility gap [38].

Thus demographic information, as just mentioned, is a major gap in the literature examined herein. Additionally, information related to morbidity and mortality, especially as this relates to work related accidents and disease, continues to be a significant gap that limits our ability to assess the full spectrum of health related issues that impact undocumented migrants. Similarly, the personal experience and impact of being permanently displaced in a foreign country and the myriad of related settlement processes that follow, have been unexplored by current literature. Related settlement processes may include, but are by no means limited to: deskilling and reskilling processes, interpersonal relations with Canadians and established immigrants or familial issues (e.g. intergenerational conflict).

Recommendations for policy and research

In a recent report published by the Standing Committee on Citizenship and Immigration [34], few references to the case of non-status workers accompanied by a very timid set of recommendations for halting the “non-status migration problem” in Canada (p. 49). The first two proposed that different avenues be created to facilitate the transition of temporary foreign workers to permanent residents; while the last recommendation necessitated a re-examination of Canada’s current points-based system [34]. Based on the review we have undertaken, we present more incisive policy recommendations and their rationale for implementation (see Table II) to achieve health as a human right for the non-status population residing in Canada.

Table II.

Recommendations for policy and rationale for their implementation

Policy Recommendation	Rationale
❖ Include undocumented migrants in census data	To acknowledge the existence of this population is the first step for policy and program planning. Accurate population estimates and demographic information are necessary for effective services.
❖ Prioritize inclusion in all policies	Health, safety, and education are fundamental human rights, and should be granted regardless of immigration status.
❖ Re-examine the language and provisions within Canadian immigration policies that are enmeshed in current exploitative relations and gender inequality and create alternatives for those presently working in Canada	There are sectors in the economy highly dependent on the undocumented workforce (e.g. construction and hospitality sectors) but no system to render such workers part of the official Canadian workforce. Also, sexist subtexts persist in immigration policy (e.g. sponsorship issues), increasing the vulnerability of women.
❖ Grant full citizenship rights to Canadian born children, regardless of their parents’ status	All Canadian citizens have a legal right to obtain benefits, and this entitlement should not be delayed or compromised in any manner due to the immigration status of third parties.
❖ Increase human and financial resource allocation for social and health services that serve non-status populations	Constrained resources limit the quality and extent of service provision and are detrimental to providers serving this population. Additional resources would improve the comprehensiveness of services, increase health status and alleviate human suffering

This scoping review has also allowed for the identification of gaps in current research. We propose six recommendations for advancing knowledge on the relatively unexplored and contentious issue of undocumentedness in Canada, recognizing this is not an exhaustive list of topics deserving attention.

1. Transnational nature of the field

To date, most health research has focused on the location in which non-status workers reside rather than on the dynamic transnational processes in which they are involved daily. For instance, people can experience fear of deportation and its subsequent distress differently if their reason for migrating were exclusively economic rather than persecution in their country of origin. Those who are separated from their children may exert their parenthood through the web or feel compelled to accept any work conditions in order to send regular remittances. When health care is required, some may obtain medical advice from physicians in other countries and try to access medication through the local community or via mail. Strong social isolation in Canada may also be remediated through the maintenance of strong ties to friends and family abroad. In addition, undocumented migration is created through multiple and reinforcing push and pull factors which involve several countries, not only the place of residence. These are some of the transnational aspects that should be considered.

2. Ethics and moral values

There is a moral complexity in the study of a contentious issue such as undocumented work. The terminology employed in different studies reveals different perspectives from researchers – from illegality (a criminal-like condition) to the right of health beyond borders. There is also an absence of voice from non-status migrants themselves in many studies, which attests to the fear of this hidden population, but also to some researchers’ values, who speak about the issues, but not with or on behalf of this population. Another theme of ethical concern is the social/moral spaces in which undocumented individuals work, which may not belong to the same sphere of rights and responsibilities that host country citizens (and researchers) experience. That means that certain social locations are ruled by a rationale of exploitation that is not mediated by national and local laws and policies. We suggest that this vulnerable population deserves careful ethical consideration. Researchers should fully implement a framework of social justice to avoid unintentional harm.

3. Gender variations in health outcomes

Despite a clear indication that non-status women are more vulnerable to poor social and health conditions, gender and migration status continue to be conceptualized independently. The current literature does not address how the structural conditions of undocumented status uniquely affect the health and well-being of particular genders [9]. For instance, personal communication with service providers in Toronto, suggests that alcohol and substance abuse is higher among non-status men, while non-status women experience higher levels of depression. Gender-based analyses in future research is therefore needed to facilitate a better understanding of the diverse effects of being non-status. This is particularly relevant when examining the effects of employment on health, since job opportunities are often gender-mediated [39–41], and women particularly face the challenge of balancing new work exigencies with traditional family and social expectations [11].

4. Facilitators and coping strategies

The debate between an asset-based perspective, rather than a problem-based approach, has been suggested in many areas of research and social action [42]. Migration researchers have been calling for more research focusing on the resilience of migrant groups rather than the unhelpful stereotypes of needy and problematic populations that further discrimination and social exclusion [43, 44]. In fact, the terms and degree of vulnerability should ideally be defined by those being struck by the hardship in question. Furthermore, the meanings attributed to, and the implications resulting from being undocumented, are very much a product of the political and social contexts in which non-status migrants reside, as well as variations in age, gender, ethnicity, nationality and social class [8]. In order to go beyond simple remediation and to provide clues for sustainable change, we recommend that a search for elements of resourcefulness, agency, and self-determination be incorporated in future research [45].

5. Examining the experiences of non-status children and Canadian-born children to non-status parents

A comparative analysis of health outcomes between undocumented children and Canadian-born children to non-status parents is also needed. The health status of these respective groups has received limited critical analysis in current literature despite inferences to profound psychosocial impacts as a result of being non-status (or having non-status guardians) and partially integrated into legal realms of society (e.g. public education). Also, accounts of high profile deportations have made clear that Canadian-born children to non-status parents are also at risk of experiencing unprecedented family separation and consequently being left under the care of Children’s Aid [38]. Hence, an exploration of the ripple effect of being non-status on children warrants further investigation.

CONCLUSION

The population of undocumented migrants in Canada has been rapidly rising, yet there is considerable variation in their estimated figures and composition. Not only does this pose a significant challenge for exploring the needs of this population, but this also augments their invisibility and unrecognized contribution to Canada. Their non-status situation leaves them and their families with little to no access to health care, education, social services, and legal rights that are basic to promote and protect one’s health [13]. In Canada, these circumstances are poorly understood due to a scarcity of studies that examine undocumented migrant health. To date, there are no sustainable efforts to promote or provide access to services to this population. We hope that the knowledge, insights, and recommendations herein, will function as a stepping stone for critically addressing the complex issues surrounding undocumentedness in Canada.