food allergy policies in public places and stories in the popular press are evidence of the rising awareness of food allergies as an important public health risk . in its most severe form , ige - mediated food allergies can lead to anaphylaxis , which is potentially fatal . for example , self - reported prevalence in the us is 9.1% ( 8% for children ) and 5.3% for respondents with a physician diagnosis [ 2 , 3 ] . in canada , the canadian estimates , however , were based on a nonrepresentative sample that underrepresented vulnerable populations ( i.e. , low income families , immigrants , and aboriginal peoples ) [ 5 , 6 ] ; a second national survey undertaken to address this limitation indicated that the prevalence of self - reported food allergy for immigrants who have lived in canada for less than 10 years ( herein referred to as  new canadians  ) was substantially lower than their canadian born counterparts : 3.2% . these researchers also investigated perceived prevalence of food allergy in the same populations and found that perceived prevalence was observed to surpass systematic estimates by up to 30% . the gap between perceived and actual risk of food allergy suggests that the public 's perception of true risk of allergy is , in fact , inflated . moreover , new canadians were found more likely to rate the risk of food allergy as  high  compared to nonimmigrants or immigrants who have lived in canada for over 10 years , despite the substantial differences in measured prevalence . in light of the above , this paper used a qualitative research design to unpack the perceptions and experiences of new canadians directly affected by food allergy by addressing the following objectives : ( 1 ) to understand how new canadians perceive food allergies and their associated risks and ( 2 ) to investigate how new canadians manage and cope with food allergies . waterloo region , ontario , canada , was chosen as the research site as it is one of the fastest - growing areas in the province with the 9th highest proportion of visible minorities of all census metropolitan areas across canada . qualitative methods have been used with several populations at risk of anaphylaxis : children [ 1113 ] , adolescents [ 14 , 15 ] , their parents [ 13 , 14 , 16 ] , allergists , and the general public [ 18 , 19 ] . first , key informants ( an allergist , public health nutritionist , and public health planner ) recruited through telephone and e - mail were interviewed in person ( averaging 30 minutes ) as representatives of key constituencies able to provide an information - rich connection to the research topic , as well as access to the wider food allergies community . service providers and health workers have been shown to be rich and largely untapped sources of information with important insights to issues of health and migration . each interview covered topics specific to the key informant 's observations and knowledge of food allergies from their professional work experience . second , in - depth interviews with affected individuals were conducted with new canadians who either had a physician - diagnosed food allergy of their own or were a parent of a food allergic child . the focus was on individuals of east and southeast asian descent as 50% of the immigrant participants in the canadian national prevalence survey were born in an asian country [ 4 , 5 ] . east and southeast asians are also two of the most common visible minorities in waterloo region . participants ( n = 18 ) were recruited using kijiji ( an online network for posting local classified advertisements ) , the interviewed key informants , and contacts made with local cultural centres . 2012 to jan . 2013 ) until saturation was reached ( i.e. , until no new themes emerged from the interviews ) . participants were also asked to complete a short demographic survey to gather additional information on their food allergy and length of time in canada . 78% of the sample was female and 72% of all participants were under 30 years old ( table 1 ) . just over half the participants have lived in canada for less than 10 years ( n = 10 ) . the most common self - reported allergen was shellfish ( n = 12 ) and the majority of participants were over 5 years old when their allergy was diagnosed ( n = 15 ) . each interview was conducted by the primary author and audio - recorded for transcription and subsequent thematic analysis using qsr international 's nvivo 9 . a theme code set was created both deductively ( based on the research objectives and interview guides ) and inductively ( themes emerging from the interview transcripts ) . coding was assessed for inter- and intra - rater reliability , achieving 81% agreement with a second coder at the graduate level . key themes that were identified were those that appeared with the greatest frequency as discrete units of text in the interview transcripts . three key themes emerged from the key informant interviews , the first being appropriate and informed diagnosis . new canadians are concerned with receiving confirmation of their allergy and getting reassurance that their problem is not life - threatening . while the diagnosis process is straightforward , it can be difficult to educate new canadians about how to avoid a reaction as well as the importance of using epinephrine in the form of an epi - pen : understanding what the issue is , is tough enough for patients that have grown up in canada . to really appreciate and understand what a food allergy is , what it involves , and the potential risks , i think for immigrants it is even tougher because in most countries where they have immigrated from , allergy did n't exist . or if it did exist , it was a really , really small issue . ( key informant 1 ) understanding what the issue is , is tough enough for patients that have grown up in canada . to really appreciate and understand what a food allergy is , what it involves , and the potential risks , i think for immigrants it is even tougher because in most countries where they have immigrated from , allergy did n't exist . or if it did exist , it was a really , really small issue . ( key informant 1 ) the second theme that emerged is the challenge of shaping a safe school environment for food allergic children . placing bans on foods in schools can be very restrictive , making it difficult for people to find food alternatives , especially if cost is a concern . a restrictive diet can also make it more difficult to ensure that children are meeting nutritional needs : it becomes very restrictive for the students who are n't allergic . so it is really concerning when foods are starting to be banned from the classroom , because soon , if there are more and more allergic students , many foods will be banned and it 's very hard for people to find those foods and for there to be foods that are within the right price range , especially for people with lower income . so this is a major issue , and we really strive towards educating that it should be an allergy safe environment as opposed to an allergy free environment , because it really , in our opinion , is almost impossible to do that . ( key informant 2 ) it becomes very restrictive for the students who are n't allergic . so it is really concerning when foods are starting to be banned from the classroom , because soon , if there are more and more allergic students , many foods will be banned and it 's very hard for people to find those foods and for there to be foods that are within the right price range , especially for people with lower income . so this is a major issue , and we really strive towards educating that it should be an allergy safe environment as opposed to an allergy free environment , because it really , in our opinion , is almost impossible to do that . ( key informant 2 ) furthermore , studies have shown that food allergic children have been known to experience stigma and/or social exclusion , particularly in the school setting . how allergic children are being perceived by their peers , especially if an incident gets reported in the media , was raised by key informants : i was really disturbed by the fact that you know [ a story about an allergic child ] was in the paper , and it was naming the school and the age of the child and the parent , so people know who this child is i do n't think it is fair to anyone involved , but it is definitely not fair to the child and we do n't want to be causing that , so i just want to make it as normal as possible for them . ( key informant 2 ) i was really disturbed by the fact that you know [ a story about an allergic child ] was in the paper , and it was naming the school and the age of the child and the parent , so people know who this child is i do n't think it is fair to anyone involved , but it is definitely not fair to the child and we do n't want to be causing that , so i just want to make it as normal as possible for them . ( key informant 2 ) four key themes emerged from interviews with affected individuals : perceived prevalence , perceived etiology , management and coping , and quality of life . initially , however , participants were asked to describe the emotions and feelings they experienced when they had their first allergic reaction . many were surprised or even shocked to learn of their allergy ( n = 12):yeah , i was actually quite surprised and so were my parents because we had been around people with allergies before , like my friends and stuff , but none of them had such a severe reaction  and especially because it was so unexpected at such a young age . ( participant 15 : female raised in singapore and japan , < 5 years in canada , allergic to peanut and shellfish)participants also felt disappointment ( n = 7 ) and even sadness ( n = 1 ) when they were diagnosed because they either found it difficult to give up a kind of food they liked or were upset that previous allergic reactions could have been prevented : i would just feel sad , like i just think that it is a kind of sickness . i just feel it is a misfortune right , why do we have a son that has food allergy ? ( participant 4 : female from china , < 10 years in canada , son is allergic to peanuts and beans ) i was actually quite surprised and so were my parents because we had been around people with allergies before , like my friends and stuff , but none of them had such a severe reaction  and especially because it was so unexpected at such a young age . ( participant 15 : female raised in singapore and japan , < 5 years in canada , allergic to peanut and shellfish ) i would just feel sad , like i just think that it is a kind of sickness . i just feel it is a misfortune right , why do we have a son that has food allergy ? ( participant 4 : female from china , < 10 years in canada , son is allergic to peanuts and beans ) one of the predominant perceptions regarding food allergies is that prevalence is lower in asia than it is in north america . current evidence supports this perception , although it is speculated that rates of prevalence in more modernized regions of asia , such as hong kong , are comparable to rates in north america [ 24 , 25 ] . this perception was also held by participants , as 83% of them thought that food allergies were less common in their birth place : well i realized especially like in grade four and grade five , all my friends could not eat peanuts , so we could n't even bring peanuts to school , so that is when i realized , oh food allergies are pretty common here in canada . whereas i never really thought about it back in the philippines . ( participant 7 : male from philippines , < 20 years in canada , allergic to shrimp and shellfish)it is a lot rarer in china . over here there is a lot of emphasis [ on it ] , like one of the first things you learn in school is do n't bring any peanuts . ( participant 12 : female from china , < 20 years in canada , allergic to shrimp and prawns ) well i realized especially like in grade four and grade five , all my friends could not eat peanuts , so we could n't even bring peanuts to school , so that is when i realized , oh food allergies are pretty common here in canada . whereas i never really thought about it back in the philippines . ( participant 7 : male from philippines , < 20 years in canada , allergic to shrimp and shellfish ) it is a lot rarer in china . over here there is a lot of emphasis [ on it ] , like one of the first things you learn in school is do n't bring any peanuts . ( participant 12 : female from china , < 20 years in canada , allergic to shrimp and prawns ) 78% of participants could not speculate on the cause of their allergy . however , when asked to speculate on the etiology of food allergy more generally , they cited examples related to diet , genetics , and the hygiene hypothesis . for example : it might be because chinese people eat everything , so from their ancestry they kind of do n't have those allergies , because they start to eat anything like from years ago , but here people only eat certain kinds of food . they do n't eat animals , like dogs and stuff , and so it is really hard to say . ( participant 14 : female from china , < 5 years in canada , allergic to peanuts , beans , fish , and shrimp ) it might be because chinese people eat everything , so from their ancestry they kind of do n't have those allergies , because they start to eat anything like from years ago , but here people only eat certain kinds of food . they do n't eat animals , like dogs and stuff , and so it is really hard to say . ( participant 14 : female from china , < 5 years in canada , allergic to peanuts , beans , fish , and shrimp ) participants also found it harder to manage their allergy in their birth place ( table 2 ) . participants attributed this difference to lower levels of awareness and , subsequently , less respect and understanding of their needs for accommodation . food allergy impacts the quality of life of not only the allergic individual , but also their family . 39% of respondents reported that the impact of the food allergy on their quality of life was  negligible  ( table 3 ) ; that is , they adapted quickly to their food allergy and never felt any serious disappointment from being allergic . impact on their quality of life as it took some time to accept the allergy and learn how to manage everyday life . three participants reported being significantly impacted by the allergy ; two had multiple allergies and one had tried various remedies , both chinese and western medicines , to alleviate symptoms . a third who reported significant quality of life impacts had been teased by family and friends : 
 my parents started helping me to treat my allergy back when i was fifteen or sixteen . ( participant 1 : female from hong kong , < 10 years in canada , allergic to lychee and lobster ) 
 my mom , she is not allergic to anything , so she is always like  why are you allergic ?  there is a phrase that she says [ often ] . she always says my sister will eat anything she cooks , but i am always the weird kid that [ she ] always has to be careful with , [ because there are ] so many limitations to the food that i eat . ( participant 3 : male raised in hong kong , < 20 years in canada , allergic to shellfish and peanut)the presence of a strong support system can make a positive difference in coping . 72% of participants said their family and friends are supportive because they understand the severity of their allergy and are willing to make accommodations ( table 4 ) . however , 39% of participants reported that their family was initially skeptical of their food allergy : my parents started helping me to treat my allergy back when i was fifteen or sixteen . it is like a drink that is similar to ginseng . it is supposed to make your metabolism better . ( participant 1 : female from hong kong , < 10 years in canada , allergic to lychee and lobster ) my mom , she is not allergic to anything , so she is always like  why are you allergic ?  there is a phrase that she says [ often ] . she always says my sister will eat anything she cooks , but i am always the weird kid that [ she ] always has to be careful with , [ because there are ] so many limitations to the food that i eat . ( participant 3 : male raised in hong kong , < 20 years in canada , allergic to shellfish and peanut ) 
 a lot of people are skeptical . my relatives [ will say something ] like  are you sure that you are allergic to it ? maybe you should try without knowing it and see if it is a psychological thing . ( participant 3 : male raised in hong kong , < 20 years in canada , allergic to shellfish and peanut)participants had to  prove  their allergy to their relatives by showing their physical reaction when they consumed an allergen . my relatives [ will say something ] like  are you sure that you are allergic to it ? maybe you should try without knowing it and see if it is a psychological thing . ( participant 3 : male raised in hong kong , < 20 years in canada , allergic to shellfish and peanut ) misinformed perceptions about oral immunotherapy were also raised , as participants had experienced situations in which they were encouraged by family members to eat an allergen . the thinking was that regular exposure to the allergen would eventually cure them of their condition:[my dad ] is like just keep eating , because whenever there were shrimps or like at home , my dad would always kind of force me to eat it , and he would be just like . you can like overcome it if you just slowly like try to build immunity against it but i kind of did n't want to do it , just because i was afraid of getting a reaction . ( participant 7 : male from philippines , < 20 years in canada , allergic to shrimp and shellfish ) [ my dad ] is like just keep eating , because whenever there were shrimps or like at home , my dad would always kind of force me to eat it , and he would be just like  oh it is all in your head . you can like overcome it if you just slowly like try to build immunity against it but i kind of did n't want to do it , just because i was afraid of getting a reaction . ( participant 7 : male from philippines , < 20 years in canada , allergic to shrimp and shellfish ) interestingly , some participants had no prior knowledge of what a food allergy was , even if they had one , until they came to canada : r ( r refers to the question asked by the researcher ) : when you were growing up were you familiar with what food allergies are ? p ( p refers to the participant 's response ) : no , i actually was n't . it was only when i came to canada that i had heard that people have allergies to peanuts and stuff like that . i did n't know how severe it can get , that people can actually get it , and so forth . ( participant 11 : male from thailand , < 20 years in canada , allergic to fish and shellfish)further , even if they were familiar , there was no mechanism in their native language to describe it . for example , 28% of participants could say  food allergy  in chinese ( mandarin and cantonese ) , but there was no equivalent chinese term for  anaphylaxis . the same observation was made by participants who spoke malay , thai , and japanese . it was speculated by some participants that familiarity with food allergies in asia may increase over time , but at this point it has not been recognized as a medical condition , at least not in the general population . r ( r refers to the question asked by the researcher ) : when you were growing up were you familiar with what food allergies are ? p ( p refers to the participant 's response ) : no , i actually was n't . it was only when i came to canada that i had heard that people have allergies to peanuts and stuff like that . i did n't know how severe it can get , that people can actually get it , and so forth . ( participant 11 : male from thailand , < 20 years in canada , allergic to fish and shellfish ) a key aspect of managing and coping with food allergies is information . approximately 56% of participants said that their physician was their go - to source for information . three of the four mothers with an allergic child identified their allergist as being extremely helpful . community and public health services were mentioned less frequently ( 14% of total mentions ) . personal internet research was the preferred method for learning more about food allergies with 67% of participants having conducted internet searches at least once:  thank god we have internet . i ca n't remember the website i went to , but i do a lot of research . ( participant 4 : female from china , < 10 years in canada , son is allergic to peanuts and beans )  thank god we have internet . i ca n't remember the website i went to , but i do a lot of research . ( participant 4 : female from china , < 10 years in canada , son is allergic to peanuts and beans ) shellfish was the most common self - reported allergen amongst participants ( table 1 ) . , the risk of peanut and tree nut allergy is much higher in individuals from western countries [ 5 , 2628 ] . while the influence of birth place in development of shellfish allergy is still unknown , it is likely that multiple environmental factors are contributing to this phenomenon , including gender , living environment ( urban versus rural ) , and age of intake . researchers are only beginning to find potential links between age of fish intake and allergic disease that may also be the case of shellfish allergy [ 28 , 29 ] . interestingly , twelve participants were 10 years or older when diagnosed ( table 1 ) . this is in sharp contrast to the high rates of allergic children in north america who are diagnosed at a much younger age ( between 2 and 4 years ) . while reasons for this are unclear , contributing factors may include a lower level of awareness in new canadians and limited availability of epinephrine autoinjectors in asia [ 30 , 31 ] . in countries such as the philippines , limited accessibility to health care in parts of asia may partially explain why several participants never opted to have their food allergy confirmed by a doctor , a challenge to determining prevalence based on self - report . these findings support the hypothesis that new canadians may have a lower level of awareness of food allergies and , hence , their inflated perception of risk . the difference in their level of awareness was evident in discussions that touched on their first allergic experience , the etiology of food allergies , and the lack of policies in their birth place to protect them in public places . furthermore , similar findings have been found in the reverse situation ; parents of expatriate children with a food allergy in singapore reported that differences in food preparation and food labeling in asia caused the greatest rise in stress levels after moving to singapore . most schools in asia do not take precautionary measures to protect food allergic children and legislature on food labeling is rare . by understanding factors that influence risk perception such as familiarity and personal ability to affect risk , policy makers can anticipate how the public will respond . furthermore , health professionals should be aware that there is a wide variation in the quality of information on food allergy distributed to patients when diagnosed overseas , if they receive any information at all . hence , health professionals and leaders in food allergy advocacy should be encouraged to tailor comprehensive , online resources that are accessible to new canadians . in terms of management and coping , participants relied on food labels and prior experience with allergens to stay safe . this is concerning as oral immunotherapy is not yet widely accepted as a treatment [ 34 , 35 ] . moreover , this practice put participants in an uncomfortable situation , which could have possibly led to accidental exposure and/or issues of management anxiety . social isolation / exclusion also emerged as participants who had lived with their food allergy in asia expressed frustration as they fended for themselves , especially if they were the only one in their social circle with a food allergy . qualitative research studies are by definition constrained by sample size but allow for a deeper exploration of lived experience . the reliance on self - reported food allergy in this study is typical of research in this field but does present a potential bias on the part of respondents . further , not all countries in east and southeast asia were represented in the sample , so transferability of research findings to other regions may not be possible . given the level of diversity within asia itself , we recognize that the treatment of our participants as a homogenous group is a limitation of this study . these findings indicate that food allergy among new canadians is an important ( and potentially growing ) public health issue deserving of attention , given the reported impacts on social isolation / exclusion and quality of life , as well as the dearth of resources available . this exploratory research raises several issues deserving of more research : health literacy levels in immigrant populations , the wider variety of allergens that immigrants may be reacting to , and further research to understand the impacts of food allergies in other ethnocultural groups in canada as immigrants represent a large and growing proportion of the canadian population . subsequently , further research will be needed to inform and facilitate change at the policy level in order to protect allergic individuals in canada and abroad .
introduction . in canada , perceived prevalence of food allergy surpasses systematic estimates . 
 canadian immigrants have been found more likely to rate the risk of food allergy as  high  compared to nonimmigrants . 
 methods . 
 qualitative interviews were conducted with 3 key informants and 18 allergic individuals of east and southeast asian descent in order to capture their lived experience with food allergies . results . 
 participants found food allergies to be more common in canada than in asia . 
 participants also agreed that having a food allergy is more manageable in canada as a result of the policy environment ( e.g. , food labelling and school policies ) . 
 in addition , participants had dealt with skepticism and disbelief about their food allergy in asia , resulting in social exclusion and impacting quality of life . 
 discussion . 
 findings demonstrate the need to recognize the varied impacts and experiences of food allergy among new canadians , given that immigrants represent a large and growing proportion of the canadian population .