Mitigating the Cultural Factors Barring Recent Immigrants’ Access to the Canadian Health Care System

SHERVIN GHAEM-MAGHAMI

Despite the advent of a new decade, we appear to have carried with us many of the same growing fears that were building up toward the end of 2019 through to 2020. Among those concerns are issues like confronting the potentially-dire impacts of climate change, managing the ballooning costs of living, and pursuing our regular day-to-day activities in light of the spread of infectious disease (never mind the prospect of another global conflict sparked by events transpiring just after the New Year). Yet, perhaps even more so than the beginning of a calendar year, federal elections provide Canadians with an opportunity to contemplate their priority issues and vote accordingly. In the lead up to the elections late last year, despite the surge in anxiety for the aforementioned concerns, health care continued to reign supreme as the most important issue for voters [1]. This is apparent in how access to the health care system featured in some way in each of the 10 most important concerns related to health care (see Table 1).

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Although Canadians have high access and utilization rates of the health care system overall, recent immigrants are one population in particular that have been restricted in their ability to take advantage of health provision services. Statistics Canada indicates that immigrant status is among few characteristics that contribute to difficulties in accessing health care services [2]. Recent research carried out in Ontario found that 84.6% of recent immigrants—defined in that study as those who have resided in Canada for less than a decade—reported having a health service provider, compared to 94% of people born in Canada and 95.1% of established immigrants [3].

The situation of immigrants’ health becomes even more urgent when we consider that even if they were able to gain access to health care services in equal measure to the Canadian-born population, immigrants’ health conditions are still deteriorating the longer they stay in Canada [4]. Primary contributors to this trend include transitions in their dietary habits and physical activity, as well as the effects brought about by the difficulties faced in adapting to the realities of migration and resettlement, including stress, anxiety, and depression [5]. Nevertheless, there also appears to be a disconnect between the health care they can utilize themselves and actual health outcomes. Some barriers they may face in accessing health services are manifested in practical terms through the financial burdens (e.g., in the case of expensive prescriptions and other pharmaceutical products for which they may not be covered) and transportation constraints (e.g., if the facilities they require are inaccessible) they have to endure [6].

Notwithstanding these pressing matters, research indicates that cultural factors capture a large share of the difficulties facing recent immigrants in trying to access the health care system. While Canada’s progressive doctrine of multiculturalism—which is designed to support the maintenance and development of cultural communities—openly embraces and celebrates the arrival of people of all backgrounds, the systems through which it takes care of its inhabitants may have some catching up to do in order to ensure that they are not shut out once they are here [7]. The most outstanding of these cultural factors include: 1. Language barriers; 2. Lack of information on accessing/navigating services; and 3. Distinct cultural practices [6].

Language barriers

Comfort with the local language plays a critical role in feeling and becoming integrated into a previously-unfamiliar society. With an immigrant community as diverse as Canada’s, which does not have a single dominant ethno-racial group and is comprised of hundreds of cultures and nationalities, meeting this population’s language needs is a complex affair. As a result, health care providers are often hard-pressed to secure interpreters who can respond to such distinct language demands. Beyond translation, interpreters also mediate between different cultural traditions and their presence serves to create a safe environment for patients [8].

In an investigation comparing health care access between permanent residents, undocumented immigrants, and refugee claimants in Toronto, all the participants mentioned language as a major obstacle to seeking health care [9]. Furthermore, if they were able to secure an appointment, language barriers were also linked to fear because of their inability to communicate with their health care provider [9]. Yet the consequences of the lack of ability to communicate go beyond fear; in another study of those taking part in the Canadian Seasonal Agricultural Worker Program, almost 75% of the survey participants stated that not knowing the English language was detrimental to their health [10].

Lack of information on accessing/navigating services

Closely related to language is the availability of knowledge about entering into the health care system. In many cases, owing to limited access to resources, health care providers are only able to translate materials on the services they provide into a few languages, and if they do so, they do not necessarily employ a cross-cultural approach that accommodates a variety of backgrounds. Furthermore, multilingual health information may be hard to locate and is not readily available through major Canadian consumer websites [11].

One review of studies evaluating health care professionals’ and policymakers’ opinions on health care barriers for immigrants noted how self-advocacy was identified as a necessary skill for navigating the Canadian health care system [6]. Again, in relation to the first factor, the participants also recognized that such self-sufficiency is a challenge for those who do not have the “language abilities or confidence to express their needs, opinions, and complaints” [6].

Distinct cultural practices

A third barrier can be found in inadequate cultural competence within the health care system, especially as it relates to recognizing the diverse beliefs, values, and feelings of patients. Beyond overcoming issues related to language and information availability, there is also a requirement of respect for alternative health values and practices. At a deeper level, this also demands the broadening of conceptions around what constitutes ‘health’ and ‘well-being’. Despite the prevalence of the biomedical health model in many places throughout the world, the need to acknowledge and appreciate traditional cultural practices is often overlooked. This can undermine healthy immigrant client/practitioner relationships, the inclination to follow advice, and, ultimately, health status [12]. Furthermore, certain members of immigrant communities may prefer to exclusively seek out health care professionals who share their own ethnicity and/or speak their own language, which can delay the process of seeking support for their health concerns [13].

A good deal of research has gone into trying to better understand the implications of cultural difference on immigrant women in particular. One study revealed that ethnic minority female immigrants were the least likely to report an unmet health care need [14]. In addition, another study with this population found that cultural differences, social stigma, and spiritual beliefs and practices, among other elements, exert a great influence on how they seek mental health care. All of these considerations demand a degree of understanding and prudence from the government entities, communities, and practitioners involved [15].

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For such an array of cultural concerns to be adequately addressed, the solutions will need to be multifaceted and require a high degree of collaboration between governments and local communities responsible for health care provision. The following includes some proposed resolutions to address some broader issues associated with the overall outlook informing Canadian health care provision. It then lays out more practical lines of action in response to the barriers described above.

A holistic approach

At a fundamental level, Canada’s health care system needs to reflect a more holistic approach to create the space necessary for service provision to be more culturally perceptive and embody culturally-appropriate treatment models in its response [16]. Consequently, a one-size-fits-all approach will not be sufficient in capturing the diversity of needs and experiences of the Canadian recent-immigrant population [17]. To deploy such a system will require a joint and complementary effort on behalf of the various levels of government and communities involved, as each have their own particular strengths. While governments are more adept in providing overarching systems that can allow for the accumulation and dissemination of the relevant resources, communities are better positioned to work more closely with local needs and gather information at the grassroots.

In addressing the cultural factors outlined above, the ability to demonstrate sensitivity to cultural practices can only be developed through the adequate training of all professionals involved with health care provision. This ranges from interpreters and first-line providers to staff involved with administration and operations. Likewise, the adoption of culturally-sensitive communication practices by health educators’ can assist with reaching and influencing vulnerable populations. Health communication training will benefit both health care providers and patients alike in order to cultivate more meaningful and effective cross-cultural relationships [18]. Furthermore, strong partnerships should be fostered between service provision workers and immigrant groups, especially through educational programs.  These programs can empower recent immigrant communities to learn more about their own health, health promoting behaviours, and the overall functioning of the health care system [19]. Such programs will need to feature an exploration of the language used to describe health-related matters (e.g., medical procedures, personal practices, etc.), both to inform internal dialogues within immigrant communities and to demystify the characteristics and workings of the health care system [20].

This brings us back to the two cultural factors presented earlier, namely language barriers and lack of information on how to draw upon health care services. As a primary step, there is a need to increase the number of interpreters who can offer translation services in a variety of languages. In one of my classes, a health care practitioner shared that he was recently brought into a doctor/patient meeting to interpret the conversation due to his familiarity with one of the Romance languages. Upon arrival, he found out that the patient spoke another seemingly-related, yet still substantially-different Romance language with largely unfamiliar medical terminology. Nevertheless, it was expected that ‘his best’ would have to suffice, since no one else was available. This points to a lack of resources, both in terms of personnel who are trained to meet Canada’s diverse language needs and in terms of budgeting for the hiring of such professionals, and the procurement of both cannot be emphasized enough.

Finally, as it relates to improving the availability of information regarding how to access and navigate health services in Canada, one available study described the advantages of sharing multilingual publications online. The study identified the need for a central repository to make publications more widely available across the country [11]. Also, certain cultural groups tend to gravitate towards using certain smartphone applications or technology to either retrieve news or maintain informal communication with their families and friends—such as Telegram with Middle Eastern communities, WeChat with East Asian communities, or WhatsApp with Latin American communities [21]. Releasing relevant information targeted to groups on such platforms may also improve concerns around knowledge availability.

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As immigrants continue to arrive on Canadian shores and form an ever-increasing proportion of the Canadian population, Canada’s health care system must continue to evolve to reflect the necessary sensitivity and appreciation of the cultural factors that may be barring newcomers’ access from benefiting from the services they require. Perhaps the reason why health care continues to rank so highly among Canadians’ ongoing concerns finds its root in the pride we hold in already having a system that we believe to be robust and accessible. Addressing and removing some of these barriers may very well serve the purpose of maintaining the integrity of our health care system.

 

References

[1] Ipsos. (2019, October 3). Health care continues to be top issue for Canadians (37%); climate change climbs to second (30%, +4), ahead of affordability (26%, -2). Retrieved from: https://www.ipsos.com/en-ca/news-polls/Health-Care-Continues-to-Be-Top-Issue-for-Canadians

[2] Statistics Canada. (2016). Health at a glance — Difficulty accessing health care services in Canada. Statistics Canada catalogue no. 82-624-X. Ottawa, ON: Queen’s Printer for Canada.

[3] Health Quality Ontario. (2016). Measuring up 2016: A yearly report on how Ontario’s health system is performing. Toronto, ON: Queen’s Printer for Ontario.

[4] De Maio, F. G., & Kemp, E. (2010). The deterioration of health status among immigrants to Canada. Global Public Health, 5(5), 462–478. doi: 10.1080/17441690902942480

[5] Dean, J. A., & Wilson, K. (2010). “My health has improved because I always have everything I need here…”: A qualitative exploration of health improvement and decline among immigrants. Social Science & Medicine, 70(8), 1219–1228. doi: 10.1016/j.socscimed.2010.01.009

[6] Kalich, A., Heinemann, L., & Ghahari, S. (2016). A scoping review of immigrant experience of health care access barriers in Canada. Journal of Immigrant and Minority Health, 18(3), 697–709. doi: 10.1007/s10903-015-0237-6

[7] Berry, J. W. (2013). Research on multiculturalism in Canada. International Journal of Intercultural Relations, 37(6), 663–675. doi: 10.1016/j.ijintrel.2013.09.005

[8] Rosenberg, E., Seller, R., & Leanza, Y. (2008). Through interpreters’ eyes: Comparing roles of professional and family interpreters. Patient Education and Counseling, 70(1), 87–93. doi: 10.1016/j.pec.2007.09.015

[9] Campbell, R. M., Klei, A. G., Hodges, B. D., Fisman, D., & Kitto, S. (2014). A comparison of health access between permanent residents, undocumented immigrants and refugee claimants in Toronto, Canada. Journal of Immigrant and Minority Health, 16(1), 165–176. doi: 10.1007/s10903-012-9740-1

[10] Hennebry, J., McLaughlin, J., & Preibisch, K. (2016). Out of the loop: (In)access to health care for migrant workers in Canada. Journal of International Migration and Integration, 17(2), 521–538. doi: 10.1007/s12134-015-0417-1

[11] Stampino, V. G. (2007). Improving access to multilingual health information for newcomers to Canada. Journal of the Canadian Health Libraries Association, 28(1), 15–18. doi: 10.5596/c07-003

[12] Edge, S., & Newbold, B. (2013). Discrimination and the health of immigrants and refugees: Exploring Canada’s evidence base and directions for future research in newcomer receiving countries. Journal of Immigrant and Minority Health, 15(1), 141–148. doi: 10.1007/s10903-012-9640-4

[13] Wang L. (2007) Immigration, ethnicity, and accessibility to culturally diverse family physicians. Health Place, 13(3), 656–671. doi: 10.1016/j.healthplace.2006.10.001

[14] Setia, M. S., Quesnel-Vallee, A., Abrahamowicz, M., Tousignant, P., & Lynch, J. (2011). Access to health-care in Canadian immigrants: A longitudinal study of the National Population Health Survey. Health & Social Care in the Community, 19(1), 70–79. doi: 10.1111/j.1365-2524.2010.00950.x

[15] O’Mahony, J. M., & Donnelly, T. T. (2007). The influence of culture on immigrant women’s mental health care experiences from the perspectives of health care providers. Issues in Mental Health Nursing, 28(5), 453–471. doi: 10.1080/01612840701344464

[16] Asanin, J., & Wilson, K. (2008). “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada. Social Science & Medicine, 66(6), 1271–1283. doi: 10.1016/j.socscimed.2007.11.043

[17] Aery, A., & McKenzie, K. (2018). Primary care utilization trajectories for immigrants and refugees in Ontario compared with long-term residents. Ontario, ON: Wellesley Institute.

[18] Kreps, G. L., & Sparks, L. (2008). Meeting the health literacy needs of immigrant populations. Patient Education and Counseling, 71(3), 328–332. doi: 10.1016/j.pec.2008.03.001

[19] Thomson, M. S., Chaze, F., George, U., & Guruge, S. (2015). Improving immigrant populations’ access to mental health services in Canada: A review of barriers and recommendations. Journal of Immigrant and Minority Health, 17(6), 1895–1905. doi: 10.1007/s10903-015-0175-3

[20] Zanchetta, M. S., & Poureslami, I. M. (2006). Health literacy within the reality of immigrants’ culture and language. Canadian Journal of Public Health, 97(2), S26–S30. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/16805158

[21] Barot, T., & Oren, E. (2015, November 9). Guide to Chat Apps – Columbia Journalism Review. Retrieved from: https://www.cjr.org/tow_center_reports/guide_to_chat_apps.php