Challenges and Barriers to Accessing Primary Healthcare Services Among Aging Immigrants in Canada

As Canada's population ages and becomes increasingly diverse with immigrants, understanding the health needs and outcomes of older adult immigrants is crucial. These individuals aged 65 and above, born outside Canada and have made it their permanent home, form a significant portion of the country's population [1]. With projections suggesting that a substantial number of baby boomers, including immigrants, will reach this age by 2031, the proportion of older adult immigrants is expected to rise further [2]. In 2022, older adult immigrants already accounted for 18.8% of Canada's population, with 30% of all older adults being born outside the country - a higher percentage than the total foreign-born population [3,4]. However, despite Canada's universal healthcare system, older adult immigrants need help accessing healthcare services. Compared to non-immigrants and younger immigrants, those who have lived in a foreign country for an extended period tend to have higher rates of poor health and chronic diseases [5,6]. Factors such as health literacy, cultural differences, language barriers, attitudes towards health, uneven distribution of healthcare resources, and financial constraints contribute to older adult immigrants' difficulty in obtaining necessary medical care [5]. Consequently, they are particularly vulnerable to health disparities [7].

The Healthy Immigrant Effect (HIE) initially states that immigrants arrive in Canada with better health than non-immigrants, attributed to the self-selection of healthier individuals and access to social support networks [8-11]. However, their health tends to decline over time, eventually resembling or even surpassing the health issues faced by Canadian-born individuals, especially among older adults [8,9]. This phenomenon underscores the significance of understanding and addressing the healthcare experiences of older adult immigrants in Canada, given its profound implications for their health and the healthcare system.

Language and Communication

Due to language barriers, aging immigrants experience difficulties communicating with healthcare providers, leading to misunderstandings and miscommunications. Insufficient interpretation services in healthcare settings are a prominent contributing factor to language barriers and diminish the quality of care for aging immigrants [5,12]. Limited language proficiency presents challenges in accessing health information, screening services, and primary healthcare for aging immigrants, often leading them to rely on improvised sign language or assistance from family members and friends as interpreters [5,12]. Language barriers contribute to reduced healthcare utilization rates, stemming from insufficient communication with healthcare providers, a shortage of interpreters, and hurried appointments [13,14]. Furthermore, the lack of transparency regarding treatment, privacy concerns that prevent individuals from fully communicating their health issues, and discontent with the quality of care provided can confuse the treatment process [14]. In addition, aging immigrants often feel like they do not have enough control over their healthcare, resulting in frustration and anxiety about accessing necessary care when most needed [14].

“Language barriers contribute to reduced healthcare utilization rates, stemming from insufficient communication with healthcare providers, a shortage of interpreters, and hurried appointments.”

Extended language barriers are closely linked with adverse health outcomes, amplifying systemic and socio-cultural obstacles to healthcare access [15]. Research indicates that older Latino and Asian immigrants with limited English proficiency exhibit elevated psychological distress compared to English-proficient counterparts, often due to underutilization of mental health services [16]. The HIE may explain the lower number of health emergencies among immigrants, as immigration screening favours healthier candidates and many older adult immigrants are cared for by family members who provide physical care and help them navigate language barriers [15].

Health Literacy

The lack of health literacy and limited knowledge about the Canadian healthcare system are significant barriers that prevent aging immigrants from accessing healthcare services. For aging immigrants, these barriers may be possibly influenced by cultural beliefs or past experiences with healthcare in their home countries [14]. A study revealed that older Latin-American immigrants lacked awareness about Alzheimer’s, often perceiving its symptoms as a natural consequence of aging and stigmatizing the disease due to misconceptions about its contagious nature, potentially hindering their prompt access to healthcare services [17]. Furthermore, another study revealed that low rates of accessing healthcare among older adult Chinese immigrants might be related to their lack of understanding about the importance and benefits of preventive annual physical examinations [18]. Lack of healthcare coverage and service availability were also significant predictors [18]. Previous research suggests that elderly immigrants depend on their past experiences with healthcare in their home country, cultural beliefs, norms, and traditional methods of seeking healthcare, leading to insufficient knowledge about the Canadian healthcare system [14,19].

Furthermore, some aging immigrants identified unfamiliarity with the healthcare system and limited resources as hindrances to accessing healthcare services [20]. For instance, some needed to be made aware of the necessity of having a family physician and visiting them when ill in Canada, while others were unfamiliar with the availability of walk-in clinics [20]. Therefore, improving health literacy and knowledge about the Canadian healthcare system among aging immigrants is essential for promoting better healthcare utilization rates and improving health outcomes.

Financial Constraints

Despite Canada's publicly funded healthcare system, older adult immigrants may face financial barriers to accessing healthcare, as provincial insurance plans typically cover only hospital and physician services deemed medically necessary, with some provinces requiring residents to pay a healthcare premium to support publicly funded services. Furthermore, some older adult immigrants need care that is not included in provincial health insurance plans, with low-income individuals unable to access crucial dental, eye, and mental health services without extended health insurance, often obtained through employment or private purchase [5].

Moreover, financially disadvantaged older adult Chinese immigrants encounter obstacles in accessing necessary services or resources, with recent arrivals or those with low socioeconomic status being particularly disadvantaged and often excluded from the Canadian pension system due to their limited work years in Canada [5]. Research has shown that older adult immigrant women are often more vulnerable, financially disadvantaged, and have fewer resources than their male counterparts [19]. For example, older adult South Asian immigrant women with lower incomes had lower rates of requesting cervical cancer screening [19]. In addition, the intersection of gender with other social identities significantly affects the health outcomes of older adult immigrants. Factors such as the family's financial situation and employment concerns may affect older adult women's access to health services [19]. Thus, there is a need for improved support services aimed at older adult immigrant women and men to address their unique healthcare access challenges.

Cultural and Religious Beliefs

Cultural and religious beliefs pose challenges for aging immigrants accessing primary healthcare in Canada, potentially leading to low healthcare utilization rates and suboptimal health outcomes. Variations in sharing medical history across cultures may lead to misunderstandings between patients and healthcare providers. For example, withholding such information is believed to prevent patients from giving up and losing their will to fight the disease [21]. When healthcare professionals are unaware of these cultural differences, it can cause distress for patients and their families.

Older adult immigrants from Chinese and South Asian communities frequently encounter a lack of respect for their traditional health beliefs within Western healthcare systems, resulting in misunderstandings with healthcare providers and challenges in communicating symptoms and treatments [5]. Additionally, cultural, and religious beliefs play a significant role in healthcare decision-making processes, with certain cultures strongly emphasizing family values and involvement in healthcare decisions [22]. Various studies have explored older adult Chinese immigrants’ health beliefs and practices in Canada and found that individuals believe in traditional health practices, Chinese medicine, and preventive diets [23,24]. A study discovered that older adult Chinese immigrants perceive mental health issues as manageable without professional intervention, underutilize mental health services compared to non-Chinese counterparts, potentially due to more robust identification with Chinese cultural values [25]. This association with Chinese cultural values correlates with less favourable health outcomes post-migration, potentially reflecting difficulties adapting to Canadian health norms and beliefs [25]. Religious beliefs can influence healthcare access, as some may prohibit specific medical procedures or blood transfusions, restricting the type of care aging immigrants are willing to accept [26,27].

Lack of Transportation

Limited transportation presents a widespread barrier for older adults seeking healthcare, often stemming from factors like lack of personal vehicles, driving restrictions, disabilities, or illness [28]. This challenge is exacerbated for older adult immigrants, who face "double vulnerability" due to aging and immigrant status, with immigrant women particularly affected by limited access to healthcare services due to transportation constraints [19,28]. A significant challenge arises from the mismatch between culturally relevant healthcare facilities and the residential areas of older adult immigrants [29]. Limited mobility, lack of transportation, poor health, and low socioeconomic status restrict access to care, as physicians and healthcare services are concentrated in densely populated urban neighbourhoods near major hospitals [5]. Underserved neighbourhoods often lack culturally appropriate healthcare options for older adult immigrants. As a result, they often rely on family members for transportation and translation assistance [30].

Stigma and Discrimination

The HIE suggests immigrants generally enjoy better health outcomes than non-immigrants, yet racialized immigrants may face health disadvantages due to discrimination. Research indicates older adults reporting recent discrimination have significantly lower odds of reporting good health, with one-third of racialized older adults experiencing discrimination compared to one-fifth of white respondents [7]. These findings underscore the heightened vulnerability of racialized older adults to discrimination and its adverse health effects. Discrimination emerges as a prevalent stressor affecting the health of older adult immigrants, refugees, and racialized individuals, irrespective of their immigrant status, leading to chronic stress and poor physical and mental health outcomes [7].

Conclusion

Involving aging immigrants in developing and implementing healthcare policies and interventions can ensure services tailored to their needs, fostering culturally appropriate care. The HIE offers valuable insights into immigrants' health outcomes in Canada, emphasizing the importance of incorporating their voices and experiences in policymaking to promote equitable, person-centred care. Doing so can enhance health outcomes for aging immigrants, addressing disparities within this population. Ensuring healthcare access for aging immigrants goes beyond justice; it is integral to their overall well-being, allowing them to maintain health and lead fulfilling lives. Culturally sensitive care improves healthcare access and utilization among aging immigrants. Healthcare providers must grasp aging immigrants' cultural backgrounds, beliefs, and practices to deliver respectful and responsive services. While cultural competency has historically been presented as a set of rules, viewing it as integral to clinical competence is crucial. Cultural competency is vital in addressing culturally specific health needs, enhancing care quality, and reducing ethnic disparities in health and healthcare access.

Jannath Kaur Chhokar is a pharmacy student at the University of Toronto pursuing a Doctor of Pharmacy degree. She holds a Master of Science in Global Health from McMaster University. Her research interests include global health, health policy, and inequities in healthcare utilization and access among migrant populations.

Satpal Multani is currently completing his Master in Public Administration at the Royal Military College of Canada, undertaking research regarding military and military family. Satpal works at the Ministry of Children, Community and Social Services.

References

1. Zou P, Fang T. Examination of Older Immigrants’ Contributions to Canadian Society: A Pathways to Prosperity Project [Internet]. 2017. Available from: http://p2pcanada.ca/wp-content/blogs.dir/1/files/2018/04/Older-Immigrants-Contributions-to-Canadian-Society.pdf

2. Government of Ontario. Ontario population projections [Internet]. www.ontario.ca. 2021. Available from: https://www.ontario.ca/page/ontario-population-projections#:~:text=The%20number%20of%20deaths%20is

3. Statistics Canada. Immigrants make up the largest share of the population in over 150 years and continue to shape who we are as Canadians [Internet]. Statistics Canada. 2022. Available from: https://www150.statcan.gc.ca/n1/daily-quotidien/221026/dq221026a-eng.htm

4. Employment and Social Development Canada. Social isolation of seniors: A Focus on New Immigrant and Refugee Seniors in Canada - Canada.ca [Internet]. Canada.ca. 2015. Available from: https://www.canada.ca/en/employment-social-development/corporate/seniors/forum/social-isolation-immigrant-refugee.html

5. Wang L, Guruge S, Montana G. Older Immigrants’ Access to Primary Health Care in Canada: A Scoping Review. Canadian Journal on Aging / La Revue canadienne du vieillissement. 2019 Feb 19;38(02):193–209.

6. Luo H. Factors Affecting Healthcare Access for Older Immigrants: A Qualitative Study with Service Users and Healthcare Social Workers in a Central Canadian City. Gerontology & Geriatrics Studies. 2018 May 10;3(3).

7. McAlpine AA, George U, Kobayashi K, Fuller-Thomson E. Physical Health of Older Canadians: Do Intersections Between Immigrant and Refugee Status, Racialized Status, and Socioeconomic Position Matter? The International Journal of Aging and Human Development. 2021 Dec 6;009141502110654.

8. Athari M. The healthy immigrant effect: A policy perspective [Internet]. summit.sfu.ca. 2020. Available from: https://summit.sfu.ca/item/20302

9. Tong CE, Lopez KJ, Chowdhury D, Arya N, Elliott J, Sims-Gould J, et al. Understanding racialised older adults’ experiences of the Canadian healthcare system, and codesigning solutions: protocol for a qualitative study in nine languages. BMJ Open [Internet]. 2022 Oct 1;12(10):e068013. Available from: https://bmjopen.bmj.com/content/12/10/e068013

10. Kennedy S, Kidd MP, McDonald JT, Biddle N. The Healthy Immigrant Effect: Patterns and Evidence from Four Countries. Journal of International Migration and Integration. 2014 Apr 15;16(2):317–32.

11. Treas J, Gubernskaya Z. Chapter 7 - Immigration, Aging, and the Life Course [Internet]. George LK, Ferraro KF, editors. ScienceDirect. San Diego: Academic Press; 2016. p. 143–61. Available from: https://www.sciencedirect.com/science/article/pii/B978012417235700007X

12. Koehn S. Negotiating candidacy: ethnic minority seniors’ access to care. Ageing and Society [Internet]. 2009 Apr 21 [cited 2020 Jan 18];29(4):585–608. Available from: https://www.cambridge.org/core/journals/ageing-and-society/article/negotiating-candidacy-ethnic-minority-seniors-access-to-care/EF7CC467B08637DDE2D72680FE5EA04B

13. Health Canada. Language Barriers in Access to Health Care - Canada.ca [Internet]. Canada.ca. 2019. Available from: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-accessibility/language-barriers.html

14. Pandey M, Kamrul R, Michaels CR, McCarron M. Identifying Barriers to Healthcare Access for New Immigrants: A Qualitative Study in Regina, Saskatchewan, Canada. Journal of Immigrant and Minority Health. 2021 Aug 23;24(1).

15. Sliz T. Breaking down linguistic barriers [Internet]. Queen’s Gazette | Queen’s University. 2021. Available from: https://www.queensu.ca/gazette/stories/breaking-down-linguistic-barriers

16. Kim G, Worley CB, Allen RS, Vinson L, Crowther MR, Parmelee P, et al. Vulnerability of Older Latino and Asian Immigrants with Limited English Proficiency. Journal of the American Geriatrics Society. 2011 Jun 30;59(7):1246–52.

17. Fornazzari L, Fischer C, Hansen T, Ringer L. Knowledge of Alzheimer’s disease and subjective memory impairment in Latin American seniors in the Greater Toronto Area. International Psychogeriatrics. 2009 Jun 9;21(05):966.

18. Lai DWL, Kalyniak S. Use of Annual Physical Examinations by Aging Chinese Canadians. Journal of Aging and Health. 2005 Oct;17(5):573–91.

19. Guruge S, Birpreet B, Samuels-Dennis JA. Health Status and Health Determinants of Older Immigrant Women in Canada: A Scoping Review. Journal of Aging Research [Internet]. 2015;2015:1–12. Available from: https://www.hindawi.com/journals/jar/2015/393761/

20. Turin TC, Rashid R, Ferdous M, Naeem I, Rumana N, Rahman A, et al. Perceived barriers and primary care access experiences among immigrant Bangladeshi men in Canada. Family Medicine and Community Health. 2020 Sep;8(4):e000453.

21. Runnels V. Understanding Immigrant Seniors’ Needs and Priorities for Health Care. [Internet]. 2017. Available from: http://olip-plio.ca/wp-content/uploads/2018/05/Senors-Report-Final-English-Low-Res.pdf

22. Alden DL, Friend J, Lee PY, Lee YK, Trevena L, Ng CJ, et al. Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries. Medical Decision Making. 2017 Jul 8;38(1):14–25.

23. Lai DWL, Surood S. Chinese Health Beliefs of Older Chinese in Canada. Journal of Aging and Health. 2009 Feb;21(1):38–62.

24. Wu T. Chinese Immigrants’ Health Beliefs and Practices of Traditional Chinese Medicine in British Columbia of Canada. Chinese Medicine and Culture. 2022 Dec;5(4):208–15.

25. Lai DWL, Tsang KT, Chappell N, Lai DCY, Chau SBY. Relationships between Culture and Health Status: A Multi-Site Study of the Older Chinese in Canada. Canadian Journal on Aging / La Revue canadienne du vieillissement. 2007;26(3):171–83.

26. Swan R. Faith-Based Medical Neglect: for Providers and Policymakers. Journal of Child & Adolescent Trauma [Internet]. 2020 Oct 9;13(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545013/

27. Swihart DL, Martin RL. Cultural Religious Competence In Clinical Practice [Internet]. National Library of Medicine. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493216/

28. Jamal S, Newbold KB. The promise of Co-design for improving transit service for older immigrants: Development of a co-design framework for Hamilton, Ontario. Urban Governance [Internet]. 2023 Jan 24 [cited 2023 Apr 14]; Available from: https://www.sciencedirect.com/science/article/pii/S2664328623000220

29. Wang L. Analysing spatial accessibility to health care: a case study of access by different immigrant groups to primary care physicians in Toronto. Annals of GIS. 2011 Nov 23;17(4):237–51.

30. Koehn S, Habib S, Bukhari S. S4AC Case Study: Enhancing Underserved Seniors’ Access to Health Promotion Programs. Canadian Journal on Aging / La Revue canadienne du vieillissement. 2016 Jan 5;35(1):89–102.