Advocacy for Immigrant and Refugee Health Needs
- Advocacy occurs at different levels with different targets and includes:
- case advocacy (for individual children/youth),
- systems advocacy (for practice changes that affect many children/youth), and
- policy advocacy (for changing legislation, regulations).
- When advocating for the health needs of immigrant and refugee children and youth, health professionals need to be aware of potential pitfalls.
- Effective advocacy involves carefully documenting and defining the problem, targeting an ‘audience’ or group that can effect change, proposing a solution, and using evidence and data as a basis for each effort.
- Individual stories can be very effective at bringing about change. Advocates need to obtain families’ permission and ensure they are aware of the implications of going public with their stories.
- Effecting change can take time. It’s important to review a strategy regularly and see whether anything needs to be changed.
Children and youth new to Canada are a heterogeneous group with health needs both similar to and distinct from Canadian-born children and youth.1,2 It can be difficult, sometimes impossible for newcomers to access health care that is both culturally and language-appropriate. Because of this service gap, clinicians often find themselves acting as patient advocates.3
Advocacy by health professionals
Advocacy—to support or defend a health cause or plead on a patient’s behalf—is a recognized role for paediatricians, family practitioners, nurses and other health care providers.4,5 In any field, advocacy works on different levels with different, targeted objectives or audiences:
- Policy advocacy: calling for changes to policies and legislation that will benefit most or all children and youth new to Canada (e.g., access to care for children of refugee parents awaiting review of their status).6
- System advocacy: working to achieve practice changes that improve quality of life and development for several or many children and youth (e.g., ensuring access to culturally and language-appropriate developmental assessments).
- Case advocacy: pleading for resources for an individual patient (e.g., access to a needed medication for a refugee child).
The Canadian Paediatric Society has a long advocacy history, particularly at the provincial/territorial and federal government levels. The biennial status report Are We Doing Enough? measures progress on a wide range of child and youth health issues including some, such as child poverty, immunization and early screening, that directly affect newcomer families.
Advocating for change: How is it done?
The steps for developing any advocacy strategy—whether case-based, systems or policy-oriented—are similar, and are described in Table 1.
Kyi, a 3-year-old girl from Myanmar with type 1 diabetes mellitus, has just arrived in Ottawa from a refugee camp in Bangladesh with her mother and three siblings. She needs glucose home monitoring but her mother cannot afford the equipment and dispensables. Kyi, along with two of her siblings, also appears to be developmentally delayed.
While advocating for this particular child may be similar to working on behalf of other disadvantaged patients, there are a few specific cautions to keep in mind. Here are some questions and steps to help develop your strategy:
- What is the health issue to advocate for? What does this child need? Gather information and evidence about immediate needs, the consequences of inaction, and how this need would be met for a Canadian-born child.
- What is the nature of the gap between this child and a Canadian-born child? Is inequity or injustice involved?
- Have all reasonable options been explored? There may be allied individuals or organizations who can help you meet or support this child’s needs.
- Who else can address this child’s needs—at what level of government or where in the health system? The answer to this question will determine your targeted group or audience.
- Does this problem need a quick resolution or is timeliness less medically crucial? Make notes based on the evidence. Focus on specific changes that will mitigate the problem.
- Is there a “win-win” solution? Look for an outcome that benefits your targeted group as well as the child. Make sure that this solution is culturally sensitive.
- Is there a story that needs telling? Include a written synopsis of this child’s personal story. You must obtain permission from the family to use their story, and be sure you explain how it will be used. Make sure the family and (if appropriate) the child or youth understand the implications of going forward with advocacy, especially if the request is made public. For example, they may not understand that the media can be intrusive, wanting details of the child and family’s personal life. Make sure the family knows exactly what you are advocating for.
- Is there an opportunity or relationship to be leveraged? Maybe there is a meeting scheduled with your targeted group on another topic or one strategically placed person who you have worked with before.
- What will the objections be? Consider what the opposition to your advocacy request will say and develop arguments and messages to address their concerns.
Remember: Successful advocacy is often timely, reflecting or highlighting an issue in the news. But having strong evidence, a well-told story and a thoughtful solution to offer can be equally important.
Present your case concisely. Being “noisy” isn’t necessarily helpful and can backfire. If your first targeted approach does not succeed, rethink the problem and who else might help address it. Could a pharmaceutical company supply a drug or medical device on compassionate grounds? Can a community organization help to bridge a gap in care?
- Will public advocacy help? Finally, ask yourself whether going public about this child’s plight is likely to speed or slow resolution of the problem. Weigh pros and cons carefully. If you use mainstream or social media for public engagement, attention on the child or family might be uncomfortably intense, and they may not appreciate being in the spotlight. Also, in a media story about an immigrant or refugee child there may be negative overtones that you cannot control. In developing your plan for advocacy, consider seeking a professional’s advice or help with a public “call to action”. The public affairs staff at your local hospital may be able to guide next steps.
The process of developing documentation for case advocacy often uncovers a wider problem which, in turn, may warrant a systems advocacy approach. Examples of practice-based improvements could be establishing a special clinic for refugee children and youth or a funding track in-hospital for specialized medical equipment or care. Typically, this approach takes longer than resolving a single child’s health needs. While the basic elements for developing a plan are the same as for case advocacy (see Table 1), there are wider themes to keep in mind:
- Defining the problem is key: Consider the range of issues involved. For example, advocating for better access to culturally and language-appropriate developmental assessment and care programs might raise internal and external complications. A refugee child sent for assessment may be older than a Canadian-born child. Their life experiences and exposures are far different, and the potential for complicating mental health problems is probably higher. If an interpreter is present, the language used may not match with the dialect, education level or culture of the patient or family. Such elements can overlay the validity and interpretation of tests standardized for Canadian-born children.
- Determining who can change the system may need some research: There is probably more than one target for advocacy. You may need to rank potential agents of change and coordinate efforts to more than one group or stakeholder.
- Make sure your solution is realistic: To make headway, your proposed outcome must mesh with existing resources, be recognized as potentially acceptable and, above all, improve health outcomes. An approach that was useful for single-case advocacy may not be appropriate for a larger population of immigrant and refugee children and youth. With systems advocacy, more care must go into assessing the impact and usefulness of proposed solutions. A proper search for best practices is crucial, and outcome evaluation is key. Having an evidence-based position statement or practice point from an organization like the Canadian Paediatric Society to support an advocacy position adds weight and credibility. Explore involving academic or other non-governmental organizations as potential supporters, especially if they have published guidelines or statements.
- Tell the story: Including stories of children caught in an unresponsive system will humanize systems advocacy. Remember to obtain permission from families, and be mindful of the cautions below.
- Describe the size of the problem: How many immigrant and refugee children need access to this service? What will it cost at present – and save the system in future – to meet this need?
A systems advocacy campaign can take years, so be sure the problem being addressed warrants the effort needed to bring about positive change.
Changing policy, legislation and/or regulations can be more complex than advocating for systems change. An example of this level of advocacy could be calling for a new federal law covering costs of urgently indicated medical equipment for refugees until they are eligible for coverage by a provincial/territorial program. It is difficult for individuals to effect change at this level, so partnering with reputable organizations such as the Canadian Paediatric Society is key to effective advocacy.
While the basics of systems and policy advocacy are similar, the target audience at government levels is usually wider. Political change is often driven by a combination of community pressure, health care providers’ advocacy and public or organizational pressure on individual legislators. However, if your targets for advocacy do not perceive the core problem as acute or of great public concern, it gets easier to ignore at higher government levels.
Immigrant and refugee child health issues often do not have the community support needed to effect change. Garnering long-term support for an issue that is not “mainstream” is hard work. Both traditional and new social media are important tools at this level, along with the linchpins noted above for case- and system-based advocacy: a clear statement of the problem, firm evidence, useful statistics, great stories that illustrate the problem and a thoughtful resolution.
Long-term results and follow-up
For any type of advocacy, success may not come easily or quickly. Strategies need to be reviewed, evaluated and updated. Ask the following questions at regular intervals or as political or other circumstances change:
- Are there new opportunities to leverage more support for a proposed solution? Is another solution more likely to be accepted at this time?
- Is this problem still pressing for a particular child (or group) or have circumstances changed?
- Has this problem been superseded by another issue, and is it now more important to resolve the newer issue first?
- How has the political landscape changed? Can wider pressure be brought to bear on this issue? Are there new examples of best practice in Canada or elsewhere that bring added support to current advocacy arguments?
- Is there new evidence of harm because this issue remains unresolved?
- Are partners and collaborators still fully engaged on this issue?
To be truly effective, advocacy on behalf of immigrant and refugee children and youth needs to be carefully examined through the cultural lens. Newcomer families should be as engaged as their advocates concerning the issue, objectives and resolution at stake. Be mindful of the following cautions when advocating for children and youth new to Canada.
- Choose the right type advocacy for your health issue, and prepare advocacy materials to fit.
- Have one well-rehearsed and knowledgeable spokesperson. If there is more than one, ensure that everyone is delivering the same key messages.
- Be clear, concise and accurate. If there is no solid evidence for an argument you are making, say so.
- Avoid being shrill (i.e., too noisy or confrontational). This approach can backfire.
- When asking a group or family’s permission to share their story, make sure they understand the implications of going public and are prepared for media intrusiveness.
- Be sure the family or group understands the health issue, what changes are being sought, and what methods will be used. Ensure this information is communicated in their first language. Make sure the proposed resolution or outcome is culturally appropriate.
- Be sure your advocacy materials are culturally appropriate and accurate by having them screened by a content expert, a topic expert, and an advocacy expert. Be sure there is harmony across these three views.
- Prepare for backlash, especially if newcomer requirements seem to exceed those funded for Canadian-born children and youth. Ensure that a child, youth or newcomer family will not be jeopardized legally because of media attention or ongoing advocacy.
- Remember that other vulnerable populations in Canada have similar unmet health needs. Be especially careful not to pit one group’s needs against another’s.
- Be sure that the motives of your partners and collaborators remain congruent with yours over time. Restate the reasons for involvement regularly, and watch for diverging agendas.
- A statement against the immigrant detention of children is supported by a number of organizations and individuals, including the Canadian Paediatric Society.
- The Canadian Paediatric Society website has helpful advocacy tools for health professionals.
- See also Agencies serving immigrants and refugees
- The Canadian Family Physician's Health advocacy for refugees: Medical student primer for competence in cultural matters and global health can be applied and adapted to for any advocacy setting or level.
- The Refugees and Global Health eLearning website has a useful training module on advocacy.
- Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011;183(12):E824-E925.
- Gushalak BD, Pottie K, Hatcher Roberts J, et al. Migration and health in Canada: Health in the global village. CMAJ 2011;183(12):E952-8.
- Pottie K, Hostland S.Health advocacy for refugees: Medical student primer for competence in cultural matters and global health. Can Fam Physician 2007;53(11):1923-6.
- Canadian Paediatric Society, 2012. Why we advocate.
- Royal College of Physicians and Surgeons of Canada, 2005. The CanMEDS Framework.
- Samson L, Hui C, Canadian Paediatric Society, 2012. Cuts to refugee health program put children and youth at risk.
- Noni MacDonald, MD
Last updated: October, 2016