A guide for health professionals working with
immigrant and refugee children and youth

Barriers and Facilitators to Health Care for Newcomers

Key points

  • Newcomers to Canada experience a range of barriers to quality health care, such as:
    • complex health insurance eligibility and entitlement rules,
    • limited pre-arrival health care,
    • limited language and literacy skills,
    • lack of familiarity with the Canadian health care system,
    • precarious finances, and
    • factors related to gender and culture.
  • There are simple things health professionals can do to help reduce some of these barriers. For example:
    • Asking about your patient’s immigration or refugee status and knowing which health care services or benefits they are (or are not) entitled to.
    • Knowing about and liaising with public health services and community organizations that work with newcomer families.
  • Although barriers to health care are well documented in the literature, solutions to address them are under-researched, especially for children and youth.

Why is it important to know about barriers to health care?

A barrier to health care is anything that restricts the use of health services by making it more difficult for some individuals to access, use or benefit from care.1

Families new to Canada encounter multiple barriers, which vary among provinces and territories. Broadly, however, they include:

  • A complex array of political, social and health system-related rules and requirements.
  • Factors relating to culture: the patient’s, a family’s, or the health care provider’s own culture.

Being aware of barriers to health care can help health professionals be more sensitive to the challenges faced by their patients. They can also take steps to reduce or overcome some of these barriers, help their patients to overcome others, and improve quality of care.

Birthplace as barrier: Roya and Shanthi

Roya, age 4, comes to your Ontario office for increasing urinary accidents and incontinence, and vague abdominal discomfort. As part of your work-up, you request a urinalysis and culture, and an abdominal ultrasound. Roya’s parents ask if you can see her 12-year-old sister Shanthi for fatigue and heavy periods. You receive Roya’s reports but Shanthi’s investigations are missing.  After questioning you learn that the girls’ parents are in Canada on work visas and provincial permits while applying for immigration status. Roya was born in Canada and has provincial health coverage. Shanthi was born in Iran and immigrated to Canada with her parents at 6 years of age. She is still ineligible for provincial health insurance and her family cannot afford investigations for her.

Systemic barriers

Problems with eligibility and entitlement

The complex array of federal and provincial/territorial health care eligibility and entitlement categories can be a serious barrier to care for newcomers to Canada. The eligibility rules and length of time that immigrants must wait for landed status and health care when they apply from within Canada vary significantly across the country. Changes to the Federal Interim Health Program in 2012 limited health care service eligibility further, and have caused confusion for care providers and recently arrived families. 

There are large populations of medically uninsured and underinsured newcomers across Canada, with a total estimated as high as 200,000.2,3 Patients who are ineligible for health care report higher levels of anxiety, stress and advanced illness.4

Care providers should know the immigration or refugee status of newcomer patients and the entitlements and exclusions to health care related to their status. Yet obtaining this information is challenging for two reasons: 

  • Patients may fear the consequences of sharing information about their status.
  • Health insurance regulations are not easy to navigate.

Read more about health insurance eligibility and entitlements for newcomers.

Emergency or not?  A care gap for the uninsured

An 8-year-old boy arrives in your Ontario clinic. He is a landed immigrant whose migration path included a Darfur refugee camp and time in Kenya. He arrived 3 weeks ago, and must wait 3 months for provincial health insurance coverage. He presents with cough, fever and dyspnea. He has bi-basal crackles and his temperature is 39°C. You hear a 5/6 systolic murmur. You refer him to the local hospital emergency room, where you know that a patient with an urgent condition will not be turned away because the family cannot pay. You are surprised to see this boy and his father in your clinic the following morning. The ER administrative staff determined that he did not meet their “criteria for an emergency”, and his family lacked the $500 fee needed for assessment. The boy’s condition has worsened. He has had no urine output for 24 hours.

Learning points

  • Ask about your patient’s immigration or refugee status but recognize that newcomers may be reluctant to share this information. Be familiar with health insurance eligibility rules.
  • Check with area hospitals for policies defining what constitutes an emergency and what doesn’t before sending newcomer patients there.
  • Write a referral letter for ER staff specifying the exact nature of a patient’s condition and why it constitutes an emergency.   

What health professionals can do

Lay some groundwork:

  • Depending on their immigration or refugee status, patients are entitled to different services. By knowing what these rules are, you can help families to navigate the health system.  Read more about health services for newcomers
  • Educate patients about their immigration or refugee status and how it affects health care access.
  • Circulate clear guidelines for practice staff and share information with newcomer patients on the care entitlements of different groups.
  • Check with area hospitals for any policies defining what constitutes an emergency and what does not. This is important information when you are treating patients who are medically uninsured.
  • The Interim Federal Health Program is administered by Medavie Blue Cross. At the point and time of service, contact Medavie Blue Cross directly to determine whether the service(s) you plan are eligible.  
  • Register with Mediavie Blue Cross and check a newcomer patient’s coverage each and every time you see them to determine whether their eligibility has changed. Read more about the Interim Federal Health Program and how to confirm eligibility through Medavie Blue Cross

Lack of care provider knowledge and skills

A health professional’s lack of knowledge can be a barrier to quality care.

What health professionals can do

Self-educate. Become familiar with:

Limited access to physicians

There are few family doctors with appropriate language or cultural skills accepting newcomer patients in some areas where they are needed.

Also, some physicians are reluctant to accept newcomers as patients because of higher administrative demands or obstacles to payment for services rendered (e.g., filling out forms for patients, delayed payments or non-payment from the Interim Federal Health Program, and the need to call ahead for care approval for treatments or services).

What health professionals can do

Streamline practice:

  • Find ways to improve the rate and completion of payment, e.g., by identifying one person in your practice to learn and run the process.
  • Consider networking with physicians and care providers in your region to pool interest in newcomer patients and information about providing care in your jurisdiction.

Patient unfamiliarity with new systems

Being unfamiliar with the Canadian health care system can make it difficult for newcomers to access quality care. For example, newcomers may:

  • Be unfamiliar with the biggest benefits of a primary care system: prevention, continuity of care and screening. They may not have experienced the benefits of seeing a family doctor regularly or know what a paediatrician is.
  • Seek most of their care from specialists, walk-in clinics or hospital emergency rooms.
  • Be uncertain where to find health care and health-related help.
  • Be unfamiliar with their rights to access health care under provincial and federal insurance plans.
  • Have limited understanding and ability to advocate for themselves or for their family’s care.
  • Fear that seeking care will affect their immigration or refugee status, or result in deportation.

What health professionals can do

Be a resource:

  • Help patients to access information about navigating the Canadian health system. Your involvement will improve access to appropriate care, preventive services and screening. Settlement services may be able to assist. 

Limited pre-arrival health care

Before arriving in Canada, newcomers may have received inadequate or substandard care leading to an unmanaged, complex medical condition. They may also have experienced psychological trauma. Other problems related to pre-arrival health care include:

  • incomplete pre-admission examinations and assessments,
  • patients not knowing their medical history,
  • incomplete, missing or undocumented immunizations,
  • experience of trauma and social deprivation in their homeland or en route to Canada, and
  • the absence of follow-up or screening (e.g., for HIV, hepatitis B or Streptococcus in pregnancy or in the perinatal period).

Read about the medical assessment of newcomer children and youth. 

Precarious finances

Financial problems can be a serious barrier to health care.

  • Newcomers may avoid or delay care if they can’t pay for services.
  • Newcomers are disproportionately poorer than the general population. Poverty affects multiple social determinants of health
  • The high costs of care can cause delays in treatment, tests and medication for those without insurance (e.g., hospital care can cost more than $2000 a day). Even people who are covered by the Interim Federal Health Program or provincial insurance sometimes need uninsured items.
  • Youth or caregivers without legal status may end up working in dangerous, injury-prone types of employment.

What health professionals can do

Be a liaison:

  • Be aware of eligibility rules for health services, what skills are needed for culturally competent care, your role as an advocate and local community resources.
  • Provide staff with education on cultural aspects of care and the needs of children and youth new to Canada.
  • Help newcomer families connect with community social services that support care (e.g., social work, transportation, interpreter services, financial aid, settlement agencies).
  • Look for volunteer health support organizations. These networks are often available in urban areas with large newcomer populations.
  • Make sure newcomer patients know that some city and provincial/territorial public health services do not require a health card (e.g., immunizations, some infectious disease screening, access to a public health nurse).
  • Help patients to access information about navigating the Canadian health system. Your involvement will improve access to appropriate care, preventive services and screening. Settlement services may be able to assist. 
  • Where needed, provide a letter stating the child’s diagnoses or needs. This can be helpful for families looking for services or having to explain to other care providers.
  • Help connect newcomer families with a regular primary care provider.

Mistrust of government and services

Newcomers to Canada may have a negative attitude toward authority and be less trusting of political and social organizations if such groups are associated with harmful experiences in the home country. Immigrants or refugees may not seek care if they believe that their health or personal information will be used against them.5

Newcomer children and youth are more likely to a have negative attitude toward authority figures if they have experienced:

  • detention,
  • abuse and torture,
  • psychological deprivation,
  • insecure residence, or
  • separation from their parents, guardians or extended family.

What health professionals can do

Build trust:

  • Convey strong messages that patient information is confidential.
  • Provide flexible appointment times to accommodate mental health needs and irregular work schedules.
  • Provide printed reminders and use tracking systems to improve patient attendance and monitor access to care.
  • Encourage positive and stable relations with all clinic staff. Provide training and education opportunities for colleagues and staff to ensure a minimum standard of culturally competent care
  • Offer preventative services directly to patients. Explain and emphasize the benefits of continuity of care, prevention and screening.
  • Use an ‘interprofessional’ team approach, including referrals to community organizations that provide services to newcomers.
  • Reinforce the abilities of refugee families to meet their own needs, for instance with support from allied services and professionals (social work, transportation, interpreters, financial aid, settlement services).  
  • To optimize health outcomes in traumatized children, focus on interventions that support and tap into an individual’s resilience and cultural values.6  Examples include encouraging participation in school, involvement with peer groups, after-school sports and recreational programs, as well as working with parents to build the skills they need to support their children.  Read more about mental health in this resource. 

Language, literacy and cultural barriers

Gaps in language or literacy

Many children and youth have difficulties explaining their symptoms. Care providers must be especially careful when trying to clarify a child’s symptoms by asking parents to explain them. This approach can make the child more reserved and result in misdiagnosis.

Other gaps include:

  • differences in language or ethnicity between care providers and patients,
  • a care provider not knowing how to use an interpreter appropriately
  • a lack of reliable professional interpreter services,
  • a lack of printed information in the patient’s first language.

Cultural gaps

Culture influences dominant views of the causes and management of illness. When care providers and patients are from different cultures, their respective understandings of illness or treatment may vary significantly. 

Cultural differences may also be a barrier when:

  • Newcomers feel stigmatized and avoid mentioning sensitive health issues such as sexual abuse, domestic violence, discipline, alcohol or substance abuse and problems with mental health.
  • Individuals from some cultures prefer to solve problems themselves and avoid doctors’ visits, viewing physician care as a last resort. They may also see hospitals as a place to die rather than a place to heal.
  • Newcomers underuse health promotion and screening services (e.g., PAP, mammography), as well as mental health and counselling services.7,8
  • There is shame around mental health problems, whether symptoms originate in Canada or stem from abuses in their home country.
  • Women avoid seeking primary care if their care providers are male, particularly for screening services.7,8
  • Family dynamics or traditions in some cultures prevent women from receiving screening, prevention and treatment services.

Read more about how culture influences health

What health professionals can do

Communicate openly:

  • Understand that eliciting information about sensitive issues from children and youth may require several consultations. Read more about medical assessment of newcomer children and youth.
  • Understand the importance of interpreters, how best to work with them and how to arrange for their services in advance. If a trained interpreter is not available, use appropriate alternatives. 
  • Raise cultural awareness and cultural competency among practice staff.
  • Use advocates or cultural brokers who are competent, knowledgeable and experienced to help newcomer patients understand and receive the care they require.
  • Promote educational programs crucial to the delivery of quality care. 
  • Be clear with patients about the services that practitioners can reasonably deliver. Directly address unrealistic expectations or stereotypes held by newcomers or other care practitioners. 
  • Try to understand the whole family's dynamic and their socio-cultural perceptions of illness. Read How Culture Influences Health for more information. 
  • Have health promotional material and health information available in multiple languages and be familiar with websites that provide such resources.  
  • Provide a letter for newcomer families explaining a child’s diagnoses or needs. This document can help when looking for supportive services or urgent care.

Be an advocate

At a systems and policy level

Advocating for improved access to health care services and social determinants of health for newcomer families is part of providing quality care. Physicians and other health professionals can be effective agents for positive change in the everyday lives of newcomers to Canada, whether they are working to raise awareness at a systems or policy level or on behalf of individual patients. Each initiative described above involves some degree of advocacy. Read more about what you can do to advocate at the systems and policy level.

Advocating for individuals

To improve health care access and support services for newcomer patients, physicians and allied care providers can achieve more by collaborating: with local health agencies, hospitals, regional health authorities, public health units, community health centres and non-governmental organizations. Learn more about what you can do in the community to improve health care for families new to Canada.  

References

  1. Scheppers E, van Dongen E, Dekker J, et al. Potential barriers to the use of health services among ethnic minorities: A review. Fam Pract 2006;23(3):325-48.
  2. Salehi R. Intersection of health, immigration, and youth: A systematic literature review. J Immigr Minor Health 2010;12(5):788-97.
  3. Caulford P, Vali Y. Providing health care to medically uninsured immigrants and refugees. CMAJ 2006;174(9):1253-4.
  4. Simich L, Wu F, Nerard S. Status and health security: An exploratory study of irregular immigrants in Toronto. Can J Public Health 2007;98(5):369-73.
  5. Davidson N, Skull S, Burgner D, et al. An issue of access: Delivering equitable health care for newly arrived refugee children in Australia. J Paediatr Child Health 2004;40(9-10):569-75.
  6. Fazel M, Reed RV, Panter-Brick C, et al. Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. Lancet  2012;379(9812):266-82.
  7. Lesjak M, Hua M, Ward J. Cervical screening among immigrant Vietnamese women seen in general practice: Current rates, predictors and potential recruitment strategies. Aust N Z J Public Health 1999;23(2):168-73.
  8. Taylor VM, Schwartz SM, Jackson JC, et al. Cervical cancer screening among Cambodian-American women. Cancer Epidemiol Biomarkers Prev 1999;8(6):541-6.

Other works consulted

  • Asanin J, Wilson K. “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada. Soc Sci Med 2008;66(6):1271-83.
  • Beach MC, Price EG, Gary TL, et al. Cultural competency: A systematic review of health care provider educational interventions. Med Care 43(4):356-73.
  • Caulford P, D’Andrade J. Health care for Canada’s medically uninsured immigrants and refugees: Whose problem is it? Can Fam Physician 2012;58 (7):725-7.
  • Hyman I. Setting the stage: Reviewing current knowledge on the health of Canadian immigrants; What is the evidence and where are the gaps? Can J Public Health 2004;95(3):14-8.
  • Morris MD, Popper  ST, Rodwell TC, et al. Healthcare barriers of refugees post-resettlement. J Community Health 2009;34(6):529-38.
  • Papic O, Malak Z, Rosenberg E. Survey of family physicians' perspectives on management of immigrant patients: Attitudes, barriers, strategies, and training needs. Patient Educ Couns 2012; 86(2):205-9.
  • Priebe S, Sandhu S, Dias S, et al. Good practice in health care for migrants: Views and experiences of care professionals in 16 European countries. BMC Public Health 2011;11:187. Doi: 10.1186/1471-2458-11-187.
  • Wu Z, Penning MJ, Schimmele CM. Immigrant status and unmet health care needs. Can  J Public Health 2005;96(5):369-73.

Editor(s)

  • Paul Caulford, MD
  • Maureen Mayhew, MD

Last updated: March, 2014

Also available at: http://www.kidsnewtocanada.ca/care/barriers
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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