Accessibility and use of primary healthcare for immigrants living in the Niagara Region
Introduction
Approximately 250,000 people immigrate to Canada each year, accounting for roughly two-thirds of its annual population growth and composing 20% of Canada's total population (Asanin and Wilson, 2008, Ng and Newbold, 2011). Previous research on immigrant health suggests that immigrants are at higher risk for a variety of negative health-related outcomes compared to Canadian-born individuals. For example, studies have shown that immigrants are significantly less likely to be screened for cancer (Howlett et al., 2009), undergo pap tests (Lebrun and Dubay, 2010), and are significantly more likely to experience poor postpartum health (Sword et al., 2006, O'Mahony and Donnelly, 2010, Ganaan et al., 2012). Furthermore, evidence suggests that immigrants are less likely to be tested for chronic conditions (Woltman and Newbold, 2007), and are subsequently at a greater risk for mortality if diagnosed with chronic conditions (Pavlish et al., 2010). These poorer health outcomes have often been attributed in part to the barriers of healthcare access that immigrants experience (Pavlish et al., 2010).
Interestingly, contrary to the evidence suggesting that immigrants as a whole are at greater risk for poorer health, the literature has also found support for a ‘healthy immigrant effect’ (Newbold, 2005) – a phenomenon whereby immigrants tend to arrive to Canada in better health relative to the Canadian-born population. With time and assimilation into Canadian society, however, this health advantage diminishes due to stresses related to the immigration process, and a lack of access to healthcare resources (Newbold, 2005, Asanin and Wilson, 2010, Lebrun, 2012). As a result, there has been more research attention examining issues of accessibility, and the unique and changing healthcare needs of immigrants in Canada. Overall, there is a greater recognition around meeting the healthcare needs of new immigrants moving into the country, potentially attenuating the associated negative health outcomes.
From a broader systems perspective, barriers to healthcare for new immigrants represent a major concern for several reasons. First and as previously discussed, the research literature has generally found that a lack of care is negatively related to health status (Asanin and Wilson, 2008, Pavlish et al., 2010, Choi, 2012, Lebrun, 2012). Second, barriers to healthcare access have been found to act as a deterrent for immigrants seeking future care (Reitmanova and Gustafson, 2007). This is particularly problematic for the healthcare system as engaging immigrants in primary care can help prevent the onset of disease, and detect and manage disease earlier, thereby potentially avoiding expensive hospital-based care (Shi, 2012). Third, the lack of universal healthcare access for new immigrants moving to the country is a direct violation of the Canadian Health Act (CHA) of 1984. The CHA, which governs provincial health insurance programs including the Ontario Health Insurance Plan (OHIP), has five principle goals related to universality, accessibility, comprehensiveness, portability and public administration of healthcare (Asanin and Wilson, 2008). Given that immigrants currently face a variety of challenges simply to access healthcare services entitled to them under OHIP, Ontario is not actually meeting the CHA standards of care, promising universality and accessibility to all Canadian citizens. In reality, one could argue that the Ontario government's failure to address these ongoing barriers continues to undermine the mandates of the CHA.
Research has consistently found that issues of language, social support, geography, and economic accessibility are the primary barriers associated with healthcare access and use among new immigrants moving to Canada (Asanin and Wilson, 2008, Pavlish et al., 2010, Reitmanova and Gustafson, 2007). A major limitation, however, has been the traditional focus on the healthcare experiences of immigrants in large urban centres such as Toronto, Vancouver and Montreal. Indeed it is estimated that three-quarter of new immigrants settle into these major metropolitan areas (Haan, 2008), but there has also been a recent increase in immigrants moving to smaller urban centres (Frideres, 2006, Radford, 2007, Teixeira, 2009, Wiseman, 2010). Movement into these second- and third-tier cities in Canada are becoming increasingly attractive, as many of these centres have fairly stable economies, established public transportation services, higher education campuses, and offer more affordable housing and costs of living (Wachsmuth, 2008, Walton-Roberts, 2011, Gasic, 2013). However, there is a gap in our knowledge related to the healthcare experiences of immigrants living within these smaller reception areas.
Considering the vast differences between larger and smaller urban centres in terms of population diversity, availability of community resources, and affordable housing and transportation, the experiences of immigrants are likely different for those transitioning into smaller cities (Wachsmuth, 2008, Walton-Roberts, 2011, Gasic, 2013). Indeed, previous research has identified common barriers faced by immigrants moving to smaller regions including greater perceptions of discrimination (Lai and Huffey, 2009, Reitmanova and Gustafson, 2009), fewer settlement services (Chadwick and Collins, 2015) and limited employment opportunities (Reitmanova and Gustafson, 2009, Sethi, 2013). Studies exploring the ‘ethnic density’ of neighbourhoods have also found that highly ethnically dense areas may have protective benefits in increasing social supports amongst community members and protecting against racism (Pickett and Wilkinson, 2008; Wang and Hu, 2013). Moreover, one study examining why immigrants relocated from smaller areas to larger cities within the province of Alberta found that better opportunities for employment and education, improved access to newcomer services, and closer proximity to social supports (in the form of family, friends or ethnic communities) were the most common motivating factors (Krahn et al., 2005).
Given the overall challenges to settlement and integration faced by immigrants living in small urban centres, as well as the health disparities experienced by immigrants as a whole, it is likely that there are also specific barriers to healthcare access for immigrants in small urban centres. Therefore, the purpose of this study was to critically examine the access and use of primary healthcare for immigrants living in the smaller urban centre of the Niagara Region, with relation to the unique settlement challenges faced by this population.
Section snippets
Study design
This study used a phenomenological approach aiming to identify perceptions and interpretations of events and lived experiences for each participant, and to find commonality in what was universally experienced (Loiselle and Profetto-McGrath, 2011). Qualitative methodologies utilizing individual interviews or small focus groups are commonly used in health research, given its ability to capture rich, in-depth, and contextualized insights related to the way people perceive, create and interpret
Results
The study had two overarching focuses related to: (1) primary care access and (2) primary care use amongst immigrants living in the Niagara Region. The results from data analyses revealed five broad themes that had a major impact on primary care access and/or use for immigrants moving to smaller urban centres.
Discussion
The current study is, to our knowledge, the first aimed at understanding the lived experiences of immigrants moving to the smaller urban centre of the Niagara Region. Specifically, we identified five broad factors contributing to the difficulties associated with navigating and using the primary healthcare system, including: lack of social contacts, lack of universal healthcare coverage during their initial arrival, language as a barrier, treatment preferences, and geographic distance to primary
Study limitations
While this qualitative study was the first to examine the barriers to immigrant health within the Niagara Region, there are several limitations that should be acknowledged. First, the study used convenience sampling for recruiting participants through a local organization providing social services to newcomers. Therefore, participants in the current study were immigrants that had connections to community services, and the results may not be generalizable to all new immigrants moving into small
Conclusion
Overall, this topic may be particularly timely given the influx of new Syrian refugees to Canada, and others seeking refuge from government instability and civil war. This study represents one of the first studies exploring the qualitative healthcare experiences of immigrants moving into smaller urban centres such as the Niagara Region. With a growing immigrant population, it is important that we understand the barriers to healthcare access and utilization for immigrants moving outside the
Acknowledgements
We would like to acknowledge the Michael G. DeGroote School of Medicine, Niagara Regional Campus, McMaster University for their financial support on the project.
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