Approach individuals with an open-mind and listen attentively to how they identify their needs and concerns. Respond to the needs identified and/or prioritized.
The Canadian Council for Refugees is a national non-profit umbrella organization committed to the rights and protection of refugees and other vulnerable migrants in Canada and around the world and to the settlement of refugees and immigrants in Canada. The membership is made up of organizations involved in the settlement, sponsorship and protection of refugees and immigrants. The Council serves the networking, information-exchange and advocacy needs of its membership.
About the author: Canadian Council for Refugees
We do so by providing opportunities for networking and professional development through conferences, working groups, publications and meetings; working in cooperation with other networks to strengthen the defence of refugee rights; providing policy analysis and facilitating information-exchange on refugee and related issues. Finally, we advocate for the rights of refugees and immigrants through media relations, government relations, research and public education.
Factors that impact newcomer health
Some newcomers have precarious immigration status that prevents them from accessing public healthcare – these include undocumented migrants (including rejected refugee claimants and tourists who have overstayed their visa), temporary foreign workers without a valid work permit, Seasonal Agricultural Workers (with the exception of those in Manitoba) and some refugees and refugee claimants. Although access to healthcare through the Interim Federal Health Program has been reinstated for most refugees and refugee claimants, there remains confusion that results in some healthcare providers turning away eligible patients and denying them care.
In some provinces (Ontario, Quebec, New Brunswick), immigrants with permanent residence in Canada must wait three months after arrival in Canada to be eligible for provincial healthcare, creating barriers for the duration of the delay, as they must pay for healthcare.
For people in the precarious situations listed above, who don’t have healthcare coverage, a key barrier to accessing healthcare is financial. Many of those living with precarious status can’t legally work, so they are likely to receive low wages when they do work, and are often unemployed. People with precarious status who suffer from chronic illness or mental illness are also likely to be unemployed and therefore have little to no income to pay for health services.
Newcomers may need interpretation to fully understand their healthcare provider and make informed decisions. Even if they speak some English or French, they may not feel comfortable discussing their health in a language they are not proficient in. There are also issues around appropriate interpretation. If a patient’s only option for interpretation is their child for example, they may not be willing to discuss certain health issues, such as sexual and reproductive health issues. Even if there is a professional interpreter, newcomers may hesitate to speak openly out of fear that their personal information may reach others from the same country, particularly if the community is small.
Coverage for Refugee health care
Refugees are often eligible for services under the Interim Federal Health (IFH) Program, in addition to, or instead of, provincial health coverage. In June 2012 major cuts were made to IFH: services covered were narrowed and complex rules were implemented about which categories of refugees were entitled to which services. Many health care providers were reluctant to provide services covered by IFH because of the complicated bureaucracy. Some provincial governments stepped in to provide some of the services cut.
In July 2014, the Federal Court ruled that the cuts were a violation of the Canadian Charter of Rights and Freedoms. To comply with the court order, the federal government added in November 2014 some additional coverage for certain categories of refugees.
The new government elected in October 2015 has committed to restore IFH as it existed prior to the 2012 cuts.
Immigration rules and health
Under the Immigration and Refugee Protection Act, non-Canadians applying to enter or remain in Canada may be inadmissible on health grounds if they have a health condition that is likely to be a danger to public health or safety or might “reasonably be expected to cause excessive demand on health or social services”. This means, for example, that a person living with HIV who applies to become a permanent resident might be refused on the basis of their HIV status, on the grounds that their condition might cause excessive demand.
People applying as refugees or sponsored by a spouse or parent are not subject to the rule about excessive demand. However, they can still be refused if they have a health condition that represents a danger to public health or safety.
Mental health issues
Many refugees arrive in Canada with Post-Traumatic Stress Disorder as a result of their experiences of persecution. In addition, the migration experience can cause mental health issues to emerge for any category of newcomer. Yet, mental health services are often not available (whether for newcomers or citizens).
Other barriers to quality and comprehensive health care
Difficulty navigating a new health system
The healthcare system in Canada is different from that in many newcomers’ countries of origin, and newcomers have often not received orientation on what to expect from healthcare in Canada. For example, some people may be used to a system where one only sees a doctor when one is sick or if there is an emergency, or they may be used to going directly to a specialist. This means that the person may not go for preventative care or to talk about healthcare strategies, or they may drop-off after an initial appointment with a general practitioner and not seek further care. It can also be challenging to schedule and keep punctual appointments, due to differences in expectations in the Canadian system.
Some service providers may want to take a participatory approach to healthcare, however not everyone has the same expectations and levels of health literacy, and there may be some patients who want their healthcare provider to be an authority figure.
Lack of access to childcare can also be a barrier for parents wanting to see a healthcare provider without their child present.
Tip: It can help for healthcare providers to be flexible (around scheduling, for example), but also to provide guidance to patients on what the healthcare system here can offer, how it works, and what the expectations of the patient are.
Stigma around sex
Many people aren’t aware of their sexual and reproductive rights because discussing sex is taboo in their community. For example, some people may not know about the right to not have sex with a spouse. Reticence to talk about sex can make preventative care difficult. On the other hand, some newcomers have plenty of knowledge on this issue.
Tip: Avoid making assumptions about who will or will not be open to talking about sex. Make sure the door is open to talking about sex on a regular basis, with patients regardless of age (young or old). Let your patient know that you’re happy to discuss it and that it’s important. If you are a male practitioner working with a female patient, and discussing with a female practitioner is an option, let them know (and vice versa).
In working with newcomers, it is important for healthcare providers to be attentive to their own preconceptions and gaps in knowledge. It is easy to make assumptions about newcomers based on generalizations or misinformation. Newcomers will be quick to notice if your words or actions show that you have certain expectations based on their country of origin, their religion, their colour or their status as newcomers.
Tips for overcoming harmful assumptions
It is important not to generalize populations based on country of origin since there can be hundreds of cultural groups within one country, differing practices and levels of healthcare literacy and vast individual differences (just as there are among Canadians).
Be aware of assumptions or judgments based on personal values and avoid letting these interfere with the quality and breadth of care.
Avoid expressing disparaging attitudes towards sexual or other health practices from other places that don’t fit within the Western model (including Female Genital Mutilation).
Avoid judging patients’ choices around sexual health, including marriage (whom people marry, under what circumstances, etc.), birth control (choosing to use birth control methods or not), pregnancy (regardless of age), abortion (especially in the context of the stigmatic assumptions around ‘gender selection abortion practices’ in racialized communities), adoption, and sexual partners and activities regardless of marital status.
Avoid making assumptions about a patient’s sexual activity based on marital status. For example, don’t discount need for STI testing simply because a patient is married.
Do not make assumptions about “cultural practices”. For example, if you see marks seeming to indicate abuse, it’s important to follow up sensitively and with open ended questions with the patient and not jump to conclusions.
Ripple Effect: Newcomers’ attitudes towards the health care system in Canada may be strongly influenced by initial impressions of whether they or others they know feel welcome and get appropriate treatment. If someone feels unwelcome or inappropriately served, word can spread rapidly in the community, and may result in individuals choosing not to access healthcare or particular points of service. This can result in decreased access and increased vulnerability for a large group of people.
How to Create a safe and welcoming environment
Put up signs and stickers to welcome people and show that certain issues are discussed, e.g. LGBT friendly posters, community-based pictures, paintings that represent diversity. Seeing their own faces is important – are there posters up representing a diverse clientele? Different skin tones? Way of dress?
Communication is very important – tone and non-verbal gestures are key. Work to gain trust.
- Greet with a smile. This is welcoming and most appropriate, as not all patients are used to shaking hands or touch
- Emphasize the positive, be aware of using negative language
- Use plain language to avoid confusion
- Ask open-ended questions, offer a wide range of options (both orally and on intake forms)
- Reiterate your confidentiality policy at the beginning of the patient encounter. Trained interpreters should also have confidentiality protocol that they inform the patient of.
Try to have resources on health issues available in different languages to help bridge the language gap, especially if there is no access to interpretation
Get interpretation for patients with language barriers – if it is unavailable use google translate or another translation site – make the effort!
Take the time to understand where your newcomer patients are coming from, what the cultural needs and norms are. For example, look into screening test needs by region.
It is important for the provider to listen to patient concerns that may intersect with healthcare (employment, housing, food access, security) and try to connect the patient to services that can help (such as settlement services or social workers). A provider’s agenda may not align with the patients agenda, but how the provider interacts with the patient to meet their client’s goals is important to improve service provision, outcomes, and trust.
Do not make assumptions about “cultural practices”.
Availability and accessibility are important elements to service provision. Best practices include offering primary care services in the evening, offering childcare and offering transit fare to support most vulnerable patients.
Make an effort to understand the different categories of coverage
Find out who in your community is providing care to uninsured newcomers so you can direct these vulnerable newcomers to them (do so yourself if you can)
Enlisting health brokers is another best practice. These are peers from the newcomer communities being worked with, who help perform community outreach and address social determinants of health.
Having community based participatory programs that engage client populations (in addition to primary care services) can go a long way in creating support networks, connect people to the services they need and break isolation. E.g. youth programs, rooftop gardening, men’s cooking program, women’s discussion group, etc.
Additional resources and helpful information
Being open, creating a safe space and gaining your patient’s trust is especially important for LGBT newcomers. Placing LGBT-friendly paraphernalia in your office, and prioritizing an open and welcoming communication style is encouraged. LGBT refugees are not always getting appropriate support at settlement agencies and may not be comfortable going to mainstream LGBT organizations, so being open and gaining trust around sexual health issues is crucial.
Many of same tips around avoiding assumptions, and being open apply in the case of newcomer youth.
Inform yourself: www.kidsnewtocanada.ca
Growing numbers of trans newcomers are being welcomed to Canada. Many come because they face persecution in their country of origin because of their gender identity, or because they will have better access to health and other support in Canada.
However, they also face many barriers in Canada because of their gender identity. Trans people often face barriers around employment, housing and healthcare that reinforce each other, and that make trans people particularly precarious. For some trans newcomers, status issues create an additional challenge. These barriers can result in economic challenges that may lead trans people to engage in potentially high-risk employment, such as sex work, which may bring with it additional health challenges. Trans people wanting to have transitional surgery – even those with status – often face significant financial barriers because these surgeries aren’t covered in many parts of the country.
Prejudice and judgement are significant barriers for trans newcomers. It is important for healthcare providers not only to create a safe and open space for trans newcomers, but to inform themselves of trans health issues, of local healthcare and social service providers who work with trans people, and to deconstruct any of their own assumptions or judgements around gender identity and expression.
Unfortunately, Immigration, Refugees and Citizenship Canada (IRCC) does not allow newcomers to change their sex and name on CIC identity documents, so patients may be identified on their ID differently from how they present themselves. It is important for healthcare providers and staff to be sensitive to these issues, and to listen to patients, and accept the information they provide about their sex or gender identity.
Tip: Avoid making assumptions about the gender identity of patients. If you’re not sure, ask respectfully, and listen to and believe what they say, rather than relying on your perceptions of their body.
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