“I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada
Introduction
On a global scale, migration has rapidly increased in the past 30 years (United Nations, 2006). Specifically, the number of international migrants increased from 87 million in 1975 to 191 million in 2005 (United Nations, 2006). International migrants comprise an increasing percentage of the population in many developed countries such as Australia (Australian Bureau of Statistics, 2006), the United States (United States Department of Homeland Security, 2007) Sweden (Statistics Sweden, 2006), and Canada (Statistics Canada, 2001). In Canada immigrants account for almost 20% of the total population and each year approximately 250,000 new immigrants arrive contributing to two-thirds of the population growth (Statistics Canada, 2001). Recent census figures indicate that immigration will be the sole driving force of population growth by 2030 (Canada, 2007).
In general, countries rely on international migrants to fill labor shortages, strengthen national economies, and contribute to demographic stability (Australian Department of Immigration and Citizenship, 2007, Citizenship and Immigration Canada, 2007, German Federal Ministry of the Interior, 2007, Government Offices of Sweden, 2007). As such, immigrants represent important economic, social and demographic assets to their host country, and ensuring that the benefits of migration are reciprocated to newcomers is similarly important. However, research suggests that immigrant populations in developed countries experience much difficulty in receiving entitled social benefits such as health care in their new countries (Bollini & Siem, 1995). Specifically, international research as well as studies conducted in Canada indicate that immigrants often face multiple barriers when attempting to access health care services including language (Aroian et al., 2005, Bischoff et al., 2003, Deri, 2005, Ponce et al., 2006, Wu et al., 2005), cost (Lasser et al., 2006, Steele et al., 2002), location (McLafferty & Grady, 2005), transportation (Stewart & Nam Do, 2003), community awareness (Aroian et al., 2005, Bader et al., 2006), and cultural sensitivity (Padilla and Villaobos, 2007, Stewart et al., 2006, Wang, 2007).
Inaccessibility to health care services for immigrants represents an important concern for all host countries because it prevents newcomers from fully participating in society (Bollini & Siem, 1995). Moreover, as global rates of immigration are expected to increase and as health care concerns such as accessibility become more widely acknowledged among migrant populations, the existence of barriers to important health care services may be a deciding factor for immigrants choice of destination country. Thus, examining issues of accessibility to health care among immigrant populations is an important and timely research issue.
This paper presents the findings of a qualitative study exploring access to health care among a diverse group of immigrants residing in one neighbourhood in the City of Mississauga, Ontario. In particular, this study sought to understand the key barriers to health care as perceived by immigrants themselves. The results are significant for understanding barriers to care that are experienced most often by immigrants in one Canadian community, but also suggest a number of policy recommendations to improve access to care. These policy suggestions may also be useful to other developed countries that face similar access difficulties among their immigrant populations.
The next section of the paper discusses the relatively recent body of literature that has explored access to health care services for immigrants in Canada in particular. This section also sets the context by describing Canada's national policy that governs health care delivery in the country. The second section provides a description of the research design and collection of data through a series of focus groups. The third section presents the results of the focus groups, which reveal three groups of factors that inhibit access to care among immigrants, namely geographic, economic, and socio-cultural. The final section of the paper reflects on the significance of the findings in the context of future research directions and health policy.
In order to understand experiences of access to care in Canada it is first necessary to provide an overview of the policy that underlies health care delivery in Canada. The Canada Health Act (CHA), which was introduced in 1984, is the major piece of federal legislation that governs health care delivery in all 10 of Canadian provinces. The overarching goal of the CHA is to ensure access to medically necessary services for all Canadians regardless of ability to pay.
Under the CHA all provinces and territories must abide by five principles – universality, accessibility, comprehensiveness, portability and public administration – in order to receive federal funding for health care (Health Canada, 2006). The principles are designed to ensure a publicly funded health care system in which all Canadians (universality) receive medically necessarily health care services (comprehensiveness), regardless of where they live in Canada (portability), which is free at the point of delivery (accessibility). The CHA has been successful in removing two key income-based barriers to care – user fees and extra billing – to “ensure that all eligible residents of Canada have reasonable access to medically necessary services on a prepaid basis without direct charges at the point of service for such services” (Health Canada, 2006, p. 3).
Despite the importance of the CHA for removing the direct costs associated with receiving health care, recent research has documented a trend of an increasing number of Canadians reporting accessibility problems (Sanmartin et al., 2000, Wellstood et al., 2006, Wilson and Rosenberg, 2002, Wilson and Rosenberg, 2004). For example, in 1994 approximately 5% of Canadians reported they did not receive health care when needed, and by 2001 this figure had more than doubled (see Sanmartin et al., 2002, Wilson and Rosenberg, 2002). The number of Canadians without access to a regular family doctor is also on the rise. Most recent figures reveal that in 2005 approximately 17% of Canadians did not have a regular family doctor (Nambalamba & Millar, 2007). In addition, research has shown a range of predisposing, enabling, and need factors that are related to access to care, including gender (Doyal, 2000, Nelson and Park, 2006, Young, 1999); socioeconomic status (Dunlop et al., 2000, Finkelstein, 2001); and health status (Haynes, 1991, Kisely et al., 2007).
While important, much of the research on access to care in Canada is based on analysis of cross-sectional data from national-level surveys (e.g., Canadian Community Health Survey, National Population Health Survey). Thus, current understandings of access to care in Canada mainly relate to the general population and, although significant, such research provides little insight into experiences of access to care for subpopulation groups such as immigrants. The CHA's principle of universality states that “the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions” (Health Canada, 2006). Given that immigrants are recognized as ‘insured persons’ under the CHA, in principle, they should have similar levels of access to care as the Canadian-born population. Yet, we know relatively less about access to health care among immigrant populations despite the increasing growth of this segment of Canada's population.
This gap in understanding is also evident in national policy discussions about access to care. Specifically, neither of Canada's two recent health care commissions (The Commission on the Future of Health Care in Canada (Romanow, 2002) and the Standing Senate Committee on Social Affairs, Science and Technology Study on the State of the Health Care System in Canada (Kirby & LeBreton, 2002)) made significant mention of health care concerns that are specific to immigrant populations. In fact, immigrant populations are all but overlooked in the recommendations outlined in the final reports of these two health care commissions. This represents a significant gap in knowledge.
Accordingly, a recent and rapidly growing body of research has focused on examining issues of accessibility among immigrants, noting that they face difficulties accessing health care (Donnelly, 2006, Elliott and Gillie, 1998, Lai and Chau, 2007, MacKinnon and Howard, 2000, Steele et al., 2002Wong and Tsang, 2004, Wu et al., 2005). For example, in their study of over 2000 Chinese seniors in Canada, Lai and Chau (2007) found that the biggest barriers to receiving care were language (i.e., difficulty with English/French speaking doctors), long wait times for services, and a lack of awareness about available services. In another study of Chinese immigrants in the Greater Toronto Area, Wang (2007) noted the importance of spatial proximity to culturally appropriate care (i.e., Mandarin/Cantonese speaking doctors) for access among immigrant populations. Specifically, Chinese immigrants in the study were more likely to access health care when the services were ethnically and linguistically similar to the patient, and when located within close proximity to the patient. Other Canadian studies have shown language (Ahmad et al., 2004b, Deri, 2005, O'Mahony and Donnelly, 2007) and cultural appropriateness/sensitivity of health care services (Ahmad et al., 2004a, Ahmad et al., 2004b, Donnelly, 2006, Elliott and Gillie, 1998, Steele et al., 2002) to be influential for accessibility among immigrant populations.
While these studies represent only some in the growing body of research that explores issues of access among immigrant populations, gaps still remain. Specifically, much of the research relies on cross-sectional national health survey data and quantitative techniques. Such quantitative studies have shown that accessibility problems exist (i.e., lack of a family physician, lower levels of health care use and unmet health care needs) (Deri, 2005, Lasser et al., 2006, Wang, 2007, Wu et al., 2005) but do not enable an understanding of the key barriers to access as perceived by immigrants. Such information can only be gleaned through qualitative research studies. However, those studies that utilize qualitative research methods tend to collect data from service providers rather than the immigrants themselves (O'Mahony and Donnelly, 2007, Steele et al., 2002), and thus may not fully represent the concerns or actual experiences of immigrant populations. Additionally, much of the research that has been conducted on accessibility to health care among immigrant populations has focused on very specific immigrant population groups (i.e., older Chinese immigrants, female South Asian immigrants) (Ahmad et al., 2004a, Ahmad et al., 2004b, Elliott and Gillie, 1998, Wang, 2007), or specific health services (i.e., preventative screening) (Donnelly, 2006, Wen et al., 1996), but have not looked at access to care among the immigrant population in general. Thus, this paper aims to provide a more in-depth and nuanced understanding of the specific accessibility barriers faced by immigrants by providing analysis of access to care difficulties from the perspective of recent immigrants in Canada.
Section snippets
Methods
The research was conducted with immigrants living in the Dixie-Bloor neighbourhood within the City of Mississauga, Ontario, Canada. With a population of close to 700,000, the City of Mississauga is Canada's sixth largest city and is one of 25 municipalities that constitute the Greater Toronto Area (GTA) (Mississauga, 2006). The Dixie-Bloor neighbourhood is located in the east end of Mississauga and is home to 104,530 residents. Like the City of Mississauga, the Dixie-Bloor neighbourhood is
Results
The focus group interviews revealed three categories of accessibility that were of concern to immigrants: geographic, socio-cultural, and economic. While the specifics of each varied among the focus groups, these three categories were discussed in all eight groups, and the difficulties with accessing care dominated the discussion. In the remainder of the paper we present the specific concerns participants raised regarding access to care as they relate to each of the three categories. Verbatim
Discussion and conclusion
The goal of the research was to contribute to current understandings of access to health care among immigrant populations in general. The results reveal that immigrants living in the Dixie-Bloor neighbourhood face three significant barriers to health care in the form of geographic, socio-cultural and economic inaccessibility. Prior to discussing the significance of the research findings, some limitations need to be addressed.
All participants in this study are agency (DBNC) users and thus have
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