One of the challenging barriers that immigrants need to overcome is access to health care services. In this study, the core category of “Tackling the Stumbling Blocks of Access” and the basic social process (BSP) of “Becoming Self-sufficient and Integrated” show how Iranian immigrants learned to address this problem. Analysis from this study shows that almost all Iranians in the first stage of transition feel like strangers who are disconnected from the new world. They have little sense of themselves in relation to the new country. They feel incapable of managing their lives, which affects their sense of identity. More importantly, they cannot use their own language in their everyday lives. Therefore, both physically and symbolically, much that they use to construct their world needs to change[3, 13].
In accessing health care services in Canada, Iranian immigrants face many challenges and barriers, both structural and nonstructural (communication barriers, cultural differences, financial limitation). In some cases, these barriers are so frustrating that they decide to return to their own country (disillusioned). Of those who stay, some feel helpless and frustrated, and isolated (holding on). These people remain in Canada but reconnect to their country of origin through families, relatives, and friends, and try to meet their health needs by obtaining medications and advice from Iran (turning back).
The potential for isolation among immigrants has important health implications. The feelings of strangeness and lack of belonging contribute to a greater level of disconnectedness from community. Individuals understand each other only through interconnectedness with one another regardless of race, color, religion, or ethnicity. Learning happens in a relationship with others, not in isolation. Disconnectedness from history, belonging, and culture and lack of interconnectedness can lead to physical and mental health problems. The results in this study are similar to those of Jafari and Emami, who reported that the loss of supports, networks, possessions, and meaningful attachments compromised immigrants’ physical and mental health[4, 13]. In the study described in this paper, we found that as participants became more isolated they ignored their health problems until these problems became critical (holding on). Although this group of people physically lived in Canada, they obtained most of their medical needs from Iran, which further complicated their care and compromised their health, partly because there was no reliable ongoing record of their health issues. Other authors have reported that immigrants are as healthy as their Canadian counterparts at the time of arrival but that their health status declines, possibly due to stress and unhealthy lifestyles. The findings of our study extend the possible explanations for the “healthy immigrant effect” whereby new immigrants tend to be healthier than their age cohort on arrival in a host country but experience health declines as settlement proceeds. Declines in the health status of our participants appeared to be related to their decisions to ignore their own health issues because of other pressing concerns, often related to settlement priorities, and to the difficulties associated with accessing the Canadian health care system as health problems emerged.
With regard to seeking information, Iranians adopt different methods based on their education, ability in English, and previous experiences. Generally speaking, Iranians are family-centered and prefer to get help from their families rather than from others[12, 13]. Those who have communication barriers try to get most of their information from families, relatives, friends, or other Iranians living in Canada. Some, although they have communication barriers, prefer to get help from public services and Canadians. In seeking information, Iranians also try to get help from other resources, such as pamphlets, Iranian satellite broadcastings, Internet, and librarians. In fact, almost all Iranians, with or without communication barriers, rely on librarians as one of the most reliable and helpful sources of information. These findings have not been reported in other studies. Because of this access to information and resources, they feel empowered.
The participants in this study sought the assistance of individuals inside and outside their community to access the health care system. They often found the process of going between “inside” and “outside” frustrating, involving a lot of trial and error. Although interpreters are one of the available resources, the participants in this study had some concerns about the quality of interpreter services. Other authors have noted that although immigrants who have language barriers ask family members, children, or friends to be their interpreters, they often do not feel comfortable with this option, as it jeopardizes privacy and confidentiality. Some participants in this study mentioned that they were afraid or ashamed of revealing signs or symptoms of their health problems in front of a family member or friend, especially in front of the opposite gender.
Lack of trust and fear of disclosure are elements that could affect client-provider relations. Clients may try to keep some of their issues private and intentionally misrepresent their symptoms to save face in front of people in general and their community in particular. Since they do not want to talk about private matters in front of friends, they may not answer some questions or may give the wrong answer. Although trusted family members and friends can be used as interpreters to help patients obtain services, these individuals may have limited English proficiency, and thus may misunderstand or misinterpret symptoms, particularly when the terms used are linguistically and culturally bound. For these reasons, mere translation or interpretation by untrained individuals only might not be helpful and could actually make things worse. Additionally, although professional interpretation may help to ease communication between health care professionals and patients, it prevents patients from being active in the dialogue. Our findings are consistent with others who have reported that interpreters sometimes act as information gatekeepers, make decisions, and select what kind of information should be exchanged, and that they often bring their own beliefs and their personal agendas into the interaction[24, 25].
The participants in this study wanted to be independent, and so they put considerable effort, energy, and time into educating themselves, learning English, and finding out how the health care system worked. These findings concerning the different strategies used by Iranian immigrants in navigating Canadian health care services are supported by Leduc and Proulx, who studied the pattern of health services utilization by recent immigrants from Algeria, the Philippines, and Sri Lanka living in Montréal, Canada. They found a similar triphasic pattern of health care service utilization, reporting that families relied on a variety of resources and information in each phase of adjustment. Interestingly, although participants were from different countries, the utilization patterns were similar.
Although the majority of health care providers do not intend to discriminate, even “well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes” ( p.15). In this study, participants reported a sense of inferiority and perceived discrimination related to having an accent, dark skin, and being Iranian. As a result, they lost trust in the Canadian health care system and were reluctant to seek health care services. This finding is similar to those of others who have reported relationships among perceived discrimination, negative attitudes, trust and delays in access to care by ethnic minorities[24, 28, 29]. Fear of being deported may also influence immigrants’ trust of health care providers. The issue of trust is important because the mistrust of health care providers is associated with failure to follow medical advice. This finding emphasizes the importance of being aware of the influence of values on seeking care. Individuals’ help-seeking behavior can be affected by fears of judgment and discrimination.
The participants in this study reported many difficulties associated with adjustment to life in Canada. They expected to find a fit between what they had before in their country of origin and what they had now in their host country, and were dissatisfied to find that this was not the case. This finding is not surprising and has been reported by others; acculturation of different ethnic groups occurs at different rates that are influenced by social class, background, and the individual’s abilities[31, 32]. Goldlust and Richmonds proposed a model of the immigrant adjustment process. They believed that many factors, such as individual factors (age and gender), pre-migration experience (reason for immigration), and post-migration factors (immigration status and unemployment) influenced immigrants’ adjustment to their host country. Health care providers caring for new immigrants need to ensure that their health assessments include appraisal of these factors so that appropriate services can be coordinated and that trust in the health care provider and the Canadian health care system is not compromised.
In this study participants who were educated and younger at the time of immigration, had previous experience of being in a country other than Iran, and knew English seemed to become integrated into Canadian society, became self-sufficient, and learned to use the health care system more quickly than others. In contrast, those who had gone through traumatic events such as imprisonment, torture, or living in refugee camps for a long time had difficulty in becoming integrated and self-sufficient. We also found that self-sufficiency and integration were reciprocal. Going through the process of accessing health care services not only helped immigrants meet their health needs but also helped them become integrated into life in Canada. Such positive experiences affected their physical and mental health. They gained mastery in how to deal with health issues in particular and with all aspects of life in Canada in general. They shared their experiences with others and so helped others go through these stages more quickly. As they learned about barriers in the health care system, their ability to navigate these barriers improved. This raises the question of whether ability to navigate the health system successfully can be viewed as an indicator of integration.
The results of this study show that Iranian immigrants who were self-sufficient and able to navigate successfully the process of accessing health services did not give up their culture but instead move back and forth between their own and the Canadian culture in a manner consistent with biculturalism and acculturation. Studies of Iranian immigrants in Canada showed that some factors such as educational background, age at entry into the host country, length of residence, gender, and level of self-esteem are positively associated with the level of acculturation[4, 34]. As Freire has pointed out, becoming integrated is an ongoing process, and it helps one acquire power over one’s life world and thus become liberated. Having power is important because it helps people to understand, interpret, and shape their lives. Integration and adjustment to new lifestyles, access to health care services, and the ability to maintain the use of health care services are intertwined. Geiger has stated that because more than ever we are dealing with diverse populations, providing health care that is free from bias is a vital responsibility for health care providers. Cultural diversity is one of the dominant attributes of Canada, and the ability of the Canadian health care system to respond to such diversity significantly influences the quality of care. As Glouberman stated, “If you look at people’s unease about healthcare system, it’s not because they have found it less than satisfying to use. It has to do with their fear that it won’t be there if they need it”.
The findings of this study highlighted immigrants’ needs for systems that are culturally and linguistically competent but that also recognize the importance of the immigrant’s ability to acquire language skill and cultural knowledge of mainstream society. Health care and social services should be tailored to facilitate this process. This means helping immigrants make decisions based on the personal significance of their historical, cultural, and social world, as individuals construct and reconstruct their reality. Each person's reality is unique, and everyone is the author of his or her own life. Individuals make health-related choices from within their own reality. Therefore, it is vital that immigrants’ viewpoints be taken into account. It is also important, however, that social services that enhance language acquisition and cultural knowledge of the host society are available to newcomers. Integration implies a reciprocal process that is both an immigrant and a host society responsibility.
The Iranian Immigrant Access Model to Canadian Health Care Services (IIAMCHCS) Figure1 is congruent with the IOM model in most respects. It does however give greater centrality to what the IOM model proposes as mediating factors (appropriateness, efficacy of treatment, quality of providers and patient adherence). While such factors do not directly affect the initiation of first contact with health care services, our research suggests that without appropriate, effective, acceptable and responsive services, patients may decide not to follow recommendations, return for follow-up, or access such services in the future. In this new model, the definition of access is expanded to include such factors. The complexity of what is actually happening is revealed in our data. Studies on health services utilization show that new immigrants are “underusers” of the health care system because of societal or cultural barriers, or because the existing services do not meet their needs. This study revealed, however, that immigrants who were struggling to access health care services sometimes misused, overused, or failed to use the provided services. In addition, the IOM model of access is a one-way model, whereas the model proposed in this study has many feedback loops. The process reported in this study was not linear. This study showed that the ability to access health care services became a vehicle for promoting integration. The better integrated the individuals were, the better their access to health care services was.
In addition, with respect to the notion of the global village and globalization, the world is changing. According to Freedman, “One of the implications of globalization is that virtually no culture is untouched by others.” ( p.437). It is imperative for health care providers to understand that culture is socially constructed and changes over time. It is impossible to learn about all cultures, as they are constantly changing, but there is a simple, practical solution to this. As citizens of a global village, we have to be aware of this phenomenon and we have to be open to others’ preferences and expectations rather than making assumptions based on what is usually an inadequate understanding of the manifestations of culture in specific clients. Although transnationalism is considered a product of globalization and helps immigrants to find their way temporarily, because it keeps them close to their ties and far from interacting with mainstream host countries, it might have a negative effect on immigrants’ integration in host countries and their access to health care services. As opposed to transnationalism, which keeps immigrants close to their homeland, a culturally competent health care system facilitates and encourages learning about cultures, understanding similarities and differences among cultures, and sharing of cultures by both immigrants and their native-born counterparts. In providing culturally competent care, health care providers need to be aware of cultural expectations and should know how to engage in discussions to clarify individual patient priorities.
In nursing programs, our mission is to help students apply their knowledge in a practical realm, at the community level, and as research partners, educators, and policy makers at institutional and organizational levels. Given the cultural diversity of Canada, it is important to have curriculum context about culture and its effects on health in nursing programs. Nursing programs should seek opportunities for students to work with immigrants, particularly those who have not yet acquired language skills.
Students and faculty members should have the opportunity to examine their ideas, opinions, and even their prejudices, both through introductions to different cultures in their classrooms and through diversity in their colleagues and peers. By doing this, before working as graduate nurses, they gain awareness of the issues and can share strategies that they applied to solve or overcome conflicts in their work with their clients or other health care providers. In addition, within the health care system, matching client and health care provider by language and ethnicity helps immigrants to trust, seek care, and follow their treatment. In this study, participants appreciated the idea of having an Iranian health care provider. They had no preference concerning gender, as in Iran having a male or a female physician is a matter of choice. Therefore, hiring providers who are immigrants from different countries can help linguistically-culturally diverse populations trust the health care services.
The findings of this study suggest that providing information regarding resources and services offers immigrants the opportunity to make their own decisions concerning health care services and also to take an active role in their treatment. One of the reliable resources that participants in this study appreciated the most was the public library, along with assistance from librarians, a strategy and resource that has not been mentioned in previous studies. It would be interesting to explore if this is a common strategy for immigrants from other groups. If so, libraries and librarians could get enhanced holdings and training regarding the Canadian health care system and how to access it. A useful resource could become more attuned to specific access needs of newcomers.
Last but not least, even if health care services are committed to helping immigrants develop language skills, there will still be some occasions when an interpreter is required. In this case, medical interpreters and cultural brokers who are trained for the job, know medical terminology, and have good knowledge of the languages and cultures of both the patients and the dominant society should be employed. Although interpreters/cultural brokers and patients might be members of the same community, because they are hired by a designated organization, confidentiality is promised and patients are more likely trust to them. This would build trust and improve encounters between patients and health care providers. Because professional interpreters/cultural brokers are familiar with the cultures and languages of both patients and the dominant society, they exchange and translate as accurately as possible, which is beneficial to both patients and physicians. This affects health care services directly and, over time, is beneficial to the whole of society through the creation of a healthier population. Although the cost for the health care system to train medical interpreters and cultural brokers and create jobs for them would be high, it may be less than the cost of misdiagnosis or of not receiving treatment until a medical crisis happens, particularly for linguistic groups commonly seem in a specific health care setting. Research directed to cost-benefit analysis of such services is warranted.
It is suggested that researchers need to consider gender, host-language proficiency, familiarity with research processes, and comfort with the study in selecting research liaisons. Considering the importance of gender as a social determinant of health, future studies need to examine the effect of gender on immigrants access to health care services in Canada. Focusing on migration and ethnic disparities, research scholars believe that it is also important to examine the reason and the cause of “why some migrant groups experience poor outcomes and why others do not” ( p.248). Further study is needed to examine the influence of gender in the process of accessing health care services and integration. In studying immigrants and refugees, some scholars believe that researchers need to go beyond sex, gender or sexual orientation and ethnicity. Vissandjee and her colleagues suggest that researchers need to use intersectionality methodology in embracing sex, gender, ethnicity and migration as social determinants of health in order to inform health policy makers, improve strategies and prevent persistent disparities in health.
In conclusion, this study’s findings reveal intertwined and complex phenomena related to accessing health care services. We found that many elements, including language proficiency, cultural differences, education, previous experiences, financial status, age, knowledge of the host country’s health care services, and insider and outsider resources, influenced our participants’ ability to access health care services effectively and appropriately. Although this study showed that the issues concerning access to health care services faced by Iranian immigrants are similar to those experienced by others, comparative research involving immigrants from different countries is needed to ascertain similarities and differences. It is hoped that this study will offer some direction for all health care providers and policy makers in their efforts to provide accessible, appropriate, effective, responsive, and acceptable care to immigrants.
Because participants were recruited from a population of Iranian immigrants in a mid-sized city with a smaller Iranian population than in Toronto, Vancouver, and Montreal, one limitation of this study is related to the representativeness of the sample. Iranian immigrant populations are not homogenous; in larger populations, the results might be different. The second limitation is the level of education. Almost all of the participants were well educated, and so the results might have been different if people with lower levels of education had participated in this study. Finally, this study involved only Iranians who could speak and were fluent in Farsi (Persian). Iranians who spoke Balouchi, Kurdish, Arabic, Lori, Azari, and Gilaki as their mother tongue and were not fluent in Farsi or English were excluded from this study.