The McMaster Health Forum strives to be a leading hub for improving health outcomes at the regional and provincial levels in Canada. Through problem-solving and discussion, the Forum harness information, convene stakeholders, and prepare action-oriented leaders to meet pressing health issues creatively.
Canadians pride themselves for having a health system founded on the principles of universality and accessibility. Over the next few years, the system must address the health-related needs of Syrian refugees in Canada. Between November 2015 and September 2016, Canada welcomed 31,444 refugees from Syria and is currently processing another 20,261 applications. Compared to the previous intake of 1,306 Syrian refugees in 2013, this represents a large influx of citizens that will undoubtedly strain the health system. To manage this increased resettlement commitment, the government has adopted a targeted approach to resettlement by prioritizing the needs of women, a particularly vulnerable group among refugees due to their possible history with sex and gender-based violence. In order for the health system to truly match the values it was founded upon, there is a need to address the specific health challenges faced by refugees and, in particular, the challenges faced by refugee women once they arrive in Canada.
Mental Health Services
It would come as no surprise that refugees may be exposed to many stressors, which place them at a higher risk for mental illness. This is especially critical for women refugees, as gender is a critical determinant of mental health. Studies have shown that depression, anxiety, and sexual domestic violence affect women to a much greater extent than men across most countries and settings. In fact, female refugees from Syria have repeatedly reported rape or fear of rape as the chief motivation to flee the country. Moving forward, it will be important to monitor the mental well-being of women refugees in Canada and offer programs that will support their health. As the healthcare of refugees has been primarily coordinated at a provincial level, it is critical for each province to organize and support mental health services for refugees, rather than relying on direction from the federal government. For example, in Ontario, the Central Local Health Integration Network funds an organization called Across Boundaries, which provides ethno-culturally specific and gender-sensitive mental health services. Existing programs such as Across Boundaries can act as models for policymakers when they are planning for the services needed to address the mental health challenges of Syrian refugee women.
While access to primary care is a concern for the general immigrant population, this challenge is magnified with refugees given their turbulent past. Refugees are nearly twice as likely to report poor health within four years of their arrival as compared to the general immigrant population, thus it is important that they engage with the primary care system. A barrier to accessing primary care is the lack of information regarding system navigation, a phenomenon that is especially pronounced among women refugees, as they are less likely to gain language proficiency compared to male refugees. Community navigators are trained healthcare workers who link patients to healthcare providers and support patients to reduce healthcare disparities. They can provide guidance to vulnerable populations in order to overcome access barriers. This guidance, however, has not yet been widely adopted for Canadian refugee populations. In the United States, community navigators have been successfully employed to decrease health disparities among female refugees. Similar programs could likewise be implemented in Canada. Additional barriers to primary care access may result from primary care providers. The Interim Federal Health Program (IFHP) provides healthcare coverage to refugees, but general practitioners may not accept a refugee’s coverage due to unfamiliarity with the program. Even if a physician knows of the program, the reimbursement process is complex as the healthcare practitioner must first submit an application to become a registered provider under IFHP. Given the aforementioned barriers for refugees to access care, the extra paperwork required from physicians further disincentivizes the process. Action is needed to revise the IFHP, such that physicians can better accommodate the health needs of refugees.
Culturally-Appropriate Healthcare Services
An underlying issue that Syrian refugee women face is their inexperience with Canadian culture and languages. Family caregivers, who are typically women, have reported significant challenges in accessing healthcare and social services due to language barriers. Health outcomes in refugee populations are directly tied to English proficiency. Specifically, language barriers interfere with all aspects of their experience, from the initial consultation to follow-up care instructions. The current lack of funding for interpreters inevitably forces the individual or community health center to bear the expense. While the IFHP does cover translation services, there are restrictions placed on the length and type of medical visit for which a translator will be reimbursed. Given that communication between the patient and provider is fundamental for care delivery, there is a need to reduce restrictions to accessing this benefit. Moreover, cultural competence needs to be interwoven into all aspects of care that are provided to Syrian refugees. Physicians should be cognizant of the religious and culturallyspecific values held by Syrian refugee women when discussing illness and treatment. For example, diagnosing mental illness and imposing a treatment schedule based on models of Western medicine may alienate some patients. To overcome this barrier, culturally-competent training can be provided at various levels within the healthcare system. This training may be situated at the level of the institution or practitioner. Implementing such an approach at the practitioner level would initially help to facilitate trust between the refugee population and healthcare providers.
As Canada accepts more Syrian refugees, it will be pertinent to address the health challenges of women, who constitute a particularly vulnerable population. Currently, Syrian women refugees face a myriad of health related challenges, including a lack of mental health services, difficulties in accessing primary care, and struggles with obtaining culturally sensitive services. Increasing access to culturally-appropriate mental health services and primary care will be an important first step to ensuring that our healthcare system is truly universal and accessible. This will allow all Canadians their rightful access to care.
By Stever Cho, Malcom Hartman, Ahmad Firas Khalid, Janice Mok & Padmaja Sreeram
Reviewed by Dr. Michael Wilson
References may be found in the journal.