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REFUGEES’ ACCESS TO HEALTHCARE IN CANADA

by

Michel Ndiom

B.A. English and French Literature, University of Buea 2003

B.A. Leadership, Trinity Western University 2013

B.S.W., University of Victoria 2018

MAJOR PAPER SUBMITTED IN PARTIAL

FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SOCIAL WORK

IN THE

Faculty of Social Work

© Michel Ndiom 2020

UNIVERSITY OF THE FRASER VALLEY

Spring 2020

All rights reserved. This work may not be

Reproduced in whole or in part, by photocopy

or other means, without permission of the author.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA ii

Approval

Michel Ndiom

Master of Social Work

Refugees’ Access to Healthcare in Canada

Examining Committee:

John Hogg, PhD, School of Social Work and Human Services

Senior Supervisor:

Lisa Moy, PhD, School of Social Work and Human Services

Second Reader/External Examiner:

Robert Harding, PhD, School of Social Work and Human Services

Date Defended/Approved:

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA iii

Abstract

Canada is a nation with a policy of multiculturalism and a deep history of welcoming refugees from around the world. As Olsen et al. (2016) state, “the integration of refugees into Canadian society is promoted as a source of pride and nation-building, adding to the richness and diversity of the Canadian population” (p. 58). However, the influx of refugees in Canada with diverse and complex health needs has presented a number of challenges within the healthcare system (Joshi et al., 2013, p. 2). Unfortunately, refugees experience various barriers when accessing healthcare services such as racism, discrimination and othering. These barriers are systemic and are influenced by a Eurocentric worldview, which does not always take into consideration other ways of knowing. As a result, this paper suggests that implementation of culturally safe practice could bridge the gap between health providers and refugees. Also, this paper demonstrates that unsafe cultural behaviours and actions continue to deny healthcare access to refugees. Rousseau et al. (2008) writes, “from a human rights perspective, regulations and administrative policies highlighted by this study target specific vulnerable groups within Canada and are completely at odds with the Equality Rights set out by the Canadian Charter of Rights and Freedoms” (p. 291).

Finally, this paper calls for an attitude change toward refugees, and corollary changes in policies, which will positively impact the health trajectories of refugees and reduce health inequality in the Canadian health system.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA iv

Acknowledgment

Throughout the writing of this paper, I received a great deal of encouragement and assistance. First, I would like to thank my instructors at the School of Social Work, who challenged me to become an effective Social Worker and whose guidance has allowed me to move into new ways of community practice. Specifically, I would like to thank my supervisor,

Dr. Lisa Moy whose influence and time were invaluable in formulating my research topic and the applied methodology. Dr. Lisa, I want to thank you for listening, your availability, and patience, without which I would not have been able to juggle my family life, work commitments and educational pursuits. Also, I would like to acknowledge the University of Fraser Valley’s

Master of Social Work cohort for their team spirit, amazing collaboration during our various projects, Blackboard postings, and countless hours of course discussion.

I would also like to thank my two supervisors: Chery Mosher with the Ministry of

Children and Family Development and Andy Sebanc with Green Timbers Covenant Church.

Their support and accommodation of my schedule allowed me to remain motivated and to be successful in completing my MSW. In addition, I would like to thank my family: My wife,

Viviane Ndiom, and my four children, Shekinnah, Shiloh, Zoe and Joshua, for their patience and love towards me during the process - you are always there for me. Finally, there are my friends, who were a great at boosting my confidence, providing insight, as well as a happy distraction and balance during this process. I cannot mention all of you here since there are so many - you know who you are.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA v

Table of Contents

Approval ...... ii

Abstract ...... iii

Acknowledgment ...... iv

Table of Contents ...... v

Introduction ...... 1

Background and Contextual Information ...... 1

Research Questions and Sub-Questions ...... 3

Social Location ...... 3

Methodology ...... 6

Theoretical Framework ...... 6

Anti-Oppressive Practice (AOP) ...... 6

Critical Race Theory (CRT) ...... 9

Cultural Safety as a Criterion for Refugees’ Successful Access to Healthcare ...... 11

Methods of Orientation ...... 13

Demographic Focus ...... 13

Intersectionality of Resources ...... 14

Literature Review ...... 15

Refugees, Characteristics and Misrepresentation by the News Media ...... 15

Refugee Population, Characteristics and Different Categories ...... 15

Canada’s Commitment to the World and to Its Population as a Humanitarian Country ...... 17

Misrepresentation of Refugees in Canada ...... 20

Westernized Worldview in a Pluralistic Society: Oppression and Systemic Discrimination .... 22

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA vi

An Obsolete Medical Paradigm in a Changing Immigration Landscape ...... 22

Lack of Agreement Around the Concept of Health Creates Poor Service Delivery ...... 25

Conflicts in the Health Provider-Refugee Patient Relationship ...... 26

Healthcare System Reconfiguration Needed to Serve Refugees Effectively ...... 30

Discrimination and Othering as Norms in Healthcare ...... 30

The Impact of Policies on Healthcare of Refugees ...... 32

The Role of Cultural Safety in Healthcare Settings in Canada ...... 35

Acculturation as a Barrier to Utilization of Care within the Healthcare System ...... 37

Social Work Implications ...... 40

Implications for Practice ...... 40

Implication for Further Research in the Areas of Systemic Discrimination in a Multicultural

Society ...... 42

Implications for Policy Creation and Implementation ...... 44

Renewal of the Role of Social Worker as an Agent of Change in the Community ...... 47

Conclusion ...... 48

References ...... 50

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 1

Introduction

This paper highlights the need for Canada a, leading country in the field of immigration to, create a healthcare system which would better support refugees fleeing from war, conflict, and natural disasters around the world. As Cheng et al. (2015) affirm, “with the assistance of the

United Nations High Commissioner for Refugees (UNHCR), 88,600 refugees were permanently resettled across 22 developed countries including the US, Canada, the UK, Sweden, Norway,

Australia, and New Zealand in 2012” (p. 171). However, refugees arrive in Canada with the unique challenges of disease pattern, language, and/or sociocultural codes of the region, some of which the medical practitioner might not be fully aware (Aggrawal, 2016, p. 83).

The purpose of this paper is to create an awareness of the perception of refugees about discrimination and racism in health care services, with the intent of creating a more inclusive and effective service delivery in Canada. Furthermore, this paper seeks to point out that, “although it is known that refugees and asylum seekers struggle to access and use general practice services in resettlement countries, there is limited published literature from the refugee perspective on the reasons why” (Cheng et al. 2015, p. 172). By acknowledging that health service providers do not always understand refugees, this paper argues that the lack of culturally safe practices is one of the main underlying problems behind refugee access to health care services.

Background and Contextual Information

In Canada, all Canadians citizens receive basic medical coverage through their provincial or territorial insurance managed by the respective health authorities. Bryson and Bosma (2018) explain that the Canadian healthcare system, or Medicare, is “an interlocking set of ten provincial and three territorial health systems” (p. 2). These provincial and territorial health authorities work to ensure that residents in their respective territorial areas receive health service

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 2 as a basic human right. The idea of health as a basic human right presupposes that health is not a privilege but a basic need that must be met for all Canadians, including vulnerable populations.

Donnelly et al. (2011) document “that immigrants’ conceptualization of health and illness, cultural beliefs, values, and expectations towards treatment influence the ways in which they view and use Western medicine and shape the ways in which individuals and families cope with illness” (p. 280).

Unfortunately, many articles reveal that healthcare providers do not serve refugees in a manner, which is understood by refugees. Saberpor (2016) writes:

For many refugees, accessing health care is more than just finding a provider. It is about

finding a provider who understands and who has a practice located in an area

comfortable to the refugee patient. In Canada, there are many issues involved with

providing culturally competent care. Not having specialized training to address the

cultural divide amongst refugees can be an issue. (p. 11)

So, it is not just about the idea of refugees finding available health providers who will help them to access healthcare facilities, but rather it is about finding providers with a clear understanding of cultural perspectives and the sensitivity required for refugees to become comfortable when interacting with the providers. Such awareness of the providers’ limitations towards the refugees should be a concern, given the large number of refugees arriving in Canada.

Marano et al. (2016) highlight that “the United Nations High Commissioner for Refugees

(UNHCR, 2016) reported that 65.3 million people were forcibly displaced from their home countries in 2015, the highest number ever recorded” (p. 985). In this article, the author finds that there is vast human movement in the world’s population of 7.4 billion people.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 3

Research Questions and Sub-Questions

The promise of service equality, irrespective of clients’ social location, is not yet a guarantee within the Canadian health system. Indeed, according to McKeary and Newbold

(2010):

It is well established that Canada’s immigrant population experiences important health

disparities, both relative to other immigrant groups as well as to the native-born

population […]. However, much of this literature does not address the potentially unique

health experiences of refugees, with this group remaining an under-researched

population.” (p. 523)

Here, Mckeary and Newbold (2010) acknowledge that the current service delivery model is flawed for two reasons. First, at the systemic level refugee groups in the community are not safe. Second, at the individual level, “many physicians do not feel equipped to deal with the often-unique challenges that refugees may bring” (Pottie et al., 2018, p. 2). Building from this, the literature review asks the following two questions: How has the construction of the concept of ‘‘refugee’’ been perpetuated within the Canadian healthcare system? To what degree does the

Canadian health system implement a culturally safe delivery approach to the refugee population?

Social Location

I have a strong desire to see equality and justice around me because my social location has led to the first-hand experience of oppression. Indeed, I was born and raised until my early twenties in Cameroon, a country located in Central Africa. In Cameroon, English and French became the official languages. My parents, with financial status, were French-speaking and could not utter a word in English but encouraged and provided opportunity for all their children to learn English by the age of five. Also, my parents feared that if the tides were to change,

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 4 meaning that the English-speaking Cameroonians were to take power, their children would be more vulnerable. So, I became one of the few native French speakers who learned to speak

English at an early age. From this unique opportunity and perspective, I grew up and discovered, to my dismay, how their French counterparts oppressed English-speaking Cameroonians. It was a wake-up call for me. French-speaking Cameroonians treated me unfairly because I could speak the English language. I did not understand how someone could be discriminated against based on the language he or she spoke. The straddling of two languages and cultures within one divided country did ingrain in me the strong desire to see equality and social justice. It led to the decision to advocate for those who were treated unfairly, particularly children, given my age when I experienced such trauma.

This reality is founded in the division amongst Cameroonians and specifically, between the dichotomous heritages left by the colonial masters, the French and British. Indeed, both

French and British colonies signed unfair treaties with the Cameroonian population who lacked any understanding of the implication involved in the day-to day actions of the French and

British. As Mbah (2009) highlights: “…on closer examination it became clear that land/boundary disputes in the region have their roots in European colonialism and derive largely from administrative policies that were disruptive on inter-village boundaries” (p. 11). The creation of the country was the consequence of arrangement between two powers in the land; as Otu et al.

(2018) claim: "Cameroon, like other independent African nations, was created by the colonizers for their convenience and not for the long-term feasibility of the new nation.” (p. 82). Also, the

French and British divided the land into regions and without taking into consideration the linguistic subdivisions that existed prior to their arrival. Consequently, many linguistic subgroups found themselves being forced to live in places with other ethnocultural groups. Some

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 5

Cameroonian lost the ability to speak their own vernacular language as evidenced by Dupraz

(2015) who reports, “French colonial administrators were adamant that instruction be undertaken only in French, local languages were more often used (at least in the first grades) in British

Africa” (p. 2) and, with time, the various traditional groups struggled to maintain their own identity through the diminishing influence of their chiefs. Nana (2015) highlights this estrangement, stating “in French Cameroon [...] the authority of chiefs was reduced to a mere auxiliary of the administration and they could be hired and fired at will” (p. 180).

As a result of my own story within this nation wide cultural trauma, I sought for years to find an identity of my own. My own parents were forced to abandon many of their customs and traditions in order to embrace a new way of life. This stripping of culture and language impacted their own family as they were unable to pass on valuable traditions and language to me and my siblings. I speak many European languages including German, French and English, yet I cannot speak any Cameroonian dialects fluently. This loss of dialect and vernacular makes me feel as if

I have been both implicitly and explicitly robbed of my core identity. This experience has ignited a passion to fight for social and cultural injustice around me, with the hope that change can take place over time.

Upon my arrival in Canada, I was inclined to work for and with vulnerable populations such as Indigenous peoples, as well as the refugee populations who experience a very negative narrative from the mainstream population. My personal experience as a father of four children, some born outside the country and others in the country, deepened my conviction to support immigrant families in their challenges to settle in a new country. I have witnessed, sometimes powerlessly, the various forms of oppression that they, like many other immigrant children, confront in the face of poverty, social isolation, discrimination, and inequality. My professional

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 6 experiences as a settlement worker, pastor, and social worker have prompted me examine social justice struggles closely and confront the disturbing and painful social ills that burden many of communities around me. So, although I am grateful for the invitation to participate in the building of a multicultural Canadian fabric, my sense of belonging in Canada has been eroded regularly in both my witnessing and experience of the marginalization of people of color.

Methodology

Theoretical Framework

Anti-Oppressive Practice (AOP)

I have chosen Anti-Oppressive Practice approach (AOP) as one of my theoretical frameworks for two reasons. First, the “key features of anti-oppressive practice are making a commitment to social justice and challenging existing social relations that highlight social injustice, particularly in forms that are reproduced in social work practice” (Larson, 2008, p. 41).

AOP is of great interest to me because:

Anti-oppressive practice [...] involves an awareness of the social worker’s location and

how this can contribute to the oppressiveness of the intervention through classism,

racism, sexism, ableism, heterosexism, and other ways that all of us as human beings

unfairly judge, rank, and ideal with others. (Larson, 2008, p. 41)

Indeed, even though Canada is usually depicted as “an extremely culturally diverse nation with a platform that mandates acceptance of individual and group differences and a strong sense of integrative multiculturalism” (Lencucha et al., 2013, p. 187), there is still much work to be done. This is true not only in regard to health, but also in many other aspects of Canadian society. Jemal (2018) echoes the same idea:

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 7

Social constructions, like race and gender, reflect social, economic, and political power

and access to opportunities. The differential treatment of people based on these socially

constructed phenomena […] has a demonstrable impact within the health domain,

denying marginalized populations their human right to health. (p. 202)

Analyzing the ways in which Indigenous Peoples are harmed by Canada’s health system is just one example of how AOP facilitates an understanding of injustice. The Canadian health system discriminates against Indigenous Peoples and forces them to live under the evacuation policy, which requires Indigenous women “to comply with a systematic evacuation policy in a secondary or tertiary hospital, far from their community, to give birth” (Lawford et al., 2018, p.

480). This loss of traditional childbirth practices in Indigenous communities created spiritual and cultural consequences that are connected to the loss of cultural identity (NAHO, 2008, p. 16).

Thus, the evacuation policy does not provide any cultural safety to women but rather perpetuates the effects of the Indian Act. According to Lawford and Giles (2012):

Pregnant First Nations women who live on reserve in rural and remote regions and

receive primary health care services by federally employed nurses, including pre- and

postpartum services, in Canada are routinely evacuated to urban Canadian cities, often

hundreds of kilometers away, when their pregnancies reach 36–38 weeks gestational age.

(p. 330)

As the authors point out, “the origins of the concept of First Nations birthing outside the home and the community were based on a goal of civilizing the ‘women in savage life’”

(Lawford & Giles, 2012, p. 331). From a social work perspective, Indigenous midwifery provides a framework for a culturally appropriate health care model, which is based on traditional knowledge. An Indigenous midwife offers the opportunity to receive care from

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 8 someone who understands and respects the uniqueness of one’s culture and traditions, an anti- oppressive approach at its very core.

It is a misrepresentation for the Canadian government to maintain and promote an image of having one of the greatest health delivery systems in the world in light of Canada’s history of discriminatory policies. Lawford and Giles (2012) write that:

Federal health care provision to First Nations peoples [is]…truncated, sporadic, or even

absent […] and lament that the health care delivery for First Nations is often rife with

jurisdictional disputes, often at a significant cost —physical, emotional, cultural and

financial — to First Nations governments and people. (p. 331)

It is a failure to think the Canadian healthcare system is a model for patient treatment and care when there are examples in history and current day that marginalized people in Canada do not have their medical needs met (Kowpak & Gillis, 2015, p. 1). Such a position shows the failure of policy makers to fully acknowledge the existence of other ways of knowing and healing, such as traditional Indigenous healing practices (sweat lodges, talking circles, healing circles, the medicine wheel). Furthermore, such barriers hint at the tension that could come into play when refugees request or hope for other alternatives of treatments and find themselves constrained within a health system contrary to their values.

It is my hope that I will be able to expose the racialization of the Canadian healthcare system and focus on the incongruent relationship between two perspectives: 1) Canada’s promise to provide equal health service to all Canadians (Canadian Nurses Association, 2000); and 2)

The systemic oppression that refugees undergo when they access services. My desire to expose the racialization of the healthcare system stems from the fact that "race is constructed as residing

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 9 in people of color, [and] whites don’t bear the social burden of race" (DiAngelo, 2018, p. 62). Di

Angelo (2011) presents the dominant position that:

Whites are almost always racially comfortable and thus have developed unchallenged

expectations to remain so [consequently]. Whites have not had to build tolerance for

racial discomfort and thus, when racial discomfort arises, whites typically respond as if

something is “wrong,” and blame the person or event that triggered the discomfort

(usually a person of color). (p. 60)

It is important for White people to be fully part of the question of racism within the health care system, if it is to be eradicated. However, such a position is not shared by all White people, who may contest the very notion, underpinning the very essence of Whiteness and perpetuating the oppression of other races. According to Corneau and Stergiopoulos (2012)

“oppression can be defined as ‘a system of domination that denies individuals dignity, human rights, social resources and power” (p. 267). Oppression is usually present when the notion of a color-blind society is legitimized and the impact of racism among people of colour who access health services is ignored, denying the existence of racial discrimination of refugees who are imposed only one way of receiving services. Hence, Larson (2008) recommends an anti- oppression framework that is “a counter-discourse to the medical or bio-psycho-social model and a way to reduce its dominance in discourse and practice” (p. 46).

Critical Race Theory (CRT)

I have also chosen Critical Racial Theory as an additional framework so the voices of refugees will be heard within a critique of available health services. Treviño et al. (2008) state:

CRT has introduced a new critical form of expression. In tuning into this ‘voice of color,’

critical race scholars have in the past dozen or so years turned to write in the form of

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 10

narrative, or ‘storytelling,’ not only as a rhetorical device for conveying their personal

racialized experiences but also as a way of countering the metanarratives. (p. 8)

In other words, CRT enables me to outline the frustration and voices of the refugee patient to the reader. It is my belief that rather than borrowing words from refugees or speaking on their behalf, health providers should pause and pay attention to the stories that recount lived experiences from non-white refugees. CRT started out as a movement during the 1980’s and aimed to investigate the role of racism and systemic discrimination within American society through Black and White binary terms (Yosso et al., 2009). However, the authors argue that CRT can be more broadly applied as it “challenges claims of objectivity, meritocracy, color blindness, race neutrality, and equal opportunity, asserting that these claims camouflage the self-interest, power, and privilege of dominant groups” (Yosso et al., 2009, p. 663).

Another interesting reason why CRT is relevant to this paper is that “CRT acknowledges race as a social construction, essential in maintaining the racial hierarchy, which situates racial and ethnic minorities into confined and restrictive locations” (Treviño et al., 2008, p. 7). The same authors also highlight that “CRT has begun to move beyond the Black-White paradigm and beyond vulgar, racial essentialism to consider the racialized lives of other oppressed minorities, the daily microaggressions inflicted upon various oppressed minorities such as Latinos, Asians, gays, Indians, and women of color” (Treviño et al., 2008, p. 7). The diversity of races in the new perspective of CRT is critical to understanding the predicament that refugees coming to Canada face. Ford and Airhihenbuwa (2010) remind us that:

Critical Race Theory challenges widely held but erroneous beliefs that ‘race

consciousness’ is synonymous with ‘racism’ and that ‘colorblindness’ is synonymous

with the absence of racism. Colorblindness, which is both an attitude and a school of

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 11

thought, posits that non-racial factors (e.g., income) fundamentally explain ostensibly

racial phenomena. (p. 31)

Cultural Safety as a Criterion for Refugees’ Successful Access to Healthcare

I am using cultural safety as a part of my theoretical framework to show how limited the current Canadian healthcare system is when it comes to the inclusion of refugee patients who access health services. Unfortunately, their health providers do not always consider the patient’s perspectives during the treatment process. The health provider needs to adjust to the various demographic changes that have occurred in Canada (Brascoupé & Waters, 2009). Cultural safety in this paper will be defined based on Brascoupé and Waters (2009) definition of:

A concept that incorporates the idea of a changed power structure that carries with it

potentially difficult social and political ramifications […] it questioned and challenged

the concept of cultural competence and, by bringing in the notion of safety, it extended

the debate by focusing less on the benefits of cross-cultural awareness and sensitivity,

and more on the risks associated with their absence. (p. 8)

Brascoupé and Waters (2009) argue: “In the context of healthcare delivery, culturally unsafe practices have been defined as ‘any actions that diminish, demeanor disempower the cultural identity and well-being of an individual’” (p. 6). Finally, this paper suggests that culturally safety implementation in the context of a growing number of refugees accessing health service is increasingly relevant. To that effect, Dell et al. (2016) remind the reader:

Value and relevance of cultural safety principles extends beyond Aboriginal peoples.

Cultural safety principles can be applied to the challenges faced by many groups in

Canada whose health status and health care access has the potential to be compromised

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 12

by historical and social context, discrimination, material deprivation, or power

imbalances. (p. 302)

As a professional worker, when I reflect on the struggles of refugees whom I have met on my own journey, I cannot help but note the important role culture plays in their health care during their settlement process. For example, I have spoken with clients from war torn countries who disclosed they were discriminated again when attempting to access local hospitals. Pollock et al. (2011) note that refugees experience, “Subtle forms of discrimination include being excluded, dismissed and/or treated rudely or unfairly, which can, at times, be more difficult for victims to detect, evaluate and process” (p. 8). However, these various forms of discrimination

“within health care and social service settings range from incidents of insensitive, unfriendly or ignorant treatment from providers, to racial slurs, stereotyping and receipt of inferior care”

(Pollock et al., 2011, p. 8). The perceptions of discrimination in health services indicate the gap between refugees and their providers. For instance, refugee mothers in Hamilton, Ontario

“referred to negative attitudes and experiences of being ignored by health care practitioners.

Prolonged periods of waiting in emergency rooms were also perceived as evidence of racism”

(Pollock et al., 2011, p. 9). Meanwhile, the providers continue to do their work without any cultural awareness. The lack of cultural awareness from providers creates a perception of discrimination for the refugee who does not understand the health system. Hence, Pollock et al.

(2011) suggest that such situations could have been avoided “if time had been taken to explain that delays in emergency rooms are the norm, then this could have helped prevent such instances from being interpreted as discriminatory” (p. 9). Subsequently, refugee patients eventually stop accessing health care facilities when they take issue with their treatment and perceive services as not culturally safe to them. As McKeary and Newbold (2010) mention:

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 13

A declining proportion of refugees who reported trying to gain health care over the four

years after arrival, dropping from 80 per cent trying to access health care within their first

six months of arrival in Canada, to 66 per cent approximately four years after arrival, a

proportion which tends to be much lower than that typically observed in the broader

Canadian. (p. 526)

Methods of Orientation

Demographic Focus

The focus throughout this paper will be refugees’ access of healthcare within the

Canadian context. Woodgate et al. (2017) mention, “immigrants and refugees form a considerable and growing proportion of the Canadian population and their access to health care services is increasingly a priority” (p. 2). Indeed, my desire to address refugee access reflects,

“Canada’s commitment to increase the number of refugees accepted necessitates further investment in short-term support to meet the health care needs of this population during the initial stages of resettlement” (Oda, 2017, p. 357). However, the scarcity of academic articles within the Canadian context prompted me to search for those articles profiled within an

American context. As Jaworsky (2019) mentions:

While scholarly work has begun to unpack the situation in Europe, less attention has

focused on the situation in countries that don’t accept many refugees. However, these

places often have the most vocal discussions concerning people seeking refuge in their

country. Nowhere is this more evident than in the United States and Canada. (p. 1)

Although they are neighboring countries, Canada and the United States differ in their health systems in that, “The United States has no single nationwide system of health insurance

[while] Canada has a national health insurance program NHI (a government run health insurance

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 14 system covering the entire population for a well-defined medical benefits package.” (Gleason &

Ridic, 2012, p. 112). I used information from American articles because despite the fact that

“Canada and the United States are not countries of first refuge but, as members of a small number of countries that offer permanent resettlement, they are an important part of the refugee story.” (Beiser & Hou, 2016, p. 464).

I chose more recent articles to underscore the issue’s relevance including, “immigration

[which] is hotly debated, particularly in advanced industrialized democracies receiving large numbers of immigrants from ethnically, culturally, and religiously diverse backgrounds” (Harell et al., 2017, p. 245). At the same time, I also want to be respectful of the various resources that provide insight into different moments in history. The initial plan was to cover the last five years, so the body of work was neither superficial nor overwhelming. However, the scarcity of the articles made me reconsider this approach, and I decided on a time frame of 15 years.

Intersectionality of Resources

To research this paper, several libraries have been accessed, including universities SFU,

UFV, and UVIC. I searched databases such as JSTOR, PsycINFO and PsycINFO (EBSCOHost) in order to identify topics that would be relevant to refugees, in particular their access to health care. Additionally, I used MCFD and Fraser Health’s own libraries, accessing journals from different disciplines such as law, immigration, health, and social work. Examples of journals which were resourced include: The International Journal of Human Rights in Healthcare,

Canada’s Journal on Refugees, The Journal for Specialists in Group Work, Journal of Education and Training Studies, Journal of Immigrant and Minority Health, African Journal on Conflict

Resolution 9(3), and Canadian Journal of Nursing Research Archive. Finally, I used Google

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 15

Scholar as a way to reduce my scope of work using key words such as ‘refugees’, ‘health access’, ‘discrimination’, ‘racism’ and ‘health care providers’.

In the context of this paper, I would like to acknowledge the term “healthcare providers” refers solely to medical doctors, nurses, midwives’ and social workers. I am aware the term

“healthcare providers” encompasses more than these professions. However, I have specifically chosen those professions as they are most frequently in contact with refugee patients upon their arrival in this country, as Marano et al. (2016) write that “nurse leaders must become culturally engaged with immigrant populations and develop mutuality that not only brings ourselves into immigrant communities” (p. 987), and nurses work alongside physicians, midwifes and social workers to ensure their patients’ healthcare and provide support to a patient’s families upon their arrival into Canada.

Literature Review

Refugees, Characteristics and Misrepresentation by the News Media

This section focuses on presenting who refugees are, their diverse circumstances, and explains the process by which these various refugees arrive in Canada. It will also highlight the historical role Canada has played in accepting refugees from around the world through international commitments, which have fostered Canada’s image as a humanitarian country.

Finally, this section will demonstrate how media misrepresentation and politicians’ divisive and threatening tones have influenced Canada’s ability to welcome refugees.

Refugee Population, Characteristics and Different Categories

An understanding of who refugees are provides a better glimpse into the complexities of the refugee experience and possibly increases awareness about the challenges they face upon arrival in Canada when accessing health services. Grant et al. (2015) affirm “Canada is home to one of

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 16 the largest populations of resettled refugees in the world (UNHCR, 2013). Approximately 28,000 refugees arrive in Canada each year” (p. 18). This number increased after amendments to the

Immigrant and Refugee Protection Act (IRPA) in 2002. Dauvergne (2003) affirms that:

On [the] 28 [of] June 2002, Canada's new Immigration and Refugee Protection Act came

into effect. [A] total [of] almost 300 pages of legislative effort mark the culmination of

close to a decade of public consultations about immigration law and policy and present a

comprehensive overhaul of the previous legislation dating from the mid-l 970s. (pp. 725-

726)

As a result of such changes, Canada accepted many refugees who would not have been able to qualify through the eligible selective process to immigrate to Canada. The article argues that by,

“understanding more about what contributes to refugees being successfully integrated into

Canada’s healthcare system may help improve existing healthcare orientation practices for newcomers as well as increase physician awareness and accessibility” (Grant et al., 2015, p. 19).

Furthermore, an understanding of the refugees’ immigration journey will put the focus back on refugees who “are more likely to have experienced combat and domestic violence; political instability and political warfare; death of family and friends; and culture shock” (Sandre &

Newbold, 2016, p. 108). Their journeys usually involve the “loss of family and a loss of

‘identity’ within the community, the family, or the workplace” (Morris et al., 2009, p. 534).

Refugees are not a homogenous group but rather three subgroups that are distinct in form and operation throughout the Canadian refugee system. Yu et al. (2007) provide clarification of refugees by dividing persons with this assigned status into two main components, namely, “the in-Canada refugee protection system [and] the refugee and humanitarian resettlement program”

(p. 18). To them, any person who makes a refugee claim inside Canada is referred to as a refugee

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 17

“claimant”. Claimants must go through the Immigration and Refugee Board (IRB) to receive the

“protected person” status in order to eventually become a Permanent Resident of Canada. This is a major difference with other refugees who come to Canada already identified as “protected person”. Newbold et al. (2013) mention “the refugee claimant exists largely outside of an institutionally protected and governed civil society—he or she is neither refugee nor citizen, a situation which in itself is likely to create stress and have an impact on health” (p. 432).

The second stream identified by Yu et al. (2007) is called the refugee and humanitarian resettlement program. The program involves a selection of refugees around the world who have the designation of ‘protected person’. These refugees brought from overseas are divided into two different categories depending on how they come into Canada (Yu et al., 2007). If these refugees “are referred by UNHCR and supported through federally funded Resettlement

Assistance Program (RAP)” (Yu et al., 2007, p. 2), they are called Government-Assisted

Refugees or (GARs). Similarly, if these Refugees “are sponsored and supported by voluntary group”, they are called Privately Sponsored Refugees or (PSRs) (Yu et al., 2007, p. 18). Since this paper does not seek to explore the core differences between the various refugees’ groups but rather the challenges they generally face when accessing healthcare services, I shall not go further into an analysis of these categories. Rather, these categories will be critiqued if any of the refugees’ categories are connected to specific difficulties accessing healthcare.

Canada’s Commitment to the World and to Its Population as a Humanitarian Country

Canada plays a role as a humanitarian country in the issue of population movement around the world. According to Esses et al. (2017), “there has been a focus on refugees around the world since the 1951 Geneva Convention relating to the Status of Refugees and its 1967

Protocol where 148 countries signed a commitment to Convention refugees” (p. 79). Since then,

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 18 the Canadian government has kept its commitment both at the national and international level with regards to refugees. Geiger (2017) reveals that Canada plays a greater role in the movement of refugees at the international level “admitting more than 250,000 permanent residents annually over the last five years” (p. 1640). This is significant, given the fact that not all countries who signed the Geneva Convention are eager to bring refugees into their own countries. This reluctance is corroborated in the statement made by Esses et al. (2017):

Despite their formal commitment to the protection of refugees, as outlined in the Geneva

Convention, citizens of Western countries (i.e. developed countries of Europe, North

America, and Oceania) do not always regard refugees with compassion and focus on their

protection. (p. 80)

Geiger (2017) states that “Canada has a great relationship with the intergovernmental organization, International Organization for Migration (IOM), a prominent international organization in the field of migration” (p. 1639). The partnership between Canada and the IOM allows each of them to fulfil their quest for influence around the world. The IOM grows in importance when it comes to migration governance around the world on one hand, while Canada polishes its reputation as a great and humanistic nation. The author stresses the fact that:

Due to Canada’s importance as a destination for migrants and the fact that Canada is

often referred to as an international ‘poster child’ for well managed migration, the IOM

as the world’s specialized intergovernmental organisation on migration can thus be seen

as a logical partner of Canada. (Geiger, 2017, p. 1640)

Hence, the relationship has been described by Geiger (2017) as, “an ideal partnership or marriage of convenience [because] both parties benefit from a relationship, which remains ambivalent, intricate and potentially conflicted given repeated crises of confidence and

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 19 cooperation, or public criticism of each other” (p. 1642). As with any relationship, parties continue to work together provided that each of their goals are achieved in the process. The next paragraph examines the impact of such underlying agreements in Canada with respect to the future of the integration of refugees in their receiving countries.

If the decision to accept refugees from around the world positions Canada as a humanitarian country, this image of Canada is not without criticism. Indeed, Presse and

Thomson (2007) explore Canada’s role in the refugee crisis around the world by mentioning that

Canada has historically been a country “among other resettlement countries [that has] been criticized for selecting the ‘best and the brightest’ refugees and thereby exacerbating the situation in the refugee camps where these individuals were selected” (p. 50). In other words, the authors suggest that behind the charitable act of Canada, there are some undisclosed interests. The message is that, “if Canada is to contribute meaningfully to managing down protracted refugee numbers, [it must serve] Canadian interests that include maintaining the public health and security of Canadians and facilitating integration of refugees” (Presse & Thomson, 2007, p. 51).

I strongly believe that of the Canadian interests mentioned above, maintaining public health and security should be the primary focus. However, I am concerned about the potential danger of a negative public reaction towards refugees in the community, stemming from the likelihood that the public’s view of refugees becomes negatively affected to that point that refugees stop receiving the support they require. Mayhew et al. (2015) confirm “the most common type of refugee in Canada is a refugee claimant, representing 43 percent of refugees who became permanent residents” (2015, p. 1)

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 20

Misrepresentation of Refugees in Canada

The misrepresentation of refugees is intertwined with political views about immigration and human rights. Atak et al. (2018) focus on the unintended consequences that the Canadian government made in 2012 in changing the Interim Federal Health Program (IFHP). At that time, the government amended regulations in the Immigration and Refugee Protection Act, Canada’s

Immigration System Act and the Balanced Refugee Reform Act. The authors point out:

The government has used the language of security to rationalise the imposition of

disproportionately harsh treatment on asylum seekers…the Federal Government

suggested that asylum claimants on board of the two boats may be supporters of or

potential contributors to terrorist activities. (Atak et al., 2018, p. 1, 6)

Some members of the government did not believe that most of the refugee claimants who had come in two irregular boat arrivals from Sri Lanka in 2009 and 2010 were genuinely in need but, instead, viewed these claimants through the lens of security and suspected the claimants of being human smugglers and terrorists.

The reception of refugees in their host countries has been marred by themes of fear, terrorism, and security, and created a negative and stressful atmosphere for refugees in many western countries. Jetten and Esses (2018) highlight, “in many major immigrant receiving countries in the world, concerns surrounding immigrants, refugees and asylum seekers, and their integration into host societies are higher than ever on the political agenda” (p. 662). Also, the authors articulate in their article that “recent years have seen new challenges as a result of unprecedented levels of migration, instability following the Global Financial Crisis, economic and security concerns surrounding immigration, and negative portrayals of immigrants by some

Western leaders” (Jetten & Esses, 2018, p. 662). Many citizens from receiving countries

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 21 sometimes greet refugees, “with intolerance, distrust and contempt, to some extent based on the perception that there is a trade-off between the well-being of refugees and the well-being of established members of potential host countries” (Esses et al., 2017, p. 80).

It is sad that some politicians contribute to the negative social construction of refugees in countries through their declarations of intolerance in a tense atmosphere. Former French

President Nicolas Sarkozy made a declaration in 2011 that fueled more anti-immigrant and refugee sentiment and this reflected how refugees are sometimes perceived in their receiving countries: “We have been too concerned about the identity of the person who was arriving and not enough about the identity of the country that was receiving him/her” (Jetten and Esses, 2018, p. 663). Viewed from that perspective, it becomes clear that the arrival and reception of refugees are under of the influence of political agendas.

The rhetoric of politicians echoed by media newspapers and magazines impacts the perception of community members towards refugees and can cause a reduction of support and create an anti-refugee sentiment. Indeed, media coverage of terrorist incidents around the world contributed to the propagation of anti-Refugees sentiments in many host countries. Jetten and

Esses (2018) affirm “it is not just attitudes toward immigrants and refugees that appear to have hardened, it is also clear that support for policies and ideologies that promote tolerance for immigrants and refugees appears to be dwindling” (p. 663). The debate around the reception of refugees intensified with a photo of the lifeless body of a Syrian child on a beach and the Paris terrorist attacks two months later in 2015 (Fehrenbach & Rodogno, 2015, p. 1122). Jaworsky

(2019) mentions, “Canadians also expressed worry; after Paris, 54 percent were moderately or strongly opposed to Trudeau’s plan to resettle 25,000 refugees by January 2016 […] even as the nation’s newspapers lauded such plans” (p. 2). These worries were fueled with various media’s

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 22 coverage around the world of various issues around the world on the topic of terrorism, refugees and immigration.

Jaworsky (2019) articulates that western countries can control migration to ensure security and assert their sovereignty by choosing who can and cannot enter their territory (p. 5).

That is, admitting refugees without having a proper and clear system, which will identify them and assess their ability to harm, is disadvantageous to these countries. Jaworsky (2019) explains:

“There is an assumption that some refugees, even if only a few, have the potential to create

‘devastating’ consequences for the country” (p. 9). Such presentation of refugees as a “threat”,

“danger” and possibly a “nuisance” contribute to a very difficult relationship between refugee patients and their health providers, and these difficulties can be heightened by differing understandings of the concept of health, expectation around treatments methods, and unmet medical needs.

Westernized Worldview in a Pluralistic Society: Oppression and Systemic Discrimination

As a country, Canada needs to make a clear adjustment within its healthcare system in the wake of a diversified immigrant population. This is important as “multicultural groups are diverse not only in their beliefs and expectations, but also in their assumptions about what the clinician can do for them” (Jaworsky, 2019, p. 2).

An Obsolete Medical Paradigm in a Changing Immigration Landscape

According to Gushulak et al. (2010), “Immigration has been and remains an important force shaping Canadian demography and identity” (p. 952). These immigration trends have

“been a significant feature of Canada’s population growth for over 100 years” (Gustafson &

Reitmanova, 2010, p. 816). For this reason, I would like to advocate for a culturally sensitive approach towards refugees by health providers in order to create a comfortable atmosphere

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 23 where refugees will stop being frustrated by the narrow-minded attitudes of some medical professionals. For example, as Mangrio and Forss (2017) state:

The majority of refugee women felt that they could not discuss their feelings of

depression with their doctors, either because they were too rushed, or because the doctors

did not ask them about possible emotional disturbances during the check-ups. For many

women, the post-natal delivery visit from a nurse was the only encounter with a

healthcare professional where they could discuss possible feelings of depression. (p. 3)

Unfortunately, Mangrio and Forss (2017) found that “not seeking care when needed might contribute to the growing health in-equality between individuals from different countries of origin that many countries in Europe are facing, as well as the US” (p. 2). I argue that the attitudes of the medical professionals stem from “the dominance of Euro-Western thought

[which] remains unconscious, standard, universal, common-sense and consequently, the yardstick by which non-white groups are judged” (Waldron, 2010, p. 262). For instance, many participants did not feel comfortable starting a conversation about their war-related trauma, however, if the doctor initiated the conversation, most state they would likely have responded.

I believe that the onus of the refugee’s health is incumbent upon health providers who have the opportunity to serve such a vulnerable population. However, these professionals do not seek to help refugees in the face of systemic issues. As McKeary and Newbold (2010) explain, providers “require training in culturally competent methods but are often constrained by time pressures, as well as access to training curriculum and opportunities” (p. 526). Additionally, these medical professionals work on a paradigm, which does not yet incorporate other ways of knowing. Sethi (2013) echoes this sentiment when she affirms “the dualism between mind and body or physical and mental health that dominates Western epistemological health practices is

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 24 not suitable for intervention with minority cultures from Asia, Africa, and the Middle East” (p.

527). Refugees can have a different understanding around the concept of health that might not align with the service delivery approach within the Canadian health care system. Most predominant in this health care system is the biomedical model, considered to be the dominant model of disease in North America. Deacon (2013) explains that the biomedical model “leaves no room within its framework for the social, psychological, and behavioural dimensions of illness” (p. 847). Hence, it is not surprising that some refugee patients have a reluctance to use any health service, including psychiatry service, as a result of the reliance on pharmaceutical medication as a primary intervention method.

Whitley et al. (2006) explain that some refugee patients “had a negative attitude toward medication. From previous doctor-patient interactions in Canada, they felt that physicians far too quickly and easily dispensed medication, which most participants did not think could solve the real root of their problems” (p. 206). These perceptions of the refugees may not be seen as issues or concerns within the western world, which heavily depends on the biomedical model to function on a regular basis. However, the use of medication as the primary means to healing shows that the health care system has not yet fully understood that refugees come from countries or cultures where there is also “a belief in the curative power of nonmedical interventions, most notably God and, to a lesser extent, traditional folk medicine and healers (Whitley et al., 2006, p.

207). The lack of agreement around what constitutes health among refugees and their healthcare workers has created a poor service delivery approach which deepens health inequalities among residents of the same country.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 25

Lack of Agreement Around the Concept of Health Creates Poor Service Delivery

Some refugees have a different understanding of health than the health providers who are mandated to help them. Alegria et al. (2010) explain: “Individuals seeking help may possess diverse views of what matters most to them as compared to the provider, which may result in a lack of shared problem definition between the individual and the provider (pp. 49-50). Newbold et al. (2013) acknowledge that “although the provider perspective is important and indeed reflective of refugee needs, the voices and perspectives of individual refugee and refugee women is further warranted” (p. 434). I support and share the views that women refugees’ needs should be considered, especially if one needs to understand how to culturally attend to them when accessing health services. Newbold et al. (2013) highlight that:

For many of the women, being healthy was directly associated with having access to

health services, yet they faced multiple barriers in accessing services when needed:

access to care was often unobtainable or problematic, whether care was sought in walk-in

clinics, family physicians, or hospital emergency rooms. (p. 439)

The Canadian health care system fails refugee patients in that it only provides a single, monolithic approach, which refugees are restricted to follow. Ter Heide et al. (2015) advise:

“According to many clinicians, traumatized asylum seekers and refugees have a reputation of being difficult to treat” (p. 182). However, all medical experts do not share this opinion; as the authors further point out, “it is the treatment offered to refugees, rather than their potential to benefit from treatment, that leads to low treatment response” (p. 183). From this perspective, the issue is not on the refugee patients who access the services but rather, the lack of culturally appropriate services of which refugees in Canada have no understanding. Therefore, it is not surprising that there was a lack “of health services available due to a limited number of health

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 26 providers willing to accept refugees as patients in Hamilton” (Newbold et al., 2013, p. 441).

According to these very same authors, the refusal to serve refuges was discriminatory as “based on their status (as noncitizens)” (2013, p. 441).

Ter Heide et al. (2015) suggest that what is missing within the health system is knowledge of the risk and trauma-filled journeys that refugees take to their host countries. Many asylum seekers and refugees, “have been exposed to multiple, prolonged, interpersonal traumatic events such as war and patient-related factors, such as trauma history, current human trafficking”

(p. 183). I believe the lack of understanding by the health workers show that the health system needs to be reconfigured to serve refugees effectively upon their arrival.

As a result of the lack of support around refugees’ families, some “Refugee claimants were, however, responsible for finding health services on their own” (Newbold et al., 2013, p.

442). Newbold et al. (2013) stress that the expectation of these refugee women is that: “the

Canadian health care system should far outperform the health care systems of their home countries in areas such as wait times and doctor availability, yet it didn’t” (p. 444).

Conflicts in the Health Provider-Refugee Patient Relationship

As illustrated in the previous paragraph, the relationship between refugees and medical professionals is paramount to refugees increasing their ability to settle into their receiving country. The role of culture cannot be overstated enough in building such relationships; as

Szajna and Ward (2015) state, “culture plays a significant role in the definition of access to healthcare services and service utilization patterns among refugees” (p. 85). So, it is paramount, if one expects a positive outcome for refugees accessing healthcare in Canada, to see healthcare providers implement a cultural safe delivery approach. Cheng et al. (2015) surmise that “during resettlement, the main burden of addressing refugee and asylum seeker health needs falls to

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 27 primary care providers such as GPs and family physicians” (p. 171). Therefore, it is quite normal for refugees to try to connect with health physicians, nurses, mental health clinicians about their predetermined health conditions due to their pre-immigration journey before arriving to Canada.

As a result, when refugees attend healthcare facilities to interact with physicians, nurses who do not always have an adequate level of cultural understanding. Kirmayer et al. (2011) write:

“Culture can profoundly influence every aspect of illness and adaptation, including interpretations of and reactions to symptoms; explanations of illness; patterns of coping, of research participant seeking help and response” (p. 963).

Cultural differences create an issue between healthcare providers, patients and patients’ family members as each group has their own understanding of what treatment methods should be used. As an example, Morris et al. (2009) share the experience of a refugee who shares: “When I go to the doctor, I want him to touch me, to look in my eye, hit me with the little hammer” (p.

535). The patient shares about his expectation when he or she meets with a doctor and expresses frustration when expectations are not met.

Schill and Caxaj (2019) argue there is a “need for clinicians to consider the background, assumptions, and values of themselves and their patients to provide conscientious, holistic, and relational care” (p. 2). For instance, refugees in Thunder Bay who participated in the research study spoke about their experience with racial discrimination and stereotyping by health care providers. Similarly, public health units were seen as having a difficult time relating to refugees in the following study by Khan and DeYoung (2018), who affirm that:

Refugee women’s traditions and beliefs related to labour and delivery also did not always

coincide with Western practices. The preference for kneeling or squatting during birth

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 28

rather than the supine position, administration of pain medication or epidurals, and the

potential for lack of modesty during childbirth concerned refugee mothers. (p. 2)

I believe that the medical staff does not always take into consideration the cultural practices amd expectations of their patient when it comes to child delivery and care after the child is born. That is why these authors deplore the fact that, for instance, “women practiced breastfeeding in most of their home countries, but it may not be encouraged in countries like the

United States, Canada, and Ireland” (Khan & DeYoung, 2018, p. 2). That is concerning in

Canada where “refugees are considered a highly vulnerable population. Compared with their

Canada-born counterparts, immigrant and refugee populations encounter barriers to accessing primary health care services.” (Stewart et al., 2018, p. 687). I suggest that more providers start working with refugees and stay aware that in the process they:

May be faced with their own misconceptions and misunderstandings of immigrant needs

or cultural and social roles related to care. Similarly, much can be learned about cultural

barriers and misperceptions of immigrants in obtaining prenatal care based on the

perceptions of health care providers working with these patients. (Ng & Newbold, 2011,

p. 562)

Wahoush (2009) debunks the sub-linguistic racism that some refugee women encounter when accessing health service:

Negative experiences reported by more than one third of mothers included witnessing or

being the object of racism and discrimination in the health-care system. “They pretend

they do not understand me,” said one refugee claimant, who was aware of her accented

English. Two mothers identified prolonged waiting in an emergency department as

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 29

evidence of racism. All other reports of racism concerned the attitude of health-service

providers (p. 200).

According to Waldron (2010), “Euro-Western ideology can be defined as the belief systems, knowledge, traditions and cultural norms that emanate from the European frame of reference and shape institutions in both Western and non-Western societies” (p. 262). Such a privileged ideology has been the standard within institutional spaces in western countries including health and, as a result, refugees who access health services receive culturally unsafe services, which do not meet their needs.

Cultural safety is the answer to inappropriate healthcare service delivery within a multicultural country like Canada. Indeed, cultural safety fills the gap created by the cultural competence model which “has been used for over four decades by medicine, nursing, social work and other allied health professions to direct research and professional education and practice” (Gustafson & Reitmanova, 2010, p. 817). These researchers argue that part of the failure of the cultural competence model is the reduction of the concept of culture to, “a set of biological characteristics (e.g. skin colour, eye shape and hair type), religious practices (e.g. wearing a headscarf, sari or habit) and health practices (e.g. carrying an amulet, drinking green tea and performing a sweetgrass ceremony)” (Gustafson & Reitmanova, 2010, p. 817). So, physicians, nurses or social workers are trained to gather cultural information about the various patients with the intent to provide effective care. The information gathered over time ends up reinforcing popularized stereotypes about culturally different groups. If refugees need to have a positive interaction with physicians, there must be a paradigm shift in their relationship. As Jones

(2017) suggests, there must be an “attitude change on the professional’s part toward the individual people they care for” (p. 9). It is a change that requires the healthcare providers to

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 30 become a partner and not the expert of the patient’s health. This idea is reiterated by Waldron

(2010) who, referring to refugee health, suggests that “if studies were conducted with both service holders and refugees, the perceptions of the refugees had to be clearly defined in order for them to be considered” (p. 262). Hence, this supports the call for a reconfiguration of the health system to serve refugees effectively.

Healthcare System Reconfiguration Needed to Serve Refugees Effectively

In the previous section, it was illustrated how the relationship between health providers and their refugee patients is impacted by a Eurocentric worldview, which perpetuates racism, discrimination, and othering as norms within the healthcare system in Canada. In this section, an analysis is offered to show how whiteness within the Canadian health system is hidden and perpetuates oppression of refugees who do not feel safe to express themselves. Finally, in this section, I shall demonstrate that the implementation of cultural safety could give a platform for refugees to share their views on the type of treatments provided to them.

Discrimination and Othering as Norms in Healthcare

An awareness of the discrimination that refugees encounter throughout the country shows that the provision of health care services is not the same for all Canadians. As Pollock et al.

(2012) state, “despite Canada’s universal health care system, it was not uncommon to hear cases of refusal of medical services based on immigrant or refugee status” (p. 65). Such an attitude, seen mostly during the IFHP’s cuts, does not encourage today’s refugees to access services even when they can speak the language or have an interpreter that is ready to accompany them to their medical appointments. Pollock et al. (2012) give a broader explanation of how “discrimination takes on many forms at a variety of scales, from conscious and unconscious interpersonal interactions between individuals to more institutionally ingrained practices occurring at the

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 31 systemic level” (p. 62). For instance, the same authors mention within the health care setting

“some, documented encounters of perceived discrimination include incidents of insensitive, unfriendly, or ignorant treatment from providers, to racial slurs, stereotyping, and receipt of inferior care” (Pollock et al., 2012, p. 63). The request by some refugee patients to their health care providers to acknowledge or respect their religious or cultural beliefs brought frustration in both camps with the patients feeling unheard and ignored and the health care provided ignorant and angry. Pollock et al. (2012) argue “some health providers were unwilling to accept refugees as patients, with refugees perceived as more challenging due to complex health needs, linguistic barriers, and/or complicated insurance coverage schemes that can delay payment for services delivered” (p. 63).

Johnson et al. (2004) mention that “in the past decade, researchers have begun to explore how certain practices in the dominant health care system marginalize particular ethnocultural groups. One form of this marginalization has been referred to as othering” (p. 254). Through othering, the mainstream group builds its own identity based on other marginalized groups, and in the health context, it is immigrants and refugees who struggle to access health services despite changing demographic landscape of the country. So, refugees arrive in a new country which has accepted them for humanitarian reasons with the intention of providing some form of support.

Yet, they encounter othering which is “a process that identifies those that are thought to be different from oneself or the mainstream, and it can reinforce and reproduce positions of domination and subordination” (Johnson et al., 2004, p. 254). The authors also assert that:

There is a tendency to attribute the problem to the cultural beliefs and practices of the

underserved group (e.g., shy- ness, folk beliefs about disease causality) rather than to

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 32

discriminatory attitudes and practices of health care practitioners that act as barriers to

health care. (Johnson et al., 2004, p. 256)

In their article, Johnson et al. (2004) present how “othering was evident in the health care providers’ discussions about South Asian patients and was illustrated in women’s discussion of their encounters with the health system” (p. 259). Besides, as the article points out, health professionals sometimes held stereotypes that a South Asian woman was, “to be ‘quiet’ in childbirth, not demand too much, and be more assertive and ask questions in their health care encounters” (Johnson et al., 2004, p. 264). Although not the direct focus of the literature review,

I would like to point out “the literature suggests that physicians from visible minority groups continue to face othering processes, although the meaning attached to these processes varies by context and over time. It can be structured around doctor’s skin colour” (Neiterman et al., 2015, p. 777).

Therefore, it is important that the Canadian health system be revamped to become more inclusive to every Canadian, including refugees, who have difficulty obtaining a doctor. Mayhew et al. (2015) state “it is well known that refugees in Canada have more difficulty finding a regular family doctor (RFD) than the mainstream population” (p.18). Such a call for additional engagement with refugees will help progressively reduce the health disparities that exist between refugees and mainstream patients. Mayhew et al. (2015) highlight this need for more change by, “the fact that some refugees do manage to secure a family doctor after discharge from a specialized refugee healthcare clinic and some do not, [which] presents a dilemma concerning continuity and adequacy of care” (p.19). Unwillingness to serve refugees in a manner that they understand is a form of discrimination against their identity. Woodgate et al.

(2017) point out that “access to health care involves a fit between the client and health care

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 33 system where the client identifies health care needs, looks for health care services, reaches out, acquires, and fulfils the need for these services” (p. 2).

The Impact of Policies on Healthcare of Refugees

An understanding of how immigration and health policies intertwine provides a glimpse of the complexity of healthcare services in Canada for refugees. Simich et al. (2005) write that,

“service providers and policymakers believed that immigrants and refugees faced many common challenges, such as communication and economic integration, although they felt that refugees face greater barriers” (p. 261). On the one hand, there is the assumption that since Canada has accepted refugees from around the world, it is up to its government to create an environment which will enable and foster proper services to refugees. I argue that the ‘host’ society have a responsibility towards refugees that have been accepted into their respective countries. Matlin et al. (2018) echo the same sentiment when they affirm that:

The onus of responsibility rests with States to respond to the health needs of

migrants and refugees arriving in their own countries and to support those trying to

meet the health needs of migrants and refugees in camps or transit locations on the

way to their destinations. (p.3)

On the other hand, there is the incomplete and inaccurate media coverage, which

“promote[s] fear and hatred within the native-born population of host countries, such as Canada, and increase the existing social distance between the natives and the non-native-born groups”

(Reitmanova et al., 2015, p. 476).

One example of such policies is the case of the Interim Federal Health Policy (IFHP), which is a health program that was initiated in 1957 to provide health care benefits to vulnerable groups not eligible for coverage under professional insurance plans and unable to make a claim

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 34 through private health insurance (Jackson, 2012, p. 2). The IFHP is a federal health policy that, since it’s inception, has extended health care benefits to protected people including resettled refugees and refugee claimants who would not have been able to receive coverage from provinces or territories. The IFHP is intrinsically connected to the Canada Health Act whose ultimate purpose is to facilitate care to all citizens (Jackson, 2012). According to Baiden et al.

(2017), the Section 3 of the Canada Health Act stipulates “that the primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers’’ (p. 1230). That is, Government Assisted Refugees (GAR), Private Sponsored refugees (PSR) and refugee claimants could be covered and have access to health services.

Refugees in all classifications (GAR, PSR and Refugees Claimants) enjoyed the IPFH coverage until a change occurred in 2012. Antonipillai et al. (2017) write:

In 2012, changes to Canada’s refugee health policy were introduced through the IFHP,

significantly reducing health care coverage for certain refugee populations and resulting

in the loss of insured medical care and hospital service provisions for many who had been

previously covered. (p. 435)

As a direct consequence, failed refugee claimants became ineligible for any provincial or territorial health insurance due to the socially constructed belief that they were not genuine or

‘real’ refugees. As Antonipillai et al. (2017) mention: “Many stakeholders recognized that

‘Canada is a nation of immigrants and refugees,’ yet throughout the political discourse, actors inappropriately referred to refugee claimants as queue jumpers” (p. 438). Indeed, the Interim

Federal Health Program (IFHP) changes were introduced by Steven Harper and denounced by the federal Liberal Party and the NDP, as well as some polling which indicated that many

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 35

Canadians did not support the changes (Frecha, 2015, p. 32). There was a “debate” in Canadian society about these regressive views, with Neo-Conservative interests supporting them while others opposing. Furthermore, several provincial governments and organizations criticized the

IFHP policy and commented on its negative impact on the refugee claimant population in

Canada. Antonipillai et al. (2017) explain that:

Concerns for refugees and refugee claimants voiced by Canadian health organizations

and professionals for two years (2012–2014) prompted the federal court to reassess the

impact of these reforms on all stakeholders involved in refugee care, including

physicians, lawyers, pharmacists and refugee claimants themselves. (p. 437)

The Role of Cultural Safety in Healthcare Settings in Canada

Health providers need to have a greater awareness of the health issues that affect their refugee patient and they can achieve it if they implement culturally safe practice with these refugees. Cheng et al. (2015) explain that “refugee perceptions of medical assessments and treatments were shaped by pre-existing health beliefs and expectations of health care. Problems occurred when there was dissonance between their expectations and their actual experiences of care” (pp. 173-174). Unfortunately, Cheng et al. (2015) also add that “refugees preferred clinical assessment methods to be consistent with cultural expectations and explanations of unfamiliar processes and treatments” (p. 175). For example, this would mean that a patient would go to the hospital and expect to speak with his or her doctor and not be ignored or seen briefly. One client said:

In Africa when you go to the hospital, they treat you quickly and [...] if the medication is

finished, they give you, you go back and collect it [...]. But here they said you have to

wait, you have to see your doctor first.” (Woodgate et al., 2017, p. 4)

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 36

This is where a discussion of cultural safety is important; as Bryson and Bosma (2018) state:

Cultural safety does not focus on the cultural identity of the ‘other’ or on practitioner

mastery of knowledge about ‘other cultures’. Rather, it requires health-care practitioners

to examine their own cultural identities, attitudes, and beliefs about ‘others’. Further, it

asks practitioners to engage in clear, value-free, open, and respectful practice. (p.16)

Cultural safety will foster favorable attitudes among health providers willing to help refugees accessing health services and establish a trust relationship with them. Studies suggest

“the need for clinicians to consider the background, assumptions, and values of themselves and their patients to provide conscientious, holistic, and relational care” (Schill and Caxaj, 2019, p.

2). As Gerlach (2012) explains in practice which foregrounds cultural safety:

The cultural lens is turned inward, prompting health care providers to critically reflect on

and question their personal, cultural heritage, colonial history, and the contemporary

cultural nature of health care and the respective impact of each on health care encounters

and relationships. (p. 153)

Floyd and Sakellariou (2017) share an example of the racist attitude that a doctor showed to one of her patients from Sudan after the doctor discovered her nationality. The doctor said,

“oh Sudanese, they are the worst people” (p. 5). It is so inappropriate for a doctor to interact with their client and expresses his or her view about that country. This attitude of the doctors coupled with the lack of interpreters affect the refugees’ ability to access health services due to the language barriers. Indeed, it is important to remember that health-care providers are under no obligation to provide interpretive services within their practice as illustrated by this woman who needed to see a specialist doctor but was told: “We can’t communicate, so there was nothing

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 37 done at that visit. And she has to wait 7 months to get a new appointment” (Floyd & Sakellariou,

2017, p. 5).

Acculturation as a Barrier to Utilization of Care within the Healthcare System

Some people might argue that it is not just the health providers who have to make the required effort within the health system towards refugees. Their argument would be that it is

‘unreasonable’ or impossible for all health care providers to be aware of a range of health

‘lenses’/worldviews. I agree with that perspective in theory, although I will argue that the expectation is not for health providers to know everything about refugees but to work within a system that takes into consideration other ways of doing when interacting with refugees.

Waldron (2010) states, “when the health system presents Euro-Western health approaches as standard and universal, the consequence is […] racially and culturally diverse groups are often less satisfied with the quality of care that they receive, or hesitant to access health services”

(p.263). So, my understanding is that it not the choice between two systems, namely the mainstream system over the refugee system; rather, it is the acknowledgment of the diversity of cultures that patients bring with them and the appropriateness of the service provided to them.

McKeary and Newbold (2010) comment that “cultural interpretation is particularly important, covering not only health care communications, but an awareness and understanding of diverse health beliefs and expectations within provider and client interactions” (p. 526).

I believe that if refugees receive proper health services, they will be able to settle into the country and become community builders as any other citizens. Beiser and Hou (2016) resounded the same idea that:

Resettlement countries expect immigrant and refugee youths to be healthy, learn the

local language, adopt the mores of the dominant society, do well at school, graduate into

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 38

full employment, use health and social services sparingly, and stay out of trouble. (p.

469)

I predict such expectations will come to pass as refugees become established in the country because they will be able to find jobs, gain independence and economic success, resulting in them being able to provide for themselves and their families. It is with the same hope that these refugees will become contributing members of the community who also welcome other refugees in search of the same identity. I am aware though, that the facilitation of refugees into a social acculturation and adaptation in the host countries require a deep understanding of refugees pre- and post-migration realities, as well as their social locations. Hence, I encourage the policy makers and healthcare stakeholders to work with the understanding that the service provided to refugees should be more sensitive towards them. Taking such a position is not unique to me as “many health care providers have recognized that immigrants often have difficulty accessing health care services to deal with health problems because of the lack of cultural acceptance and appropriate health care services, a lack of social resources” (Donnelly et al., 2011, p.280).

I believe that empathy towards refugees must come with the understanding that the

“majority of refugees spend the greater part of their lives in refugee camps before repatriation or resettlement to a host country” (Morris et al., 2009, p. 529). As Matlin and colleagues (2018) remind us, “it is therefore important to search for solutions that recognise migrants, refugees and asylum seekers as ‘part of society’ and that make them ‘structural’ rather than ‘external’ in health systems as well as other areas” (p.4). There is a known gap between the life which refugees experience prior to their arrival in Canada and the lack of acknowledgment of such experiences when receiving services through health providers. I would argue that this

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 39 acknowledgement of the pre-immigration period is key to properly supporting refugees as they did not come to Canada by choice, rather they came because they were forced to migrate due to major life-changing processes, which have more impact on their health than one can imagine.

Danso (2002) to that effect affirms:

People who migrate under stressful and excruciating circumstances experience many

difficulties adjusting to life in a new society. The suddenness of displacement and the

conditions of flight combine to produce a set of social, cultural, economic, and

psychological challenges to the refugees, which may impede successful integration. (p. 3)

Refugees lack accessibility to health services due to the lack of culturally appropriate care is not in alignment with Canada multicultural discourse as Wylie et al. (2020) states,

“Canada has a long history of immigration and significant ethnic diversity based its construction as a settler nation” (p. 2). I argue throughout the paper that refugees need extra support during their migration and settlement due to the psychological and emotional toll on their lives. I advocate for a “resilient health system can enhance accessibility, usability and effectiveness of services to promote, treat and maintain holistic patient health.” (Wylie et al., 2020, p. 8). I believe that it is difficult to describe the immigration a process of refugees, which is most of the time complex and non-linear, as every story is unique. Hence, McMurray et al. (2013) argue that refugees need to access healthcare practitioners “with knowledge of the refugee experience is particularly important for newly arrived GARs whose medical conditions are often uncommon in

Canada and exacerbated by overcrowding in refugee camps due to in adequate sanitation, nutrition and infrastructure" (p. 578).

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 40

Social Work Implications

Awareness of the discrimination that refugees face when they access health services needs to be addressed by all health providers. According to Asgary and Segar (2011):

Refugees and asylum seekers often come from conflict areas with poor access to

adequate health care and most have experienced significant trauma, including torture.

Upon arrival, they are often subjected to further trauma through detention, language

barriers, and difficulty navigating the health care and social systems of their host

countries. (pp. 506-507)

Othering of vulnerable populations such as refugees must be eradicated despite the debate about refugees in host countries. Indeed, further research is needed in the access refugees have with health services. Phillimore (2010) affirms:

Much has been written in policy and academic fields about the importance of integration,

particularly concerning the settlement of refugees. However, little attention has been paid

to the varied settlement experiences of individual refugees or how personal, cultural, and

experiential factors combine to influence settlement experiences. (p. 575)

It is important to pay attention to how healthcare providers work within the health care system with refugees to implement cultural safety towards them.

Implications for Practice

One of the first practical implications that this study highlights is the need for social workers to understand the concept of “refugeeness” in Canada to effectively support refugees when working with them. Lay and McGuire (2010) state, “there is a potential gap between the academy and the world of practice in many professions, including social work” (p. 542). In other words, there is a discrepancy between what social workers learn while in school and what these

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 41 social workers do after graduation while at work in the field. Social workers appear to not know much about the refugee population nor understand their predicament once these refugees have arrived in their host countries. Lacroix (2004) affirms that “refugees are people with an identity, a past, a history, [and] a cultural heritage” (p. 147). One could describe refugees as human men and women, not unlike the population already living in the host country, who deserve to be treated as human beings, despite their life circumstances. It is my belief that social work practice with refugees requires specialized knowledge about these populations as well as application of mainstream services and interventions for the refugees’ needs. Indeed, refugees are often confronted with cultural, linguistic, political, and socioeconomic barriers which make them vulnerable to physical and psychological sicknesses. As a result, there is a tension within the community about what should be done with refugees to the point that “refugees’ policy in

Canada is one of the most controversial and debated political and social issues” (Lacroix, 2004, p. 147).

Hill et al. (2009) put refugees at the centre of social work practise by emphasizing the need for social workers to advocate for refugees since refugees are often ostracised, discriminated against and end up experiencing social isolation. Furthermore, the authors ask some social workers to stop continuing to be “complicit in implementing social policies that have led to people being denied access to welfare, dispersed into impoverished areas and denied jobs”

(p. 300). This paper challenges social workers to reflect on their engagement in the society by becoming a critic of the health care system until it become inclusive to all Canadians. Hill et al.

(2009) comment that:

It has been suggested, for example, that one in six refugees has a physical health problem

(severe enough to affect quality of life) and that two-thirds experience anxiety and

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 42

depression (Burnett and Peel, 2001). In addition to this, many refugees and asylum

seekers experience periods of homelessness, which places them in further jeopardy” (p.

299).

In a nutshell, the focus of social workers throughout their practise should be to encourage refugee inclusion into the Canadian health care system and integration in the community.

Implication for Further Research in the Areas of Systemic Discrimination in a Multicultural

Society

Another outcome of this study is the need for further research around refugee access to healthcare services. Kobayashi et al. (2008) explain that “Canada, like the United States, the

United Kingdom, and Australia, is a multiethnic society with a global reputation for recognizing the ethnocultural diversity of its populace through celebrated federal policies and programs like the 1985 Multiculturalism Act” (p. 129). However, there is ignorance on the part of the population and policymakers when it comes to the situation of refugee people in Canada when they access health services. It has become clear from the existing literature “that immigration and ethnicity interact to influence health… Yet little is known about how immigration and ethnicity intersect to shape the distribution of health in Canada” (Kobayashi et al., 2008, p. 131).

Information is not widely collected or available about refugees’ beliefs, attitudes, and lifestyles when they first arrive in Canada or regarding their health and expectation around how health providers’ interactions with them impact their health journey. It is this lack of information that, unfortunately, does not allow changes to the manner in which refugees are treated when they access health services. Over time, the health of refugees deteriorates as their length of residence in Canada increases, causing health disparities within the health system and population.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 43

Unfortunately, the limited research about access to health services by refugees does not help improve the kind of services provided to them. Floyd and Sakellariou (2017) state, “greater knowledge about the experiences of refugees accessing care is necessary to improve services.

Furthermore, very little is known about how refugees cope with the problems they face in accessing healthcare” (p. 1). It is suggested that if there was more research, refugees would have a better trajectory upon their arrival in Canada and settle into the country better. Mangrio and

Forss (2017) put it this way: “Research suggests that understanding the refugees experience of and access to healthcare are important factors for improving their health, as access has been found to be a leading health indicator” (p. 1). There is an intricate relationship between research, practice and policy and it is therefore important to assess how policymakers perceive the research. Further research about the health trajectory of refugees who have settled in the country after two years should be done with the purpose to appreciate how culturally safe the health system has begun. This research will assist with refugee inequalities in healthy care, as it assists health care providers dealing with the arrival of new refugee groups, when providers have little expertise and no understanding of the refugees’ needs. It is my hope and desire that such research will be done irrespective of the political divides and refugees’ interest will be at the centres of the policymakers’ decisions. Brown-Bowers et al. (2015) draw our attention on the fact that:

Social construction of refugee and asylum-seeker is not static or fixed; rather the

meanings associated with these categories change depending on who is in power and how

particular constructions of these people fit with particular political agendas, social

climates, economic factors, and global events. (p. 322)

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 44

Research will equip health care providers with knowledge and opportunity to provide care to refugees upon their arrival in the country. On a different note, an invitation to assess discrimination toward foreign-born medical doctors should be explored. The rationale of such further research would be to highlight the discrimination experienced by medical professionals within the health system. Foster (2008) mentions: “the medical profession is culturally regulated to the disadvantage of foreign-born and foreign-trained and predominantly non-European and non-White immigrant practitioners” (p. 1). If the Canadian health system is to make a step towards cultural appropriate delivery service among refugees, there needs to be an implementation of a multicultural health care team to serve patients, including refugees.

Implications for Policy Creation and Implementation

One notable impact, which this literature review illustrates, is the role that policies play in community building. In light of the struggles of refugee claimants, there was a critique of the negative impact that the 2012’s Interim Federal Health Policy (IFHP) created amongst refugee claimants. Many provincial governments and organizations debunked the policy and commented on its negative impact on the refugee claimant population in Canada. For instance, the former

Premier of Saskatchewan, Brad Wall, was among the first to condemn the new changes made by the Federal government and proclaimed that his province “would cover the costs of chemotherapy for a refugee claimant who was denied coverage by the federal government shortly after the changes to the IFHP, echoing what he considered to be the sentiment of many others in the province” (Enns et al., 2017, p. 30). Another example is the legal challenge that a national group of doctors faced, working along side the Canadian Association for Refugee

Lawyers (CARL) and a Toronto-based non-profit clinic named Justice for Children and Youth

(JCY). These advocators presented the case of two individual plaintiffs in the Federal Court of

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 45

Canada, both of which were being denied medical coverage under the restricted health benefits of the new IFHP. One of them, named “Daniel Garcia Rodrigues[,] was a refused [refugee] claimant from Colombia sponsored by his wife, whose refugee claim had been granted.

Rodrigues had been refused eye surgery for a retinal detachment under the new IFHP” (Ennes et al., 2017, p. 31). The other claimant, named Hanif Ayubi, “was a type 1 diabetic and, under the changed program, was no longer eligible to receive the insulin or other necessary medications that he had been receiving” (Enns et al., 2017, p. 31). Harris and Zuberi (2014) mention “recent legislative reform has drastically altered the ways in which asylum seekers are processed and treated upon, and after, their arrival to Canada.” (p. 1041). The authors emphasized the fact that the Interim Federal Health Program by the then Conservative government made “the IFHP into a hierarchal, three-tiered system, the reform significantly limits the access of most refugee claimants to preventative care, essential services, and vital medications” (Harris & Zuberi, 2014, p.1042). As a result, refugees became vulnerable to the very country that has welcomed them and provided them a safe haven. Interestingly enough, what happened previously is still happening today in terms of the lack of culturally safe service delivery, despite the refugee’s traumatic journey. As Shommu et al. (2016) state, “without adequate access to care, including comprehensive primary healthcare, minority groups remain at higher risk of developing acute and chronic illnesses, including diabetes, hypertension, coronary disease and cancer” (p. 2).

Consequently, refugees are present with various diseases that put pressures on the healthcare system and allow me to conclude that, “although Canada has a universal healthcare system, there is ample evidence documenting that vulnerable populations, including immigrants and refugees, experience substantial barriers to accessing healthcare, including primary care” (Shommu et al.,

2016, p. 3).

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 46

Implementation of policies, which are mindful of refugee’s movement into Canada, would be considered culturally safe. As LeBrun et al. (2015) state that, “although western countries, and particularly the US and Canada, have a long history of migration and cultural diversity, social and health institutions must increasingly adapt to a shift in immigration patterns”

(p. 45). As a result, there is a need to identify any policy that has been created from a western worldview perspective and ensure that refugees are not negatively affected. Higginbottom et al.

(2013) add, “Canadian history has been stamped by injustices toward its indigenous peoples as well as a catalogue of oppressive and discriminatory policies and practices toward earlier non-

Anglo migrants/minorities” (p. 944). Policy makers need to work alongside health industry stakeholders to eliminate any form of discrimination and allow refugees from across the globe to feel “at home” in Canada. Strang and Ager (2010) affirm “it is the responsibility of the ‘host’ society to create the conditions to enable integration” (p. 601). It is not an easy process, given that policymaking can be a highly complex process depending on the social, cultural, political, and historical context, in which one lives.

I suggest policy implementations in several areas of Canadian healthcare. First, health care workers to gather information about refugee populations according to the health conditions in their country of origin; second, to use the collected information to create a data base for policy makers to evaluate existing health policy and refugee service delivery approach. Gabriel et al.

(2011) note:

Most federal and provincial databases are inadequate to provide reliable, valid and

comprehensive profiles of refugees’ health due to lack of details data on refugees […]

The available literature tends to be non-Canadian and usually examines only one specific

ethnic population. (p. 270)

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 47

Determination of a refugee’s origin country does not constitute an invitation to labelling these countries, but rather a means to better support refugee patients based on the data collected.

I believe that the Canadian government should invest in the health care system by requesting quality data which informs policy making that tackles discrimination towards refugees when they access healthcare. Langlois et al. (2016) emphasize that “refugees experience conditions of vulnerability, marginalisation, and poverty, in addition to the high stress of displacement, which seriously affect the health of these populations, including women, children, and older people” (p.

319). Consequently, it is important that the Canadian government keeps its commitment to provide services which will meet the needs of refugees with physical and psychological challenges. Such commitment will allow the refugee population access to all available health care and social services which mainstream patient receive on a regular basis. In other words, granting access to refugees is not a privilege, but a basic human right. Langlois et al. (2016) echo similar sentiments that “access to essential health services for refugees should be recognised as a fundamental human right. As such, host countries must address refugees’ exclusion from health- care services and their unmet health needs” (p. 320).

Renewal of the Role of Social Worker as an Agent of Change in the Community

This study has put back the role of social worker as an agent of change in the transformation of society. That is not to say that social workers were not in role of advocate, but rather, that such role should become a priority. Social workers vow to stand for social justice in the Code of Ethics and, therefore, it should be normal that social workers question the systemic discrimination and racism that refugees encounter when accessing healthcare services, irrespective of their own social location. Urdang (2010) mentions:

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 48

During their Master of Social Work (MSW) training, students need guidance in becoming

aware of how their own feelings, attitudes, relationships with clients are major factors in

the helping process, and further, that helping others is in itself a process. (p. 524)

So, it is by remembering their position of privilege that social workers can become the voice of the oppressed and speaks on their behalf. Yee (2016) says, “until we are able to look at how our systems and institutions reproduce privilege; we will remain prone to stay at the emotional level of blaming one another and constructing allies and foes” (p. 497). Also, as

Burnes and Ross (2010) puts it: “Some scholars have documented that oppression is often allowed to occur in group settings because group members’ privilege is left unchecked and unchallenged” (p. 170). Community building is done effectively through the advocacy of those in power.

Conclusion

In this paper, I argued that with the increasing numbers of displaced persons in the world, there is significant room for improvement and much needed work to be done when it comes to refugee access to healthcare services. Unfortunately, these refugees have left their home country, moved through various unknown and uncertain circumstances to become “liable to arbitrary action on the part of the host country” (Aggrawal, 2016, p. 85). Refugees do not always receive culturally safe services when accessing health services. Unfortunately, some historical, social and political factors that are entrenched in colonialism and a Eurocentric worldview prolong the oppression of refugee patients. Refugee patients are often dissatisfied with the type of service they received and desire services, which they can identify with themselves. Cultural safety within healthcare is a work in progress, both at individual and systemic levels, and, ultimately, this will improve the health of all Canadians. Policymakers should be encouraging various

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 49 service delivery alternatives, which can and should be taught to health care professionals. The widespread and underlying assumption that healthcare providers have the expertise and the know-how to heal all their patients including refugees is, at this point, inaccurate. This paper showed that refugees’ varying needs and expectations when they access healthcare, and the political context in which refugees arrive to Canada can also impact refugee health. Hence, this paper suggests the implementation of cultural safety is a fundamental tool for health providers to use when interacting with refugees.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 50

References

Aggrawal, A. (2016). Refugee Medicine. Encyclopedia of Forensic and Legal Medicine, 83–87.

doi:10.1016/b978-0-12-800034-2.00321-9.

Alegria, M., Atkins, M., Farmer, E., Slaton, E., & Stelk, W. (2010). One size does not fit all:

Taking diversity, culture and context seriously. Administration and Policy in Mental

Health, 37(1-2), 48-60. doi:10.1007/s10488-010-0283-2

Antonipillai, V., Baumann, A., Hunter, A., Wahoush, O., & O'Shea, T. (2017). Impacts of the

Interim Federal Health Program Reforms: A stakeholder analysis of barriers to health

care access and provision for refugees. Canadian Journal of Public Health = Revue

Canadienne De Sante Publique, 108(4), e435-e441. doi:10.17269/CJPH.108.5553

Asgary, R., & Segar, N. (2011). Barriers to Health Care Access among Refugee Asylum Seekers.

Journal of Health Care for the Poor and Underserved, 22(2), 506–522.

doi:10.1353/hpu.2011.0047

Atak, I., Hudson, G., & Nakache, D. (2018). The securitisation of Canada’s refugee system:

Reviewing the unintended consequences of the 2012 reform. Refugee Survey Quarterly,

37(1), 1-24. doi:10.1093/rsq/hdx019

Baiden, P., den Dunnen, W., den Dunnen, W., Fallon, B., & Fallon, B. (2017). Examining the

independent effect of social support on unmet mental healthcare needs among Canadians:

Findings from a population-based study. Social Indicators Research, 130(3), 1229-1246.

doi:10.1007/s11205-015-1224-y

Beiser, M., & Hou, F. (2016). Mental health effects of premigration trauma and postmigration

discrimination on refugee youth in canada. The Journal of Nervous and Mental Disease,

204(6), 464-470. doi:10.1097/NMD.0000000000000516

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 51

Brascoupé, S., & Waters, C. (2009). Cultural safety: Exploring the applicability of the concept of

cultural safety to Indigenous health and community wellness. Journal of Indigenous

Health, 5(2), 6.

Brown-Bowers, A., McShane, K., Wilson-Mitchell, K., & Gurevich, M. (2015). Postpartum

depression in refugee and asylum-seeking women in canada: A critical health psychology

perspective. Health, 19(3), 318-335. doi:10.1177/1363459314554315

Bryson, S. A., & Bosma, H. (2018). Health social work in Canada: Five trends worth noting.

Social Work in Health Care, 57(8), 1-26. doi:10.1080/00981389.2018.1474161

Burnes, T. R., & Ross, K. L. (2010). Applying Social Justice to Oppression and Marginalization

in Group Process: Interventions and Strategies for Group Counselors. The Journal for

Specialists in Group Work, 35(2), 169–176. doi:10.1080/01933921003706014

Canadian Nurses Association. (2000). The Canadian Health Act [Fact sheet] https://www.cna-

aiic.ca/~/media/cna/page-content/pdf-en/fs01_canada_health_act_june_2000_e.pdf

Cheng, I., Drillich, A., & Schattner, P. (2015). Refugee experiences of general practice in

countries of resettlement: A literature review. The British Journal of General Practice:

The Journal of the Royal College of General Practitioners, 65(632), e171-e176.

doi:10.3399/bjgp15X683977

Corneau, S., & Stergiopoulos, V. (2012). More than being against it: Anti-racism and anti-

oppression in mental health services. Transcultural Psychiatry, 49(2), 261-282.

doi:10.1177/1363461512441594

Danso, R. (2002). From 'there' to 'here': An investigation of the initial settlement experiences of

ethiopian and somali refugees in toronto. Geojournal, 56(1), 3-14.

doi:10.1023/A:1021748701134

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 52

Dauvergne, C. (1969; 2003;). Evaluating Canada's new Immigration and Refugee Protection Act

in its global context. Alberta Law Review, 41(3), 725-726. doi:10.29173/alr1321

Deacon, B. J. (2013). The Biomedical model of mental disorder: A critical analysis of its

validity, utility, and effects on psychotherapy research. Clinical Psychology Review,

33(7), 846-861. doi:10.1016/j.cpr.2012.09.007

Dell, E. M., Firestone, M., Smylie, J., & Vaillancourt, S. (2016). Cultural safety and providing

care to Indigenous patients in the Emergency department. Cjem, 18(4), 301-305.

doi:10.1017/cem.2015.100

DiAngelo, R. J. (2018). White fragility: Why it's so hard for white people to talk about racism.

Boston: Beacon Press.

Donnelly, T. T., Hwang, J. J., Este, D., Ewashen, C., Adair, C., & Clinton, M. (2011). If I Was

Going to Kill Myself, I Wouldn’t Be Calling You. I am Asking for Help: Challenges

Influencing Immigrant and Refugee Women’s Mental Health. Issues in Mental Health

Nursing, 32(5), 279–290. doi:10.3109/01612840.2010.550383

Dupraz, Yannick. (2015). French and British Colonial Legacies in Education: A Natural

Experiment in Cameroon. Paris: Paris School of Economics

Enns, R., Okeke-Ihejirika, P., Kirova, A. and McMenemy, C. (2017). Refugee healthcare in

Canada: responses to the 2012 changes to the interim federal health program,

International Journal of Migration and Border Studies, 3(1), 24-42), doi:

10.1504/IJMBS.2017.081192

Esses, V. M., Hamilton, L. K., & Gaucher, D. (2017). The Global Refugee Crisis: Empirical

Evidence and Policy Implications for Improving Public Attitudes and Facilitating

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 53

Refugee Resettlement. Social Issues and Policy Review, 11(1), 78–123.

doi:10.1111/sipr.12028

Fehrenbach, H., & Rodogno, D. (2015). A horrific photo of a drowned Syrian child:

Humanitarian photography and NGO media strategies in historical perspective.

International Review of the Red Cross, 97(900), 1121–1155.

doi:10.1017/s1816383116000369

Floyd, A., & Sakellariou, D. (2017). Healthcare access for refugee women with limited literacy:

Layers of disadvantage. International Journal for Equity in Health, 16(1), 1-10.

doi:10.1186/s12939-017-0694-8

Ford, C. L., & Airhihenbuwa, C. O. (2010). Critical race theory, race equity, and public health:

Toward antiracism praxis. American Journal of Public Health, 100(S1), S30-S35.

doi:10.2105/AJPH.2009.171058

Frecha, L (2015). The perils and possibilities of citizenship transformation: health-based claims

and the Canadian Interim Federal Health Plan reform debate. P.26-37Refugee Review:

Re-conceptualizing Refugees and Forced Migration in the 21st Century. An e-publication

of the ESPMI Network www.refugeereview2.wordpress.com Volume 2, Number 1, June

2015

Gabriel, P. S., Morgan-Jonker, C., Phung, C. M. W., Barrios, R., & Kaczorowski, J. (2011).

Refugees and health care – the need for data: Understanding the health of government-

assisted refugees in Canada through a prospective longitudinal cohort. Canadian Journal

of Public Health / Revue Canadienne De Sante'e Publique, 102(4), 269-272.

doi:10.1007/BF03404047

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 54

Geiger, M. (2017). Ideal partnership or marriage of convenience? Canada’s ambivalent

relationship with the International Organization for Migration. Journal of Ethnic and

Migration Studies, 44(10), 1639–1655. doi:10.1080/1369183x.2017.1354033

Gerlach, A. J. (2012). A Critical reflection on the concept of Cultural Safety. Canadian Journal

of Occupational Therapy, 79(3), 151-158. doi:10.2182/cjot.2012.79.3.4

Grant, K. J., Mayhew, M., Mota, L., Klein, M. C., & Kazanjian, A. (2015). The Refugee

experience of acquiring a family doctor. International Journal of Migration, Health and

Social Care, 11(1), 18–28. doi:10.1108/ijmhsc-12-2013-0047

Gushulak, B. D., Pottie, K., Roberts, J. H., Torres, S., & DesMeules, M. (2010). Migration and

health in Canada: Health in the global village. Canadian Medical Association Journal,

183(12), E952–E958. doi:10.1503/cmaj.090287

Gustafson, D. L., & Reitmanova, S. (2010). How are we 'doing' cultural diversity? A look across

English Canadian undergraduate medical school programmes. Medical Teacher, 32(10),

816-823. doi:10.3109/01421590903394595

Harell, A., Soroka, S., & Iyengar, S. (2017). Locus of control and anti-immigrant sentiment in

Canada, the United States, and the United Kingdom: Locus of control and anti-immigrant

sentiment. Political Psychology, 38(2), 245-260. doi:10.1111/pops.12338

Harris, H. P., & Zuberi, D. (2014). Harming Refugee and Canadian Health: The Negative

Consequences of Recent Reforms to Canada’s Interim Federal Health Program. Journal

of International Migration and Integration, 16(4), 1041–1055. doi:10.1007/s12134-014-

0385-x

Higginbottom, G., Reime, B., Bharj, K., Chowbey, P., Ertan, K., Foster-Boucher, C., . . . Salway,

S. (2013). Migration and Maternity: Insights of context, health policy, and research

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 55

evidence on experiences and outcomes from a three country preliminary study across

Germany, Canada, and the United Kingdom. Health Care for Women International,

34(11), 936-965. doi:10.1080/07399332.2013.769999

Hill, L., Gray, R., Stroud, J., & Chiripanyanga, S. (2009). Inter‐professional Learning to Prepare

Medical and Social Work Students for Practice with Refugees and Asylum Seekers.

Social Work Education, 28(3), 298–308. doi:10.1080/02615470802659514

Jackson, S. (2012). New interim federal health program: How reduced coverage adversely

affects refugee claimants' employment. S.l.: Ryerson Centre for Immigration and

Settlement.

Jaworsky, B. N. (2019). It’s (not) who we are: Representing the nation in US and Canadian

newspaper articles about Refugees entering the country. Nations and Nationalism. 1-9.

doi:10.1111/nana.12574

Jemal, A. (2018). Transformative consciousness of health inequities: Oppression is a virus and

critical consciousness is the antidote. Journal of Human Rights and Social Work, 3(4),

202-215. doi:10.1007/s41134-018-0061-8

Jetten, J., & Esses, V. M. (2018). The reception of Immigrants and Refugees in western

countries: The challenges of our time. Journal of Social Issues, 74(4), 662-673.

doi:10.1111/josi.12292

Johnson, J. L., Bottorff, J. L., Browne, A. J., Grewal, S., Hilton, B. A., & Clarke, H. (2004).

Othering and being othered in the context of health care services. Health Communication,

16(2), 255-271. doi:10.1207/S15327027HC1602_7

Jones, J. (2017). Going back to the source: Cultural safety in Diverse Societies. Whitireia

Nursing and Health Journal, (24), 9-12.

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 56

Joshi, C., Russell, G., Cheng, I., Kay, M., Pottie, K., Alston, M., . . . Harris, M. F. (2013). A

narrative synthesis of the impact of primary health care delivery models for refugees in

resettlement countries on access, quality and coordination. International Journal for

Equity in Health, 12(1), 88. doi:10.1186/1475-9276-12-88

Khan, A., & DeYoung, S. E. (2018). Maternal health services for refugee populations:

Exploration of best practices. Global Public Health, 1–13.

doi:10.1080/17441692.2018.1516796

Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., . . . for the

Canadian Collaboration for Immigrant and Refugee Health (CCIRH) (2011). Common

Mental Health problems in Immigrants and Refugees: General approach in primary care.

CMAJ: Canadian Medical Association Journal = Journal De l'Association Medicale

Canadienne, 183(12), E959-E967. doi:10.1503/cmaj.09029

Kobayashi, K. M., Prus, S., & Lin, Z. (2008). Ethnic differences in self-rated and functional

health: Does immigrant status matter? Ethnicity & Health, 13(2), 129-147.

doi:10.1080/13557850701830299

Kowpak, D., & Gillis, L. (2015). Aboriginal Mental Healthcare in Canada: The role of

Alternative service delivery in transforming the provision of mental health services.

Dalhousie Journal of Interdisciplinary Management, 11. doi:10.5931/djim.v11i0.5531

Lacroix, M. (2004). Canadian Refugee Policy and the Social Construction of the Refugee

Claimant Subjectivity: Understanding Refugeeness. Journal of Refugee Studies, 17(2),

147–166. doi:10.1093/jrs/17.2.147

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 57

Langlois, E. V., Haines, A., Tomson, G., & Ghaffar, A. (2016). Refugees: Towards better access

to Health-care services. The Lancet, 387(10016), 319–321. doi:10.1016/s0140-

6736(16)00101-x

Larson, G. (2008). Anti-oppressive Practice in Mental Health. Journal of Progressive Human

Services, 19(1), 39–54. doi:10.1080/10428230802070223

Lawford, K., & Giles, A. R. (2012). An Analysis of the Evacuation Policy for Pregnant First

Nations Women in Canada. AlterNative: An International Journal of Indigenous Peoples,

8(3), 329–342. doi:10.1177/117718011200800308

Lawford, K. M., Giles, A. R., & Bourgeault, I. L. (2018). Canada’s Evacuation policy for

pregnant First Nations Women: Resignation, resilience, and resistance. Women and Birth.

479-488. doi:10.1016/j.wombi.2018.01.009

Lay, K., & McGuire, L. (2010). Building a Lens for Critical Reflection and Reflexivity in Social

Work education. Social Work Education, 29(5), 539-550.

doi:10.1080/02615470903159125

LeBrun, A., Hassan, G., Boivin, M., Fraser, S., & Dufour, S. (2015). Review of Child

Maltreatment in Immigrant and Refugee families. Canadian Journal of Public Health,

106(7), eS45-eS56. doi:10.17269/CJPH.106.4838

Lencucha, J. C., Davis, J. A., & Polatajko, H. J. (2013). Living in a Blended World: The

Occupational lives of children of Immigrants to Canada. Journal of Occupational

Science, 20(2), 185-200. doi:10.1080/14427591.2013.786799

Mangrio, E., & Sjögren Forss, K. (2017). Refugees’ Experiences of Healthcare in the host

country: A scoping review. BMC Health Services Research, 17(1). 1-16.

doi:10.1186/s12913-017-2731-0

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 58

Marano, N., Wojno, A. E., Stauffer, W. M., Weinberg, M., Klosovsky, A., Ballew, J. D., Cetron,

M. S. (2016). Partnerships that Facilitate a Refugee's Journey to Wellbeing. The

American Journal of Tropical Medicine and Hygiene, 95(5), 985-987.

doi:10.4269/ajtmh.16-0657

Matlin, S. A., Depoux, A., Schütte, S., Flahault, A., & Saso, L. (2018). Migrants’ and Refugees’

health: Towards an agenda of solutions. Public Health Reviews, 39(1), 1-55.

doi:10.1186/s40985-018-0104-9

Mayhew, M., Grant, K. J., Mota, L., Rouhani, S., Klein, M. J., & Kazanjian, A. (2015).

Facilitating Refugees’ access to family doctors. International Journal of Migration,

Health & Social Care, 11(1), 1-19.

Mbah, E. M. (2009), Disruptive colonial boundaries and attempts to resolve land/boundary

disputes in the grasslands of Bamenda, Cameroon. African Journal on Conflict

Resolution 9(3)

McKeary, M., & Newbold, B. (2010). Barriers to care: The challenges for Canadian refugees and

their health care providers. Journal of Refugee Studies, 23(4), 523-545.

doi:10.1093/jrs/feq038

McMurray, J., Breward, K., Breward, M., Alder, R., & Arya, N. (2013). Integrated Primary Care

Improves Access to Healthcare for Newly Arrived Refugees in Canada. Journal of

Immigrant and Minority Health, 16(4), 576–585. doi:10.1007/s10903-013-9954-x

Morris, M. D., Popper, S. T., Rodwell, T. C., Brodine, S. K., & Brouwer, K. C. (2009).

Healthcare barriers of refugees post-resettlement. Journal of Community Health, 34(6),

529-538. doi:10.1007/s10900-009-9175-3

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 59

Nana, G. (2015). Journal of Education and Training Studies Journal of Education and Training

Studies Vol. 4, No. 4; April 2016 ISSN 2324-805X E-ISSN 2324-8068 Published by

Redfame Publishing URL: http://jets.redfame.com

National Aboriginal Health Organization. 2008. Celebrating Birth – Aboriginal Midwifery in

Canada. Ottawa: National Aboriginal Health Organization

Neiterman, E., Salmonsson, L., & Bourgeault, I. L. (2015). Navigating otherness and belonging:

A comparative case study of IMGs' professional integration in Canada and Sweden.

Ephemera, 15(4), 773-795.

Newbold, K. B., Cho, J., & McKeary, M. (2013). Access to Health care: The experiences of

refugee and refugee claimant women in Hamilton, Ontario. Journal of Immigrant &

Refugee Studies, 11(4), 431-449. doi:10.1080/15562948.2013.808390

Ng, C., & Newbold, K. B. (2011). Health care providers’ perspectives on the provision of

prenatal care to Immigrants. Culture, Health & Sexuality, 13(5), 561–574.

doi:10.1080/13691058.2011.555927

Oda, A., Tuck, A., Agic, B., Hynie, M., Roche, B., & McKenzie, K. (2017). Health care needs

and use of health care services among newly arrived Syrian refugees: A cross-sectional

study. CMAJ Open, 5(2), E354-E358. doi:10.9778/cmajo.20160170

Olsen, C., El-Bialy, R., Mckelvie, M., Rauman, P., & Brunger, F. (2016). “Other” Troubles:

Deconstructing Perceptions and Changing Responses to Refugees in Canada. Journal of

Immigrant and Minority Health, 18(1), 58–66. doi:10.1007/s10903-014-9983-0

Otu, E. G., Tabe, E., Mbuoben, B. C. (2018). Alienation and Loss of Identity in Cameroon

Anglophone Drama: The Convergence of History and Politics in Bate Besong’s Change

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 60

Waka and his Man Sawa Boy. International Journal of History and Cultural Studies,

4(1), 81-89.

Phillimore, J. (2011). Refugees, acculturation strategies, stress and integration. Journal of Social

Policy, 40(3), 575-593. doi:10.1017/S0047279410000929

Pollock, G., Newbold, B., & Lafrenière, G. (2011). Perceptions of discrimination in health

services experienced by immigrant minorities in Ontario. Welcoming Communities

Initiative. Ottawa, Ont. Citizen and Immigration Canada (2011). Ottawa, Ontario:

Canadian Electronic Library, 2012.

Pollock, G., Newbold, K., Lafrenière, G. and Edge, S. (2012). Discrimination in the Doctor’s

Office Immigrants and Refugee Experiences. Critical Social Work, Vol. 13(2), 60-79.

Pottie, K., Gruner, D., & Magwood, O. (2018). Canada's response to Refugees at the Primary

Health care level. Public Health Research & Practice, 28(1), 1-4.

Presse, D., & Thomson, J. (2007). The resettlement challenge: Integration of refugees from

protracted refugee situations. Refuge, 24(2), 48-51.

Reitmanova, S., Gustafson, D. L., & Ahmed, R. (2015). “Immigrants can be deadly”: Critical

discourse analysis of racialization of immigrant health in the Canadian press and public

health policies. Canadian Journal of Communication, 40(3), 476.

doi:10.22230/cjc.2015v40n3a2831

Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United

States, Germany and Canada. Materia Socio Medica, 24(2), 112.

doi:10.5455/msm.2012.24.112-120

Rousseau, C., Kuile, S. t., Muňoz, M., Nadeau, L., Ouimet, M., Kirmayer, L., & Crépeau, F.

(2008). Health care access for refugees and immigrants with precarious status: Public

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 61

health and human right challenges. Canadian Journal of Public Health / Revue

Canadienne De Sante'e Publique, 99(4), 290-292. doi:10.1007/BF03403757

Saberpor, T, 2016. Refugee and Asylum Seekers in Canada: Barriers to Health Care Services,

Glendon Journal of International Studies, York University

Sandre, A. R., & Newbold, K. B. (2016). Telemedicine: Bridging the gap between refugee health

and health services accessibility in Hamilton, Ontario. Refuge, 32(3), 108

Schill, K., & Caxaj, S. (2019). Cultural safety strategies for rural Indigenous palliative care: a

scoping review. BMC Palliative Care, 18(1). doi:10.1186/s12904-019-0404-y

Sethi, B. (2013). Service delivery on rusty health care wheels: Implications for visible minority

women. Journal of Evidence-Based Social Work, 10(5), 522-532.

doi:10.1080/15433714.2012.760986

Shommu, N. S., Ahmed, S., Rumana, N., Barron, G. R. S., McBrien, K. A., & Turin, T. C.

(2016). What is the scope of improving immigrant and ethnic minority healthcare using

community navigators: A systematic scoping review. International Journal for Equity in

Health, 15(1), 1-12. doi:10.1186/s12939-016-0298-8

Simich, L., Beiser, M., Stewart, M., & Mwakarimba, E. (2005). Providing social support for

immigrants and refugees in Canada: Challenges and directions. Journal of Immigrant and

Minority Health, 7(4), 259-268. doi:10.1007/s10903-005-5123-1

Stewart, E. W., De Souza, L. R., & Yudin, M. H. (2018). Access to prenatal care for pregnant

Refugee women in Toronto, Ontario, Canada: An audit study. Journal of Health Care for

the Poor and Underserved, 29(2), 687-700. doi:10.1353/hpu.2018.0052

Strang, A., & Ager, A. (2010). Refugee integration: Emerging trends and remaining agendas.

Journal of Refugee Studies, 23(4), 589-607. doi:10.1093/jrs/feq046

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 62

Swinkels, H., Pottie, K., Tugwell, P., Rashid, M., & Narasiah, L. (2011). Development of

guidelines for recently arrived immigrants and refugees to canada: Delphi consensus on

selecting preventable and treatable conditions: Canadian guidelines for immigrant health.

CMAJ: Canadian Medical Association Journal, 183(12), E928-E931.

doi:10.1503/cmaj.090290

Szajna, A., & Ward, J. (2015). Access to health care by refugees: A dimensional analysis:

Access to health care. Nursing Forum, 50(2), 83-89. doi:10.1111/nuf.12051

Ter Heide, F. J. J., & Smid, G. E. (2015). Difficult to treat? a comparison of the effectiveness of

treatment as usual in refugees and non-refugees. BJPsych Bulletin, 39(4), 182–186.

doi:10.1192/pb.bp.114.047928

Treviño, A. J., Harris, M. A., & Wallace, D. (2008). What’s so critical about critical race theory?

Contemporary Justice Review, 11(1), 7–10. doi:10.1080/10282580701850330

Urdang, E. (2010). Awareness of self-A critical tool. Social Work Education, 29(5), 523-538.

doi:10.1080/02615470903164950.

Wahoush, E. (2009). Equitable Health-Care Access: The Experiences of Refugee and Refugee

Claimant Mothers With an Ill Preschooler. Canadian Journal of Nursing Research

Archive, 41(3). Retrieved from https://cjnr.archive.mcgill.ca/article/view/2212/2206

Waldron, I. G. (2010). The impact of inequality on health in Canada: A multi-dimensional

framework. Diversity in Health & Care, 7(4), 261-270

Whitley, R., Kirmayer, L. J., & Groleau, D. (2006). Understanding immigrants' reluctance to use

mental health services: A qualitative study from montreal. The Canadian Journal of

Psychiatry, 51(4), 205-209. doi:10.1177/070674370605100401

REFUGEES’ ACCESS TO HEALTHCARE IN CANADA 63

Woodgate, R. L., Busolo, D. S., Crockett, M., Dean, R. A., Amaladas, M. R., & Plourde, P. J.

(2017). A qualitative study on African immigrant and refugee families’ experiences of

accessing primary health care services in Manitoba, Canada: It’s not easy. International

Journal for Equity in Health, 16(1), 1-12. doi:10.1186/s12939-016-0510-x

Wylie, L., Corrado, A. M., Edwards, N., Benlamri, M., & Murcia Monroy, D. E. (2020).

Reframing resilience: Strengthening continuity of patient care to improve the mental

health of immigrants and refugees. International Journal of Mental Health Nursing,

29(1), 69-79. doi:10.1111/inm.12650

Yee, J. Y. (2016). A paradox of social change: How the quest for liberation reproduces

dominance in higher education and the field of social work. Social Work Education,

35(5), 495-505. doi:10.1080/02615479.2016.1170113

Yosso, T., Smith, W., Ceja, M., & Solórzano, D. (2009). Critical race theory, racial

microaggressions, and campus racial climate for Latina/o undergraduates. Harvard

Educational Review, 79(4), 659-691. doi:10.17763/haer.79.4.m6867014157m707l

Yu, S., Ouellet, E., & Warmington, A. (2007). Refugee integration in Canada: A survey of

empirical evidence and existing services. Refuge, 24(2), 1-17.