Three major themes emerged from the study: language barrier and the lack of knowledge of Canadian health care services/systems; lack of trust in Canadian health care services due to financial limitations and fear of disclosure; and somatization and needs for psychological supports.
Language barrier and lack of knowledge of the Canadian health care system
Many non-English speaking newcomers, in general, find communication to be an important obstacle to living in a new country and to accessing health care services. A study of Iranian immigrants living in Edmonton showed that upon their arrival, they were provided many forms and pamphlets about living in Canada in English, French, and other languages that they did not understand. Those who could read English or French found the pamphlets hard to follow, long, in small print and inconvenient. Consequently, they put them away without going through all the pages. Although they received some information in Farsi, for cultural reasons they did not consider information written on a piece of paper seriously [20
In this study, Iranian health care providers indicated that although language barrier was an issue for Iranian immigrants in Canada, ethnic matching helped these patients overcome communication and cultural differences to some extent. They emphasized that most of the newcomers had limited knowledge of the host country's health care services. The health care professionals pointed out that health literacy and cultural understanding of the Canadian health care system and services by immigrants remained outstanding.
Almost all the participants agreed that language deficit poses a health care barrier for these patients. One of the health care professionals considered language barrier as a two-sided issue.
"For some health care providers like me, Farsi is our second language in the profession not used on a daily basis. Since we got our education in English, we don't know how to translate some phrases to Farsi. We don't understand some slang or Farsi idioms related to health. Therefore, it is health care providers who cannot understand or communicate with them. The language barrier is for both sides, both sides could run into problems." (HCP # 5)
Apart from language barrier, some participants believed that lack of knowledge of the Canadian health services might lead health care consumers to delay using provided services effectively.
"Since I can speak the same language as my clients, language is not an issue. There are still numbers of issues in regards to making decisions about treatment, and following up necessary advice. Most of our patients don't know how the Canadian health care system runs. They expect us to manage their problems as we do in Iran. As a result, sometimes they are not happy with our methods of practice." (HCP # 7)
"The most challenging part is to educate them about what is right and what is wrong regarding their issues. They understand the system differently, as a result they follow it differently. They do not accept the definition of terms." (SW # 4)
"They are scared. They have a vague idea about reporting child abuse. They are afraid, so when they come to me they don't say much. Because they say, "we've heard they will come and take our kids away". Again, it shows lack of knowledge ... as a result, they cannot use services properly. They don't know what's right [correct], what's wrong [incorrect]." (HCP # 3)
Lack of trust in Canadian health care services
Trust is a multilayered concept, and it can be influenced in many ways. Most participants believed that their clients were skeptical and unable to trust the services and never felt completely comfortable using them.
"Some patients do not trust Canadian health care services due to long waiting hours, not having access to their lab reports, and not having direct access to specialists. Some of my patients ask me to refer them to specialists. They like to choose their specialists and shop around to find the one they can trust, as they do in Iran." (HCP # 10)
Some mentioned that a few Iranians preferred to visit non-Iranian physicians or social workers in order to keep their personal life private and secure.
"Since our community is not large, and people know each other, they are reluctant to talk about their limitations and personal issues. Despite a language barrier, in order to keep their face and honor they prefer to have non-Iranian health care providers or social workers." (SW # 2)
In addition, a participant mentioned that the unique culture of an individual health consumer played an important role in their ability to establish trust in providers and services.
"When it comes to some issues, such as violence or committing suicide, we have to help them and report the incident. We have to support and protect them. In this case, they get angry at us. I had one patient who was stressed out and crying a lot. After a two-hour meeting, she was sobbing and said that "as soon as I leave your office, I will kill myself". Many times, I asked her many times about the seriousness of her statement. Each time she nodded "yes". I reported the suicide. She got mad at me and said, "the big mistake I made was trusting you, and I'll never do it again." (HCP # 3)
Some participants pointed out that their clients had unrealistic expectations that led to dissatisfaction and mistrust of health care providers and services.
"Sometimes, they called me in the middle of the night and asked me what to do for their kids. My area of practice is different. When I told them, I couldn't do anything, but they could ask help from such and such.... and I would be there to help them. They got upset and they thought I could do something, but I didn't want to help them. That is very frustrating and heart breaking." (HCP # 17)
In this study, clients' financial limitations and looking for shortcuts to services or alternatives were identified as factors that affected trust. Participants mentioned that few immigrant families could afford the cost of treatment such as medications and some special medical tests, eye care, dental care and the like. Without having a stable well-paid job, they could not afford to buy private insurance.
"As a social worker, I face many challenges every day. We have limited resources available to help people in need. The biggest and the most frustrating part is the paper work. The process takes a long time and clients lose their interest. They think that we do not take them seriously. I know some doctors, dentists, and optometrists who are willing to help clients with limited incomes. Still, it is not enough. We need more help and support." (SW # 1)
Considering the lack of knowledge of the health care system and services, mistrust and the need to save face and hold on to their honor, many of these clients looked for shortcuts and alternatives such as sharing medications, self treatment, and using emergency services rather than visiting family physicians.
"They ask for short cuts. They ask us to show them how they can cut the costs. I do my best to show them what is available, but as you know there are few things that we can do to help them." (HCP # 20)
Confidentiality is very important when it comes to disclosure, and plays an essential role in building and maintaining trust between health care providers and their patients. The Iranian community is small and people may recognize and see each other often. Therefore, this situation makes them hesitant to reveal sensitive issues to the health care professionals. In this study, participants believed that clients' fear of disclosure was a contributing factor to mistrust of the system.
"Our community is a small community. People know each other somehow. We meet each other on different occasions. We grew up in a hush-hush country, and we are very cautious about sharing personal issues. They worry that their stories may leak out to the community. They feel threatened." (FG # 1)
Some participants pointed out that in addition to confidentiality and fear of disclosure, some clients had difficulties differentiating between what was private and public information.
"They think whatever happens in their house, behind closed doors, should stay private. If spousal or child abuse happens in the home, they believe it should stay private. The most frustrating issue that I have with Iranians is the mandatory report that I have to do. They do not trust me. I explain to them that it is for their own good. They don't accept it. They hate me. They think that I am their enemy." (HCP # 3)
It was notable that in spite of having previous bad experiences regarding trust, these clients tried to create a safe space for communication.
"Making decisions about what, how and how much to say is hard. Since they are very selective in disclosing events in their lives, the experience causes many pressures. They have different lives; they share things with their parents but not with partners or their children; they share things with their partner that they never share with their families. They are more comfortable in disclosing their issues to their close friends who often live in Iran or another country. They try to create a safe space and see the disclosure to providers as a threat to it." (FG # 2)
Somatization and needs for psychological support
All the above-mentioned issues are interwoven and may lead to psychological stress and mental disorders. The stressors related to adjusting to a new country, new culture, new language, and new job are very common for most immigrants. One of the psychological stress manifestations is somatization. Most participants noted that their patients were overwhelmed, and under a great deal of psychological stress--they complained of chest pain, headache, and other physical symptoms leading to a negative impact on overall well-being.
"They complain of having chest pain, headache, insomnia, and lack of concentration. Consequently, they drop courses, take leave from jobs and don't show up for appointments and meetings. They do not believe in our practice. They think that they are really sick physically and they need treatment and some days off work. This situation puts practitioners in a difficult position." (HCP # 27)
Although somatization is considered a defense mechanism, it can lead to severe mental and psychological disorders. These patients need timely care and treatment with serious consideration.
"Due to bearing a lot of stress, they develop anxiety and possibly become isolated. Meanwhile, when they come to our office and talk about their problems, I find that most of their symptoms are related to their psychological status and this puts their mental health at risk. When educated as to what is going on, they invariably disagree with the diagnosis, and ultimately won't accept the advised method of treatment." (FG # 3)
Because they (immigrants) wanted to build a good record of Canadian experience, and keep their jobs, they were hesitant to ask for sick leave. This situation led them to delay or avoid medical follow up. They felt they were trapped.
"They tell me that even if they accept my diagnosis and visit a psychologist, it will create more problems for them. They say, "I have no coverage for that, and I cannot afford it. Moreover, my manager thinks that I have some mental issues, and I might lose my job. It goes on my record, and it will have a negative effect. After that, whatever happens will be judged based on my psychological status". After listening to them, I believe I would think and feel the same way." (HCP # 30)
Clearly, it is not entirely about immigrants accepting their health issues--it is also about providing a support system and helping them to gain control over their lives in a new country.