Perceived barriers and primary care access experiences among immigrant Bangladeshi men in Canada

Introduction

Easy and timely access to healthcare services is a fundamental concern for the health of Canadians.1 2 Primary healthcare (PHC) services are the first point of contact with healthcare when Canadians are in need, providing increasingly comprehensive services like prevention, treatment of common diseases and injuries, basic emergency services, referrals to and coordination with other levels of care (eg, hospital and specialist care, primary mental healthcare, palliative and end-of-life care), health promotion, healthy child development, primary maternity care and rehabilitation services.3 Canada provides publicly funded healthcare that ensures all Canadian residents have access to necessary hospital and physician services without paying out of pocket.4

Regardless of publicly covered healthcare services, immigrants continue to face significant difficulties when seeking healthcare in Canada.5 6 Studies show that the health status of immigrants who have lived in Canada for 10 years or more to be worse than those of recent immigrants,7 8 despite arriving with similar or better self-reported health than the general Canadian population, a phenomenon described as the ‘healthy immigrant effect’, indicating worsening immigrant health status over time.9 With over one-fifth of the Canadian population being foreign born,10 this lack of equitable healthcare access is an important issue for the healthcare system.9 Researchers have reported a number of causal factors for this quick deterioration of immigrant health. These include acculturation of the new immigrants or adoption of Canadian lifestyle,11 environmental factors,12 postmigration stress13 and discrimination.14

Gender differences in disease distribution have been well noted and show that certain chronic conditions may be higher for men. Indeed, studies analysing the National Population Health Survey have found that immigrant men report a higher number of unmet healthcare needs as compared with women.15 These differences have been attributed to intersections between genetic predispositions, cultural background, spiritual beliefs and racialised masculinity.16 The results are predominant health behaviours linked to men, which include the adoption of high-risk activities, denial of illness, under-utilisation of healthcare services and poor uptake of health promotion programmes. In this case, immigrant health offers a layer of complexity, where gender-cultural-sensitive healthcare is needed to approach problems of access to primary care.17 Gender and cultural factors affect both the development of health problems (such as genital mutilation in certain ethnic groups) and the use of health services (men use less healthcare services than women).18 19 The utilisation of healthcare resources is needed to be targeted to facilitate uptake of healthcare services by both men and women equally from different sociocultural groups.18 Spending more time and putting more effort into the consideration of immigrant men’s sociocultural perspective, including the differences within various immigrant communities, may potentially improve the gender and cultural sensitivity of the healthcare.17

While there is a reasonable number of studies describing the barriers faced by immigrants while accessing healthcare,5 20 21 research lacks a focus on immigrant men and their nuanced views, attitudes and experiences with PHC services.5 To fill this gap, the aim of this study is to explore the experience of Bangladeshi immigrant men while accessing PHC services in Canada by means of community-based focus group discussions (FGDs). Bangladeshi-Canadians are part of the rapidly growing South Asian community in Canada, with an increased rate of 110% from 2001 to 2011.22 Bangladeshi-Canadian immigrants have been studied regarding barriers to access healthcare as a part of greater South Asian communities, however, Each South Asian community is remarkably different from each other in their sociocultural and religious nuances, and Bangladeshi community is no different.23 It has been postulated that Bangladeshi-Canadian immigrants are often lost in the shadow of other bigger South Asian communities.24 This is reflected in the literature as well where there are only a handful of studies on Bangladeshi immigrants in Canada and globally. However, none of the studies captured specifically Bangladeshi men’s perspective with respect to accessing healthcare in the host countries.

Methods

Optimal access to care is not established only by the existence of the service but also it is accomplished when the services are utilisable by all consumers irrespective of their sociocultural background, gender identity and economic status. Immigrant health and access to care may differ based on sociocultural beliefs, individual health behaviour, desire and need of services and delivery of the services in terms of time, place and provider of the services.16 While research exploring healthcare issues is abundant focusing on broad ethnocultural communities (eg, South Asian, Latin American, Middle Eastern, etc) in Canada, little research has been done on country or language-based small immigrant groups such as Bangladeshi immigrant community. To explore the attitudes and perceptions of immigrant men regarding the healthcare system and health services, we applied the focus group technique.25 26 Perceived barriers to healthcare may differ from immigrant men to immigrant women as well as one immigrant population group to another depending on their sociocultural nuances and the interaction of that background with the culture of their host country. While such complex scenario may blind the researchers and policymakers to foresee the unique experiences of each immigrant population group and subgroup (ie, women, men, youth, elderly or other group based on gender/sexual identity, chronic diseases, etc), the group interaction of the focus groups may reveal those key perspective and hidden nuances.27 Moreover, to engage the Bangladeshi immigrant community, community-based participatory research (CBPR) or integrated knowledge translation (iKT) approach was used in this study. CBPR or iKT are collaborative research approaches that equitably involves community members, organisational representatives and academic researchers in all aspects of the process, enabling all partners to contribute their expertise and share responsibility.28 29 These approaches bring the researchers close to the community that facilitates them to be open to the ‘outsider’ researchers, thus help researchers identify and resolve the health and wellness disparities in the community.30

In the community engagement phase of our programme of research, we conducted a number of informal conversations with Bangladeshi-Canadian community members. This research question was one of the derivatives of those consultations. We also had Bangladeshi-Canadian community-based citizen researchers as members of our research team (NR, AR and ML). They have been involved in community engagement, participant recruitment, transcription and translation process related to our study. They were also engaged during the analysis process to contextualise the codes and themes arising from the FGDs as well as writing manuscript. We also discussed the study codes and themes during our paper writing phase with three FGD participants who agreed to be contacted for this purpose.

We conducted six FGDs in Calgary among 38 Bangladeshi immigrant men; each FGD consisted of four to eight participants. The FGDs were conducted between July and December 2018 in community organisations, considering the convenience and accessibility of the participants. Informed consent was obtained from all the participants.

Result

Table 2 shows the sociodemographic characteristics of the study participants. They were predominantly educated and in the age range of over the age of 46–55 years. The majority of the participants was married, Muslim and Bangla speaking men. Most of the participants were employed either full time or were self-employed. Over half of the participants migrated to Canada 5–19 years ago.

The inductive thematic analysis of the findings of these FGDs revealed the following four themes: Accessibility of Care in Time, Communication Gap, Unfamiliarity with the healthcare System and Lack of Resources. The first theme, Accessibility of Care in Time, provides a glimpse into participants’ frustration and suffering from long wait time accessing care in the emergency room (ER), at the doctor’s clinic, and to get an appointment from doctors and diagnostic services. The second major theme, Communication Gap, explains how language barriers and ineffective communication between physicians and immigrant patients influence their access and quality of care. The third theme, Unfamiliarity with the Health Care System, examines the barriers participants experienced because of the lack of information about available resources, care and how the system works. The final theme, Lack of Resources, highlights participants’ perception of lack of resources of healthcare systems impacting their access to healthcare services. Representative quotes from each of the main themes and sub-themes arising from the FGDs are set out in table 3.

Unfamiliarity with the healthcare system

Participants of the study discussed that unfamiliarity with the Canadian healthcare system structure and lack of information on available resources negatively impacted access to healthcare. For example, some participants mentioned that they did not know that unlike home country, people in Canada are supposed to have a family physician and visit them when they are sick. However, they also did not know about walk-in clinics where one can visit doctors without prior appointments, which is rather more similar to the healthcare system of their home country (table 3).

Perception of lack of resources

Data analysis of the FGDs of the study further revealed that access to care was largely influenced by the availability of resources. Participants stated that the number of clinics, especially after-hours and urgent care clinics, were not sufficient to provide care. They also discussed the lack of hospital resources and mentioned that patients were discharged only a few hours after surgery or delivery, leaving the patient suffering.

Participants also identified that there were insufficient physicians proportionate to the population size. They also mentioned that the unavailability of physicians negatively impacted access to and utilisation of primary care. Physicians from different ethnic groups could also improve access to care for many immigrants.

Discussion

This study attempts to start filling the gap in the literature on a particularly visible minority group in Canada with a gender-focused view in terms of healthcare access barriers. Previously unexplored perspectives of immigrant men regarding barriers to access PHC services were investigated in the study through FGDs. Bangladeshi-Canadian immigrant men reported unavailability of care in time, communication barrier, unfamiliarity with the healthcare system and lack of resources as their common barriers. Long wait time and communication difficulty were commonly voiced by the participants across the FGDs. However, all these four types of barriers might be deemed to be interconnected to each other. For instance, overlapping of clinic time with work hours and lack of resources (eg, lack of a sufficient number of family physicians, unavailability of urgent-care options, walk-in clinics etc) largely contributed to the crowding in ER and further increased the wait time. And, in turn, accessibility of care was hindered. Moreover, the language barrier demands interpreter services, and a lack of interpreter services (lack of resources) has hampered accessibility of care.

Long wait time for specialised services, non-emergency surgery and selected diagnostic tests were also reported to be the biggest barrier to accessing PHC by the overall Canadian population,1 2 making it a general concern for all Canadians. Dissatisfaction with walk-in clinic services due to longer wait time, unfamiliarity and lack of continuity of care was also noted by the general Canadian population.33 However, in our study sample, we also observed some level of acceptance regarding the unavailability of care in time, indicating that during acute illness, people can avoid long wait time from their family physicians by going to a walk-in clinic; long wait time in the ER is reasonable for non-urgent patients, and wait time in diagnostic centres is avoidable if someone is willing to travel to surrounding rural area centres or a less densely populated area. The discrepancy in opinions of the participants may reflect the fact that many immigrants, especially more recent immigrants, are not well aware of the Canadian health system and culture, leading to an expectation–reality mismatch and overall dissatisfaction. A lack of information about the Canadian healthcare system that was voiced by the FGD participants of the study may further contribute to this.

When approaching healthcare services, the language barrier has been reported to be a global encounter for immigrants.5 21 34–38 Likewise, our study participants frequently struggled with explaining their problems and understanding instructions from physicians due to a lack of fluency in one of Canada’s official languages and a lack of knowledge about medical terminology. Less time spent by physicians explaining their condition, medication and prognosis also created frustrations among participants. The use of interpreter services has previously shown some positive results in improving communication gaps among immigrants,39 however, the participants of this study reported a lack of adequately trained medical interpreter services that was also a major challenge for immigrant and ethnic populations outside Canada.40 This may be attributed to the perceived lack of resources (eg, lack of interpreter services, insufficient after-hours clinics, shortage of hospital resources, inadequate ethnic representations among physicians etc) that were also mentioned by the participants of this study as well as in previous studies.41–44

Previous studies showed that immigrant men tend to show reluctance in accessing health services due to sociocultural values.45 46 Men in many immigrant communities think it is a masculine feature not to access healthcare services when sick.46 Moreover, despite social support is positively related to better health, men tend to seek social and peer support less commonly than women.47 Reasons may include that men are less likely to share confidential information with others and they receive less health-related and mental support from their friends and others.48 However, our study did not reveal any barriers that are relatable particularly to men. Interestingly though, it was mentioned that they would prefer a female provider for their female members of the family, but no preference of gender of providers for themselves was expressed. Gender preference by female patients has widely been reported, especially among South Asian immigrant women.5 49 The findings of our study indicate that the observed gender preference for female healthcare providers by the immigrant women might have been influenced by their ethnocultural customs; where male members of their family are concerned about their female counterparts being exposed to male healthcare providers while not being apprehensive about the gender of provider for their own healthcare.

A strength of the study is our approach of community-engaged programme of research.50 Also, we had citizen researchers involved in the research process. These resulted in a friendly and comfortable atmosphere for the participants to talk freely. Thus, the group discussions, being informal with occasional jokes and laughter, gave room to the participants to open up and express their feelings, concerns and understanding freely. The frank environment also led the shy participants to come out of their shell and share their experiences. We collaborated with the community leaders and community organisations during the recruitment process and approached participants through them. This increased the credibility of the research and improved trust between the researchers and the community. Also, the bilingual capability of the research team was an added asset for the work with the Bangladeshi-Canadian grassroots community. As a result, the participants felt engaged and showed interest in further implications. We believe that this approach has laid the first stone of future research collaboration with the community to identify ways of improving access to PHC and will help guide future policy initiatives to improve patients’ experiences in obtaining PHC services in Canada.

A limitation of the study is the susceptibility of the FGDs to bias. In FGDs, group and individual opinions can be influenced by more dominant participants.26 However, our FGDs were conducted in a structured way to minimise dominance bias and shyness bias by providing each participant a time slot in which to speak, so they did not have to compete for the floor or attempt to gain the attention of the moderator. We also used snowball sampling for our study, which may lead to selection bias, but, again, this is an effective and efficient strategy for recruiting hard-to-reach minority groups like the one in this study.51 The fact that our study population was limited to Bangladeshi immigrant men needs to be kept in mind as they may not be representative of other immigrant populations in Canada. Within the Bangladeshi-Canadian diaspora, the study sample predominantly represents married, educated, Muslim, Bangla speaking men over the age of 25 living in an urban centre. This sample characteristic is not surprising due to the immigration criteria under which a substantial number of Bangladeshi immigrants migrated to Canada. The point-based immigration criteria favoured migrants who are educated, married and had work experience.52–54

Despite the limitations, our study provides valuable insights into potential barriers encountered by this particular group of immigrants to PHC services in Canada. The findings of the study reverberate those of other visible minority study findings while laying the groundwork for further gender-focused and community-focused studies that are warranted to see the complete picture and find any disparities between different groups of immigrant populations. It builds on existing knowledge to illustrate the various nuances expressed by this group of immigrants and highlights the value of qualitative research to adequately document and contextualise specific concerns on this critical issue. More similar qualitative studies focusing on a certain group of immigrants are needed particularly to identify ways to address these barriers because different groups of immigrant men and women might need to be approached in different ways. For example, from a health system perspective, arranging interpreter services for a patient belonging to a smaller ethno-cultural community (language) may not be as feasible as arranging service for a patient belonging to a larger ethno-cultural community. Using remote telephone or video interpretation may resolve this barrier, however, these facilities are still developing, have their own limitations, and often underutilised at current healthcare settings.55

Conclusion

This study attempted to capture the perspective of Bangladeshi immigrant men, an understudied group of visible minority immigrants in Canada, in terms of barriers to accessing PHC services. Information concerning patients’ experiences in accessing healthcare services is needed to provide a more comprehensive picture regarding access to care. In this era of global migration, the healthcare needs and issues of various immigrant communities need to be evaluated and addressed. This contributes towards the concept of precision population health; one size fits all types of community health, and well-being approach will not be appropriate.