Originally published December 2015
Canada is home to an increasing number of immigrants. While immigrants are very diverse group, physicians should be attentive to certain unique issues when delivering care to these individuals, including those going through the immigration process.
Immigrant health screening
In general, studies have found the health of immigrants tends to be better than that of the overall population. This is largely due to certain sociocultural aspects of diet and health behaviour, and because immigrants must pass a variety of screening and criteria during the immigration process. However, the health of immigrants generally tends to worsen over time to match that of the general population.1
Canadian immigration legislation requires that all permanent residents, including refugee claimants, undergo an immigration medical examination. This screening assesses the potential burden of illness and a limited number of health risks. It is generally not designed to provide clinical prevention that is routine in primary care. While the assessment has been shown to be generally effective in identifying people with active infectious disease, it is not designed to exclude the possibility of the individual immigrating to Canada before receiving treatment. Physicians should be vigilant in looking for infections or diseases among newcomers from high prevalence countries.2 As with all patients, doctors should comply with legislative and medical regulatory authority (College) requirements regarding communicable and reportable diseases.
Health coverage on arrival
Most newcomers to any Canadian province or territory, including immigrants from other countries, are required to wait a few months before publicly-funded healthcare coverage begins. During this waiting period, it would generally be reasonable for physicians to deliver emergency care to newcomers who present with a life-threatening condition. Physicians should be familiar with the rules relating to publicly-funded healthcare services in their jurisdiction, including temporary health insurance for some immigrants.
Immigrant health issues
Immigration generally includes a series of transitions: changes in personal ties and the reconstruction of social networks, the move from one socio-economic system to another, and a change from one cultural system to another. For immigrants each transition may be filled with disruption, uncertainty, risk, and potentially unmet expectations.3 Physicians should take these transitions into consideration when meeting immigrant patients and when planning and providing care.
The health of immigrants is a product of environmental, economic, genetic, and socio-cultural factors related to when they immigrated to Canada, where and how they lived previously, and how and why they immigrated. Post-immigration factors such as place of residence, employment, education, income, and access to healthcare can also influence the health of immigrants.4 Certain migrant populations experience a higher risk of infectious diseases, cancer, diabetes, and heart disease, and this has clinical implications. Physicians should obtain appropriate health histories from immigrant patients to help determine their health risks and the appropriate next steps in patient care.5 Appreciation of the many pre- and post-immigration factors may help to reduce delays in diagnosis and lead to culturally appropriate health services.6
Mental health issues among immigrants and refugees
The prevalence of specific types of mental health problems among immigrants is often influenced by the nature of the immigration experience, particularly any adversity encountered before, during, or after immigration.7 Immigrants are less likely than the general Canadian population to seek out or be referred to mental health services, even when they experience similar levels of distress.8 Refugees in particular are at higher risk than the general population for a variety of psychiatric disorders, and this is often related to their exposure to war, violence, torture, forced migration, or exile.9
Specific challenges in immigrant mental health include communication difficulties, particularly due to language and cultural differences; the effect of culture on coping and treatment; and diverse family structures affecting adaptation, acculturation, and intergenerational conflict. Integration challenges affecting employment and social status in particular may also impact the mental health of immigrants. Physicians can address some of these challenges, at least in part, by asking the patient about their social and cultural background, using interpreters or culture brokers, meeting the family, and consulting with community organizations that may be able to provide assistance.10 Some community health centres, for example, offer support groups, drop-in clinics, language classes, and settlement counselling for immigrants.
Preventive care for immigrants
To assess immigrants for clinical preventive care, it is important to determine the patient’s age, sex, country of origin, and migration history. The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) has produced clinical guidelines for immigrants and refugees11 which may be a source of information. The guidelines focus on:
- infectious diseases — because many immigrants are susceptible to vaccine-preventable diseases upon arrival to Canada
- mental health and physical and emotional maltreatment
- chronic and non-communicable diseases — because early treatment and lifestyle interventions can be effective for disease management
- women’s health
Physicians know the importance of understanding patients’ beliefs, behaviours, and values, and delivering care in a culturally competent and culturally safe manner.
Some immigrants will choose to not access healthcare services because of language barriers. Doctors may seek out a trusted translator or a medical interpreter to assist with language impediments. All discussions with patients and translators should be documented in the medical record. This includes consent discussions together with questions asked by patients and the answers given, patients’ apparent understanding, and any handout materials provided to the patient.
A patient’s culture can also affect their interpretation of symptoms, coping skills, and overall approach to health. Moreover, culture may impact a patient’s level of engagement in care planning, their choice of treatment, and adherence to treatment. Physicians should seek to involve patients in their healthcare as much as possible, but they must also be mindful of the impact of culture. By missing clues or misunderstanding a patient’s cultural viewpoint, it is possible for physicians to unintentionally offend, or place the diagnosis, adherence to treatment, and health outcomes at risk.
Points to keep in mind
Treating immigrants to Canada can pose a unique set of challenges for physicians. The risk factors for poor health in this population are numerous, however CCIRH guidelines may be a useful source of information.
When caring for immigrants and refugees, physicians should:
- Be vigilant in looking for infections or diseases among newcomers from high prevalence countries.
- Keep in mind immigrants’ life experiences and transitions when planning and providing care.
- Obtain appropriate health histories from immigrant patients to help determine their health risks and suitable next steps in patient care.
- Be mindful of language and cultural differences which may impact patients’ coping and their engagement in the healthcare system.
- Identify and share community health supports that may assist immigrants and refugees.
Members with specific questions can contact the CMPA for advice.
- Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., Hassan, G., Rousseau, C., Pottie, K., “Common mental health problems in immigrants and refugees: general approach in primary care,” Canadian Medical Association Journal (2011) Vol. 183 No.12, p.E959-E967
- Elwood, K., "Immigration medicals: What’s the point?" BC Medical Journal (2009) Vol. 51, No.8, p.341
- Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., Hassan, G., Rousseau, C., Pottie, K., "Common mental health problems in immigrants and refugees: general approach in primary care," Canadian Medical Association Journal (2011) Vol. 183 No.12. p.E959-E967
- Gushulak, B.D., Pottie, K., Hatcher Roberts, J., Torres, S., DesMeules, M., "Migration and health in Canada: health in the global village," Canadian Medical Association Journal (2011), Vol. 183 No.12, p.E952
- Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., Hassan, G., Rousseau, C., Pottie, K., "Common mental health problems in immigrants and refugees: general approach in primary care," Canadian Medical Association Journal (2011) Vol. 183 No.12, p.E959-E967
- Pottie, K., Greenaway, C., Feightner, J., Welch, V., Swinkels, H., Rashid, M., Narasiah, L., Kirmayer, L.J., Ueffing, E., MacDonald, N.E., Hassan, G., McNally, M., Kahn, K., Buhrmann, R., Dunn, S., Dominic, A., McCarthy, A.E., Gagnon, A.J., Rousseau, C., Tugwell, P., "Evidence-based clinical guidelines for immigrants and refugees," Canadian Medical Association Journal (2011) Vol. 183 No.12, p.E824