Equity in practice: Integrating cross cultural health brokers for culturally safe primary care for immigrants and refugees in British Columbia.

Umbrella Multicultural Health Co-op is a community health centre serving cultural communities of immigrants/refugees in British Columbia. It uses Cross Cultural Health Brokers (CCHBs), multicultural workers bridging patients and the healthcare system, to better meet the primary care needs of immigrant/refugee populations. Through the Team Primary Care initiative, Umbrella Co-op: (1) added new CCHBs alongside allied health practitioners; and (2) implemented team workshops and evaluation for quality improvement. The learning health system framework guided project activities. Comprehensive, culturally responsive primary care for immigrants and refugees benefits from a team-based approach that includes the integration of CCHBs. Team development activities improved team function. Co-developing evaluation with the interprofessional team enabled meaningful participation. Health system design for equity-oriented team-based primary care for immigrants and refugees should include resources for CCHBs and team development infrastructure.

How immigration shapes health disadvantages and what healthcare organizations can do to deliver more equitable care.

That immigration is a determinant of health and that immigration systems themselves contribute to structural disadvantage remains under-addressed within healthcare in Canada. This article offers context for how immigration shapes health, and recommendations for how health systems can be better prepared to respond to the diverse needs of immigrants and migrants (together referred to as im/migrants), based on a community-based research project in British Columbia. Findings call attention to the varied and intersecting ways in which immigration status, access to health insurance, language, experiences of trauma and discrimination, lack of support for health system limits access to healthcare, and the roles community-based organizations play in supporting access. Recommendations are intended to help make sure that all health services are accessible to everyone, and move beyond a homogenizing category of "newcomers" into practical, meaningful strategies that attend to diverse and intersecting community needs.

A Curricular Audit Method: Addressing the Erasure of Intersex, Trans and Two-Spirit People and the Imprecise Use of Gender and Sex Concepts in Undergraduate Medical Education.

Phenomenon: Intersex, trans, and Two-Spirit people report overwhelmingly negative experiences with health care providers, including having to educate their providers, delaying, foregoing, and discontinuing care due to discrimination and being denied care. Medical education is a critical site of intervention for improving the health and health care experiences of these patients. Medical research studies, clinical guidelines, textbooks, and medical education generally, assumes that patients will be white, endosex, and cisgender; gender and sex concepts are also frequently misused. Approach: We developed and piloted an audit framework and associated tools to assess the quantity and quality of medical education related to gender and sex concepts, as well as physician training and preparedness to meet the needs of intersex, trans, and Two-Spirit patients. We piloted our framework and tools at a single Canadian medical school, the University of British Columbia, focused on their undergraduate MD program. We were interested in assessing the extent to which endosexnormativity, cisnormativity, transnormativity, and the coloniality of gender were informing the curriculum. In this paper, we detail our audit development process, including the role of advisory committees, student focus groups, and expert consultation interviews. We also detail the 3-pronged audit method, and include full-length versions of the student survey, faculty survey, and purpose-built audit question list. Findings: We reflect on the strengths, limits, and challenges of our audit, to inform the uptake and adaptation of this approach by other institutions. We detail our strategy for managing the volume of curricular content, discuss the role of expertise, identify a section of the student survey that needs to be reworked, and look ahead to the vital task of curricular reform and recommendations implementation. Insights: Our findings suggest that curricular audits focused on these populations are lacking but imperative for improving the health of all patients. We detail how enhancing curriculum in these areas, including by adding content about intersex, trans, and Two-Spirit people, and by using gender and sex concepts more accurately, precisely and inclusively, is in line with the CanMEDS competencies, the Medical Council of Canada's Objectives for the Qualifying Examinations, many institutions' stated values of equity, inclusion and diversity, and physicians' ethical, legal and professional obligations.

Primary Care and Access to Mental Health Consultations among Immigrants and Nonimmigrants with Mood or Anxiety Disorders: Soins de première ligne et accès aux consultations en santé mentale chez les immigrants et les non-immigrants souffrant de troubles de l'humeur ou anxieux.

OBJECTIVE: To examine the association between usual place of primary care and mental health consultation among those with self-reported mood or anxiety disorders. We also describe access to mental health services among people who are recent immigrants, longer-term immigrants, and nonimmigrants and determine whether the association with place of primary care differs by immigration group. METHODS: We used data from the Canadian Community Health Survey (2015 to 2016) to identify a representative sample of individuals with self-reported mood or anxiety disorders. We used logistic regression, with models stratified by immigration group (recent, longer-term, nonimmigrant), to examine the association between usual place of primary care and receiving a mental health consultation in the previous 12 months. RESULTS: Higher percentages of recent and longer-term immigrants see a doctor in solo practice, and a higher percentage of recent immigrants use walk-in clinics as a usual place of care. Compared with people whose usual place of care was a community health center or interdisciplinary team, adjusted odds of a mental health consultation were significantly lower for people whose usual place of care was a solo practice doctor's office (AOR = 0.71; 95% CI, 0.62 to 0.82), a walk-in clinic (AOR = 0.75; 95% CI, 0.66 to 0.85), outpatient clinic/other place (AOR = 0.72 95% CI, 0.59 to 0.88), and lowest among people reporting no usual place other than the emergency room (AOR = 0.59; 95% CI, 0.51 to 0.67). Differences in access to mental health consultations by usual place of primary care were greatest among immigrants, especially recent immigrants. CONCLUSIONS: People with mood or anxiety disorders who have access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Expanded access to team-based primary health care may help reduce barriers to mental health services, especially among immigrants.

Induced abortion according to immigrants' birthplace: a population-based cohort study.

BACKGROUND: Most abortions occur due to unintended pregnancy. Unintended pregnancies are linked to poor health outcomes. Canada receives immigrants from countries with disparate sexual and reproductive health contexts which may influence abortion rates post-migration. We examined the association between abortion and region of birth and birth order among Canadian immigrants. METHODS: We conducted a population-based person-years (PY) cohort study in Ontario, Canada using administrative immigration (1991-2012) and health care data (1991-2013). Associations between induced abortion and an immigrant's region of birth were estimated using poisson regression. Rate ratios were adjusted for age, landing year, education, neighborhood income quintile and refugee status and stratified by birth order within regions. RESULTS: Immigrants born in almost all world regions (N = 846,444) were 2-5 times more likely to have an induced abortion vs. those born in the US/Northern & Western Europe/Australia & New Zealand (0.92 per 100 PY, 95% CI 0.89-0.95). Caribbean (Adjusted Rate Ratio [ARR] = 4.71, 95% CI 4.55-4.87), West/Middle/East African (ARR = 3.38, 95% CI 3.26-3.50) and South American (ARR = 3.20, 95% CI 3.09-3.32) immigrants were most likely to have an abortion. Most immigrants were less likely to have an abortion after vs. prior to their 1st birth, except South Asian immigrants (RR = 1.60, 95% CI 1.54-1.66; RR = 2.23, 95% CI 2.12-2.36 for 2nd and 3rd vs 1st birth, respectively). Secondary analyses included further stratifying regional models by year, age, education, income quintile and refugee status. CONCLUSIONS: Induced abortion varies considerably by both region of birth and birth order among immigrants in Ontario.

Growing inequities by immigration group among older adults: population-based analysis of access to primary care and return to in-person visits during the COVID-19 pandemic in British Columbia, Canada.

BACKGROUND: The onset of the COVID-19 pandemic drove a rapid and widespread shift to virtual care, followed by a gradual return to in-person visits. Virtual visits may offer more convenient access to care for some, but others may experience challenges accessing care virtually, and some medical needs must be met in-person. Experiences of the shift to virtual care and benefits of in-person care may vary by immigration experience (immigration status and duration), official language level, and age. We examined use of virtual care and return to in-person visits in the Canadian province of British Columbia (BC), comparing patterns by age and across immigration groups, including length of time in Canada and language level (official languages English and French) at time of arrival. METHODS: We used linked administrative health and immigration data to examine total primary care visits (virtual or in-person) and return to in-person visits during the COVID-19 pandemic (2019/20-2021/2) in BC. We examined the proportion of people with any primary care visits and with any in-person visits within each year as measures of access to primary care. We estimated the odds of any primary care visits and any in-person visits by immigration group and official language level assessed prior to arrival: non-immigrants, long-term immigrants, recent immigrants (< 5 years) with high assessed official language level and recent immigrants (< 5 years) with low assessed official language level (assessed prior to arrival), stratified by age. RESULTS: In general, changes in access to primary care (odds of any visits and odds of any in-person visits) were similar across immigration groups over the study period. However, we observed substantial disparities in access to primary care by immigration group among people aged 60 + , particularly in recent immigrants with low official language level (0.42, 0.40-0.45). These disparities grew wider over the course of the pandemic. CONCLUSION: Though among younger adults changes in access to primary care between 2019-2021 were similar across immigration groups, we observed significant and growing inequities among older adults, with particularly limited access among adults who immigrated recently and with low assessed official language level. Targeted interventions to ensure acceptable, accessible care for older immigrants are needed.

Respectful community engagement in health research with diverse im/migrant communities.

INTRODUCTION: Global migration and immigration are increasing, and migrants and immigrants (im/migrants) have specific health needs and healthcare experiences. Yet, im/migrant involvement in immigration and health research in Canada is inconsistent. Heretofore, involvement has primarily been in research planning, data collection and analysis, with little community involvement during knowledge exchange or through training and colearning opportunities. Community engagement has been especially uncommon in mixed-method and quantitative research in Canada. OBJECTIVE: This article describes lessons learnt from the Evaluating Inequities in Refugee & Immigrants' Health Access (IRIS) project from 2018 to 2023, an ongoing mixed-method, community-based research project in British Columbia, Canada. Specifically, we share our core community engagement project structures, Commitments to Community and our Community Engagement Backbone, both collaboratively developed with im/migrant community memebers. PARTICIPANTS: People with varied experiences of im/migration and connections to multiple, specific im/migrant communities participate in the project as participants, community researchers, community advisory board members, faculty members and students. Core research activities are supported in English, Farsi, Spanish and Tigrinya. We engage community members throughout the research process, from identifying research topics to knowledge exchange. CONCLUSION: We found that these structures offer an accessible visual representation of the project's commitments to community engagement, and the ways these commitments are demonstrated through values and action. Our training opportunities, colearning activities and knowledge exchange efforts also confirmed the accuracy of interpretation, prompted additional analysis to clarify or add depth to findings, and helped us identify additional research topics. We hope these learnings can be used to expand engagement with diverse im/migrant communities in health and immigration research.

'We don't have the right to get sick': A qualitative study of gaps in public health insurance among Im/migrant women in British Columbia, Canada.

Globally, the exclusion of im/migrants from public health care systems remains a significant health and human rights issue, calling into question claims of 'universality' of public health systems where eligibility for coverage is determined by immigration status. We aimed to describe lived experiences of health insurance coverage and the health and social impacts of gaps in health insurance amongst im/migrant women in British Columbia (BC), Canada. This analysis draws on qualitative in-depth interviews (n = 78) with im/migrant women and im/migrant-focused service providers (n = 10) conducted between July 2018-March 2021 in Metro Vancouver, BC, as part of a larger community-based, mixed-methods study of im/migrants' health access (IRIS). In contrast to common perceptions of Canada's health system as 'universal', participants faced multifaceted barriers to health insurance and necessary healthcare for themselves and their families following arrival in BC. Narratives highlighted the ways in which ineligibility for public health insurance coverage resulted in unmet needs for essential sexual and reproductive health and preventive care among im/migrant women, children, and families. Participants also described ineligibility for public health insurance as resulting in a high economic burden, and that exclusion from public health insurance perpetuated experiences of discrimination, invisibility, and exclusion from systems of care amongst im/migrant participants. Despite these structural challenges, participant narratives highlighted the crucial role of community-based supports for minimizing harm and navigating oppressive immigration and health systems. Changes to immigration and health policies are required to remove barriers to public health care for im/migrant women and ensure that Canada's health system is accessible to all. Expanding health insurance options to cover all residents and decoupling health insurance eligibility from immigration status are recommended, alongside implementation of 'Sanctuary' policies at the local level.

SARS-CoV-2 testing and COVID-19-related primary care use among people with citizenship, permanent residency, and temporary immigration status: an analysis of population-based administrative data in British Columbia.

OBJECTIVES: Having temporary immigration status affords limited rights, workplace protections, and access to services. There is not yet research data on impacts of the COVID-19 pandemic for people with temporary immigration status in Canada. METHODS: We use linked administrative data to describe SARS-CoV-2 testing, positive tests, and COVID-19 primary care service use in British Columbia from January 1, 2020 to July 31, 2021, stratified by immigration status (citizen, permanent resident, temporary resident). We plot the rates of people tested and confirmed positive for COVID-19 by week from April 19, 2020 to July 31, 2021 across immigration groups. We use logistic regression to estimate adjusted odds ratios of a positive SARS-CoV-2 test, access to testing, and primary care among people with temporary status or permanent residency, compared with people who hold citizenship. RESULTS: A total of 4,146,593 people with citizenship, 914,089 people with permanent residency, and 212,215 people with temporary status were included. Among people with temporary status, 52.1% had "male" administrative sex and 74.4% were ages 20-39, compared with 50.1% and 24.4% respectively among those with citizenship. Of people with temporary status, 4.9% tested positive for SARS-CoV-2 over this period, compared with 4.0% among people with permanent residency and 2.1% among people with citizenship. Adjusted odds of a positive SARS-CoV-2 test among people with temporary status were almost 50% higher (aOR 1.42, 95% CI 1.39, 1.45), despite having half the odds of access to testing (aOR 0.53, 95% CI 0.53, 0.54) and primary care (aOR 0.50, 95% CI 0.49, 0.52). CONCLUSION: Interwoven immigration, health, and occupational policies place people with temporary status in circumstances of precarity and higher health risk. Reducing precarity accompanying temporary status, including regularization pathways, and decoupling access to health care from immigration status can address health inequities.

RéSUMé: OBJECTIFS: Le statut d'immigration temporaire confère des droits, des mesures de protection au travail et un accès aux services limités. Il n'y a pas encore de données de recherche sur les impacts de la pandémie de COVID-19 chez les personnes ayant un statut d'immigration temporaire au Canada. MéTHODE: Nous utilisons des données administratives maillées pour décrire le dépistage du SRAS-CoV-2, les tests positifs et l'utilisation des services de soins de première ligne liés à la COVID-19 en Colombie-Britannique entre le 1er janvier 2020 et le 31 juillet 2021, stratifiées selon le statut d'immigration (citoyenneté, résidence permanente, résidence temporaire). Nous reportons sur des graphiques les taux hebdomadaires de personnes testées et confirmées positives pour la COVID-19 entre le 19 avril 2020 et le 31 juillet 2021 dans les groupes d'immigration. Nous utilisons la régression logistique pour estimer les rapports de cotes ajustés d'un test positif pour le SRAS-CoV-2, de l'accès au dépistage et de l'accès aux soins primaires chez les personnes ayant le statut de résidents temporaires ou permanents comparativement aux personnes ayant la citoyenneté canadienne. RéSULTATS: En tout, 4 146 593 citoyens, 914 089 résidents permanents et 212 215 résidents temporaires ont été inclus. Chez les personnes ayant le statut de résidents temporaires, 52,1 % étaient de sexe administratif « masculin ¼ et 74,4 % avaient entre 20 et 39 ans, contre 50,1 % et 24,4 % respectivement chez les personnes ayant la citoyenneté. Chez les résidents temporaires, 4,9 % avaient obtenu un test positif pour le SRAS-CoV-2 au cours de la période de l'étude, contre 4 % chez les résidents permanents et 2,1 % chez les citoyens. La probabilité ajustée d'un test positif pour le SRAS-CoV-2 chez les personnes ayant le statut de résidents temporaires était près de 50 % plus élevée (RCa 1,42, IC de 95 % 1,39, 1,45), même si leurs probabilités d'accès au dépistage (RCa 0,53, IC de 95 % 0,53, 0,54) et aux soins primaires (RCa 0,50, IC de 95 % 0,49, 0,52) étaient moitié moindres. CONCLUSION: La conjugaison des politiques d'immigration, de santé et de main-d'œuvre met les personnes ayant le statut de résidents temporaires en situation de précarité et de risques accrus pour la santé. La réduction de la précarité qui accompagne le statut temporaire, dont les voies de régularisation, et le découplage entre l'accès aux soins de santé et le statut d'immigration pourraient répondre aux iniquités en santé.

Cervical cancer screening among vulnerable women: factors affecting guideline adherence at a community health centre in Toronto, Ont.

OBJECTIVE: To see if refugee women at a community health centre (CHC) in Toronto, Ont, are appropriately screened for cervical cancer and if there are any demographic characteristics that affect whether they are screened. DESIGN: Chart review. SETTING: A CHC in downtown Toronto. PARTICIPANTS: A total of 357 eligible refugee women attending the CHC. MAIN OUTCOME MEASURES: Papanicolaou test received or documented reason for no Pap test. RESULTS: Ninety-two percent of women in the study sample were either appropriately screened for cervical cancer or had been approached for screening. Eighty percent of women were appropriately screened. Demographic variables including pregnancy, being uninsured, not speaking English, recent migration to Canada, and being a visible minority did not affect receipt of a Pap test after migration in multivariate analyses. Not speaking English was associated with a delay to receiving a first Pap test after migration. CONCLUSION: The clients at our centre are demographically similar to women who are typically overlooked for Pap tests in the greater Toronto area. Despite belonging to a high-risk population, refugee women in this multidisciplinary CHC were screened for cervical cancer at a higher rate than the local population.

Determinants and Inequities in Sexual and Reproductive Health (SRH) Care Access Among Im/Migrant Women in Canada: Findings of a Comprehensive Review (2008-2018).

Given growing concerns of im/migrant women's access to sexual and reproductive health (SRH) services, we aimed to (1) describe inequities and determinants of their engagement with SRH services in Canada; and (2) understand their lived experiences of barriers and facilitators to healthcare. Using a comprehensive review methodology, we searched the quantitative and qualitative peer-reviewed literature of im/migrant women's access to SRH care in Canada from 2008 to 2018. Of 782 studies, 38 met inclusion criteria. Ontario (n = 18), British Columbia (n = 6), and Alberta (n = 6) were primary settings represented. Studies focused primarily on maternity care (n = 20) and sexual health screenings (n = 12). Determinants included health system navigation and service information; experiences with health personnel; culturally safe and language-specific care; social isolation and support; immigration-specific factors; discrimination and racialization; and gender and power relations. There is a need for research that compares experiences across diverse groups of racialized im/migrants and a broader range of SRH services to inform responsive, equity-focused programs and policies.

"It's not just about being here, but what brought you here": A qualitative study of the role of migration experiences in shaping im/migrant women's access to healthcare.

This qualitative study aimed to understand how migration experiences shape im/migrant women's needs, desire for, and expectations of healthcare in the British Columbia (BC), Canada context. Interviews with 33 im/migrant women (December 2018-January 2020) highlighted that traumatic experiences across migration increased healthcare needs; insufficient prior health system information contributed to poor experiences; and comparative healthcare experiences across places shaped future healthcare expectations. We use the BC setting to demonstrate the need to abide by global commitments to protect people during migration, train providers in trauma-informed care, develop health assessments that center migration journeys, and appropriately fund im/migrant-serving community organizations.

Cervical Cancer Screening by Refugee Category in a Refugee Health Primary Care Clinic in Calgary, Canada, 2011-2016.

Newly arrived refugees and refugee claimants experience low cervical cancer screening (CCS) rates in Canada. We investigated CCS at a dedicated refugee clinic. We completed a retrospective cohort study among patients at the Mosaic Refugee Health Clinic in Calgary, Canada, between 2011 and 2016. We investigated CCS offers and completion by refugee category. We then used multivariable logistic regression to estimate the association of CCS screening and refugee category, accounting for sociodemographic and clinical factors. We included 812 refugees. Most were married (71%) and had limited English proficiency (57%). Overall, 88% and 77% of patients were offered and completed screening, respectively. Compared to government assisted refugees, privately sponsored refugees completed CCS more often (OR 1.60, 95% CI [1.02-2.49]). A dedicated refugee clinic may provide effective CCS to newly arrived refugees irrespective of refugee category, insurance status or other barriers.

Qualitative evaluation of a mandatory health insurance 'wait period' in a publicly funded health system: understanding health inequities for newcomer im/migrant women.

OBJECTIVES: To evaluate impacts of a residency-based waiting period for health insurance coverage on lived experiences of health and settlement for im/migrant women in British Columbia, Canada. DESIGN: The IRIS study is a mixed-methods, community-based, qualitative evaluation of recently arrived im/migrant women's access to sexual and reproductive care. In-depth, semistructured interviews were conducted by trained multilingual and multicultural interviewers with lived migration experience in the participant's preferred language. SETTING: Metro Vancouver, British Columbia, Canada from July 2018 to January 2020. PARTICIPANTS: Data collected from community focus groups (four groups, n=29) of both service providers and im/migrant women was used. Following this, qualitative interviews with service providers (n=10) and im/migrant women (n=47) were conducted. Eligible participants self-identified as women; were aged 18-49 and had arrived in Canada from another country. Eligible providers were employed in the health, social or legal sectors working with im/migrant women. RESULTS: The wait period resulted in mistrust and internalised stigma for racialised im/migrant women, for whom the policy resulted in feeling 'undeserving' of care. Resulting administrative burden produced delays and unmet need for care, particularly related to sexual and reproductive healthcare and children's health. Unexpected costs meant difficult choices between survival and care. Negative health outcomes included the inability to family plan, difficulties during pregnancy, as well as hardships related not being able to seek help for sick children. Community-based organisations provided support in many areas but could not fill all gaps produced by this policy. CONCLUSIONS: Findings highlight severe, yet commonly overlooked, health inequities produced by a mandatory health coverage wait period within a purportedly 'universal' healthcare system. Health system policies such as mandatory 'waiting periods' produce discriminatory and inequitable outcomes for im/migrant women. Policy reforms towards full 'healthcare for all' are urgently needed to affirm the health and human rights of all im/migrants.

Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study.

ABSTRACT: This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.