1. LOGISTICAL BARRIERS
➤ Navigation
Refugee and newcomer patients often missed appointments. Several key logistical barriers contribute to these missed appointments:
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Understanding and using the public transit system – the St. John’s transit system is often unreliable and difficult to navigate.
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Understanding and using complex registration systems – it is often unclear how to register for appointments at health care clinics
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Difficulty finding offices/sites – specific health care clinics can be difficult to locate
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Administrative errors – referral letters may include incorrect or incomplete information
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Use of English-language letters for appointment details – patients who do not speak English fluently may struggle to understand their referral letters
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➤ Accessing to Family Physicians
There is also a shortage of family physicians available to treat refugee and newcomer patients. One reason family physicians are unwilling to take on newcomers is their lack of familiarity with working across languages and cultures, and a lack of familiarity with and expertise in some of the diseases that refugee patients present with. Additionally, refugee patients take more time to treat properly, because they require more conversation and an interpreter. The fee-for-service pay structure acts as a disincentive to take on these patients.
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➤Government Assisted Reugees versus others
There are two kinds of refugees: government-assisted, and privately sponsored. Patients and health care providers misunderstand the role of the ANC and perceive inequities in health resettlement assistance. The ANC’s goal is to assist newcomers until they can manage health care navigation on their own. Privately sponsored refugees are supposed to be resettled by their sponsors but the ANC will assist that process when needed. The RHC began with government assisted refugees and then expanded to serve privately sponsored refugees as well, especially those who were themselves sponsored by refugees.
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“The time we spent with Dr. [X], it was horrible actually because he is a family doctor and walk-in clinic at the same time, so you can take an appointment or you just go there; and we didn’t have a car at that time, so always we had to take three buses if I want to go, and wait for two hours at least to see him, and you know with five children ... It’s not easy to travel with [2 babies] with a stroller and you know three buses to go to the doctor” [Refugee patient 6: woman, Arabic speaking]
“Sometimes the patient will not even know where they are, where he or she is going. Like, I will ask, ‘So why do you have to see Dr. [X]?’ and she’s, like, ‘I don’t know, I don’t know who is this person and I don’t – I just received this by mail and I don’t know’” [Formal and informal support worker 5, interpreter, international student, recent immigrant patient]
“So, like, [mimics doctor speaking] ‘I can’t see three of them together’ [that is, each family member required a distinct appointment]. So I was like, ‘Okay, I know that you can’t see them together when there’s something that’s really, let’s say, urgent or something … [But to renew a prescription], you know it’s nothing – you’re not going to examine the patient!’ [And the doctor said] ‘She needs to book another appointment’, and then so I was like ‘You know what, you can help her; it’s not going to– it’s nothing! you know’” [Formal and informal support worker 5, interpreter, international student, recent immigrant patient]
“It is fee-for-service, you know, it probably costs [the doctor] to see these patients because it takes a huge, you know, it takes an hour for each patient. I mean it doesn’t pay at all if you’re a fee-for-service physician. So [names physician working with refugee patients] did this really out of the goodness of her heart and so did the others, [other doctors] who were fee-for-service – because they felt it was the right thing to do, but they certainly didn’t get paid for it” [Physician 1]