An ethnographic investigation of the maternity healthcare experience of immigrants in rural and urban Alberta, Canada
© Higginbottom et al. 2016
Received: 23 December 2014
Accepted: 3 December 2015
Published: 27 January 2016
Canada is among the top immigrant-receiving nations in the world. Immigrant populations may face structural and individual barriers in the access to and navigation of healthcare services in a new country. The aims of the study were to (1) generate new understanding of the processes that perpetuate immigrant disadvantages in maternity healthcare, and (2) devise potential interventions that might improve maternity experiences and outcomes for immigrant women in Canada.
The study utilized a qualitative research approach that focused on ethnographic research design and data analysis contextualized within theories of organizational behaviour and critical realism. Data were collected over 2.5 years using focus groups and in-depth semistructured interviews with immigrant women (n = 34), healthcare providers (n = 29), and social service providers (n = 23) in a Canadian province. Purposive samples of each subgroup were generated, and recruitment and data collection – including interpretation and verification of translations – were facilitated through the hiring of community researchers and collaborations with key informants.
The findings indicate that (a) communication difficulties, (b) lack of information, (c) lack of social support (isolation), (d) cultural beliefs, e) inadequate healthcare services, and (f) cost of medicine/services represent potential barriers to the access to and navigation of maternity services by immigrant women in Canada. Having successfully accessed and navigated services, immigrant women often face additional challenges that influence their level of satisfaction and quality of care, such as lack of understanding of the informed consent process, lack of regard by professionals for confidential patient information, short consultation times, short hospital stays, perceived discrimination/stereotyping, and culture shock.
Although health service organizations and policies strive for universality and equality in service provision, personal and organizational barriers can limit care access, adequacy, and acceptability for immigrant women. A holistic healthcare approach must include health informational packages available in different languages/media. Health care professionals who care for diverse populations must be provided with training in cultural competence, and monitoring and evaluation programs to ameliorate personal and systemic discrimination.
KeywordsDiversity Ethnographic study Healthcare access Maternity care Immigrant woman Canada
International migration, largely from east to west and south to north, results in increasing ethnocultural diversity in immigrant-receiving nation states . Canada is among the top immigrant-receiving countries globally . According to Statistics Canada, 20 % of the total population increase in the last decade (approximately 2,000,) consists of individuals born outside Canada . This proportion was also seen in rural areas . A gender analysis demonstrates that almost 50 % of immigrants are women , many of whom are in the reproductive phases of their lives. Research evidence indicates that immigrant women experience many challenges in receiving both community and hospital maternity care [6–8]. Canadian health policy is committed to providing safe, accessible, and equitable care for mothers and their children [9, 10]. This goal is congruent with the G8 Millennium Goals. This study explores critical points and barriers faced by immigrant women who seek maternity care. Our target population was heterogeneous and may have included economic migrants and skilled workers, temporary foreign workers, documented and undocumented residents, refugee claimants, refugees, asylum seekers, and students.
Maternity care in Canada
With the exception of the Aboriginal population, maternity care in Canada is a provincial matter and public health insurance plans cover most expenses related to childbirth . Physician specialists provide maternity services, and almost half of family doctors (47 %) include prenatal care as part of their practice [11, 12]. Standard practice is for pregnant women to receive prenatal care every 4 to 6 weeks in the early stages of pregnancy and every 1 to 2 weeks in the third trimester . Midwives also provide a full scope of maternity care for about 3 % of women in Canada. Hospital stays have dramatically shortened since 1980 with current lengths of maternity stay being an average of one to two days. Community health services provide prenatal classes and postpartum visits by public health nurses (typically a phone call and home visit within 24 and 48 hours, respectively, of hospital discharge). The overriding goal of the latter is to assess and prevent postpartum problems and to enhance maternal and newborn wellbeing and adjustment .
Why focus on maternity care?
Access to healthcare, including maternity care, and the quality of services received by immigrants are influenced by low health literacy levels , stigma and mental health problems , language barriers, cultural barriers, lack of provider cultural competence, and lack of social support and isolation [16–18], despite policy suggesting that care is to be provided equally for all members of society [19, 20]. Maternity care that is adapted poorly to serve diverse cultural populations can result in low birth weight and preterm birth, which can impact the short or long-term health of women and children [12, 19, 21, 22]. Inadequate health assessment and communication issues between care givers and their clients may encourage unnecessary interventions, thereby wasting precious resources . More information about the diversity of experience and the factors that shape the experiences of immigrant women in the Canadian healthcare system will help us to improve maternity health in Canada [24, 25].
Immigrant women’s access to and experiences within the healthcare system may be viewed usefully within the context of both organizational behaviour and critical realism theories. Organizational behaviour theory concerns the study of individuals’ interactions within specific units of an organization  in which there is structure to meet specific goals for certain populations . Within this theory there is no universal or ideal way to manage organizations; the organization is thought to require flexibility and plasticity based on circumstances and environmental factors . A change in demographics, such as an increase in diversity, will impact the healthcare system, and system adjustment will be required based on the emerging needs of the precursor of demographic change. . A major factor is the level of cultural competence of healthcare providers and at a macro level, the organizational cultural competence. Many definitions of cultural competence prevail in the literature. We found the following pertinent for our use: within the healthcare sector is “the ability of healthcare providers and healthcare organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the healthcare encounter” . As an overall aim is to have the ongoing capacity to provide equitable healthcare services for diverse populations , healthcare organizations need to continually make the changes and adjustments that will provide culturally appropriate care for these populations . More specifically, the organization needs to provide timely, efficient, safe, and equitable care for all clients regardless of gender, age, ethnicity, and socioeconomic status [26, 32]. In this study we considered the maternity healthcare setting in Canada, and investigated the experiences of immigrant women regarding access to and navigation of Canadian maternity services.
Critical realism theory within the social sciences provides analysis of the nature of the social world by incorporating two main features: (a) understandings of the dialectical interplay between social structures and human agency, in this case maternity care services and immigrant women, and (b providing critique of the prevailing social order, which for this study is the notion that immigrant women may be regarded as “the other” [33–35]. In healthcare science, critical realism can help the researcher to understand and explain health related phenomenon [36, 37]. Critical realism theory applies to investigations of complex and multilayered contexts; an example of such a context is the healthcare service, in which therapeutic encounters occur and dialogical interaction exists between patients, health professionals, managers, and policy makers [35, 37]. Healthcare practitioners may have different ethnocultural and socioeconomic backgrounds that influence their practice and subsequently affect care outcomes . Critical realism is applied in this study to accommodate the existence of multiple social perspectives (immigrant women patients, healthcare and social service providers, and other key stakeholders), which may or may not coalesce. It also enables us to identify existing barriers at both macro and micro levels, taking account of the notions of personal agency and healthcare structure [34, 35, 37].
The study locations included a metropolitan city and a smaller, rural town in a Canadian province. The study sites were selected to provide insights into immigrant experiences in both rural and urban locations. The provincial location is a popular destination for immigrants to Canada, and in 2011 the urban site ranked fifth for its number of new immigrants . Canada Census 2006 documented one million people, of which 189,775 had an immigrant background and most of these (174,729) belonged to a visible minority group . There is considerable heterogeneity within immigrant communities  and the study site receives refugees from Sudan, Afghanistan, Somalia, Democratic Republic of Congo, Sierra Leone, Liberia, Colombia, Iran, Iraq, and other countries. In the rural town location, 2,135 people (17 %) were identified as visible minorities and 16.6 % as immigrants . In 2006, almost 50 % of those identifying as visible minorities in the entire health region resided in the rural town of our study. The top source countries for refugees arriving in Canada over the last few years have been Ethiopia, Sudan, Somalia, Burundi, Democratic Republic of Congo, Afghanistan, Pakistan, and China; 75–80 % of the immigrants have either basic or no fluency in English.
Sample and recruitment
Focused ethnographers aim to investigate a particular phenomenon in a specific setting and/or for a specific group of people , thus we generated a nonprobability purposive sample who could inform us about the experiences of immigrant women in maternity care within their area (Fig. 1). Those eligible for inclusion were (1) immigrant women with current or recent (previous 2 years) experience of using maternity services while residing in either the urban or rural location, (2) healthcare providers having experience with providing perinatal care to immigrant women, and (3) stakeholders, including social service providers and decision makers, who have a mandate or involvement in immigrant women’s health or service provision. The study team worked closely with an immigrant-serving agency, the Multicultural Health Brokers Co-operative (MHBC), where cultural health brokers (employed as community researchers) assisted with both recruitment of immigrant women and language interpretation during interviews. The MHBC offers liaison, referral, and information services, often through trained cultural health brokers, to help immigrants and refugees access and navigate the health system. The brokers informed the immigrant women of the study using a prepared information package, which was translated if requested. The bi-lingual brokers also gained initial consent from the women for the research team to contact them to arrange procedures for obtaining informed consent and data collection. In the rural location, it was routine for participating healthcare or social service providers to assist with informing and gaining contact consent from immigrant women in their care. Snowball sampling was used on several occasions, whereby participants would pass along the research team contact information to suitable acquaintances or colleague.
We used semistructured individual and focus group interviews to obtain data. Interviewers were guided by an interview topic guide having topic prompts which shifted in focus from an immigrant’s general impression of Canadian maternity services (including comparison to the home country) to more specific topics relevant to specific experiences of the immigrant , including barriers and facilitators that affected access to and reception of care and impressions of care provision. The interviews were audiotaped (with permission), transcribed verbatim by a professional transcriptionist, and then verified by the interviewer. Data from the focus groups were also verified by the cultural health broker who served as the interpreter for the immigrant women. Data were gathered over a two year period and recruitment ceased once data saturation was reached, as confirmed through our iterative data analysis process. All data were collected by female researchers trained in qualitative interviewing to prevent difficulties for immigrant women in expression or sharing of maternity experiences. Although our recruitment efforts facilitated recruitment of immigrant women of all ethnocultural groups, there is always the possibility that our results have some inherent bias from failure to capture differing perspectives.
The background of immigrant women (IW) participants was diverse, with 12 from Sudan, 8 from the Philippines, 6 from China, 2 from Columbia, and one each from Tajikistan, India, Mauritania, Pakistan, and Eritrea. Eighteen (78.3 %) of the social service providers/stakeholders (SSP) and 8 (27.6 %) of the healthcare providers (HCP) had immigrant backgrounds. Seven (24.1 %) among the HCP sample were bilingual whereas 96.6 % of the SSP were bilingual; 73.5 % of the IW reported that they could understand English. The average age of the IW sample was 35.5 years and the majority of the HCP and SSP participants were female.
Principal investigators, coinvestigators, collaborators, and trainees reviewed transcripts to gain preliminary interpretations. Several reflective team analytical meetings were scheduled to provide and train novice team members in collaborative, reflexive analysis and interpretation. Drawing upon the tenets of critical realism we sought to establish both individual and structural factors for the existence of the phenomenon focusing on the stratification of the women’s experiences in respect of a) the empirical b) the actual or observed c) the real. Data were analyzed with the aid of Atlas.ti (ATLAS.ti Scientific Software Development GmbH, Germany)  following Roper and Shapira’s  framework for analysis of ethnographic data. Data were first coded with descriptive labels, then categorized into “code families” based on identified patterns. During this process, analytical and theoretical memos were written for narrative construction of the results (Fig. 1).
Ethical approval was granted for this study by the institutional review board at the University of Alberta, Edmonton, Alberta, Canada, that is, the Health Review Ethics Board – Panel B.
Written informed consent to participate was obtained from all participants after emphasizing the participant’s right to withdraw at any time. Participants were informed of the study using both written and verbal means; interpreters were present when necessary throughout the consent and interview procedures. All information collected from this study is being kept secure; only individuals designated as research personnel have access to the data.
Demographics of the participating immigrant women (IW), social service providers (SSP; this includes some other key stakeholders), and healthcare providers (HCP)
n = 34 (39.5 %)
n = 23 (26.8 %)
n = 29 (33.8 %)
Rural Town, n = 31 (36.5 %)
Urban Town, n = 55 (63.5 %)
Accessibility of maternity services
Although maternity care is available for all women in Canada regardless of their ethnicity, age, religious beliefs, and/or immigration background, several issues were found to be limiting factors for IW. Communication barriers, lack of information, lack of social support and isolation, cultural beliefs, inadequate healthcare services, and cost of medicines/services were all identified as potential risk factors for not accessing maternity services in a timely manner.
…the nurse came to my house to visit me and she talk about lots of things but I didn’t understand … so whatever she asked me, I said, yeah, yeah, yeah. I just wanted to say, oh, you just leave. (IW-FGI-Urban Town).
… sometimes when we get into hospital … they speak very, like very fast English, and being new to the country you don’t – you are not really used to the accent, you know. And so, and they are scared to ask questions. (IW-FGI-Urban Town)
It’s usually more on the gut feel that this person has no idea what you are talking about, no matter how slowly and simple you explain it. It’s just not getting through … I had someone send one of my patients for a triple screen which came back nicely with a positive for Down Syndrome and I couldn’t explain that in Arabic. (HCP-Rural Town)
Interestingly, the HCP failed to acknowledge that interpretation services might be required to render professional accountability and to ensure key healthcare information was conveyed.
Limited fluency in English sometimes prevented an IW from participating in prenatal classes; an IW FGI participant stated, “I didn’t quite understand because it’s in English and so I only attended I think two times and then I just quit because I didn’t quite understand.” To help overcome this problem in the healthcare sector, albeit mostly in tertiary care centres, professional interpreters or a language service (e.g., an online service based in the United States is currently under contract in the rural location) is made available. While these efforts reduce communication barriers, there seem to be challenges in regard to their being “time-consuming,” unavailable in delivery rooms and during the busy night hours, Alternatively, many immigrants bring along a family member (often their child) or a friend to assist with their communication, but this approach can lead to confidentiality and ethical issues.
Lack of information
Many people, they are not informed, they don’t have information about any services…when you see something in English we are not interested to read it. (IW-Rural Town)
An HCP observed: “The thing is, when people come here, because they have no idea about community resources, they don’t go. They don’t come” (HCP-Rural Town).
I was completely lost because I didn’t know … about the system and I had difficulties with the system again … that I did not understand initially there.
… I am also interested in them actually talking with you instead of just giving you the paperwork. (IW-Urban Town)
This participant clearly expressed a need for a greater level of therapeutic interaction and care from her healthcare provider.
Lack of social support and isolation
Many IW are used to receiving help and support during the pregnancy, birth, and the immediate postnatal period from their extended family in their home country, especially female relatives. Lack of social support can lead to a delay or irregularity of medical visits, thereby substantially affecting maternal physical and mental health.
Several of the IW commented on this topic, “I was very scared because my husband, he works at … and I have a baby, so I cannot go in Medicine Hat every like 15 days and month” (IW-Rural Town). Another IW pointed out: “I don’t have any. No neighbor, nobody here, no friend, no any family. This is too hard for me…Sometimes I sit only myself and I cry because I do not know what can I do” (IW-Rural Town). One IW mentioned that she was working in the late stage of her pregnancy since she was alone at home and wanted to be cared for at least by her colleagues, “I was in my eighth month I was still working. You know why? Because I don’t have anyone in the house. I was actually worried that I might give birth here and then I don’t have anybody.” Another issue related to social support is transportation. This is especially pertinent in a country that experiences adverse winter weather patterns (often with subzero temperatures extending to minus 40). For many IW arriving from more tropical environments, transportation and accessing services during winter can be a substantial challenge. Many of the women’s spouses worked long and/or irregular hours or did not have a driver’s licence. This was challenging given that spouses provided the primary support for the women participants in this study. Even women who had access to a vehicle and ability to drive thought that their pain or stress prevented them from going out alone. One SSP commented, “Some of them are pregnant and they are left alone by themselves, and transportation is a big issue for them, to go for the care.”
Ethnocultural beliefs and traditions
In some cases, a conflict existed between the values and beliefs in a woman’s native country and those in her new country. For example, several women viewed pregnancy as a natural life event and a physiological process during which they did not require special medical attention. The predominance of Western biomedicine and medicalisation of childbirth in Canada may be oppositional to these views. For example 98 % of all births in Canada are attended by a physician . Both HCP and SSP commented on this topic, “They don’t believe that maternity care is [a] necessity … so to them pregnancy is not a disease, it’s like, I am not sick, I’m pregnant. It’s normal. I will get better” (SSP-Rural Town).
Health care providers in Canada tend to view pregnancy and childbirth as a “medical event” rather than a normal physiological process. Indeed this very issue may create “cultural dissonance.”
Another issue related to cultural values for some ethnocultural groups, particularly those of the Muslim religious faith, was the unacceptability of being cared for (especially being physically examined) by a male physician or nurse. This barrier seemed strong for some women and sometimes prevented them from using healthcare services: “They have request of not seeing male at all in their care. So that involves like the residents, so any medical students or resident who we have … that ethnic group refuse to have male” (HCP-Urban Town). Another HCP noted: “It’s been 35 years since they’ve had a pap because they don’t want to, come and see [a] male doctor” (HCP- Rural Town).
It was reported by one HCP that some IW may even reject the emergency services of a male obstetrician, “You know, an emergency during labour, in which case we needed the obstetricians to help but they didn’t want a man under no circumstances.” The comments elicited from care providers on this topic tended to be pejorative in nature rather than adopting a “woman centred” approach affording respect for religious and cultural diversity.
Inadequate healthcare system
It’s hard to find a family doctor because I phoned everyone … it took me for a while, and then you can’t go with him because his appointment [book] was full. I phoned a lot of clinics and then they cannot accommodate. (IW-Rural Town) It might take up to one year to find a family doctor. Moreover, after finally getting a family doctor and referral to a specialist clinic there was often another long waiting period because of the shortage of gynecologists or obstetricians. Some women complained that they received their first appointments in the advanced stages of their pregnancy. The issue of long wait periods was a great barrier to accessing care at an appropriate time.
Cost of medicines/services
The doctor prescribed medication, which cost about a hundred dollars than she’s expected to pay for. Every month she’s supposed to pay to buy that … she doesn’t earn a lot of money and child tax is not a lot of money. (IW-Urban Town)
For example, one that we use for nausea and vomiting in pregnancy, Diclectin, is very expensive and it isn’t, if you don’t have a great plan it isn’t covered, or if you don’t have a plan it’s very, very expensive. (HP-Urban Town)
I have seen like some pharmacists, whereby when the family presented the, IFH, and they say: No, not covered … I do not deal with that. I know it’s covered but they don’t want to process it, and they make the client pay the money. (SSP-FGI- Urban Town)
At that moment we did not have the bucks to provide the $650, $600 dollars that (the operation) costs. Then I was going to do it, but that will be in the long term, because in that moment we did not have it. (IW-Urban Town)
Factors influencing client satisfaction
IW who had experienced positive birth outcomes and the birth of healthy infants were very satisfied with their maternity care. Despite this, several important issues were identified that negatively influenced the IW’s perception of the quality of Canadian maternity care, they included: lack of understanding of the informed consent process, lack of respect for IW’s privacy, short consultation times, immediate discharge from the hospital after birth, discrimination and stereotyping, and cultural shock.
Full comprehension of the process of informed consent
You’re trying to offer them an operation for what you feel are correct reason[s], so whether they understand English or don’t understand English, one could argue that their consent is perhaps not optimal in a stressful situation. (HCP- Urban Town)
An IW who thinks that a doctor will make decisions about her birthing method without consulting her will feel that her autonomy is compromised: They are going to take the baby with the C-section; I know that … there might be something that might cause the caesarean section. It can have side effect of, you know, progress of labour … if you have epidural you’re going to have a higher chance of C-section. (IW-FGI-Urban Town)
Nurse asks me: you know about HPV test? So I said: I don’t know. She said to me: you suggest yes or no? So I said no because I can’t understand so that’s why I said no. (IW-Rural Town)
Lack of privacy for a patient’s confidential information
I also have another client who has been hospitalized many times and people will come to visit her, and some people are curious and they will go to the front desk and ask: What happened to her? Why is she sick? And the nurse out loud told them. (HCP-FGI-Urban Town)
In such cases the ethical principle of confidentially has been transgressed.
Short consultation time
… [They are] quick [like]: “Okay, how are you feeling today?” “Oh, I feel better.”
“Oh. Okay. Do you feel painful?” “No.” “Okay, you can go.” Like I don’t care.
That’s the information but, I don’t care about you. Just the doctor in this way, just cold. (IW-Urban Town)
The preceding statement suggests a lack of trust and empathy during the health care interaction.
Another IW opined: “… this doctors have so little time for you anyway. They come five minutes maximum and then he’s gone, so he doesn’t ask you a lot of questions, if you forget, then next time” (IW-FGI-Urban Town).
“All I need [from physician] is to pay a little attention; more time and attention.
That is enough I think” (IW-Urban Town). This participant clearly expressed a need for a greater level of therapeutic care and enhanced communication.
Discharge immediately from the hospital
… in China after you deliver you can stay in hospital one week. And because in the first 72 hours [is] very important for the woman so they always stay in hospital and get some medicine to help … but here the doctor or the nurses just gave her the feeling that they want to push her out. (IW-Urban Town)
Although these women were satisfied with the quality of the care they received, they felt that HCPs were mostly concerned with “pushing” them out of the hospital: “After the C-section I was really weak in the hospital and I stayed there for three nights. Three nights and then you have to go home” (IW-Urban Town).
She preferred to stay in the hospital a little bit longer, maybe one more day or anything. But [the] OB didn’t care and sent her home and then she actually fainted or lost consciousness at home and then her husband would have to call 911 and send her back to the hospital. (IW-Urban Town)
Discrimination and stereotyping
The notion of cultural safety is predominant in Canadian health research, practice, and policy. Cultural safety is the recognition of power relationships between healthcare providers, patients, and clients [51, 52]. Recognition is required of the colonial and often racist historical antecedents that have created these power relationships, and the promotion of well-being [51, 53]. Key components of cultural safety are that we, as health professionals and researchers, are all bearers of the culture, that the unequal power relationships within society need to be recognized, and that the historical antecedents of these unequal power relationships need to be acknowledged . Hence, the concept recognizes the processes of colonization that many immigrant women may have experienced in their home countries, and we acknowledge the primacy of white Eurocentric perspectives in the Canadian context. The concept has been widely embraced by Aboriginal groups in Canada, but the key tenets and axioms of cultural safety are equally pertinent to observe in research with immigrant populations [54, 55].
I never thought that there was as much discrimination in Urban Town until I started working in here with more immigrant people … . (SSP -Urban Town) Probably it’s the people of colour versus the white. It may not be – because you don’t know if they’re citizen or not. Whether you’re a citizen or not, if you are white then there is a different kind of treatment, like more special treatment than, you know, other. (SSP-FGI-Urban Town)
Most of the immigrant and mostly refugees, I think they come to Canada and everything to be given to them, so they treat us a little bit like a hotel … and some of them are very demanding … They are all quite easy except for the [ethnic group name] . They are the most demanding. (HCP-Rural Town).
It was reported that older pregnant women from African communities get targeted for more prenatal care, in the form of more medical tests, and even get “ear-marked” for
When you are pregnant and if you are over 30 …in the African community, the doctors scared to hell. You have to do this, you have to do that. You do this, we have to test this, we have to give you the amnio … so start talking to you about C-section. (IW-FGI-Urban Town)
You assess basically at the door and you know what’s happening and then you, you know, you plan your action before the patient hits the stretcher sort of … like I‘ve had practitioners say: you know what? All those people from such and such a country; they all have more than one wife. (HCP-Urban Town)
The kind of treatment you get before you have a baby and then after you have a baby is completely different, and there’s things for us, we’re used to getting that treatment after we have birth, culturally … I think it’s the system, the ways it’s set up is that right after you have a baby it’s like: Get on it, like move on. Whereas in our culture we’re supposed to be looked after for 40 days, 60 days, so we expect that”
Divergence in food choices and nutrition
Chinese or Asian basically, we don’t drink cold water after [birth], and they give you a bottle of ice chips … for us it’s totally unacceptable. And also, like cold foods – sandwich, salad, cereal. Oh, my gosh, we don’t eat those things. (IW- FGI-Urban Town)
So right now when we have the prenatal class we always tell the clients, like if the ask you to go wash, take a bath, shampoo, whatever, just say yes and then you don’t need to do it. Don’t argue with them. (SSP-FGI-Urban Town)
My baby was crying during the night and I said [to nurse]: please can you take her in the nursery and so that she can be there and I can sleep … but she said: Here in North America, in Canada…you have to sleep with your baby. (IW-FGI- Urban Town)
Migrant women are reported to underutilize formal healthcare and other community services, largely because of language barriers, difficulties understanding healthcare information, experiences of discrimination, and challenges in navigating the Canadian healthcare system [24, 64, 65]. Moreover, the medicalized view of maternity promoted by Western biomedicine may powerfully influence immigrant women’s perceptions of maternal care in ways that may not be congruent with their frames of reference.
In light of the theories of organizational behaviour and critical realism, in this study barriers to accessing and navigating maternity care for immigrant women were explored at personal and structural levels. By studying these barriers in relation to organizational behaviour within healthcare units, we identified that although healthcare services are meant to be provided universally in the Canadian context, immigrant women experience inequity due to several personal and organizational barriers.
Maternity care in these situations fails to meet the specific needs of diverse populations and can be regarded as available but inaccessible to immigrant women of particular cultures. We also applied the theory of critical realism to understand the dialectical interplay between social structures (maternity care) and human agency (immigrant women) [34, 35]. Critical realism often addresses the causal relationship between personal (agency) and structural factors, such as norms, values, and beliefs that can influence an individual’s health and wellbeing [34, 37, 66]. Thus, to better understand the whole phenomenon and nature of the barriers and experiences, this study included three subpopulations: immigrant women, healthcare providers, and social service providers/stakeholders. This theoretical lens enabled us to elicit and uncover the multifaceted dimensions of barriers and experiences in respect of access to and navigation of maternity care services by immigrant women in rural and urban settings. Our findings indicate that some of the issues were commonly identified by all three study cohorts in both the rural and urban city sites in this study. Notably there is wide variation of demographic and ethnocultural profiles in Canadian cities. The critical realism theory illuminated our identification of the most critical points with respect to access to and navigation of maternity services by immigrant women. Some of these barriers are influenced by personal factors, such as lack of knowledge and low language proficiency by some of the immigrant women and discriminatory practices by some healthcare providers, while other factors are mostly structural, such as shortage of healthcare providers and inadequate professional interpreting services.
Inadequate language proficiency emerged as one of the main factors that limit access to Canadian maternity care services. This finding is supported by previous studies about immigrant health communication [15, 18, 67, 68]. A language barrier not only hinders communication but also limits access to the information resources about availability of services [15, 23]. Immigrant women who do not have information and knowledge about the availability of the services simply are not accessing these services. This challenges one important dimension of organizational behaviour theory, where the system aims to provide services universally, equally, and effectively for all members of the society . As our findings revealed, although the services are available equally for all members of the society, in practice the services are not accessible to immigrant women due to lack of newcomer awareness about existence of these services. Consultation times were also considered problematic. Participants who thought the consultation times were insufficient suggested that times could be allocated selectively to reflect the purpose of the visit; for example, a routine visit could be shorter than a visit that involved a health concern. Physician attention during the consultation was another issue. Some participants noted that a physician’s attention during consultation was divided among conferring with the client, working with a computer, and writing notes – to the extent that the client had to request the physician’s attention. Participants felt that the physician was not interested in what they were saying if he or she was distracted by other activities.
There is evidence that besides language barriers, lack of social networks is associated with a lack of information . Even though these sources of information may be informal, they form an important dimension. Some of the participants found that the information received contradicted their own customs and perceptions .
Our study supports previous findings that immigrant woman lose supportive networks from their home country and many do not find the social support they need in Canada [70, 71]. We found that lack of social support limits their ability to access maternity services, particularly when they have other children at home or no one to help them with transportation, as previously reported .
Another important issue related to organizational behaviour theory is that human resource challenges (healthcare provider shortage) can lead to negative or less satisfactory maternity outcomes . Indeed, our findings revealed that a lack or shortage of healthcare providers impacts greatly on the issue of access to and navigation of maternity healthcare facilities by immigrant women, as some women in this study could not obtain a family doctor for almost a year. This finding is consistent with earlier studies addressing the difficulties of finding desired physicians in Canada [73, 74]. Timely access to healthcare services is a major aim of organizational behaviour theory; reductions in waiting times and in delays for receiving healthcare services are important for wellbeing . A shortage of healthcare providers not only limits the reception of services in a timely manner, but also increases physician work load and may reduce consultation times, resulting in the provision of minimal services for all clients. In the consultation period, some of our participants perceived that that due to the physician’s workload, the physicians did not pay much attention to what they were saying.
A health organization needs to provide equal services for all clients, free of any stereotyping based on personal characteristics such as ethnicity or “race” [26, 74]. Our findings indicated that systematic  discrimination was experienced in Canada. In some situations, health insurance (Interim Federal Health) claims of refugees were not accepted by pharmacies and institutional discrimination was reported to be evident [18, 76]. This is mostly due to bureaucratic barriers that lead to the delay of payment by government and the time-consuming paper work required [18, 76, 77]. Other forms of discrimination were seen to be a result of lack of cultural competence . Cultural competency helps to reduce disparities in healthcare organizations [31, 78]. Lack of awareness about “others’” cultural norms and values can lead to misunderstandings or stereotyping of populations. Findings from this study support the probability that some immigrant women may have origins in countries where health beliefs and behaviours are in opposition to Western medical beliefs. Many of the women continued to follow their healthcare beliefs and some experienced cultural shock when confronted with different healthcare practices such as the types of food served in maternity wards and less focused postnatal care. In a pluralistic multicultural society such as Canada, cultural competency of healthcare providers plays an important role in providing sufficient healthcare services with reduced risk of misunderstandings [23, 29].
Perceptions of inadequate care experiences by service users can lead to resistance to utilising Canadian maternity care and discourage IW from using services in future instances [15, 75].Wood and Newbold [15, 65] recommend having continuous cultural competency training of medical science students and it is essential to achieve culturally competent health services to meet the needs of Canada’s multicultural society.
Limitations and strengths
The study was conducted in one province in Canada, therefore our findings are not necessarily universally transferable to all contexts, globally. The inclusion of immigrant women, services providers, and other key stakeholders is a strength of the study, as a 360 degree perspective is obtained on a specified phenomenon. Whilst we adopted a multi-faceted recruitment strategy it is possible we may not have recruited women with very poor language fluency and immigrant women who experience the most marginalisation. Women who are recently arrived in a new ethno-culture because of pre-migration experiences (e.g. war, civil unrest and transgression of human rights) may be reluctant to criticize state institutions and formal health care services.
Research on the reduction of barriers in accessing healthcare services is not only beneficial at personal and practical levels; it also supports important health policy and strategy messages. Clarity regarding the barriers, critical points, and other factors creating obstacles for immigrant women’s access to and navigation of healthcare services may help healthcare decision makers when planning and creating a more adequate system for meeting the needs of diverse societies.
Following immigration to a new ethnocultural context women may be faced with challenges such as diminished social networks and family support. Support from family and friends makes a difference because they can provide lay translation and interpretation services, accompany the women to healthcare appointments, provide child care during appointments, and encourage support during delivery.
We identify structural factors that limit access to maternity services by immigrant woman from various perspectives. The barriers to accessing maternity care were analysed using critical realism theory. Our findings indicate that maternity health services are not fully comprehensive and do not function at a level sufficient to serve immigrant women in the two cities in Alberta that received the study. Although data from qualitative research with a purposive sample obtained from two cities may not be generalized to the broader context of the country, many of the findings will be applicable to other jurisdictions, and to other countries. The results of this study show that maternity care in Canada would be hugely improved if the following recommendations were executed by health policy makers: (1) health informational packages need to be developed in different languages and dispersed widely throughout local populations; (2) continuous cultural competence programs, with a focus on personalized women- centered care, need to be created, and healthcare professionals must be required to undertake these programs; (3) healthcare professionals must be recruited from diverse ethnocultural groups; and (4) adequate monitoring and evaluation programs for prevention of personal and systemic discrimination must be implemented.
The authors thank Shireen Bell and Dr. Rebecca Malhi (Faculty of Nursing, University of Alberta) for their assistance with data collection and/or analysis, Tracey Kaczanowski (Alberta Health Services, Rural Town) for her great assistance with initiating the study and disseminating the findings in the study community, and Barbara Osswald (Faculty of Nursing, University of Alberta) for editing the manuscript. They would also like to thank Killa Ibraham Maragang of the Multicultural Health Brokers Co-operative (Urban Town) for her assistance with participant recruitment, organizing and translating during the focus groups, and for commenting on the manuscript draft. This study was funded by an emerging team grant from the Faculty of Medicine and Dentistry (University of Alberta), Alberta Health Services, and the Women and Children’s Health Research Institute (Urban Town, Alberta). The funders had no role in the study design, or in the collection, analysis, and interpretation of data, nor did they assist or influence the writing of the manuscript or partake in the decision to submit the manuscript for publication.
This work was funded in part by GH’s Canada Research Chair ( http://www.chairs-chaires.gc.ca10.1186/s12884-015-0773-- chaires.gc.ca/).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Hugo G. Migrants in Society: Diversity and Cohesion. Adelaide: Global Commission on International Migration; 2005.Google Scholar
- Bloemraad I. Understanding “Canadian Exceptionalism” in Immigration and Pluralism Policy. Washington: Migration Policy Institute; 2012.Google Scholar
- Canada S. Population Growth in Canada: from 1851 to 2061 (Census in Brief No. 98-310-X2011003). Ottawa, ON: Statistics Canada; 2011.Google Scholar
- Canada S. Canada Census Profile (Census No. 98-316-XWE). Ottawa, ON: Statistics Canada; 2012.Google Scholar
- Caron ME, Lebel A, Martel L. Projections of the Diversity of the Canadian Population, 2006 to 2031. (No. 91-551-x). Ottawa, ON: Statistics Canada; 2010.Google Scholar
- DesMeules M, Gold J, McDermott S, Cao Z, Payne J, Lafrance B, et al. Disparities in mortality patterns among Canadian immigrants and refugees, 1980–1998: results of a national cohort study. J Immigr Health. 2005;7:221–32. 10.1007/s10903-005-5118-y, 19813288View ArticlePubMedGoogle Scholar
- DesMeules M, Kazanjian A, Maclean H, Payne J, Stewart DE, Vissandjee B. Women's health surveillance report: introduction. BMC Womens Health. 2004;4 Suppl 1:S1. 2096695, 10.1186/1472-6874-4-S1-S1, 15345064View ArticlePubMedPubMed CentralGoogle Scholar
- Vissandjee B, Desmeules M, Cao Z, Abdool S, Kazanjian A. Integrating ethnicity and migration as determinants of Canadian women's health. BMC Womens Health. 2004;4 Suppl 1:S32. 2096680, 10.1186/1472-6874-4-S1-S32, 15345095View ArticlePubMedPubMed CentralGoogle Scholar
- Canadian International Development Agency: Maternal, Newborn and Child Health. [http://www.acdi-cida.gc.ca/acdi-cida/acdi-cida.nsf/eng/FRA-127113657- MH7]
- World Health Organization (WHO). Maternal Health, 2013. [http://www.who.int/topics/maternal_health/en/]
- Canadian Institute for Health Information. Giving Birth in Canada: The Costs. Ottawa, ON: Canadian Institute for Health Information; 2006.Google Scholar
- Laroche M. Health status and health service utilization of Canada’s immigrant and non-immigrant populations. Canadian Public Pol. 2001;7:51–73.Google Scholar
- Canada H. Family-Centred Maternity and Newborn Care: National Guidelines. Ottawa, ON: Minister of Public Works and Government Services; 2000.Google Scholar
- Shieh C, Mays R, McDaniel A, Yu J. Health literacy and its association with the use for information sources and with barriers to information seeking in clinic based pregnant women. Health Care Women I. 2009;30:971–88. 10.1080/07399330903052152View ArticleGoogle Scholar
- Wood J, Newbold KB. Providers perspective on barriers and strategies for achieving culturally sensitive mental health services for immigrants: a Hamilton, Ontario case study. Int Mig Integration. 2012;13:383–97.Google Scholar
- Crooks VA, Hynie M, Killian K, Giesbrecht M, Castleden H. Female newcomers' adjustment to life in Toronto, Canada: sources of mental stress and their implications for delivering primary mental health care. GeoJournal. 2011;76:139–49. 10.1007/s10708-009-9287-4View ArticleGoogle Scholar
- Gabriel PS, Morgan-Jonker C, Phung CM, Barrios R, Kaczorowski J. Refugees and health care--the need for data: Understanding the health of government- assisted refugees in Canada through a prospective longitudinal cohort. Can J Public Health. 2011;102:269–72. 21913581PubMedGoogle Scholar
- McKeary M, Newbold B. Barriers to care: the challenges for Canadian refugees and their healthcare providers. J Refug Stud. 2010;23:523–45. 10.1093/jrs/feq038View ArticleGoogle Scholar
- Higginbottom GM, Morgan M, Dassanayake J, Eyford H, Alexandre M, Chiu Y, et al. Immigrant women's experiences of maternity-care services in Canada: a protocol for systematic review using a narrative synthesis. Systematic Rev. 2012;1:27. 10.1186/2046-4053-1-27View ArticleGoogle Scholar
- Holmes E, Chick J. Health Promotion in Immigrant and Refugee Populations: Culturally Appropriate Strategies for Health Promotion. Calgary, AB: Alberta Health Services; 2009.Google Scholar
- Clark Callister L, Khalaf I. Culturally diverse women giving birth: their stories. Childbirth Across Cultures. 2009;5:33–9. 10.1007/978-90-481-2599-9_3View ArticleGoogle Scholar
- Gagnon AJ, Dougherty G, Platt RW, Wahoush O, George A, Stanger E, et al. Refugee and refugee-claimant women and infants post-birth: migration histories as a predictor of Canadianhealth system response to needs. Can J Public Health. 2007;98:287–91. 17896738PubMedGoogle Scholar
- Higginbottom GMA, Richter MS, Young S, Ortiz LM, Callender SD, Forgeron J, et al. Evaluating the utility of the FamCHAT ethnocultural nursing assessment tool at a Canadian tertiary care hospital: a pilot study with recommendations for hospital management. J Nursing Prac. 2012;2(2):24–40.Google Scholar
- Higginbottom GMA, Bell S, Arsenault J, Pillay JP. An integrative review of experiences of maternity services for immigrant women in Canada. Diversity Equality in Health Care. 2012;9(4):253–66.Google Scholar
- Higginbottom GM, Safipour J, Mumtaz Z, Chiu Y, Paton P, Pillay J. I have to do what I believe”: Sudanese women’s beliefs and resist ance to hegemonic practices at home and during experiences of maternity care in Canada. BMC Pregnancy Childbirth. 2013;13:51. 3599128, 10.1186/1471-2393-13-51, 23442448View ArticlePubMedPubMed CentralGoogle Scholar
- Borkowski N. Organizational behavior, theory, and design in health care. Ontario: Jones & Bartlett Learning; 2008.Google Scholar
- Godwyn M, Gittell JH, editors. Sociology of Organizations: Structures and Relationships. Los Angeles: SAGE; 2011.Google Scholar
- Ashour AS. The contingency model of leadership effectiveness: an evaluation. Organ Behav Hum Perf. 1973;9(3):339–55. 10.1016/0030-5073(73)90057-3View ArticleGoogle Scholar
- Gordon J. Diversity in health care. In: Brokowski N, editor. Organizational Behavior, Theory, and Design in Healthcare. Ontario: Jones & Bartlett Learning; 2008. p. 17–40.Google Scholar
- Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19(2):101–10. 1492144, 10.1111/j.1525-1497.2004.30262.x, 15009789View ArticlePubMedPubMed CentralGoogle Scholar
- Weech-Maldonado R, Elliott MN, Pradhan R, Schiller C, Dreachslin J, Hays RD. Moving towards culturally competent health systems: organizational and market factors. Soc Sci Med. 2012;75:815–22. 3669592, 10.1016/j.socscimed.2012.03.053, 22647564View ArticlePubMedPubMed CentralGoogle Scholar
- Brach C, Keller D, Hernandez LM, Baur C, Parker R, Dreyer B, Schyve P, Lemerise AJ, Schillinger D: Ten Attributes of Health Literate Healthcare Organizations (Discussion Paper). Washington: Institute of Medicine of the National Academies; 2012.[http://www.ahealthyunderstanding.org/.../IOM_Ten_Attributes_HL_Paper.pdf].
- Abrahamson P. Social exclusion in Europe: old wine in new bottles? J Druzboslovne Razprave. 1995;6(19–20):119–36.Google Scholar
- Lewis P. Realism, causality and the problem of social structure. J Theory Soc Behav. 2000;30(3):249–68. 10.1111/1468-5914.00129View ArticleGoogle Scholar
- McEvoy P, Richards D. Critical realism: a way forward for evaluation research in nursing? J Adv Nurs. 2003;43(4):411–20. 10.1046/j.1365-2648.2003.02730.x, 12887360View ArticlePubMedGoogle Scholar
- Clark AM, Maclntyre PD, Cruickshank J. A critical realist approach to understanding and evaluating heart health programmes. Health. 2007;11(4):513–39. 17855471PubMedGoogle Scholar
- Connelly J. A realistic theory of health sector management: the case for critical realism. J Manag Med. 2000;14(5):262–71. 10.1108/02689230010362882, 1:STN:280:DC%2BD3M7jt1Chtw%3D%3D, 11200295View ArticlePubMedGoogle Scholar
- Brewer JD. Ethnography. Buckingham: Open University Press; 2000.Google Scholar
- Fetterman DM. Ethnography: Step by Step. 3rd ed. Thousand Oaks, CA: Sage Publications; 2010.Google Scholar
- Roper JM, Shapira J. Ethnography in Nursing Research. London: Sage Publications; 2000. 10.4135/9781483328294View ArticleGoogle Scholar
- Cruz E, Hgginbottom G. Focused ethnography in nursing research. Nurse Res. 2013;20(4):36–43. 10.7748/nr2013.03.20.4.36.e305, 23520711View ArticlePubMedGoogle Scholar
- Muecke MA. On the evaluation of ethnographies. In: Morse JM, editor. Critical Issues in Qualitative Research Methods. Thousand Oaks, California: SAGE; 1994. p. 187–209.Google Scholar
- Polit-O'Hara D, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. Philadelphia, PA: Lippincott Williams and Wilkins; 2010.Google Scholar
- Streubert Speziale HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative. 3rd ed. Philadelphia, PA: London: Lippincott Williams & Wilkins; 2003.Google Scholar
- Citizenship and Immigration Canada. anada Facts and Figures: Immigration Overview. Ottawa, Ontario: Research and Evaluation Branch, Citizenship and Immigration Canada; 2011.Google Scholar
- Canada S.Immigrant Population by Place of Birth, by Census Metropolitan Are (2006 census). Statistics Canada: Ottawa, ON; 2007.Google Scholar
- Meadows ML, Wilfreda ET, Melton C. Immigrant women's health. Soc Sci Med. 2001;52(9):1451–8. 10.1016/S0277-9536(00)00251-3, 1:STN:280:DC%2BD3MzisVCrtw%3D%3D, 11286368View ArticlePubMedGoogle Scholar
- Higginbottom GM, Pillay J, Boadu N. Guidance on performing focused ethnographies with an emphasis on healthcare research. Qual Rep. 2013;18(17):1–13.Google Scholar
- Friese S. Qualitative Data Analysis with ATLAS.ti. London: Sage; 2012.Google Scholar
- Canadian Institute for Health Information. Giving Birth in Canada: Providers of Birth and Maternity Care. Ottawa, ON: Canadian Institute for Health Information; 2004.Google Scholar
- Ramsden IM: Cultural safety and nursing education in Aotearoa and Te Waipounamu (Unpublished doctoral dissertation) Victoria University of Wellington, New Zealand; 2002. Retrieved from http://www.nzno.org.nz/resources/library/theses. February 7, 2011.
- National Aboriginal Health Organization. Cultural competency and safety: a guide for healthcare administrators, providers and educators. Ottawa, ON: Author; 2008.Google Scholar
- Nursing Council of New Zealand: Guidelines for cultural safety, the treaty of Waitangi, and Maori health in nursing and midwifery education and practice (2nd ed.) Wellington 2009.Google Scholar
- Salway S, Allmark P, Barley R, Higginbottom G, Gerrish K, Ellison GTH: Researching ethnic inequalities. Social Research Update 2009,No. 58—Winter 9Google Scholar
- Salway S, Allmark P, Higginbottom GMA, Gerrish K, Ellison G. Social research for a multiethnic population: Do the research ethics and standards guidelines of UK Learned Societies address this challenge? 21st. Century Soc. 2009;4(1):53–81. 10.1080/17450140802483688View ArticleGoogle Scholar
- Higginbottom GMA, Safipour J, Yohani S, O’Brien B, Mumtaz Z, Paton P: An ethnographic study of communication challenges in maternity care of immigrant women in rural Alberta. Midwifery 2015, 31(2): 297–304. DOI: http://dx.doi.org/https://doi.org/10.1016/j.midw.2014.09.009
- Higginbottom GMA, Morgan M, Alexandre M, Chiu Y, Forgeron J, Kocay D, et al. Immigrant women’s experiences of maternity-care services in Canada: a systematic review using a narrative synthesis. Systematic Rev. 2015;4:13. doi:https://doi.org/10.1186/2046-4053-4-13.View ArticleGoogle Scholar
- Meddings F, Haith-Cooper M. Cultural and Communication in Ethically Appropriate Care. Nurs Ethics. 2008;15:52–61. 10.1177/0969733007083934, 18096581View ArticlePubMedGoogle Scholar
- Reitmanova S, Gustafson DL. “They can’t understand it”: maternity health and care needs of immigrant Muslim women in St John’s, Newfoundland. Matern Child Health. 2008;12:101–11. 10.1007/s10995-007-0213-4View ArticleGoogle Scholar
- Guendelman S, Siega-Riz AM. Infant feeding practices and maternal dietary intake among Latino immigrants in California. J Immigr Health. 2002;4(3):137–46. 10.1023/A:1015698817387, 16228757View ArticlePubMedGoogle Scholar
- Harley K, Eskanazi B, Block G. The association of time in the US and diet during pregnancy in low-income women of Mexican descent. Paediatr Perinat Epidemiol. 2005;19(2):125–34. 10.1111/j.1365-3016.2005.00640.x, 15787887View ArticlePubMedGoogle Scholar
- Hyman I, Dussault G. Negative consequences of acculturation on health behavior, social support and stress among pregnant Southeast Asian immigrant women in Montreal: an exploratory study. Can J Public Health. 2000;91(5):357–60. 1:STN:280:DC%2BD3M%2FkvFWjtA%3D%3D, 11089289PubMedGoogle Scholar
- MacDonald JT, Kennedy S. Is migration to Canada associated with unhealthy weight gain? Overweight and obesity among Canada’s immigrants. Soc Sci Med. 2005;61:2469–81. 10.1016/j.socscimed.2005.05.004View ArticleGoogle Scholar
- Higginbottom GMA, Hadziabdic E, Yohani S, Paton P. Immigrant women’sexperiences of maternity services in Canada: a meta-ethnography. Midwifery. 2014;30(5):544–59. doi:https://doi.org/10.1016/j.midw.2013.06.004. 23948185View ArticlePubMedGoogle Scholar
- Mumtaz Z, O’Brien B, Higginbottom G. Navigating maternity health care: a survey of the Canadian prairie newcomer experience. BMC Pregnancy Childbirth. 2014;14:1–4. 10.1186/1471-2393-14-1View ArticleGoogle Scholar
- Sword W, Clark AM, Hegadoren K, Brooks S, Kingston D. The complexity of postpartum mental health and illness: a critical realist study. Nurs Inq. 2012;19(1):51–62. 10.1111/j.1440-1800.2011.00560.x, 22212370View ArticlePubMedGoogle Scholar
- Binder P, Borne Y, Johnsdotter S, Essen B. Shared language is essential: communication in a multiethnic obstetric care setting. J Health Commun. 2012;17(10):1171–86. 10.1080/10810730.2012.665421, 22703624View ArticlePubMedGoogle Scholar
- Ng E, Pottie K, Spitzer D. Official language proficiency and self-reported health among immigrants to Canada. Health Rep. 2011;22(4):15–23. 22352148PubMedGoogle Scholar
- Courtright C. Health information-seeking among Latino newcomers: an exploratory study. Inform Res. 2005;10(2):1–10.Google Scholar
- Collins CH, Zimmerman C, Howard LM. Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors. Arch Women Ment Hlth. 2011;14(1):3–11. 10.1007/s00737-010-0198-7View ArticleGoogle Scholar
- Miszkurka M, Goulet L, Zunzunegui MV. Contributions of immigration to depressive symptoms among pregnant women in Canada. Can J Public Health. 2010;101(5):358–64. 21214048PubMedGoogle Scholar
- Johnson JA. Organization theory and organizations. In: Health Organizations: Theory, Behavior and Development. 1st ed. Johnson JA. Ontario, ON: Jones & Bartlett Publishers; 2008. p. 1–9.Google Scholar
- Asanin J, Wilson K. I spent nine years looking for a doctor": exploring access to healthcare among immigrants in Mississauga, Ontario, Canada. Soc Sci Med. 2008;66(6):1271–83. 10.1016/j.socscimed.2007.11.043, 18194831View ArticlePubMedGoogle Scholar
- Wang L, Rosenberg M, Lo L. Ethnicity and utilization of family physicians: a case study of mainland Chinese immigrants in Toronto. Canada Soc Sci Med. 2008;67(9):1410–22. 10.1016/j.socscimed.2008.06.012, 18692946View ArticlePubMedGoogle Scholar
- Edge S, Newbold B. Discrimination and the health of immigrants and refugees: exploring Canada’s evidence base and directions for future research in newcomer receiving countries. J Immigr Minor Health. 2013;15(1):141–8. 10.1007/s10903-012-9640-4, 22729289View ArticlePubMedGoogle Scholar
- Miedema B, Hamilton R, Easley J. Climbing the walls: structural barriers to accessing primary care for refugee newcomers in Canada. Can Fam Physician. 2008;54(3):335–6. 2278339, 18337519PubMedPubMed CentralGoogle Scholar
- Spitzer DL. In visible bodies: minority women, nurses, time, and the new economy of care. Med Anthropol Q. 2004;18(4):490–508. 10.1525/maq.2004.18.4.490, 15612412View ArticlePubMedGoogle Scholar
- Brach C, Fraser I. Reducing disparities through culturally competent health care: an analysis of the business case. Qual Manag Health Care. 2002;10(4):15–28. 10.1097/00019514-200210040-00005, 12938253View ArticlePubMedGoogle Scholar