Reprinted from the "Health Literacy" issue of Visions Journal, 2013, 8 (2), pp. 20-23
When you arrive in Canada as an immigrant, everything is new—from where to stay to where to buy groceries. Of course, understanding how the health care system works is extremely important because it’s about your health. When you come, you carry an idea of how the system works in your country, but you have no idea how to get a doctor here.
I will give you my personal example. I come from India, where there is no government health care. There is only private health care. I just have to look for a doctor, any doctor, and I can enter his clinic. That’s how I will access services, and I don’t need to be in the government system for that. Here, you need a CareCard to access service, or, if you are a visitor, you need to have health insurance. I knew about this system, but it was a system that I was not used to.
Health literacy starts right from there—understanding how the system works in Canada. It’s the ability and knowledge to get a CareCard, and then find a family doctor that has space for you. That was new for me. I thought I could just approach any doctor in the community and they should take me on, but I realized that was not the case. They have to have space for you.
If you don’t have a family doctor, you have to go to a walk-in clinic. That can be quite hard for a lot of immigrants who have come from developing countries or countries where there is no government health care. When you have your own doctor and you have a relationship with that doctor, going to a walk-in clinic can be very hard. You’re talking about something which is very personal, very private. Even if it’s the common cold, you still have to explain everything—if you have certain allergies, for example. It’s something that you may not be used to.
In order to understand the factors that affect health literacy in immigrants, it is important to understand that immigrants are a diverse group coming from different countries, religions, cultures, and ethnic backgrounds. There are also categories in how a person comes as an immigrant to Canada. You can come as a skilled immigrant, under family reunification, or as a common-law partner. If you have come here as a skilled immigrant, you have already come with a set of skills and a certain level of education. But if you have come as a grandparent under the family reunification plan, your health literacy will be quite different than that of a skilled immigrant who is coming in at the age of thirty.
There is so much information that you have to learn when you come to Canada as an immigrant. When I interviewed a settlement worker, she put it very well, saying that health literacy comes in a bit later. You do your initial part in getting a CareCard, but the basic things—finding a job, getting your children into school, finding a safe place to stay—come first. Of course you never know what might happen in the future, but the immigrants who come here are generally healthy, both physically and mentally.
However, immigration does affect your mental health. You may have high anxiety when you come here, especially if English is not your first language. You may come in as a very hopeful person, but not having the language can isolate you so much that it can have an effect on your mental health. This doesn’t mean that you’ll experience depression or any sort of anxiety disorder, but it’s important to recognize that it does take time to settle.
When I came to Canada as an immigrant, I could speak English, but there was still a certain level of anxiety. For example, you might get lost driving down the road. You don’t know the road. Getting lost in a place and not knowing where to stop or where to turn and who to ask for help—all of these little things cause a lot of anxiety. You may be a capable person, but it does take a toll on you.
Coming here as an immigrant and settling down is a process. It takes time. We do get an information package from the Canadian government when we come in, so it’s also that person’s responsibility to try and do something. In that sense, health literacy is actually related to time.
Suppose you need to go to the doctor in the first month of your arrival in Canada. That experience could be completely different from going to the doctor two years later. One recommendation would be to include this sort of information in the settlement process. For example, someone could write a fact sheet that explains what you could feel, such as feelings of being lost or having anxiety or not knowing the system. It would give people permission to understand that it is a process and you will feel lost at times.
Change starts with sensitivity
One change I would like to see at the point of service is sensitivity. This is sensitivity towards any person who walks through the door, not just cultural sensitivity. If the doctor or mental health clinician is not a first-generation immigrant, they may not understand what the person could be going through, why the person is not answering their questions, or why the person doesn’t understand something. It’s not that the person doesn’t understand the questions. The person may have their own anxiety, or they may have a certain image of a doctor or expectations of a doctor. But it’s a two-way process. Yes, the clinician needs to be sensitive, but the immigrant or newcomer to the country also needs to learn the process.
The human aspects of health literacy
I interviewed a mom as part of my research for this article. She had a baby born with a heart defect. English was not her first language, and she experienced distress and trauma because she was not able to understand directly what her child was going through. If someone could have explained it to her in her own language, she would have understood. Instead, she had to wait for her husband to translate this information. Very often, people assume that you don’t understand anything if you don’t understand English. It’s important that clinicians, doctors and nurses understand that people come with very good education. When people don’t look at you and make eye contact with you because you don’t speak English, your dignity is hurt in the process. This mom definitely wanted to know what was happening with her child, but she could not follow what the doctors were saying. That doesn’t mean she didn’t have the intellectual capacity or ability to understand.
I also interviewed a mom who had the opposite experience, where both parents were fluent in English and could understand what the doctors were saying. This mom had meetings with the doctors. Different people explained what was happening with the child and what the process of treatment would look like and handed her fact sheets. I can imagine how relieved this mother felt at every step and every level, knowing what was happening with her child because she knows the language. On the other side, you see the child that had a heart defect and had surgery at two months old. The mom had to wait for every piece of information to be translated for her. This is the human aspect of health literacy.
We have problems and we have solutions. That’s what the medical system is used to. But these solutions—sensitivity and dignity—are not that straight-forward. The doctor can’t just say one thing or do one thing and solve the problem. It’s absolutely about bringing human aspects into services. You have to listen to people’s emotions and look at the bigger picture.
Moving forward: Equity, not equality
In my diversity workshop, Safe Harbour, we talk about equitable treatment. Equitable treatment is fair treatment. The medical system has to think about treating people with equity, not equality. Whether you are an immigrant or non-immigrant, that equity piece is more important than anything else.
Dignity and dignifying processes are also important. I think the Canadian government does a lot. For example, there are a lot of services available in different languages, and settlement agencies provide people who can go along with you if you don’t speak the language.
Health literacy is a process. It’s not related to any individual, intelligence level, or anything else. Once people are settled—and that may take several years—things get easier. In spite of all the challenges, many immigrants improve their skills in navigating the system as they gain confidence and familiarity. It is this resiliency of the thousands of immigrants and new Canadians that needs to be recognized and valued so that their health and their positive contributions to Canadian society are sustained.