Telemedicine: Bridging the Gap between Refugee Health and Health Services Accessibility in Hamilton, Ontario.

Author:Sandre, Anthony Robert
 
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Abstract

Refugees face considerable challenges upon seeking asylum in Canada, and accessing health care services remains a prominent issue. Recurrent themes in the literature outlining barriers to health-services accessibility include geographic, economic, and cultural barriers. Drawing on the experiences of service providers in Hamilton, Ontario, we explored the efficacy of telemedicine services in bridging the gap between refugee health and health-services accessibility. Research methodology included structured interviews with clinicians who provide health-care services to refugees, complemented by a scoping literature review. The results of this exploratory study demonstrate the efficacy of telemedicine in encouraging dialogue and policy change in the greater health-care setting, and its potential to increase access to specialist health-care services.

Resume

Les refugies doivent faire face a des defis considerables lors du processus de demande d'asile au Canada, et l'acces aux services de sante demeure un enjeu important. Parmi les preoccupations qui reviennent frequemment dans la documentation portant sur l'accessibilite aux services de sante sont les obstacles de nature geographique, economique, et culturelle. En nous basant sur l'experience vecue des fournisseurs de service etablis a Hamilton, en Ontario, nous etudions l'efficacite des services de telemedecine a combler l'ecart entre les besoins en matiere de sante des refugies et l'accessibilite aux services de sante. La methodologie de recherche comportait des entrevues structurees avec le personnel traitant charge de fournir des services de sante aux refugies, accompagnee d'une revue exploratoire de la documentation sur le sujet. Les resultats de cette etude exploratoire ont demontre l'efficacite de la telemedecine a stimuler le dialogue et le changement en matiere de politique dans le contexte general des services de sante, ainsi que sa capacite a accroitre l'acces aux services de sante specialises.

Introduction

The social, (1) health, (2) and medical (3) needs of refugee populations are unique. Refugees are more likely to have experienced combat and domestic violence; (4) political instability and political warfare; death of family and friends; and culture shock. (5) The combination of these adverse events before, during, or after migration frequently manifest as physical and mental health issues, predominantly post-traumatic stress disorder, generalized anxiety disorder, and depression. (6)

Several international systematic reviews have outlined general barriers to accessing health-care services across all vulnerable populations, i.e., immigrants, refugees, and asylum-seekers. Carrasco, Gillespie, and Goodluck outline the challenges for immigrants in accessing primary-care services in Canada, where primary care is considered to be the first point of contact with medical services or the health-care system, usually mediated by a family physician. (7) Medical practitioners who were unable to address the needs of immigrants, that is, unwilling to accommodate the culturally sensitive demands of the patient or unwilling to participate in culturally sensitive training, deterred patients from accessing services. (8) Joshi et al. draw on similar principles in emphasizing the need to provide identical health care to refugees and other members of the general public. (9) The authors call for regular physician-patient communication in the provision of primary-care services in order to improve access to and quality of health-care services. (10) Hadgkiss and Renzaho explored the utilization of healthcare services for asylum-seekers in Australia. Six general themes were identified: affordability, including transportation and prescription medication costs; poor health literacy and understanding of the health system; perceived effectiveness and quality of health services; medical mistrust; discrimination and health professionals' attitudes, or witnessed substandard treatment of patients; and linguistic and cultural factors. (11)

Accessibility to health care in Canada is guided by the 1984 Canada Health Act, with the over-arching objective to ensure that all medically necessary services will be provided free of charge, with the implication of unimpeded access to health-care services for all. (12) In considering these principles and the fluidity of the Canadian refugee population, the Government of Canada enacted the Interim Federal Health Program (IFHP). (13) Currently, and following major restructuring in 2012, 2014, and again in 2016, the IFHP provides health coverage to protected persons (resettled refugees), government-assisted refugees, refugee claimants, and other specified groups. (14) The IFHP is a temporary health insurance program for non-Canadian citizens, and six types of coverage are offered on the basis of immigration status of the individual. (15) Recurrent barriers, including a limited number of subsidized health services, call for a solution to health services accessibility between clinician and patient. (16)

Telemedicine or telehealth, which refers to the provision of health-care services using specialized technology, (17) spans consultation, (18) referral, diagnosis, treatment, and follow-up. (19) Notably, over an array of medical specialties, telemedicine has been shown to increase satisfaction for patient and health-care provider; (20) increase services access for vulnerable and distant populations; (21) and improve linguistic and cultural appropriateness of care. (22) Within Ontario, existing and well-known telemedicine services include Telehealth Ontario (23) and the Ontario Telemedicine Network (OTN). (24) Telehealth Ontario provides patients with 24/7 phone access to a registered nurse who may assist in symptom management and/or booking appointments with other health-care providers; all services are free for citizens of Ontario. (25) The OTN was created to link patients in rural and remote settings with health-care providers across the province using two-way videoconferencing. (26) Although telemedicine is classified as an uninsured service, physicians offering their services through OTN will submit their bills for consultation to the Ontario Health Insurance Program (OHIP). (27) In light of the IFHP and its divide from OHIP, the medical-legal landscape in Canada poses immediate barriers to the care of refugee patients via technology, e.g., Telehealth and OTN.

While several authors have explored the efficacy of telemedicine in addressing the health intricacies of vulnerable and underserved populations, few authors have explicitly focused on its applicability to refugee populations. Herein, we propose telemedicine as a means to bridge the gap between refugee-health and health-services accessibility for refugee populations. The objective of this study is to explore the efficacy of telemedicine for remediating health-services accessibility for refugees, with special attention paid to accessing specialist care. In order to understand the relationship between telemedicine and health-services accessibility for refugee populations, research methodology included structured interviews with clinicians who provide health care to refugees in Hamilton, complemented by a scoping literature review focused on the implementation and delivery of telemedicine services to vulnerable and/or underserved populations. This study will also contribute to the existing literature concerned with barriers to accessing health-care services for refugee populations. The authors hope that this study will serve as a dialogue piece surrounding health inequity for refugees, and will encourage clinicians to implement telemedicine services in their practice.

Methods

Two research methods were used to explore the efficacy of telemedicine to bridge the gap between refugee health (and its intricacies) and health-services accessibility. Data obtained from structured interviews with health-care professionals who provide health care to refugees in Hamilton were complemented by a scoping literature review.

Qualitative research methods provide an understanding of personal truths, and five physicians and one nurse practitioner were interviewed in 2015 and 2016. Research ethics board clearance was obtained from the Hamilton Integrated Research Ethics Board of McMaster University. Non-probability, purposive sampling of health-care professionals was performed to obtain the study sample. Three family physicians, one internal medicine subspecialist (subspecializations: medical microbiology and infectious diseases), one pediatrician, and one nurse practitioner were interviewed. In an effort to improve the credibility of results, we sampled a unique and interdisciplinary team, including one family physician who was a former refugee. Participants were contacted by electronic mail and were identified using physician referral and/or place of employment. Participants were fully informed of the research objective, study design, results reporting, confidentiality of information, and the intended use of results. Participants remain anonymous, save professional qualifications. One-on-one interviews were recorded, and each respondent was asked six questions about the implementation and delivery of telemedicine services when serving refugee populations.

Open coding methods were utilized to interpret the collected data, and underlying themes were identified, labelled, and categorized. (28) In order to elucidate an in-depth understanding of the opinions of the health-care providers and their experiences in working with refugees, analysis followed grounded theory. Grounded theory methodology necessitates constant comparison between accounts, i.e., health-care provider perceptions, and through repeated and systematic assessment, the author is able to generate social truths grounded in empirical data. (29)

A scoping literature review was conducted in order to complement interview data and to...

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