This study suggests that overall immigrants who make contact with the primary care system experience a similar level of access to, and somewhat higher utilization of, the primary health care system compared with Canadian-born. The rich data collected from this study allowed us to use a number of access measures to explore this relationship and to account for potentially relevant patient and practice factors that might impact access.
We found that recent immigrants reported poorer health compared to the Canadian-born, a finding that was not expected based on the healthy immigrant effect found in population surveys [2, 3]. This may be explained by two factors. First, we were unable to distinguish refugees and asylum seekers from other immigrants groups based on the data available. This may have biased our results towards finding a less healthy immigrant population as refugees report poorer health on arrival than other immigrant classes . Second, our study included immigrants who had already accessed primary health care and, thus, may have included less healthy immigrants who required more health care services.
We were encouraged to find that immigrant access to primary care across several measures of access did not differ significantly from Canadian-born. Primary care practice visits were equivalent or higher amongst immigrant groups compared to Canadian-born, after adjusting for factors that relate to need (age, sex, health status) suggesting that immigrants in this population had adequate access to care. Our results agree with previous research that found health care utilization for immigrants varies with years since arrival but over their lifespan immigrants have a similar level of utilization to the Canadian-born .
The higher use of primary care services reported by recent immigrants in our study can be reasonably explained by a number of factors both medical and socio-demographic [3, 21, 22]. We see a similar pattern of health care use in other vulnerable populations in Canada where, once initial contact is made, they have more frequent visits [23, 24]. Higher utilization for recent immigrants may be driven by initial preventative health care needs (such as vaccinations and health screening) or, given the high proportion of females in this immigrant group, by antenatal or postnatal visits. Socio-demographic variables such as poverty, culture and language may also drive utilization [5, 10, 25]. Newly arrived immigrants in our study were more likely to be low income, non-white and non-English or French speaking immigrants. Previous research has found that, due to language and cultural communication barriers, immigrants made repeated visits for the same problem because they did not fully understand the care provided in previous visits .
Our exploratory analysis of the impact of primary care model identified differences in the distribution of immigrants across models of care and in the access to, and utilization of, care by recent immigrants. More than half of all immigrants in Canada for less than 20 years received care in Community Health Centres; a distribution that may be appropriate given that Community Health Centres have a specific mandate to care for vulnerable populations. In our experience caring for newly arrived immigrants in an urban setting, these patients are often specifically directed to seek care in Community Health Centres. Recent immigrants in Fee-For-Service practices reported poorer access compared with Canadian-born and had fewer primary care visits compared to similar immigrants in other models. The lower performance in two access measures strengthens the likelihood that there may be barriers to access in this model. Recent research from Ontario has suggested that access to primary care services may be different across primary care models for vulnerable populations [26, 27]. Future research will need to explore the potential impacts of the organization and structure of primary care on immigrant populations.
The cross-sectional study design means the length of residence categories should be interpreted with caution, as these groups represent different arrival cohorts of immigrants and, thus, changing immigrant populations over time.
We acknowledge that some immigrant groups may have been underrepresented as our population was limited to only those who had accessed primary health care. Furthermore, while translators were available, immigrant patients who did not speak English or French or who had low literacy levels may have been excluded from the study. However, immigrants made up 21% of our study population, a proportion similar to that of the latest national census .
We acknowledge that self-reported measures are subject to recall bias and bias of past experience. For immigrants their past experience could have an important impact on their present experience. For example, those who come from countries with very limited access to health care might have lower expectations of care in Canada. We have attempted to minimize these biases by conducting the survey in the waiting room and with the use of access measures that are less subjective and measure patient experience, not simply satisfaction.