
==== Front
J Migr Health
J Migr Health
Journal of Migration and Health
2666-6235
Elsevier

S2666-6235(24)00013-8
10.1016/j.jmh.2024.100223
100223
Article
Patient-reported primary health care experiences in Canada: The challenges faced by Nepalese immigrant men
Dahal Rudra ab
Bajgain Bishnu Bahadur ab
Thapa-Bajgain Kalpana ab
Adhikari Kamala bc
Naeem Iffat b
Chowdhury Nashit bd
Turin Tanvir C turin.chowdhury@ucalgary.ca
bd⁎
a Nepalese-Canadian Community, Calgary, Alberta, Canada
b Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
c Department of Population and Public Health, Alberta Health Services, Calgary, Alberta, Canada
d Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
⁎ Corresponding author at: Department of Family Medicine, Cumming School of Medicine, University of Calgary, G012F, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. turin.chowdhury@ucalgary.ca
01 3 2024
2024
01 3 2024
9 10022324 12 2020
18 8 2023
28 2 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Despite the Canadian universal healthcare system, new immigrants face a number of challenges in accessing primary healthcare (PHC) services. As immigration to Canada consistently increases, understanding various types of barriers to PHC and how they differ across different sub-groups is critical. We conducted a qualitative study among Nepalese immigrant men to learn from their experience with PHC access to inform healthcare providers, stakeholders, and policymakers to devise feasible approaches to enhancing access to care.

Methods

We undertook a qualitative research approach employing focus groups among a sample of first-generation Nepalese immigrant men who had prior experience with accessing PHC in Canada.

Data collection and analysis

We conducted six focus groups in total with 34 participants (each group comprising 5–7 participants) in their preferred language, Nepalese, or English. Demographic information was collected prior to each focus group. Transcriptions of the discussions were prepared, and thematic analysis was employed in the qualitative data set.

Results

Participants reported experiencing barriers at two stages: before accessing PHC services and after accessing PHC services. The barriers before accessing PHC were long wait time for an appointment with physicians, limited knowledge of own health- and services-related issues, limited service availability hours, cultural differences in health practices, and transportation and work-related challenges. The barriers after accessing PHC were long wait time in the clinic to meet with the physicians at the time of appointment, communication challenges and misunderstandings, high healthcare costs associated with dental and vision care and prescribed medicines, and inappropriate behaviours and practices of doctors and service providers. To our knowledge, this is the first study in Canada which explored barriers faced by Nepalese immigrant men in accessing PHC.

Conclusions

This study identifies barriers to accessing PHC in Canada from a group of immigrant men's perspective. It is important to account for these while making any reforms and adding new care services to the existing healthcare system so that they are equitable for these groups of individuals as well.

Keywords

Nepalese
Immigrant
Access
Barrier
Primary healthcare
Knowledge
Primary care
Nepal
Canada
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pmcBackground

Migration across countries has risen due to increasing globalization, and this has led individuals from different cultures and countries to reside in a new host country that differs from their origin in terms of lifestyle, approach to healthcare, and overall living environment. Immigrants leave their countries of origin for various intentions, such as to secure better employment, escape from natural disasters and war, reunite with their families, and obtain a better education for improved personal development and growth (Walton-Roberts, 2011). According to Statistics Canada 2017, 7.5 million immigrant populations reside in Canada, which represents 21.9 % of the total population (Mehra et al., 2019). It is predicted that the immigrant population would reach up to 30.0 % in 2036 in Canada (Setia et al., 2011).

Canada has a universal, publicly funded healthcare system, a model of universal health coverage (Eriksson and Lindström, 2008). An essential principle of Canada's healthcare system is equity across ethnicity, gender, and socio-economic status. The system aims to promote equal access to adequate healthcare services, including primary healthcare (PHC) for the entire population, regardless of their immigration status and ability to pay (Eriksson and Lindström, 2008). Access to PHC implies the timely use of available health services to achieve the best health outcomes. Adequate access to PHC is associated with the increased use of PHC services, improved health outcomes, and reduced healthcare costs (Starfield, 2012; Starfield et al., 2005). In contrast, inadequate access to PHC leads to less utilization of PHC services, which contributes to poorer health outcomes (including increased risk of the severe form of health problems and complications, compromised quality of life) and increased use of health resources or interventions (Higginbottom et al., 2016; Shi, 2012; Starfield, 2012; Woodgate et al., 2017).

Despite the universal healthcare system in Canada, immigrants have been known to experience inadequate access to PHC services as they encounter numerous obstacles when accessing such services (Ahmed et al., 2016; Fenta et al., 2007; Lebrun, 2012; McLeroy et al., 1988). Longitudinal studies have mapped various healthcare access issues experienced by immigrants in Canada using population health surveys, which showed reduced access to regular doctors in immigrant populations, despite having multiple unmet healthcare needs (Setia et al., 2011). Several sources of barriers can contribute to unmet healthcare needs and inequitable access to PHC within the immigrant context (Bajgain et al., 2023; Chowdhury et al., 2021). This can include multiple factors operating at different levels of the social hierarchy including personal, interpersonal, institutional or structural, and policy (McLeroy et al., 1988). However, research on these factors and how they operate to form barriers to accessing PHC among immigrants living in Canada are few, even fewer when focusing on immigrant men. Studies have shown that unique societal, cultural, and religious factors exist that contribute to the understanding of health and healthcare practices among men (Macintyre et al., 1996). In Canada, the epidemiology of common diseases, such as cancer and heart disease, warrants the need for a more nuanced analysis of men's health, including intersections with immigration status, culture, and socio-economic status. Upstream causes of such health outcomes along with a large life-expectancy gap between men and women in Canada both contribute to the importance of healthcare access research (Oliffe et al., 2010). Although studies to understand healthcare access in racialized men, little research exists (Whitley et al., 2005).

Our focus in this study was to include a specific and seldom studied immigrant population group, Nepalese immigrant men in Calgary. The Nepalese community in Calgary is an emerging immigrant community in Canada. According to Statistics Canada 2016, there were 11,450 Nepalese immigrants in Canada in 2011 and that number reached 21,380 in 2016 with a continued growing trend (Bajgain et al., 2023). They are one of the fastest growing communities in Canada and have their own language, culture, traditions, beliefs, and separate identities. However, in previous research, they were not sufficiently studied separately but rather grouped into the bigger South Asian community, thus failing to capture the nuances specific to the Nepalese people (Bajgain et al., 2023). According to the Nepalese Community Society of Calgary (NCSC), there are over 7000 Nepalese who reside in Calgary with varying migration statuses (i.e., permanent residents, students, and work permit holders). Similar to many other racialized newcomers in Canada, Nepalese immigrants are often at risk of experiencing marginalization.

We chose only Nepalese men as the participants for this study because, despite the evidence of differences in experience of healthcare access across genders, previous studies mainly studied immigrant women only with very few studies on immigrant men (Dahal et al., 2022; Thapa-Bajgain et al., 2023). Also, no studies to our knowledge have been conducted to understand the perspectives and experiences of Nepalese men in Canada (Dahal et al., 2022; Thapa-Bajgain et al., 2023). According to previous literature, men tend to use fewer healthcare services compared to women (Socías et al., 2016). Due to the cultural norms, values, beliefs, traditions, and behaviours, Nepalese men are less likely to seek healthcare until it is an absolute necessity. Therefore, we choose this unique population to explore their challenges while accessing PHC. Thus, this study was conducted to explore barriers to accessing PHC services by Nepalese immigrant men in Calgary, Canada, to improve our understanding regarding this issue and to inform research and health practice/policy gaps in Canada.

Methods

This was a community-engaged qualitative research design that used the focus group discussion (FGD) technique to explore the barriers to accessing PHC among Nepalese immigrant men in Calgary.

Community-engaged research approach

This study employed the principles of community-based participatory research (CBPR) (Wallerstein and Duran, 2006) approach to ensure the Nepalese immigrant community was actively engaged as equal partners throughout the research process (Turin et al., 2021a). The lead researcher, RD, served as a community scholar who himself immigrated from Nepal. His-insider perspective and established relationships within the local Nepalese community created a rapport with the Nepalese community of Calgary to the research team and allowed access to the community (Turin et al., 2021b; Turin et al., 2023a). RD led participant recruitment by leveraging his social networks and connections with Nepalese cultural organizations. Community members were invited to provide input on the study design and development of the discussion guide to align priorities and make it culturally appropriate. FGDs were conducted by RD in Nepalese and in English based on the participants’ preferences. Preliminary analyses were shared back with community members as well to validate the interpretation of results. Through this collaborative process, the community was empowered to shape the research based on what mattered most to Nepalese immigrants. The CBPR approach upheld principles of co-learning, capacity building, and power sharing between academic and community partners to produce actionable findings that can help address disparities in healthcare access experienced by the Nepalese immigrant community (Hacker et al., 2012).

Qualitative descriptive approach

Due to the exploratory nature of this study, the qualitative descriptive approach was taken (Bradshaw et al., 2017). This methodology allows us to understand the phenomena under study without straying far from the literal description. In this case, this methodology respects and acknowledges the contextualized experiences of study participants and aims to provide a rich description of such experiences that is easily understandable by the reader. The goal of this study was to describe the experiences and processes through which Nepalese men in Canada face barriers to accessing PHC.

Study methods

The use of FGD is common practice in participatory research, which is readily used in health services use and policy research to identify how health interventions operate within a community (Hart and Bond, 1995). Within this, the authors used the advantages of the FGD technique to gather participants’ views on barriers to accessing PHC whilst interacting with other participants. This facilitated discourse amongst the participants, including debating points, and commenting on each others’ experiences (Kidd and Parshall, 2000). Not only did this allow for an environment for participants to comfortably share their experiences, but also point out to the facilitators a common frame of reference and understanding along with the point of controversy and disagreement regarding barriers to accessing PHC.

Recruitment of participants and data collection

As our objective was to learn from a very specific group of population - Nepalese immigrant adult men - we opted for the snowball sampling technique to recruit the study population. Nepalese migrants are scattered in different parts of the city of Calgary. We communicated with the initially identified participants through our advertisement through posters and social media and asked them to refer us to other potential participants who identify themselves as men and had experience with accessing PHC in Calgary. This allowed us to recruit participants with enriched experiences and reach diverse individuals who otherwise would be difficult to connect with. Further, the Nepalese Community Society of Calgary [NCSC] assisted in forwarding our study information to potential participants (Turin et al., 2022). When interested participants came across our study information they contacted the research coordinator and then we explained the study purpose and the participants’ role in detail. Once they agreed to participate, the research coordinator contacted them through cell phone and proposed a date, time, and venue for the FGD. After confirming from them, the research coordinator fixed the day, time and venue and sent a reminder one day before the session.

Upon obtaining informed consent, participants filled out a short survey about socio-demographic information and proceeded to the FGD. The FGDs were conducted with no restriction in language, which means participants could express their opinion in Nepalese or English or both languages. The FGDs were conducted between February and June 2019. A total of 34 participants with 6 FGDs were conducted, with each group consisting of 5 to 7 participants. The FGDs were conducted by a trained bilingual and bicultural facilitator (i.e., English and Nepalese) with the responsibility to apply the appropriate working group technique. The facilitator was engaged in this community since 2014 through various community programs and identified the need for study in this community. Many community leaders and members were in contact with this facilitator and he conducted many health-related trainings, workshops and educational programs to literate Nepalese community members about the healthcare system and available services and programs under the universal healthcare system in Canada. Therefore, he led this project and connected to the Principal Investigator and other team members to start the project as a critical part of the larger community-engaged program of research (Turin et al., 2023b).

Open-ended questions about barriers to accessing PHC experiences were asked using the interview guide. The research team developed the interview guide, and a facilitator was trained on the use of the guide and the FGD procedures. The interview guide included open-ended questions: What is your experience accessing primary healthcare with your family physicians? What are the barriers you have experienced in accessing primary care with your family physicians? The facilitator was required to provide equal communication opportunities for all FGD members. The facilitator did not act as an expert but stimulated and supported the discussion and probed as needed. FGD lasted for about 1.0 to 1.5 h. All FGDs were held in the NCSC office in northeast Calgary where all the participants felt a convenient and safe place to discuss and maintain the confidentiality of the thoughts discussed throughout the data collection period.

All FGDs were audio-recorded and transcribed verbatim. Besides, a filed note was maintained to ensure that information/discussion is captured in an alternative way if audio recordings are missing, unclear, or not enough. Audio recorded verbatim data were translated into English (if participants expressed their opinion in Nepalese language) and transcribed by the same facilitator. The accuracy of words and concepts being transcribed and translated was reviewed against the taped/audio records by a different bilingual and bicultural research team member. Furthermore, the research team shared the main findings with the FGD participants (15 % of total participants, i.e., n = 5) and ensured that their concerns were reflected as they shared during the FGDs. Ethics approval for this study was obtained from the Conjoint Health Research Ethics Board at the University of Calgary.

Data analysis

For this study, we employed a thematic analysis approach of the transcripts to illustrate barriers faced by Nepalese immigrant men while accessing PHC in Canada. We followed Braun and Clarke's thematic analysis (Braun and Clarke, 2006) approach which has six steps which are described as follows:1. Familiarizing with the data: First, we transcribed the recorded data verbatim [using Rev.Com] and compared them with recorded audio to make sure transcription and audio matched each other. For this, the facilitator checked all the transcription with audio and confirmed that everything discussed was reflected appropriately.

2. Generating preliminary codes: The facilitator [RD] coded the excerpts from the first two FGDs and discussed them with the research team including PI to make sure the preliminary coding was done properly. Then, the remaining four FGDs were coded by the facilitator [RD] and another team member [KA] independently, followed by a compilation of the codes and presentation to the PI to resolve any discrepancies that appeared during coding.

3. Searching for the themes: After the completion of coding, we made a large table where we put all our codes in one place. After that, we narrowed down it to related codes to the objective of this study only and minimized the previous broad table. Then we identified emerging themes from the codes and respective excerpts and labelled them as preliminary themes. We categorized barriers in the following two dimensions- barriers before accessing PHC [wait time, health and health system-related knowledge, availability of services, transportation, workplace, and culture] and barriers after accessing PHC [long wait to see doctor/specialist, communication challenge, healthcare cost-dental and vision, health professional's interpersonal skills]. After the initial analysis, the research team assembled relevant themes and detailed them for further analysis to make a research report.

4. Reviewing the themes: To examine and analyze the data, our research team created a thematic map. The team members discussed and provided their opinions to refine them according to the objective of the study. We identified that no new themes were appearing after the analysis of the 5th and 6th focus group data. So, we stopped holding focus groups after six. We conducted member checking to make sure their opinions were reflected in the themes without any modifications. The discussion in this step helped us name and define themes for the final presentation in the report. All research team members were involved in this phase.

5. Naming and defining themes: In this step, we wrapped up the themes and provided the names of each of the themes according to the consensus made by the research team.

6. Producing the report: This is the final step of the analysis where we reported the identified and agreed upon themes and supported them with relevant quotes our participants expressed during FGDs.

Results

Characteristics of participants

As shown in Table 1, the FGDs were conducted in 34 Nepalese immigrant men. Most of the participants (88.24 %) were in the age group of 26–55 years, and all were married. Most of the participants had a graduate-level education, followed by those with a bachelor-level education. Similarly, most of the participants had full-time jobs, and a few of them had part-time jobs or were self-employed or students. All participants could speak the English language (at various levels) and the Nepalese language as a first language. Around one-third of the participants had a yearly household income of $51,000 – $75,000, another one-third had a yearly household income of ≥$96,000, and the least participants had a yearly family income of ≤$25,000. All participants had a family doctor, and most of them had extended health insurance (i.e., support for care services beyond provincial health care plans such as dental and vision care, ambulance services, etc.)Table 1 Demographic characteristics of respondents [n = 34].

Table 1Characteristics	Number (%)	
Age group:		
 26–35 yrs.	7 (21 %)	
 36–45 yrs.	18 (53 %)	
 46–55 yrs.	5 (15 %)	
 56–65 yrs.	2 (6 %)	
 ≥66 yrs.	2 (6 %)	
Marital status:		
 Married	34 (100 %)	
Total family members:		
 2 members	3 (9 %)	
 3 members	9 (26 %)	
 4 members	20 (59 %)	
 ≥5 members	2 (6 %)	
Number of dependents in family:		
 No dependents	5 (15 %)	
 1 dependent	4 (12 %)	
 2 dependents	20 (59 %)	
 3 dependents	3 (9 %)	
 ≥4 dependents	2 (6 %)	
Level of education:		
 Graduate level	24 (71 %)	
 Bachelor level	8 (24 %)	
 Some collage levels	2 (6 %)	
Employment status:		
 Full-time job	28 (82 %)	
 Part-time job	2 (6 %)	
 Self-employed	2 (6 %)	
 Student	2 (6 %)	
Language spoken:		
 English	34 (100 %)	
 Nepalese (Mother tongue)	34 (100 %)	
Length of stay in Canada:		
 ≤5 years	7 (21 %)	
 5–9 years	16 (47 %)	
 10–14 years	6 (18 %)	
 ≤15 years	5 (15 %)	
Yearly household income:		
 ≤$25,000	2 (6 %)	
 $26,000–50,000	8 (24 %)	
 $51,000–75,000	12 (35 %)	
 $76,000–95,000	6 (18 %)	
 ≥$96,000	6 (18 %)	
Respondents with family doctor:		
 Yes	34 (100 %)	
Respondents with extended health insurance coverage:		
 Yes	31 (91 %)	
 No	3 (9 %)	

Barriers to accessing primary healthcare

Participants mostly faced barriers to accessing PHC due to long wait times, cultural differences, communication challenges, limited health information/knowledge, financial hardship, practices, and behaviours of healthcare providers, transportation, and workplace-related issues (Table 2). Participants experienced these barriers at two stages: before accessing the healthcare system and after accessing the healthcare system. Verbatim quotes have been selected from the focus group transcription to apprehend the barriers shared by the participants with respect to access to the PHC. Here, we present a few specific concerns raised by participants as they relate to each of these stages of healthcare access, and some are depicted in Table 2.Table 2 Barriers experienced by Nepalese immigrant men in Calgary while accessing primary healthcare.

Table 2Theme	Sub-theme	Codes	
Barriers before accessing primary healthcare	Wait time	Long wait time to get an appointment with a specialist	
Culture	Not comfortable to discuss own problems with women doctor/service providers.
Do not have practice to seek medical attention until case becomes worse.	
Health-related knowledge of patients	Lack of knowledge about healthcare system	
Limited knowledge about health issues	
Limited information provided on our health conditions by healthcare providers	
Limited health-related information provided by healthcare providers	
Availability of services	Limited clinic opening hours	
No extended services for weekends and extended hours	
No clinic services at night except emergency services at hospital	
Transportation	Lack of public transportation	
Parking issues (parking cost, unavailability)	
Distant service centers	
Workplace-related	No time off for health check-up appointments	
Barriers when accessing primary care in the health care system	Long wait time	Long wait time in family doctor's clinic to see family doctor	
Long wait time in hospital/emergency	
Long wait time for diagnostic investigation	
Communication/language	Insufficient English language capacity; unable to explain health problems to doctor	
Unclear communication by health professionals (use of medical terminologies)	
No Nepalese language-speaking doctor and interpreter available	
Feelings that doctors do not understand well what we are saying	
Difficult to understand what doctors or clinic receptionists are saying	
Financial / health care cost	Expensive dental service	
Expensive vision care	
Uncovered prescribed medicine by universal health care and extended health insurance	
Unregulated dental care	Price differences across clinics	
Service providers do not provide information on dental problems and their plans for treatment procedure	
Behaviours/practices of doctors	Doctors are always rushing	
Doctor do not like to listen to patient's problem properly	
Doctor do not discuss more than two complains at a time	
Doctor do not treat appropriately.	
Too short consultation time by doctor	
Descrimination against immigrants by healthcare providers	

Difficulties before accessing primary healthcare

Wait time: Long wait time to get an appointment with specialists was one of the main barriers to primary care, overwhelmingly expressed by most of the respondents.“For me, timing and schedule is barrier for me and my family. We are unable to visit doctor on workdays and doctor is not available on weekends and we have to wait long to meet the specialist and laboratory tests as well. I waited almost one year for myself to meet specialist. I think long waiting time is a big problem” [FGD 1, Participant 5]

"Going to see the family doctor even is not easy as we need to wait at reception, doctors' room, and pharmacy to get medicines, but the hardest part is when you need specialist service, it is a too-long wait. One experience from our community: one lady needed to see a specialist as she was suffering from severe headaches, many times she went to the family doctor, but he treated her with Tylenol and did not refer her to the specialist. After a long debate, the family physician referred her to the specialist, then she got an appointment after eight months to see the specialist, but she died before her turn came." [FGD-5, Participant 3]

Health and health system-related knowledge: Participants expressed that they have limited health knowledge, which hinders them from accessing PHC. Additionally, the participants were concerned that they have limited knowledge of the Canadian healthcare system and health-related issues and that healthcare providers do not provide enough information on health-related issues, resources, and patient's health conditions. According to participants, these factors ultimately created barriers to them accessing PHC.“I am not from health background and I do not know much about health but what I know is that when I do not feel well. I need to go and see doctor, that is my right.. But here, they system is very complicated and not as our back home, the health system is complicated here. That's why I found it a bit harder to get used to with this new healthcare system which sometimes downs me to go and meet the doctor” [FGD 4, Participant 6]

"Being new to Canada and being unaware of the Canadian healthcare system, we have a lack of information regarding where the health services are available? Some even do not have a family doctor; they do not know how to make the family doctor, and they go walking clinics here and there. I have little knowledge of health-related issues and have not accessed health-related information from the providers. I should get information through healthcare providers regarding my health conditions and health-related issues and resources such as a place to go to find a family doctor and for dental care and eye checkup." [FGD 1, Participant 7]

Availability of services: Participants voiced that they experienced barriers in accessing PHC due to limited clinic opening hours and no extended services at weekends and out-of-office hours and nights. They added that their working hours overlapped with the clinic hours, and it prevented them from accessing PHC when it is needed.“We can be sick any time but there are no services available at nighttime except emergency in hospital. No family doctors are available at nighttime. All the clinics are closed. One time in the past, my daughter was sick at middle night. We went to the clinic, but all were closed. If there are any solution to open service center at nighttime that would be great solution” [FGD 3, Participat 3]

"Most of the clinics open on Monday to Friday. I work Monday to Friday, 9 am-5 pm. On Saturday and Sunday, very few clinics open. The doctor works from 7 am-5 pm, or 7 am-3 pm. If I want to see the doctor after my work, it is not possible as the clinic will be closed, or the doctor is off at 3 pm. When I have time after work, the clinic is already closed. Because of this certain time opening of the clinic, I cannot see the doctor. Sometimes, I must work two jobs to survive here, and I do not care about my health. My priority is to stay live here because I have a responsibility to my family too." [FGD 2, Participant 6]

Transportation: Participants experienced barriers in accessing PHC due to the issues related to transportation (specifically, expensive parking costs, unavailability of parking space, and long-distance service centers). Not all health centers are connected by public transport."Not all the service centers are connected by city transit. Service centers are scattered here and there. When you go to the hospital with your vehicle, parking is a big problem. First, it is hard to find parking. Second, it is too expensive. It should be a reasonable amount of charge, and all hospital needs to have public parking for the visitors and patients". [FGD1, Participant 3]

“It is hard for new immigrants to have driving privileges in very few months after migrated here. As I know, not all the healthcare facilities are connected with public transit system. Taking taxi [Cab] is expensive. Therefore, for new immigrants like me, has a challenge to have access during appointment time. Also, one of my friend told me that clinics are located various places and hard to find as there is no signboard or clinic names displays outside the clinic” [FGD 6, Participant 5]

Workplace: Some participants expressed the fear of asking for time off for medical checkups in their workplace. According to them, they have a survival job, and they do not know more about Canadian systems and are hesitant to request time off with managers for health appointments."Last year I had a back problem, I thought to go to the doctor but thought that how can I request time off with the manager. I perceived that if my manager knew that I have chronic backache, he would fire me from work. Then I did not ask about time for health checkup even though I was badly suffered from this problem. As an immigrant finding a job is hard here; if I lost the survival job, the situation would be terrible, so I waited about two years to ask for time off to my manager. New place, new rules, a lot of problems for us to sustain in this new world"! [FGD 2, Participant 5]

“You know, my work place is quiet flexible but still I do not feel comfortable to ask day off from my work for clinic appointment. Because, I am a new in the work and always like to be a honest and good employee. I don't like to bother my manager asking time off for health checkups if it is not an emergency. I should be stick with this job for the sake of my dependent family here as I have small kids and I am the father of them and I should maintain my standard according to my culture [FGD 5, Participant 1]

Culture: Healthcare-seeking practices of Nepalese people and their unfulfilled expectations while accessing PHC led by cultural differences between Nepal and Canada became another barrier to accessing PHC."In Nepal, there is no habit of regular doctor checkups without having serious conditions. Similarly, we have a culture of using traditional medicine first before seeking medical help. So, it may be our habit or culture not to use PHC without extreme need. Additionally, we hesitate to tell our problems with a female doctor, and we prefer a male doctor. Most importantly, when we go to the doctor, we expect medicine prescription and laboratory tests to rule out the problem".[FGD 6, Participant 5]

“As we are born and raised in back home, we have collective culture. We prefer to go together. Our wives do not explain much of their problems to doctor, husband describes the problem. Here people do not allow to go with wife and husband together in doctor's room. Ladies cannot explain their problems. There is not any humanity with health workers here, I would say. They behave differently to white people. The humanity is important. It comes differently by people to people, so culture becomes barrier sometimes” [FGD 4, Participant 1]

Difficulties after accessing PHC

Long wait: Participants critically expressed that they had to wait for a long time in the clinics to see their family doctor, in the hospital or emergency, and for the diagnostic investigation, even harder to get a specialist service."Whenever I go to see my doctor, I have to wait for a long time even I had already taken the appointment. When I go there, the receptionist says, ok, just wait like 5 min, but it takes 30 min or more to get to see the doctor. In addition, when I need to see a specialist, it takes four months or six months to see them. Last year, I had one serious kind of cyst in my hand; it took me more than four months to just see the specialist. Additionally, in our community, one man waited to have USG for nine months who was suffered from stomach pain. What is this? No kidding!!! 9 months for one diagnostic test, what type of healthcare is this?” [FGD 3, Participant 5]

“Long waiting is a kind of culture here, I guess! I don't know why they make us waiting? Last week after consultation with doctor I went to the pharmacy to buy medicines, there was very quiet in the pharmacy. When I gave my prescription to the person, he said wait about 45 min…… I am shocked why? If there is crowd, many people are waiting, it ia reasonable to wait, but if none is there, why I need to wait? 10–15 min is understandable but 45 min, no idea why they do it? Are they producing my medicines after I gave the prescription to them like restaurant makes food after they got order[laugh]!!! Same thitng happens in laboratory or diagnostic centres as well! I don't like mention about specialist waiting time, it is terrible!” [FGD 4, participant 2]

Communication/language: Communication was another common barrier for Nepalese immigrant men while accessing PHC. The communication-related barriers such as not having sufficient skills in the English language, unclear communication by health professionals, unavailability of Nepalese-speaking doctors and interpreters, unable to understand what doctors and receptionists say, and perceived misunderstanding complicated their interactions with healthcare providers and hindered them to accessing PHC."I was not able to tell the exact terminology to the doctor like "Chassakka dukheko," meaning severe pain. How can I tell it! What word can I use in English for it? I do not have a proper word to tell this. Also, I do not understand what the doctor says. They use medical terminologies that I have no idea".[FGD 4, Participant 6]

“Doctor do not talk much with their patients, how they know their patient's problems. They underestimates when they see our colour. If there is not communication, there is no relationship. If you do not have mutual relationships, how you share your problems with doctor, I mean your health problems. So doctor must talk to the patient eventhough their English is not that good. There is no need of perfect English language efficiency to tell doctor about the health problems of any of us, I guess! This creates distance among doctor and patient which becomes an obstacle to create a rapport between two of them. I feel ashamed if I can not talk to the doctor and next time I will not happy to meet him” [FGD3, Participant 4]

Healthcare cost and unregulated dental care: Other additional barriers experienced by Nepalese immigrant men include expensive dental and vision care, unregulated dental care, and certain medication not covered by universal healthcare and extended health insurance."Dentist told me that I have to take out my tooth due to infection. I said I am ready to take out the tooth. After extraction, he asked me to put the implant. He did not tell me the price. I enquired to the receptionist, and she said I must pay $5000. I was surprised! When I researched, I found that there was another alternate in my case. I need not extract my tooth. What types of service is this? It might have been worthy of doing RCT in my case. I was shocked after finding that! Here in Alberta, dental clinics are profit-making businesses, not service. They should be regulated and strictly monitored". [FGD 6, Participant 5]

“Last year I had a problem with my teeth and booked an appointment in dental clinic. The dental office person asked me only if I have a insurance. When I went for the appointment, they asked me to do this and that which was not my primary problem. After consultation I escaped from the clinic and enquired the price of that procedure they recommended to me. Every clinic has different prices. It looks like there is no any regulations to fix the price of the procedures. I denied the procedure and planning to do it in Nepal when I am going to there for other purposes next year. Dental services should be controlled by governing body and price should be similar for the standard procedures, otherwise dental services will be money making businesses, not a service!!!” [FGD 6, Participant 2]

Health professional's interpersonal skills: Doctor's behaviours and practices perceived by Nepalese immigrants may also affect accessing PHC. According to them, some doctors did not behave professionally, such as not giving enough time to patients, not paying attention to patient's problems, and not showing respect as well."Some specialist does not care us nicely: My family doctor referred me to a skin specialist, called dermatologist, he did not come near to me, he saw my skin from a distance and even did not touch my skin, what was wrong with me? why he wanted to stay away from me." [FGD 4, Participant1]

Discussion

This qualitative study explored barriers to accessing PHC services by Nepalese immigrant men in Calgary. This study found that Nepalese immigrant men experience barriers at two stages: before accessing PHC services and after accessing PHC services. Barriers operated at multiple levels as reported by the men interviewed in this study (Fig. 1). This included personal level barriers which included health and health-related knowledge gap. Next, interpersonal barriers such as language barriers along with strained doctor-patient relationships. Institutional and structural level barriers included long wait times to seek care, availability of services to meet health needs, transportation, and non-lenient workplace policies. The study also found a unique community-level barrier that acted as a barrier to PHC–Nepalese cultural practices. Finally, policy-level barriers such as certain healthcare costs and unregulated dental care also operated as barriers to seeking PHC in Nepalese men. To our knowledge, this is the first study in Canada that explored barriers faced by Nepalese immigrant men in accessing PHC.Fig. 1 The barriers faced by Nepalese immigrant men framed using the socio-ecological model.

Fig. 1

Our study found that Nepalese immigrant men face several barriers while utilizing PHC services in Canada, although the healthcare act (1984) of Canada states that "all Canadians should have equality in healthcare regardless of their immigrant status". Previous studies conducted on Canadian immigrants including a systematic review have shown that immigrants face several barriers in accessing PHC services in Canada (Higginbottom et al., 2016; Woodgate et al., 2017; Ahmed et al., 2016; Dahal et al., 2022; Mbanya et al., 2019). A systematic review found cultural differences, communication challenges, low socioeconomic status, new health system structure, and lack of knowledge about the Canadian healthcare system as major barriers to PHC (Ahmed et al., 2016). Additionally, the complexity of the healthcare system, medical terminologies used by providers, and negative prior experience with the healthcare system led to difficulties for immigrants in accessing PHC services in Canada (Higginbottom et al., 2016). A qualitative study on African immigrants and refugee families living in Manitoba reported that long wait times, shortage of healthcare providers, high cost of medication, language and cultural differences, unfamiliar healthcare system environment, lack of social support, and unemployment, transportation, and weather challenges created barriers for immigrants to access PHC (Woodgate et al., 2017). A study on immigrants living in the Niagara region found that immigrants frequently experienced barriers in accessing PHC due to the lack of social support, lack of Ontario Health Insurance Plan (OHIP) coverage, language barriers, differences in treatment preferences, and geographic distances (Lum et al., 2016). In addition to those barriers reported by previous studies, our study participants experienced transportation-related barriers in accessing PHC services due to long distances to reach the clinic and high parking costs and unavailability of parking places in the clinic area. Similar findings were reported among another seldom studied South Asian community, Bangladeshi immigrant men in Canada (Turin et al., 2020; Turin et al., 2021c; Turin et al., 2021d). However, our participants did not express negative prior experiences, lack of social support, unfamiliar environment, harsh weather, geography, and treatment preferences as barriers, while these barriers were expressed in previous Canadian studies (Higginbottom et al., 2016; Woodgate et al., 2017; Lum et al., 2016) (Dahal et al., 2022).

Studies conducted outside of Canada also observed similar barriers experienced by immigrants in accessing PHC services. A study of Thai adult immigrants living in Auckland found high cost, long wait time, language, culture, and affective barriers (i.e., barriers that stem from negative emotions such as feeling uncomfortable or unwilling to show problems) (Woodgate et al., 2017). Similarly, a study among sub-Saharan African immigrants examining barriers to accessing the Norwegian healthcare system reported the following barriers: lack of information, financial barriers (for dental service and physiotherapy and the perception that these services were expensive and unaffordable), patient's preference for doctors from the same culture, family and job responsibility, long wait time, communication and language barriers (Mbanya et al., 2019). In comparison, these barriers were mostly experienced by our participants except affective barriers, financial barriers to access physiotherapy services, and patient's preference for doctors from the same culture.

The observed barriers experienced by Nepalese immigrant men in Calgary may have partly originated from their previous health-seeking practices in Nepal and their expectations. For example, not seeking medical attention until they are very sick, medicine, and diagnostic test prescription at the doctor's visits a routine medical practice in Nepal and many Asian countries. This is also supported by a systematic review as it found that doctors in Asia prescribe medicines and laboratory tests to make their patients satisfied with the consultation (Ahmed et al., 2016). This type of medical practice is not persistent in Canada. However, there are several unique obstacles immigrants face in the host countries, which were also observed in our study. For example, the communication barriers due to insufficient skills in the English language lead to unclear interaction and misunderstanding between providers and patients and eventually prevent patients from addressing their health needs. Similarly, economic difficulties: Nepalese immigrants experienced financial constraints in dental and vision care and certain medication which are not covered by universal healthcare and extended health insurance. Some of the participants even sought dental and vision care from Nepal due to the high cost in Canada. A similar finding was reported in a study conducted among Thai immigrants in Auckland, New Zealand. Additionally, immigrants suffer from several challenges, including unemployment or low-paid job, language and financial hardship, discrimination, and lack of social support, which are associated with inadequate healthcare utilization and declined health status (Higginbottom et al., 2016; Asanin and Wilson, 2008).

Therefore, a supportive physical and social environment that addresses their obstacles appears to be created to encourage immigrants to access PHC. The barriers faced by Nepalese immigrants are directly related to negative health consequences, including increased human suffering and treatment costs. For example, increased severity of the health problems decreased quality of life, loss of productivity, and high healthcare management costs. Allocation of resources to identify and implement strategies that reduce wait time, increase the availability of services, improve provider-patient interaction and patient literacy on the Canadian healthcare system and health-related issues, reduce financial barriers, and workplace-related difficulties can create a supportive environment for immigrants. For instance, translation services can increase the satisfaction level of both patients and service providers; removes misunderstanding among them and improves provider-patient relationship (Ahmed et al., 2017). Similarly, if the Canadian government allowed more internationally trained health professionals in the Canadian healthcare system with adequate provision of exposure to the Canadian healthcare system and training and volunteer opportunities; this can fulfill health professional shortages, improve cultural competence, improve long wait times, and availability of services. This eventually encourages them to access available PHC. Furthermore, given the unique obstacles faced by immigrants in accessing PHC and their cultural differences, the PHC service provision should be tailored and personalized to meet the need of immigrants. For example, providers should be more culturally sensitive and competent in providing quality primary healthcare services.

Policy implications/recommendations

There are several access barriers faced by Nepalese immigrant men while accessing PHC in Canada. Those barriers can be addressed by creating an immigrant-friendly supportive environment in the healthcare system such as the provision of culturally competent translator in healthcare centers that removes communication barriers to them (Ahmed et al., 2017). Similarly, policy can include dental and vision care in a PHC stream and provide services to them for certain periods of time and remove it from PHC after 3–5 years when immigrants adopted in Canadian system and improve their economic and other social status by that time. Also, providers should train in respecting multiculturalism which enhanced them to be culturally sensitive and competent in providing the best possible quality care to immigrants with respecting their diversity.

In addition to the above strategies, drawing on international best practices could offer valuable insights. For instance, the USA has a Culturally and Linguistically Appropriate Services (CLAS) with 15 action steps that proved to significantly improve equity and remove healthcare disparities by providing a blueprint for healthcare services for diverse individuals (Zuniga et al., 2013). For Nepalese men in Canada, creating dedicated community healthcare centers with Nepalese-speaking staff and culturally familiar settings could facilitate comfort and trust in the healthcare system. At a policy level, the government could consider collaborations with community-based organizations to identify the specific needs of Nepalese immigrants and enact policies to improve the PHC access by them and guide them through the Canadian healthcare system. These additional measures reflect a holistic approach to reducing access barriers and could be instrumental in ensuring that Nepalese immigrant men in Canada receive the necessary primary healthcare.

Strengths and limitations

We applied a collaborative research approach to engage Nepalese community members, community scholars and citizen researchers in this study. We also engaged with a Nepalese community organization and community champions to expand our research scope within the Nepalese community. Also, our participants had varied lived experiences [newly landed immigrants to already lived here for 5–10 years] and experienced barriers to accessing PHC at various levels which gave us a knowledge of barriers in different stages of life course while adopting in a new environment. While qualitative research does not aim for statistical representation, efforts were made to recruit a demographically diverse sample that lead us to obtain enriched data from multiple perspectives. Our participants varied in age groups ranging from 26 to 55 years. There were both highly educated and college-level educated participants. Participants included both those with high proficiency in English as well as those with language barriers. Socioeconomic status also varied largely in our sample.

The limitation of this study was the susceptibility of the FGDs to biases. There is always a chance of being influenced by the dominant nature of people who try to control or lead the conversation. However, our group discussion was carried out by a well-trained experienced facilitator using FGD guidelines. Also, our participants represented only from Calgary, so, we may not generalize the findings to the whole Nepalese Canadian diaspora because people from other provinces may experience barriers differently. We need another research on the perspective of healthcare providers in making immigrant friendly healthcare environment to address present access barriers to immigrants in Canada, and a comparative study on the same question among new and experienced immigrants.

Conclusion

This study highlights that Nepalese immigrant men encounter numerous barriers while accessing PHC services in Calgary, Canada. They encounter two dimensions of barriers which include those before accessing services and those after accessing services. Key barriers encountered spanned across the continuum of care, including long wait times to get appointments, communication difficulties with providers due to language/cultural differences, lack of health system knowledge, and unavailability of certain services. This illustrates the need for a culturally competent, supportive healthcare system that meets the needs of diverse immigrant populations in order to facilitate equitable access. Providing culturally competent interpreters, cultural training for providers, community collaboration, and involving community health workers from Nepali backgrounds can help address barriers to primary care access among Nepali immigrant men. Increased funding and resources are needed to facilitate organizational and systemic changes that will optimize these men's health outcomes.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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