Make changes to programs, policies and institutions

While there are a number of things that individual providers can do to improve interactions with immigrants and refugees, program, policy and institution changes are also required. These changes will support improved service use and outcomes.

As a first step to increase access, health systems, institutions and/or individual providers can increase health literacy among immigrants and refugees. This refers to increasing accessibility and use of health information to make appropriate health decisions and maintain basic health. The development of comprehensive health promotion and prevention campaigns that are targeted, specific and culturally appropriate (WHO, 2010) (WHO, 2018) for immigrant and refugee groups can help increase use of services for mental health problems and illnesses. These types of campaigns could orient immigrants and refugees to mental health problems and illness and also to how the health system works (WHO, 2010) (WHO, 2018).

Some examples of these types of campaigns include:

Caring for Kids New to Canada: Mental Health Promotion:
A Guide for Professionals Working With Immigrants & Refugee Children & Youth.

Ontario Council of Agencies Serving Immigrants:
Mental Health Promotion Integrated Service Model.

Another key change that health systems or institutions can make to improve access to care is to provide free interpretation services (WHO, 2010) (WHO, 2018). The use of qualified professional medical interpreters can improve the quality of treatment received by:

Limiting communication errors
Increasing patient comprehension
Equalizing health care utilization
Helping reduce misunderstandings that may lead to potentially serious medical consequences
Increasing satisfaction with communication and clinical services for clients with limited English language proficiency

(Laher et al., 2018; Lindholm et al., 2012)

In mental health care settings, individuals who need but do not get interpreters have poorer self-reported understanding of diagnosis and treatment plans (Bauer & Alegria, 2010; Pandey et al., 2021). Clients also report greater satisfaction in trained professionals over ad hoc interpreters (untrained person called to interpret, for example, a family member)(Flores, 2005; Karliner et al., 2007).

As stated in previous modules, properly treating immigrants and refugees with mental health problems can pose some difficulties for individual service providers due to differences in language, differences in culture, and the combined effect of stressors connected with migration and post-migration circumstances (Kirmayer et al., 2011).

For these reasons, to improve services for these populations, we recommend the following:

Take an extended history, including asking questions about immigration history and related stress, their support system, their cultural context and their understanding and beliefs about health care. Focus on trying to understand how clients view the nature and causes of their particular issues.
Do not make general assumptions about clients with similar ethnic backgrounds. Recognize the diversity within newcomer communities.
Provide services in a language in which the client is fluent—work with a qualified interpreter, not a child or relative.
Do not initially screen refugees for trauma, as doing so might cause unnecessary harm. Over-screening can result in an increase in false-positive reports.
Provide empathy, reassurance and advocacy to support the recovery process. (Module 10 will provide more details on self-awareness & self-care).

(Pottie et al., 2011)

The above is only part of what is needed to improve services for newcomers. Overall, improving services for newcomers requires cultural humility, improving linguistic services, improving the diversity of treatments and an improved method of linking the needs of immigrants and refugees to the appropriate expertise and specialized treatment (Hansson et al., 2010) (WHO, 2018).