Knowledge translation and better health and health care for migrants in Canada

Canada has a responsibility to promote migrants’ health

In May 2017, at the Seventieth World Health Assembly, a resolution on “promoting the health of refugees and migrants” was endorsed.⁷ The World Health Assembly urged member states of the World Health Organization, including Canada, to identify, collect, and develop evidence-based information and best practices toward addressing the health needs of migrants; to ensure the information’s and practices’ relevance and acceptability; and to provide informed translation of the knowledge generated.⁷

Following the World Health Assembly, a team of researchers at Monash University in Melbourne, Aust, conducted a rapid review to identify key considerations for addressing the health needs of refugees and migrants.⁸ They identified that to better promote the health of migrants, member states must identify population health needs, monitor interventions, and measure health outcomes; develop strategies to encourage healthy living and address the upstream determinants that affect health; develop targeted screening, prevention, and treatment programs, including culturally adapted health education for infectious and noncommunicable diseases, including for mental health; and provide culturally adapted sexual and reproductive health services and education that empower women and girls and improve their health outcomes.⁸ In addition, they recommended that countries enhance health service access in several ways: by improving the training of health care professionals to ensure that they understand service eligibility for various migrant groups (eg, asylum seekers) and provide culturally safe care; by increasing the use of interpreters, translated information, and cultural mediators; and by addressing stigma and discrimination, which are known to deter migrants from using health care services.⁸

More efforts are needed in Canada

More work is needed to better address not only the health concerns of migrants but also the barriers they encounter when trying to access care in Canada. A number of studies show that migrants are not receiving the health care they need for a range of health concerns, including psychosocial support and mental health, oral and dental health, maternal and child health, and sexual and reproductive health.^3,9-13 Research also shows that migrants encounter a number of challenges that restrict their use of or benefits from health care. These challenges include communication, cultural and socioeconomic barriers, poor health literacy and difficulties in navigating the health care system, and issues in how the health care system is structured and care is delivered.¹⁴ A fear of being reported to authorities, a lack of health insurance or the insurance not being recognized or accepted, discrimination, mental illness, and resettlement issues are also key barriers for more vulnerable migrants.^1,3,15

Moreover, further research is required to identify the health needs, measure the health outcomes, and determine the appropriate interventions for migrants, especially for more marginalized groups. Despite the growing body of literature on migrant health, some groups continue to be understudied. For example, little is known about the health needs and outcomes of undocumented migrants and temporary foreign workers.^16,17 For some health conditions (eg, palliative care), it is not known whether services are adequately accessible or culturally acceptable. And finally, the quality of evidence regarding appropriate screening and intervention for certain health concerns (eg, posttraumatic stress disorder, iron deficiency, social isolation) remains low to moderate, leaving care providers unclear on how to best address these issues.^4,5

Clearly, more relevant and more useful knowledge, and greater application of the knowledge that is developed, is necessary. In short, we need more, and better, knowledge translation.

Barriers to translating and applying migrant health knowledge

Knowledge translation is a dynamic and iterative process that involves the creation, dissemination, and application of knowledge toward improving health and health services.¹⁸ Knowledge creation comprises the production of relevant knowledge, the synthesis of research findings, the development of guidelines and tools, and further research aimed toward tailoring the knowledge to the real-life context.¹⁸ An integrated approach to knowledge translation also involves key stakeholders (patients, health care and other service providers, policy makers) to ensure that the knowledge generated is relevant, addresses needs, and is in a usable format. The stakeholders’ involvement, in turn, enhances the likelihood of knowledge uptake and implementation by knowledge users.

Common barriers to knowledge translation lie in the knowledge creation phase.^18,19 These obstacles include health needs and outcomes remaining unknown, not having sufficient information on how to apply best practices, responses to existing problems not fitting needs, and the knowledge not being adequately adapted to the real-life context. In migrant health, one of the main reasons that knowledge gaps exist is because the more vulnerable migrants remain underrepresented in research. Migrants are often excluded because it is costly and time-intensive to recruit and gather data from participants who do not speak English or French and are members of more isolated, hard-to-reach groups (eg, those who are undocumented).²⁰ Ethical concerns (ie, a fear of causing harm) might also dissuade researchers from conducting research with these populations.²¹ Another reason for knowledge gaps is that migrant health, generally, still seems to be underresearched. We conducted a crude search of the Canadian Institutes of Health Research (CIHR) Funding Decisions Database (https://cihr-irsc.gc.ca/e/38021.html), which includes all funding decisions announced since January 2009. Using a range of migration-related terms (migration, migrant, immigrant, refugee, asylum seeker, immigration, newcomer, foreign-born, minority), the search yielded fewer than 700 hits among the more than 33 500 items in the database at the time of writing (ie, about 2% of items).

The lack of pertinent migrant health knowledge is partially owing to the difficulty of including key stakeholders in the research process,²² in particular, migrant patients who might be less familiar with research procedures and principles, who do not speak English or French, or who are afraid to participate because, for example, they have a precarious migration status. An examination of CIHR’s Strategy for Patient-Oriented Research webpage (https://cihr-irsc.gc.ca/e/41204.html) seems to confirm this notion; none of the projects funded by this program appear to have a migrant health focus, and there is no evidence of mechanisms in place to engage more marginalized migrant patients in the research process through this initiative. Furthermore, knowledge continues to not be adapted for migrants because randomized controlled trials and implementation research projects with migrants remain limited—of the 2% of items identified in the CIHR Funding Decisions Database, fewer than 15 items were randomized controlled trials or implementation research.

Health funders’ and researchers’ roles in improving migrant health research and knowledge translation

To address the issue of inadequate knowledge translation of migrant health research in Canada, health funders and researchers need to ensure that the research conducted is relevant and addresses gaps, and that the knowledge it generates is usable (Box 1).²³

Regarding the use of participatory approaches, the involvement of communities and organizations is considered not only a way to improve knowledge translation, but also a method to overcome some of the ethical concerns that lead to the exclusion of vulnerable migrants from research.^21,23 Organizations can provide guidance on how to ensure the safety of participants, offer direct support and care for those in need, and ensure that results are disseminated and used such that they do not cause harm.