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Precarious patients: health professionals’ perspectives on providing care to Mexican and Jamaican migrants in Canada’s Seasonal Agricultural Worker Program

Authors:
  • Occupational Health Clinics for Ontario Workers, Hamilton, Ontario, Canada

Abstract and Figures

Introduction: The intersecting vulnerabilities of migrant agricultural workers (MAWs) impact both their health and their access to health care in rural areas, yet rural clinicians' voices are rarely documented. The purpose of this study was to explore health professionals' perspectives on health care for MAWs in sending countries and rural Ontario, Canada. Methods: Qualitative research design occurred over three distinct projects, using a multi-methodological approach including semi-structured interviews in Mexico, Jamaica and rural Ontario (n=43), and session field notes and questionnaires administered to healthcare providers (n=65) during knowledge exchange sessions in rural Ontario. A systematic analysis of these data was done to identify common themes, using NVivo software initially and then Microsoft Excel for application of a framework approach. Results: Structural challenges posed by migrant workers' context included difficulties preventing and managing work-related conditions, employers or supervisors compromising confidentiality, and MAWs' fears of loss of employment and return to countries of origin prior to completing treatments. Structural challenges related to health services included lack of adequate translation/interpretation services and information about insurance coverage and MAWs' work and living situations; scheduling conflicts between clinic hours and MAWs' availability; and difficulties in arranging follow-up tests, treatments and examinations. Intercultural challenges included language/communication barriers; cultural barriers /perceptions; and limited professional knowledge of MAWs' migration and work contexts and MAWs' knowledge of the healthcare system. Transnational challenges arose around continuity of care, MAWs leaving Canada during/prior to receiving care, and dealing with health problems acquired in Canada. A range of responses were suggested, some in place and others requiring additional organization, testing and funding. Conclusion: Funding to strengthen responses to structural and intercultural challenges, including research assessing improved supports to rural health professionals serving MAWs, are needed in rural Canada and rural Mexico and Jamaica, in order to better address the structural and intersecting vulnerabilities and the care needs of this specific population.
ORIGINAL RESEARCH
AUTHORS
Donald C Cole MD, MSc, FRCP(C), Emeritus Professor *
Janet E McLaughlin PhD, Associate Professor
Jenna L Hennebry PhD, Associate Professor
Michelle A Tew RN, BScN, Occupational Health Nurse
CORRESPONDENCE
*Dr Donald C Cole donald.cole@utoronto.ca
AFFILIATIONS
Occupational Health Clinic for Ontario Workers, 848 Main St E, Hamilton, ON L8M 1L9, Canada; Dalla Lana School of Public Health,
University of Toronto, Health Sciences Building, 155 College St, Toronto, ON M5T3M7, Canada; and Institute for Work & Health, 481
University Ave Suite 800, Toronto, ON M5G 2E9, Canada
Health Studies, RCE 242, Wilfrid Laurier University, Brantford, Ontario N3T 2Y3, Canada; and International Migration Research Centre,
Balsillie School of International Affairs, Wilfrid Laurier University, 67 Erb Street West, Waterloo, ON, Canada
International Migration Research Centre, Balsillie School of International Affairs - BSIA 243, Wilfrid Laurier University, 67 Erb Street
West, Waterloo, ON, Canada; and Communications Studies, Wilfrid Laurier University, Waterloo, Ontario N2L 3C5, Canada
Occupational Health Clinic for Ontario Workers, 848 Main St E, Hamilton, ON L8M 1L9, Canada
PUBLISHED
1 December 2019 Volume 19 Issue 4
HISTORY
RECEIVED: 7 February 2019
REVISED: 21 August 2019
ACCEPTED: 5 September 2019
CITATION
Cole DC, McLaughlin JE, Hennebry JL, Tew MA.Precarious patients: health professionals’ perspectives on providing care to Mexican and
Jamaican migrants in Canada’s Seasonal Agricultural Worker Program. Rural and Remote Health 2019; 19: 5313. https://doi.org/10.22605
/RRH5313
This work is licensed under a Creative Commons Attribution 4.0 International Licence
Rural and Remote Health rrh.org.au
James Cook University ISSN 1445-6354
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ABSTRACT:
Introduction:The intersecting vulnerabilities of migrant
agricultural workers (MAWs) impact both their health and their
access to health care in rural areas, yet rural clinicians’ voices are
rarely documented. The purpose of this study was to explore
health professionals’ perspectives on health care for MAWs in
sending countries and rural Ontario, Canada.
Methods:Qualitative research design occurred over three distinct
projects, using a multi-methodological approach including semi-
structured interviews in Mexico, Jamaica and rural Ontario (n=43),
and session field notes and questionnaires administered to
healthcare providers (n=65) during knowledge exchange sessions
in rural Ontario. A systematic analysis of these data was done to
identify common themes, using NVivo software initially and then
Microsoft Excel for application of a framework approach.
Results:Structural challenges posed by migrant workers’ context
included difficulties preventing and managing work-related
conditions, employers or supervisors compromising confidentiality,
and MAWs’ fears of loss of employment and return to countries of
origin prior to completing treatments. Structural challenges related
to health services included lack of adequate
translation/interpretation services and information about insurance
coverage and MAWs’ work and living situations; scheduling
conflicts between clinic hours and MAWs’ availability; and
difficulties in arranging follow-up tests, treatments and
examinations. Intercultural challenges included
language/communication barriers; cultural barriers /perceptions;
and limited professional knowledge of MAWs’ migration and work
contexts and MAWs’ knowledge of the healthcare system.
Transnational challenges arose around continuity of care, MAWs
leaving Canada during/prior to receiving care, and dealing with
health problems acquired in Canada. A range of responses were
suggested, some in place and others requiring additional
organization, testing and funding.
Conclusion:Funding to strengthen responses to structural and
intercultural challenges, including research assessing improved
supports to rural health professionals serving MAWs, are needed in
rural Canada and rural Mexico and Jamaica, in order to better
address the structural and intersecting vulnerabilities and the care
needs of this specific population.
Keywords:
agricultural farm workers, Canada, intercultural health, migrant health, occupational health, physician–patient relations, primary care,
rural health and medicine, qualitative methods.
FULL ARTICLE:
Introduction
Migrant farm or agricultural workers (MAWs) have formed a critical
part of many rural economies for decades. In 1966, as a response
to agricultural labour supply challenges, the Canadian federal
government developed the Seasonal Agricultural Worker Program
(SAWP), bringing workers initially from the Caribbean and,
beginning in 1974, from Mexico for up to 8months annually. In
2011, the Canadian government instituted a smaller, general
agricultural stream of Canada’s broader Temporary Foreign Worker
Program (TFWP), allowing workers to enter from any country with
contracts of up to 2years, with some additional MAWs through
TFWP’s general streams for low- and high-wage positions . These
workers now include those from Asia, as well as other Latin
American countries. Over 53000 temporary foreign agricultural
worker positions were approved in Canada in 2015, of which nearly
42000 were through the SAWP .
Social determinants of health figure prominently in MAWs’ lives .
Working conditions include physical hazards (egoutdoor physical
labour using farm equipment), environmental factors (such as
extreme heat, inadequate lighting, biting insects), farm chemicals
(such as pesticides and fertilizers), and mechanical hazards (farm
machinery on rough terrain and unsafe transportation), which
heighten their risks of specific occupational injuries and
illnesses . However, unlike citizen farmers and permanent
resident workers, MAWs are precarious workers , under a
managed labour migration program in Canada that renders them
‘permanently temporary’, compounding their vulnerability .
Studies in the Canadian and US contexts have demonstrated that
MAWs are likely to experience a range of health outcomes: injury
and illness from agrochemical and climatic exposures;
musculoskeletal injury from repetitive motion, awkward postures,
and lifting heavy loads; and motor vehicle and machinery
accidents . In addition, MAWs are required to live in
employer-provided housing, which is typically on farms and is
highly variable due to inconsistent application of housing
regulations. Studies of migrant worker housing in Ontario and
British Columbia have demonstrated numerous housing
deficiencies, including insufficient food storage and cooking
facilities, over-crowded and poorly ventilated dormitories lacking
privacy, insufficient cooling and heating systems, and proximity to
pesticides and fertilizers among many other concerns , similar to
those in North Carolina .MAWs lack resources such as
transportation , common among poor people in rural settings.
They also may lack dominant language communication capacity ,
have different understandings of health and illness, and expect
different healthcare treatment, all of which pose intercultural
competency challenges to providing care .
A substantial literature exists on rural health service provision to
MAWs in the USA . As is the case for other rural residents,
access to health care, particularly specialists, remains an ongoing
challenge for migrant and non-migrant farm workers alike . Yet
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MAWs often face particular barriers to health and social services
utilization . In Canada, MAWs are eligible for provincial
health coverage and workers’ compensation systems, and
supplementary insurance benefits (for prescription drugs or
physiotherapy, for example) are usually in contracts. However,
processing delays occur, and health card access is a challenge for
some: nearly 20% of 600 Ontario MAWs in one survey had not
received their cards . The SAWP and other TFWP streams create
structural vulnerabilities and additional barriers to accessing
healthcare systems among MAWs . For example, MAWs may
not take time off work when sick or injured due to fear of loss of
current or future employment or wages. In a survey of
approximately 600MAWs in Ontario, 45% reported working
despite illness or injury for fear of telling their employers, and 55%
worked in these conditions to avoid losing paid hours . Indeed,
under the SAWP, employers can terminate employment and return
workers to their country of origin if MAWs refuse work for any
reason, including for medical reasons .MAWs, their families
and their providers can encounter challenges of transnational
coordination of care across different healthcare systems ,
particularly when MAWs become ill and injured in Canada and are
returned home with their condition not fully investigated,
managed or compensated .
Rural health professionals and health services may have limited
preparation for responding to both the specifics of MAWs’
challenges and their complexity. They may have limited
preparation in evidence-informed management of MAWs for
the determinants of health, the particular health problems, and the
range of structural challenges to care which MAWs present.
However, unlike those serving other migrants, immigrants and
refugees in the US , Canada , and Europe , views of health
professionals providing services to MAWs in Canada have rarely
been documented. Hence, the research reported here asked ‘What
are rural health professionals’ perspectives on health care for
MAWs, both in sending countries and in Canada?’
Methods
Design
This research starts from the theoretical underpinnings of
structural vulnerability , which recognizes the social determinants
of health, and the social structures that create systematic barriers
to equitable health care for migrant workers. The researchers
developed a qualitative design to tap the perspectives of
healthcare practitioners responding to migrant workers in rural
Southern Ontario. The critical realist, qualitative research design
drew upon multiple methods to gather data, carried out by the
authors (individually and in collaboration) over a 10-year period
(Fig1). Below the authors comment on various aspects of this
design in reference to key components of the ‘consolidated criteria
for reporting qualitative research’ (COREQ) criteria for qualitative
studies .
Figure1:Timeline for data collection.
Research team
Lead project researchers included two interdisciplinary PhD social
scientists (female), each with more than 15years of qualitative and
community-engaged scholarship with migrant workers in Canada.
Other research team members were an occupational physician
(male) and an occupational health nurse (female), each with
extensive clinical experience with migrant workers, masters’
research training and respect among Ontario clinicians. Three
authors are fluent in Spanish, having worked extensively in Latin
America. Interviews were predominantly carried out by the
research team members, with some Mexican interviews carried out
by a male doctoral research assistant from Mexico. The research
assistant received training in research ethics and interviewing and
was provided an interview protocol and informed consent
information for participants.
Interviews
Qualitative interviewing was the primary data collection method,
allowing for an emphasis on health providers’ knowledge and
perspectives. In keeping with semi-structured interview
approaches, guides of open-ended questions with potential
probes were developed for each set of interviews. Key questions-
domains were similar, focusing on the challenges and
particularities of providing care for the vulnerable population of
migrant workers, including access to health services and workers’
compensation processes. Questions were added according to
experience-expertise of the interviewee, given their different roles
and national contexts. Interview guides were not formally piloted,
but were iteratively adapted to ensure comprehension and
responsiveness to interviewee concerns and insights. Interviewers
had flexibility in order of questioning and extent of follow-up
probing, but were careful not to frame the latter in a leading
fashion.
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Potential interviewees were discussed among research team
members and purposively selected based on role and experience,
with supplementary suggestions emerging from interviewees.
Interviewers approached potential interviewees by phone or email
and arranged the interview in a mutually convenient location,
usually the clinician’s office. Some proposed interviews were
unable to be concretized due to logistical challenges, but no
potential interviewees refused outright. In total, 43interviews were
carried out with healthcare practitioners across the three countries,
with no repeat interviews. During 2006–2009, co-investigator JM
conducted semi-structured interviews in person with doctors,
nurses and other healthcare professionals (n=24) who administer
health examinations as well as provide care to migrant workers
before they leave from and/or return to Mexico and Jamaica, as
well as those who provide care to workers while in Ontario . As
part of investigating transnational aspects of care for MAW in a
second project, additional interviews were carried out in
2010–2012 with primary care practitioners in Mexico and Jamaica
(n=12) and with health professionals in Simcoe, Norfolk county,
Ontario (a top receiving area for MAWs) (n=7) . The interviews in
Canada and Mexico were carried out in person, while the Jamaican
interviews were conducted over the phone. The Canadian
interviews were conducted by a Canadian physician, the Mexican
interviews by a Mexican doctoral student research assistant, and
the Jamaican interviews by one research team member (JM). All
were conducted in private settings, usually the providers’ office,
with no other individuals present. Interviewees in Mexico and
Jamaica were referred to researchers from consular and Ministry
officials and from migrant workers undergoing treatment.
Although interviewees covered a range of genders and years in
practice; only health professional role and province/country have
been used in identifying interviewees to maintain
anonymity.Interview duration was between 30 and 90minutes,
depending upon health professional availability and engagement.
In all interviews, detailed notes were taken, and most interviews
were transcribed verbatim, while some were partially transcribed
for pertinent quotes only.Mexican interviews were conducted and
audio-recorded in Spanish by bilingual researchers, and later
translated into English for analysis.
Initial data analysis of the interviews occurred as interviews were
conducted by the lead social scientist researchers with NVivo v7
(QSR International; https://www.qsrinternational.com/nvivo/home).
Listening to audio-recordings, reviewing notes and reading
transcriptions enabled a focus on relevant content areas (such as
access to services and emerging themes, and language
challenges). This iterative process informed judgements of
saturation in each wave of interviewing: when no new content
areas or themes emerged, additional interviews were not sought
out. Subsequent coding incorporated the theoretical perspective
on structural vulnerability.
Knowledge exchange sessions
In addition to these interviews, 20 knowledge exchange sessions
were held with health professionals in Southern Ontario
communities at hospitals, medical schools and medical clinics
serving MAWs as part of a third project. These professionals were
recruited through a sampling strategy that identified rural areas
with high proportions of migrant workers in Southern Ontario, as
well as with medical trainees (egmedical students) at surrounding
medical schools. Sessions were held in the Ontario regions of
Brant, Chatham-Kent, Essex, Haldimand-Norfolk, Hamilton,
Middlesex, Niagara, Simcoe, Toronto, and Waterloo. Researchers
contacted healthcare practitioners in these regions directly in order
to seek participants, and referrals to other potential participants
were solicited following a snowball approach. Participants were
actively recruited by email and phone calls, and personal contacts
were made with primary care and rural hospital providers, who
advertised the sessions with staff and colleagues. Sessions were set
at convenient hours and locations, and refreshments were served.
At the beginning of the sessions, informal knowledge testing
questions, prior to the introduction of relevant material, were
designed to obtain a baseline qualitative assessment of
participants’ knowledge of, sentiments about, and experiences
with healthcare and workers’ compensation access for migrant
workers. Presenters took notes, and fielded questions and
concerns expressed, recorded feedback on the presentation format
and content, and developed an understanding of participants. At
the close of each session, self-administered anonymous
questionnaires gauged respondents’ perceptions of barriers to
healthcare services and ways of overcoming them (n=65). The
questionnaire assessed what participants had learned from the
presentation, and obtained their perspective on what ways care or
practices could be modified in response to migrant worker health
issues and challenges accessing health care and compensation.
Additionally, open-ended qualitative sections of the questionnaire
gathered further qualitative information on possible
improvements, concerns and questions.
All responses were entered into Excel worksheets by a research
assistant and then checked with hard copy questionnaires by an
author for accuracy and reliability. The 65survey respondents
worked in community health centres (24%), followed by acute care
hospitals (21%), public health units (18%), and family health teams
(8%) (other and unspecified 29%). Of these, the largest proportion
were nurses and nurse practitioners (n=24, 38.1%), physicians
(n=7) and administrators/managers (n=9), with a wide range of
other health providers (n=12) (n missing=13).Most respondents
reported seeing at least some migrant workers, with 42% of
respondents seeing more than 20migrant workers over their
careers.
Analysis
Across primary sources, a framework analysis approach was
used, informed by the literature, clinical experience and earlier
research by the authors. The framework method of analysis is most
suitable for analysis of multiple and disparate sources of interview
data, and provides a well-structuredoverviewof summarised data,
which has guided interpretation of the study’s findings.
Based upon these orientations and the literature cited, data from
each primary source was integrated into a database and then
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coded into three high-level nodes related to structural factors,
which emphasized the contexts of the temporary migration
program and the Ontario healthcare system; intercultural factors,
which emphasized the factors related to language and cultural
differences for migrant workers; and transnational factors, which
reflected the experiences and challenges related to providing care
to a group of patients who move transnationally from year to year.
Using the framework approach, interview excerpts were coded into
these three categories and then interpreted and discussed with
specific reference to quotes and phrases employed by
respondents. Findings were then consolidated into four tables
(Supplementary tables S1–S4). Data were triangulated across data
sources in order to strengthen the validity of findings. Co-
consultation across authors, joint narrative writing, and iterative
revisions produced the synthesis.
Ethics approval
Approvals for this research were through research ethics boards at
the University of Toronto (Social Sciences, Humanities and
Education (#18873) and Wilfrid Laurier University (#2865 and
#2388).
Results
Good workers, poor patients? How structures of international
labour migration programs and healthcare services influence
provision of care
Most rural health professionals deeply admired MAWs:
I think these people work extremely hard; it’s back-breaking
work, it’s repetitive work. They’re up early hours, they’re to bed
late. They never leave the farm, except for Friday evenings and
Sundays, but even still, some of them are working seven days a
week for many, many months. (Ontario physician)
… they’re very easy to deal with, probably because they’re
motivated. They’re motivated to get better. They want to work
– most of them – and they come in here and you know, they’re
genuinely concerned about some issue and you kind of feel
that you’re their only person that they can talk to, so you kind
of feel you’re doing something useful … (Ontario physician)
These health professionals faced a number of challenges providing
care to MAWs (Table1, with more detail in Supplementary tables
S1,S2). Responses to these challenges (Table2) were limited in the
face of the structures of the migration program and health
services. As one Mexican health professional noted for migrants, ‘…
a Mexican is not going to be cared for like a Canadian’.
About half of knowledge exchange session participants
understood that migrant workers were eligible for provincial health
insurance, but only a third understood that migrant workers were
eligible for workers’ compensation, with the remainder responding
‘no’ or ‘unsure.’ Health professionals noted the numerous barriers
that MAWs face accessing care, with one Ontario physician
commenting, ‘they wouldn’t see a doctor unless they’re very sick’.
In rural Ontario, healthcare facilities are often long distances from
farm residences and workers normally lack independent
transportation (Supplementary table S1), only going into town on
Friday evenings or weekends. In some cases, volunteer community
support workers, bilingual co-workers or supervisors facilitate
healthcare access for MAWs. However, most often transportation is
provided by employers, whose involvement in medical
consultations raised concerns about privacy and confidentiality
(Table1), including the use of medical information by consular
officials (whose roles include mediating concerns between SAWP
workers and their employers and arranging repatriation of
workers). For example, when speaking about a health form
requested by a consular official, one doctor explained, ‘I don’t
really even know what that form is for. All I know is, I have to fill it
in.’ MAWs’ concerns about jeopardizing current or future work in
Canada, and fears of their employer or consular officials learning of
their health problems, and ultimately leading to deportation if
unable to work (Tables 1, Supplementary table S1), were noted by
several Ontario rural physicians.
MAWs’ lack of insurance and/or health insurance cards at the
beginning of the season impedes access to healthcare services,
particularly specialists, and may limit investigations and treatment
options (Tables 1, Supplementary table S2). Although a few rural
physicians took on MAWs ‘as quasi-regular patients’, others
argued for formal, continuous rostering of MAWs so that they
could be regularly monitored each season in a primary care
setting. The mismatch between when MAWs could get into town
to see a health professional and most providers’ hours was a
recurrent challenge, often resulting in workers seeking care at
over-burdened rural emergency departments (Table1,
Supplementary table S2). Suggestions included modifying clinic
hours (11, 22% of knowledge exchange participants); for example,
one Simcoe clinic and pharmacy stayed open later on Friday nights
when workers are typically bussed into towns in order to buy
groceries, send money home, etc. Others suggested modifying
locations (9, 18%), including mobile clinics to farms
(Supplementary table S2).
Diagnosis of work-relatedness of diseases, such as asthma, which
often required additional testing and follow-up, was difficult with
MAWs (Supplementary table S2). Among Ontario physicians who
were aware of workers’ entitlements to workers’ compensation,
most indicated that they would offer to complete the required
forms for a clear workplace injury. In more ambiguous cases, they
would be less likely to do so, often because of the preference of
workers, out of fear or pressure from employers, not to file a claim.
Responses (Supplementary table S2) included education on the
first visit, community volunteers who ensured the follow-up, and
involving employers in work modification ‘and if he’s not getting
better ... bring him back’ (Ontario physician).
Table1:Overview of challenges perceived by health professionals serving migrant agricultural workers
Supplementary table S1: Structural challenges posed by
migrant farmworkers’ context and suggested responses
Supplementary table S2:Health services related structural
challenges and suggested responses for improving fit
Worlds apart: intercultural challenges, knowledge gaps and
responses
Communication barriers and knowledge gaps were the most
commonly expressed challenge in knowledge exchange sessions
with Ontario rural health professionals, particularly for English-only
providers (the vast majority) serving Spanish-speaking MAWs
(Table1, Supplementary table S3). Challenges in mutual
comprehension included language and accents for several Ontario
physicians, and comprehension or literacy, including for a Jamaican
physician: ‘Farmworkers are mostly illiterate, do not understand,
even me sometimes. … Education level is a big barrier’. None of
the rural Ontario health professionals had a regular translation
service, so providing access to translators/interpreters
(Supplementary table S3) was a priority for knowledge exchange
participants (15, 31%).Multilingual resources, both printed and
telehealth versions, for MAWs and health professionals were also
mentioned as desirable (Supplementary table S3).
Some health professionals identified ‘cultural issues’ as challenges
(Supplementary table S3). Different interpretations of illness
presentations between MAWs and health providers were noted
(egaround pain and bodily discomfort with mental
distress).MAWs’ different expectations of care and treatment often
reflected common practices in their countries of origin, such as
injections in Mexico .
Providers’ limited knowledge of MAWs’ work/living contexts and
contractual situation posed difficulties in identifying and managing
work-related health problems (Supplementary tables
S1,S2).Mexican health professionals noted the need for training of
primary care providers in occupational health (Supplementary
table S2).Given the burden of musculoskeletal problems, Mexican,
Jamaican, and Ontario providers encouraged training in
‘Ergonomic practices applied consistently including work
modification, stretches, etc. which could help us work towards
injury prevention’ (knowledge exchange participant). Health
officials in Mexico noted that they instituted education sessions,
which include some limited information about workers’ health-
related rights and entitlements, primarily focusing on issues such
as sexual health, nutrition and substance abuse.Many providers,
particularly in sending countries, were unaware of Canadian
workers’ compensation systems.
Supplementary table S3:Intercultural challenges faced by
healthcare providers and suggested responses
Care across borders: transnational challenges and responses
Both sending-country and Canadian rural providers had difficulty
understanding preventive practices in the other country, for
example sanitation and personal protective equipment when
spraying pesticides in Canada among Mexican providers, and
screening for conditions in Mexico among Canadian providers
(Table1, Supplementary table S4). A Jamaican physician bemoaned
the lack of provision of training in body mechanics. Some Mexican
providers critiqued the exploitation of MAWs, arguing that the ‘era
of exploitation has passed’ and policies (particularly around
providing greater protections and care to migrant workers) should
be changed. They reported raising concerns with their Ministry of
Labour and at binational meetings to correct deficiencies
(Supplementary table S4).
Chronic conditions such as hypertension and diabetes presented
challenges to continuity of care due to differences in medication
names and availability, leading families in Mexico to request
medication for a MAW in Canada from Mexican providers
(Supplementary table S4). Further, MAWs would not always have
sufficient funds to continue treatment started in the other country.
When MAWs had to leave Canada prior to receiving full diagnostic
workups and/or treatment, Ontario providers faced tough
decisions about whether and when to approve a patient as fit to
travel back to their country, and with what consequences
(Supplementary table S4). One Ontario physician refused to
discharge a patient with a newly diagnosed cancer until the
worker, the specialist and the consulate official had laid out a plan
of care and follow-up in the sending country. On the receiving
end, Mexican providers complained ‘… that the migrants come
with a problem from Canada that they are trying to solve here’.
Both occupational conditions and sexually transmitted infections
were mentioned. While clinicians identified the significant
contribution of occupational factors to presenting health
conditions and the need for preventive activities, no pathways for
these were identified at the clinical level. A Jamaican physician was
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frustrated by the delays in approval by Canadian workers’
compensation authorities for investigations (egMRIs) and
treatments (egphysiotherapy).Mexican providers described
shifting MAW screening to post-migration, decentralizing the
services, and improving coordination of care with state health
services to better manage MAW health problems. However, they
noted that travel, equipment, medications, and treatments are
often not fully covered by state health services, supplementary
insurance, or workers’ compensation, leaving workers’ families to
pick up the costs if they could (Supplementary table S4).
Supplementary table S4:Transnational challenges faced by
healthcare providers and suggested responses
Discussion
Health professionals, working in sending countries and Canada,
demonstrated substantial understanding of the complex
challenges involved in providing care to MAWs in rural settings. As
per Fennelly’s work , the importance of ‘listening’ to rural
providers’ experience as reflective insiders, in order to articulate
better the challenges that they face and the opportunities for
improvement, is clear.Much prior work has emphasized the views
of health professionals in high-income countries (egEuropean
providers grappling with competencies for addressing ethnic and
cultural diversity) . Previously, only Holmes interviewed
providers in rural areas of both a sending country (Mexico) and a
receiving country (USA). The present findings echo those of
Holmes on the challenges that rural health providers grapple with
in order to even partially address the social determinants of MAW s
health within rural health services facing their own structural
constraints. Recognizing the potential for feelings of
powerlessness, as voiced by a Mexican physician in this study, is
particularly important given the sometimes overwhelming nature
of structural constraints, with providers feeling ‘caught in the same
web’ .
However, in contrast with Holmes’ work on rural health service
provision to irregular migrants, interviewees in the present study
described potential for joint sending–receiving country governance
mechanisms to address some of the challenges (Table2) .
Suggestions for joint social protection have included ‘agreements
between the Canadian insurers (Ontario) and the home country
social security scheme’ , but few models of social protection
agreements pertain to health , particularly for migrants labelled
low skilled . Such a transnational perspective is increasingly
germane as those with chronic conditions cross borders and
health burdens accrued in one country fall upon another. Babe, I
Hate to Go is a film about one such Jamaican worker diagnosed
with cancer in Canada . Ullman et al also documented different
health burdens among rural Mexicans returning from the USA .
Such added health burdens pose challenges for MAWs and their
providers, particularly in rural areas with limited access to care and
medicines , despite other improvements in health systems . As
Stan noted, the practice and governance task is to negotiate
adequate health care for MAWs in an emerging ‘healthcare
assemblage and citizenship regime in which patients’ movements
across borders are closely interlinked with .… increasingly unequal
access to public healthcare services’ .
Table2:Towards continuity of culturally safe, transnational care for migrant agricultural workers
Limitations
Although this is the first study in Canada sharing rural health
professionals’ perspectives, it had limited coverage geographically
(only focused on the two largest MAW sending countries and the
Canadian province where the largest numbers of workers are
concentrated: Ontario) and professionally (focused on primary care
versus a full range of specialties). Jamaican provider experience
was inadequately covered with the few providers interviewed and
primarily one sharing key insights. Although the data are
5–13years old, little has changed in laws and programs that might
affect MAWs’ structural vulnerability . Innovative occupational
and primary care services have been developed in some
community sites (storefronts, churches, shopping malls) on Friday
evenings and weekends , but overall health care access and
appropriateness has not substantially changed. Hence, the findings
are still relevant, although substantial scope exists for further
research, particularly transnationally.
Conclusion
A range of opportunities could enhance care for MAWs in rural
Canada and in countries of origin. At the system level, health
service delivery innovations could improve ‘fit’ between people
and providers . In the USA, funded migrant farmworker clinics
exist in major rural agricultural areas and student-run community
35
43 20
44
15
45
46
47
48
49
50
51 52
53
54
55,56
57
medical outreach approaches have been used . Nurse-staffed
cluster clinics for common conditions such as diabetes have been
shown to improve MAW satisfaction with care . Communication,
access and follow-up challenges could be better addressed
through budgeting for remote interpretation services and
building on the work of care navigators . Such responses could
be amplified, building upon international examples of innovations
to promote equity in primary health care . At the rural provider
level, training and resources for culturally safe approaches to
health care could be expanded, in partnership with health
professionals from the top MAW sending countries (egMexico and
Jamaica, in the case of Canada). Other strategies include
adaptations of existing guidelines for particular health problems,
such as Kirmayer et al’s work on mental health , implementation
of tailored structural vulnerability assessment tools , social
prescribing initiatives , and sharing of online resources on
conditions and benefits for MAWs specifically . The rewards in
treating MAWs, expressed by interviewees in Holmes’ work and in
this study, are important resources for innovation, although
funding and support to rural health services overall will have to
increase to ensure implementation.
Acknowledgements
The authors acknowledge participants, research assistants (Aaraon
Diaz, Andres Furet, Eduardo Huesca, Pauline O’Connor, Lisa
Stadelmayer), physician colleagues (Mike Pysklywec, Ted Haines)
and community partner (Industrial Accident Victims Group of
Ontario).
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... Several structural factors exacerbate the risk of workplace abuse in the SAWP (Bhuyan et al., 2018;Robillard et al., 2018). First, the SAWP allows employers to dismiss and deport migrant workers without sufficient avenues for workers to appeal this process (Cole et al., 2019;Cortina-Castro & Kobayashi, 2020;Strauss & McGrath, 2017). Since SAWP workers are assigned temporary work visas linked to specific employers, workplace dismissal can jeopardize the immigration status of migrant labourers (Binford, 2019;Edmiston, 2020;Preibisch, 2004;Strauss & McGrath, 2017). ...
... Thirdly, government regulation of the SAWP is inadequate and demonstratively biased towards employers (Caxaj & Cohen, 2019;Cole et al., 2019;). Through complaint-driven systems, government regulatory bodies require migrant workers to identify and report workplace violations committed by their employers (Caxaj & Cohen, 2019;Edmiston, 2020;Strauss & McGrath, 2019). ...
... Current research has identified that language barriers often compound the pre-existing structural harms of the SAWP, which highlights the importance of interpretation services (Basok, 2009;Caxaj & Cohen, 2019;Cole et al., 2019;Mysyk et al., 2009). In the context of the SAWP, the inaccessibility of government-provided interpretation services, and the associated cost of private interpretation, have prompted pro-worker groups to rely on the support of uncertified interpreters (Cole et al., 2019;Mysyk et al., 2009). ...
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... Likewise, employers or supervisors may encourage or enforce this behavior if it is viewed as posing a threat or delay in farm operations [48,55,56]. Furthermore, when workers seek medical care, they often continue to rely on employers or supervisors for spoken language interpretation, which poses challenges for full disclosure and adequate follow-up in care for both workers and healthcare providers [37,57]. For instance, employers may discourage workers from reporting workplace injuries, or censor workers' concerns to a physician [51,54]. ...
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... The teams realized that the relationship between work and community health problems was unknown to the communities' health care staff. This so-called "blind spot" in occupational health [51,52] of health care providers is well known globally [24,25,41,49,[51][52][53][54]. Likewise, local authorities were unaware of the association between work and health. ...
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