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Access to Primary Health Care Services for Spanish-Speaking Agricultural…
Access to Primary Health Care Services for Spanish-Speaking Agricultural Temporary Foreign Workers (TFWs) in Ontario
In 2021, 27,000 TFWs were employed in agriculture in Ontario, with 44% of workers originating in Mexico and 23% originating in Guatemala [16]. TFWs experience significant barriers to accessing primary health care compared to the general Canadian population, with precarious immigration status and fear of deportation as primary factors driving this disparity [15].
Season Agricultural Worker Program (SAWP)
Federally operated program
Allows employers to obtain low-wage cyclical labour, structured to "import labour but not people" [6]
Closed contracts tie workers to a single employer, quitting/being fired/switching employers means losing legal authorization to work in Canada [1]
Worker health is placed in employers hands who may not have tools, capacity or commitment to address worker health [15]
Specific partnerships with Mexico and various Caribbean countries to recruit workers for up to 8 months of the year [16]
Family status criterion in worker selection, preference is for married fathers who will return to their family [6]
Limited to no opportunities for workers to pursue permanent residency [6]
Employers are entitled to terminate workers' employment for non-compliance, work refusal, "or any other sufficient reason", including medical repatriation [11]
Repatriation may occur before receiving health care, despite workers' entitlement to receive health care prior to medical termination/repatriation [11]
Public Policy:
Advocate for path to permanent residency so the ability to remain in Canada or access health care is not completely contingent on employer, permanent residency status provides agency to exercise rights to refuse unsafe work or leave abusive employment situations [4]
Employers are obligated to provide access to accommodations for workers [10]
Community:
Be aware of local industry participation in SAWP, advocate with local Members of Parliament to hold employers accountable in meeting accommodation and occupational health standards
Ontario Health Insurance Plan (OHIP) Coverage
Provincially operated program
Health insurance coverage contingent on work permit [2], eligibility for OHIP application requires proof (i.e., work contract) of physically remaining in Ontario for 153 days of a 12 month period [7]
Employers are obligated to provide private insurance when employees are not OHIP eligible, often "bare bones" and require worker payment for health care service upfront with reimbursement following an insurance claim [4]
Public Policy:
Advocate for OHIP coverage regardless of length of contract. Advocate for language accessibility through access to interpreters, forms in Spanish, written information about health coverage in plain language Spanish
First time applicants must apply in person at a ServiceOntario location, previous OHIP card holders may apply by mail using English or French language forms [7]
Of 600 surveyed workers, 20% did not have an OHIP card, 93% did not know how to make a Workers Compensation claim, 85% did not know how to make a health insurance claim, 74% had a poor understanding of their health insurance [4]
Workers are often uncertain about how payment will be made or what the cost of service will be when accessing health care [13]
Intersecting Identities
Psycho-social and spiritual background
Male
: 97% of TFWs are male, 3% female, other gender identities have not been captured in routine data collection [8]
Parent:
Most male TFWs are fathers who spend up to 8 months of the year in Canada to provide financially for their family [6],[14]. Estrangement from children and children feeling abandoned is common [7]
Latin-American:
Precarious immigration status, temporary presence in country of current residence, socially and physically isolated from local community [7]
Tend to originate from rural areas in home country with limited income opportunities [14]
Typically Spanish is first language [15]
English verbal fluency and Spanish/English literacy is often limited [9],[15]
Likely to identify with Catholic faith, may or may not actively practice Catholicism [6]
Employee:
Entering into a working relationship who holds power over worker and family's livelihood [15]
Agricultural work delegated to TFWs is generally low-skilled, repetitive, inflexible, low pay, long hours [15]
Spouse:
Isolated from family, strained spousal relationships, partner remaining in home country takes on role of single parent for many months of the year [7]
Immigrant:
Entering a country and culture different from their own with precarious immigration status, no guarantee of remaining in Canada for the duration of their contract [6]
Population Health Indicators
Challenging to accurately measure due to inconsistent reporting, workers working while sick/injured for fear of repatriation [11]
Occupational Health:
Incidence of workplace injuries and exposures
Hours of Work:
Long hours, limited days or time off, unpredictable work schedule, unreasonable productivity targets [12],[15]
Primary Care Service Hours:
Clinics are often closed during workers time off, appointments are required that workers may not be able to commit to, lengthy wait times for after-hours walk-in services [8]
Institutional:
Offer evening and weekend hours of service targeted to and reserved for TFWs [8],[9]
Repetitive strain injuries, skin irritation, muscle strain, headaches [12],[15]
Inadequate PPE access, inadequate workplace training, inaccessible training and challenges communicating workplace hazards due to language/literacy barriers [3],[12],[15]
Falls, vehicle accidents, heavy machinery accidents, use of poorly maintained equipment [12],[15]
Prolonged exposure to sun, chemicals, pesticides [5],[15]
Mental Health:
Incidence of depression, anxiety, other mental health conditions
Poor sleep due to overcrowded accommodations, excess heat/cold, uncomfortable mattress [15]
Loneliness, competition among colleagues, poor nutrition, stressful home and work environment, abusive and exploitive employer relation [15]
Physical Health:
Incidence of infectious disease (i.e., COVID-19, tuberculosis, foodborne illness)
Poor ventilation in accommodations and work spaces [15]
Public Policy:
Advocate for federal housing standards to be established in consultation with public health (access to handwashing and hygiene/sanitation supplies and infrastructure, safe and well-maintained accommodations, ability to maintain physical distancing when needed, adequate physical space allotted to each worker in accommodations) [4]
Public Policy:
Advocate for culturally safe methods of health indicator assessment of TFWs, share data with public health agencies for public reporting to increase worker visibility and support program planning [4]
Barriers to Primary Health Care Access
Precarious Immigration Status Barriers
Employer-Driven Barriers
Employer Mediation in Health Care Access
: Workers are often reliant on employers to provide transportation, translation assistance, permission for time off work [8]
Transportation:
Workplace and accommodations are typically rural, limited access to transportation results in geographic and social isolation from general population [6]
Loss of Income:
Workers may not be able to afford time off to access medical services if pay is deducted for missed work hours [9]
Financial Barriers
Primary Care Barriers
Health Care Provider Attitudes:
Insensitivity from service providers to TFW health concerns, workplace realities, constraints in maintaining commitments, lack of control in personal and professional choices [1]
Intrapersonal:
Critically examine personal biases and prejudices, discrepancies in privileges and oppressions between self and clients
Intrapersonal:
Client centred approach, set realistic expectations for what workers may or may not be able to follow through on when planning interventions and making recommendations
Intrapersonal:
Be aware of immigration status and fear of medical repatriation, developing trusting client relationships will take an investment of time and demonstration of good faith in maintaining confidentiality [15]
Bureaucracy and Administrative Requirements:
Patients are often required to complete a rostering process a requirement for service, may be tied to only accessing a specific clinic once rostered, more reliance on English-centric telemedicine due to pandemic, fees or de-rostering consequences for missed appointments [3],[4]
Institutional/Public Policy:
Advocate for funding structures and clinic access policies that are not dependent on client rostering
Location:
Primary care services are often in fixed clinic locations [8]
Institutional:
Collaborate with employers and workers to provide primary care services and health care provider connection onsite at workplaces or accommodations [8]
Language
: Spanish language service or interpretation is often not available [15]
Institutional:
Access telephone, video, or in person interpretation services
Institutional:
Offer alternate means of clinic contact (i.e., WhatsApp, a messaging application frequently used by TFWs and has been utilized by researchers and community health workers in maintaining direct contact with workers without involving employer [9])
Intrapersonal:
Be aware of strategies for bridging language barriers (i.e., print resources available in Spanish language, online text translators when appropriate)
Health Care Service Complexity:
Confusion and lack of clarity for what services are offered by which providers (primary care, urgent care, sexual health, etc.) [9]
Institutional:
Clear, plain language descriptions of available services written in Spanish language
Overcrowded accommodations, no physical distancing or separate space for ill workers [2],[4], lack of bathroom facilities, hand washing facilities, laundry and washing facilities, food storage/refrigeration for personal food [5],[15],