Week6 case study_dynamicsofhealth_jess
Upcoming SlideShare
Loading in...5
×
 

Week6 case study_dynamicsofhealth_jess

on

  • 303 views

 

Statistics

Views

Total Views
303
Views on SlideShare
246
Embed Views
57

Actions

Likes
0
Downloads
1
Comments
0

2 Embeds 57

http://unelti.androgogic.com.au 47
http://study.uneopen.com 10

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Week6 case study_dynamicsofhealth_jess Week6 case study_dynamicsofhealth_jess Document Transcript

  • The Impact of Policy Changes onthe Health of Recent Immigrantsand Refugees in the Inner CityA Qualitative Study of Service Providers’ PerspectivesLeah S. Steele, MD, CCFP1Louise Lemieux-Charles, PhD2Jocalyn P. Clark, MSc, PhD candidate3Richard H. Glazier, MD, MPH, FCFP1ABSTRACTBackground: Dramatic changes to health and social policy have taken place in Ontarioover the last five years with few attempts to measure their impact on health outcomes. Thisstudy explored service providers’ opinions about the impact of four major policy changeson the health of recent immigrant and refugee communities in Toronto’s inner city.Methods: Semi-structured key informant interviews.Results: Reductions in funding for welfare, hospitals and community agencies were seen tohave had major effects on the health of newcomers. Emergent themes included erosion ofthe social determinants of health, reduced access to health care, increased need foradvocacy, deterioration in mental health, and an increase in wife abuse.Conclusions: Several areas were identified where policy changes were perceived to havehad a negative impact on the health of recent immigrants and refugees. This studyprovides insights for policy-makers, inner-city planners and researchers conductingpopulation-based studies of immigrant health.The translation of the Abstract appears at the end of the article.1. Inner City Health Research Unit and the Department of Family and Community Medicine,St. Michael’s Hospital, University of Toronto, Toronto, ON2. Associate Professor, Department of Health Administration, University of Toronto3. Department of Public Health Sciences, University of Toronto and The Centre for Research inWomen’s Health, Sunnybrook & Women’s College Health Sciences Centre, Toronto, ONCorrespondence and reprint requests: Dr. Leah S. Steele, Inner City Health Research Unit, St.Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, E-mail: leah.steele@utoronto.caAt the time of writing, Dr. Steele was supported by the Joint Centre of Excellence for Research onImmigration and Settlement (CERIS) in Toronto and by a Medical Research Council of CanadaTraining Fellowship. Ms. Clark holds a Ph.D. fellowship from NHRDP/CIHR.Twelve percent of individuals living inToronto are recent immigrants, havingarrived in Canada in the last five years.1In addition, about 7,000 individuals inToronto are assigned refugee status annually.2While recent immigrants tend to be healthierthan Canadian-born residents in terms ofchronic disease and disability,3they may facepersonal hardships that stem from social isola-tion, cultural adjustment and financial strain.4-6Refugees are persons who cannot return totheir countries because of a fear of persecutiondue to their belonging to a particular social,political or religious group. The health status ofrefugees tends to be poorer than that of recentimmigrants.7Together, these two groups ofnew Canadians represent an important andvulnerable inner city population.Socio-economic factors have been shown tobe more important in determining health forimmigrants than for non-immigrants.5Consequently, new Canadians may be partic-ularly vulnerable to policy changes that affecttheir socio-economic environment. Policychanges resulting in reductions in services tonewcomers may contribute to disruptions insocial support systems, which then maythreaten the health outcomes of individualsliving in low-income, newcomer communi-ties. While major changes in health and socialpolicy have been implemented in Ontario(Table I), there have been few efforts to mea-sure their impact on new Canadians.7This qualitative study was designed toinform the development of research ques-tions for a population-based quantitativeanalysis.8We chose to explore the impact offour policy changes: 1) the reductions to hos-pital funding and hospital restructuring,2) the reductions to funding of community-based health and social services, 3) the reduc-tions in welfare payments, and 4) the imple-mentation of user fees for prescriptions. Thepurpose of this study was to elicit serviceproviders’ opinions about the impact of thesepolicy changes on the health of recent immi-grant and refugee communities in Toronto’sinner city.METHODSResearch methodThis exploratory study drew on the induc-tive approach advanced by grounded theo-ry scholars.9,10We used semi-structured,face-to-face interviews and followed stan-dardized guidelines set out by Miles andHuberman.11This study received approval118 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 93, NO. 2
  • from the Research Ethics Board at theUniversity of Toronto.Sampling and recruitmentThrough clinical experience and collabora-tion with community health workers, a listwas developed of community agencies thatprovide services to new Canadians in theinner city of Toronto. Using purposive sam-pling to maximize diversity among our par-ticipants, we recruited key informants fromthese agencies who represented a variety ofcultural backgrounds and occupational rolesthat may have influenced their opinionsabout the impacts of policy changes.12Thissampling strategy allowed us to describe thecentral themes that cut across heterogeneousprograms and participant roles.12Followingan initial telephone invitation to participate,key informants were sent additional studyinformation prior to the interview, includingan outline of the interview questions.Data collectionThe interviews were conducted in the com-munity agencies by the first author. Informedconsent was obtained prior to each interviewand confidentiality was discussed. The inter-viewer followed a guide containing questionsand probes that encouraged respondents toreflect on the impact of the policy changes onthe health of newcomer communities andrelated programs and services. The develop-ment of the interview tool was facilitated bythe authors’ community-based clinical andresearch experience and aided by consultationwith community groups. Some examples ofthe questions asked are: “What impact, ifany, did hospital closures have on the healthof the immigrant and refugee communitiesthat you serve?” “What changes, if any, didyour organization make in response to thereduction of social services funding?”Interviews ranged from 45 to 90 minuteslong, were tape-recorded and transcribedverbatim. Reviewing the tapes and transcriptson an ongoing basis allowed monitoring ofthe reliability of the data collection.AnalysisThe method of data analysis was qualitativecontent analysis – the process of identify-ing, coding and categorizing patterns.12One reviewer (LS) read and open-coded theentire set of transcripts. Upon completion,the entire set of transcripts was reviewedagain, codes were applied back to the data,the coding scheme was refined and cate-gories were established. A second reviewer(JC) independently reviewed the completeset of transcripts. The initial coding schemewas challenged and then systematically re-applied to the data by the second reviewer.In the first stage of the analysis, the datawere explored and categories were used toorganize the codes into meaningful clusters.Data were categorized by specific policychange (e.g., welfare reductions, hospitalfunding, etc.) and by focus of impact (e.g.,immigrant community, service agency,etc.). Data matrices were developed thatallowed systematic comparison of therespondents’ perceptions of impact withrespect to each policy change.11Emergingthemes were evaluated. Disagreements incoding and discrepancies in interpretationwere discussed and decided by consensus.To ensure the trustworthiness of the analy-sis, a second researcher reviewed an audit trailto affirm that conclusions were supported bythe data. Validity was addressed at variousstages of the analysis through consultationwith an interdisciplinary research team thatincluded health professionals, social scientistsand community liaison workers, as well asthrough discussion at two panels related tothe impact of policy on immigrant health.POLICY CHANGES AND IMMIGRANT HEALTHTABLE ISummary of Important Health and Social Policy Changes in OntarioDate Policy/Project Affected Type of Change Group Affected1993 Welfare Legislation – Ontario $100 deduction in benefits to recent immigrants whose Low-income recent immigrants.sponsorship has deteriorated.1994 Ontario Health Insurance Plan (OHIP) 3-month wait before new immigrants are eligible for OHIP Recent immigrants.insurance.1995 Interim Federal Health Program Refugees and refugee claimants provided limited health Refugee and Refugee claimants.coverage by the federal government.1995 Social Housing Projects - Ontario Cancelled 385 planned social housing projects in Ontario. Marginally-housed and low-This included 80 projects in Metro and 23 projects in the income groups.(former) City of Toronto.1995* Welfare and Family Benefits – Ontario The Provincial Government of Ontario instituted a 21.6% All welfare and family benefitsreduction in welfare payments. recipients except thosewith disabilities and seniors.1996* Canada Assistance Plan Changed to Canada Health and Social Transfer – Reduction Provincially funded social serviceof 23% for health, welfare, social services and agencies and others.post-secondary education.1996 Federal Unemployment Insurance Reduced the amount and duration of benefits. Unemployment insurancerecipients.1996* Ontario Drug Benefit Plan Low-income individuals or families face a $2 co-payment Low-income groups and seniors.for prescriptions. Seniors who are not low-income paydispensing fees and a $100 yearly deductible.1997 Welfare Legislation – Ontario Bill 142 enacted. Replaced welfare legislation with the Low-income groups.Ontario Works Act and the Ontario Disability Support ProgramAct. Eligibility requirements for welfare were tightened.1997 Tenant Protection Act Bill 96 instituted “vacancy decontrol” which allows landlords Tenants.to move rents to market value when their units become vacant.1997* Health Services – Toronto Recommendation of Health Services Restructuring Residents of Toronto requiringCommission resulting in the closures of two hospitals and hospital services.amalgamation of three hospitals in central Toronto. Alsorecommended a 14% reduction of in-patient psychiatricbeds in Toronto by the year 2003.1997 Federal Employment Insurance Eligibility based on number of hours worked rather than Unemployed workers.number of weeks worked, allowed part-time workers eligibilitybut increased the number of hours required to be eligible.* These four policy changes were the primary focus of this study.MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 119
  • RESULTSKey informantsTen key informants were interviewed repre-senting nine community agencies that servenewcomers. Seven key informants werewomen and three were men. The culturalbackground of the participants varied, withrepresentation from Asia, Africa, Europe,North America and Latin America. They hadworked at their agencies an average of 7 years(range 4-15). They included two physicianswho provided clinical care to newcomers,two registered nurses who were involved inclinical care and community health promo-tion, four community workers, and two exec-utive directors who were involved in programplanning, administration and staffing of pro-grams related to immigrant and refugeehealth.Characteristics of the community agenciesand their clients are described in Table II.ThemesA summary of themes that emerged throughthe interviews is depicted in Table III.A. Reductions in hospital funding andhospital restructuringBetween 1996 and 1998, the provincial gov-ernment in Ontario reduced funding for hos-pitals by over 10%.13,14All of the key infor-mants working in health service agenciesidentified negative impacts resulting from thechanges to hospital funding. Key informantsfelt that funding reductions had resulted in ascarcity of beds that led hospitals to dischargepatients into the community earlier than waswarranted. Services such as home-care wereunder increasing strain to care for sickerpatients in the community. Consequentlyboth service providers and families facedincreased caregiver burdens.These problems were felt to be particularlydifficult for newcomer groups for two rea-sons. First, newcomers may face languagebarriers and a lack of familiarity with the sys-tem that results in a greater need for advoca-cy from service providers than that requiredfrom Canadian-born clients. Second, manykey informants described a culturally-specificnotion of familial duty that leads to greatercaregiver burden, since new immigrant fami-lies tend to assume more of the responsibilityfor the care of their family members than istypical of a Canadian-born family (see TableIV).B. Reductions in funding of community-based health and social servicesAt the time of the reduction in federal transferpayments, provincial support for community-based health and social service agencies wasbroadly reduced. Some reports indicate thatservices targeted at new immigrants andrefugee groups were disproportionatelyaffected.15-17Key informants believed thatthese service losses had broad effects for newCanadians, including: 1) increased barriers toaccess, 2) increased need for advocacy,3) increased provider stress, and 4) housingproblems (See Table V).Key informants identified an urgentneed for interpretation services, case-management and culturally-appropriatefood-bank services. However, funding restric-tions had precluded attempts to improve theaccessibility of such services for newCanadians. Moreover, changes to healthinsurance legislation were perceived to haveexacerbated existing barriers to access. Six ofthe key informants noted that a new three-month wait for OHIP eligibility for landedPOLICY CHANGES AND IMMIGRANT HEALTH120 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 93, NO. 2TABLE IICharacteristics of Community AgenciesAgency Type Size* % New- % Social % No Health Funding Personnel Servicecomers Assistance Coverage Cuts? Cuts? Cuts?1 Social Small 100% >50% <50% Yes No No2 Health Large 30% 60-75% <50% Yes Yes Yes3 Health Mid 40% 25% <50% Yes Yes No4 Health Mid >90% 50% 70% No No No5 Health Large >50% 95% 20% Yes Yes Yes6 Social Small 50% NK NK Yes Yes Yes7 Health Large 40% NK 15% Yes Yes Yes8 Social Small 100% 25% <50% Yes Yes Yes9 Health Large 50% >50% 30% Yes Yes No* Estimated budgets (small = less than $1 million, mid = $1 - $2 million, large = more than $2 million).NK = not knownTABLE IIISummary of Emergent Themes andImpacts Grouped by Policy ChangeA: Reductions in hospital funding and hospitalrestructuringEarly dischargeInadequate home-care servicesIncreased care-giver burdenB: Reductions to funding of community-basedhealth and social servicesIncreased barriers to accessIncreased need for advocacyProvider burn-outLack of affordable housingC: Reductions in welfare paymentsDiminished quality of lifeMental health issuesWife abuseTABLE IVThe Effects of Reductions to Hospital Fundinga) Early discharge“What we have noticed is that people are definitely being kicked out of hospitals earlier … weare seeing sicker people at home and hospital.”b) Inadequate home-care services“We had asked for homemakers or nurses and they would just be really, really sticky. It hasnever really recovered to the levels it was in the mid-1990s. A woman with dementia that’s wan-dering all over the place was told she was not appropriate. I had to advocate and … we wouldfind that somewhere down the line, someone had refused her. That happens fairly frequently.”c) Increased caregiver burden“People have to go back to their family for support. Sometimes their married daughter or son willhave to stay with them for a few days after their discharge. It makes it very difficult because theyhave their own children to take care of. For the Chinese and Vietnamese - they take care of theseniors, even though they have a lot of difficulties, they try to take care of them. … However, itdoes not mean that there is no problem … because they draw resources from their families, itseems that there is no problem.”
  • immigrants had caused significant accessproblems. Unlike landed immigrants, refugeeclaimants have immediate health care cover-age through the Federal Interim HealthProgram.18However, key informants indicat-ed that this plan is inadequate because it isless comprehensive than the provincial planand it is burdensome for physicians to nego-tiate.According to our participants, newCanadians with inadequate health coverageare seeking care at provincially funded com-munity health centres. Staff at these agenciesare under pressure to provide care for com-munities with growing needs from a shrink-ing pool of social and health serviceresources. Seven of the ten key informantsbelieved that diminishing services have led toan increasing need for patient advocacy thathas left less time for other functions such ascounselling, preventive care and case-management. This situation has led to a sig-nificant amount of stress and staff burnout.In addition, nine out of ten key infor-mants noted that there was a scarcity ofaffordable housing that seemed to be worsen-ing. In new immigrant communities, thisplaced an extra burden on families to providehousing for their relatives.C. Reductions in welfare paymentsThere was a consensus among our key infor-mants that the 21.6% reduction in welfarebenefits and the changes to the qualifyingrules have had significant deleterious impactson immigrant communities in the followingareas: 1) quality of life, 2) mental healthissues, and 3) wife abuse (see Table VI).Many of the key informants noted a deep-ening of poverty in their communities.Newcomers were seen to have become morefocused on meeting their basic needs, often atthe cost of personal development and qualityof life. Similarly, benefit reductions were seento have contributed to an increase in mentalhealth problems within immigrant commu-nities. In addition to financial strain, low-income individuals were coping with stressthat stems from negotiating the increasinglyrestricted social service system. Increasedstress and diminished support were seen to berelated to worsening of mood disorders andincreases in suicidality.Nine of ten participants felt that wifeabuse was increasing as a result of conditionsexacerbated by the policy changes. Key infor-mants argued that benefit reductions havelimited the ability of women to leave abusivesituations. Since 1993, recent immigrantswho have had a breakdown in sponsorshipand who subsequently require welfare sup-port, are subject to an additional $100monthly deduction from their benefits.19,20Those who were aware of this policy uni-formly viewed it as detrimental to the well-being of new immigrants – and particularlyso to immigrant women since it served tofurther reduce their financial autonomy.D. Implementation of user fees forprescriptionsSince July 1996, low-income individuals andfamilies have faced a new $2 co-paymentfor prescriptions.21,22The majority of keyinformants (7 of 10) felt that prescriptionuser fees had not had a significant impact onpatients’ adherence to medications. Manykey informants noted that community phar-macies were waiving the $2 user fee. In thissense, community pharmacies, and not low-income communities, absorbed the burdenof this funding reduction.DISCUSSIONKey informants expressed considerable con-cern about the impact of recent health andsocial policy changes on the wellbeing ofimmigrant and refugee communities ininner-city Toronto.Immigrant women were seen to have beenparticularly affected by the policy changes.While seniors and the disabled had beenPOLICY CHANGES AND IMMIGRANT HEALTHTABLE VThe Effects of Reductions in Social Spendinga) Increased barriers to access“Refugees no longer covered by OHIP are on this interim federal health plan. We have hadproblems with accessibility to specialists through that because it is very cumbersome to makethose claims (to the federal interim health plan) and some specialists are refusing to see thosepatients. There is a very clear guideline as to what things are covered. Psychiatry is one of thesurprising ones - you are allowed one consultation and that’s it. So if you have someone who isvery sick with depression or post-traumatic stress disorder because they have been tortured orincarcerated, it is often quite hard to get repeat consultations and ongoing care.”“Well people are kind of bashing down our door and we have a waiting list of 60-80 peopleoften at a time. A lot of them are without health cards and may be not able to access other ser-vices.”b) Increased need for advocacy“It is very obvious when compared with before, that we spend more and more time to go afterhome care and welfare on the phone and to advocate for people. Because sometimes when weadvocate successfully, the services lasts for a few weeks and then they quit. Then, we have tocall them again. So, more time is used in going after the service providers to ask for services andmore time has been taken away from counselling.”c) Provider burn-out“The need has increased. I have watched it the six years I have been here and I can tell you. Ihave seen it in the patients’ behaviour. I have seen it in the numbers. I see it in the staff’s faces.And I hear it. And I see them crying. And I see them take money out of their own pockets. I seethem go to the fridge and feed people. I don’t like what I see. They burn out. They can’t debrief.They go from one [person] to another to another to another.”d) Lack of affordable housing“Some of them move from one relative’s home to another. Sometimes when they cannot find aplace to stay, if they are single they will try to sneak in and sleep in the malls. They sneak inbefore it is closed for one or two nights and then they try to find other places in a relative’shouse. Sometimes they are in and out of shelters. In a way, they are homeless, but they are noton the streets.”TABLE VIThe Effects of Reductions in Welfare Benefitsa) Diminished quality of life“When you are doing community development and people move along in the continuum, theirself-esteem improves. They begin to take control. They feel a sense of control. They organise. …You help them to go back to school. They get a job. All that has been turned backwards with thecuts. What the cuts have done, is they have put most people back at Maslow’s bottom rungs, sothat your whole day is spent securing food and shelter, or worrying about how you are going topay the rent and buy groceries too.”b) Mental health issues“We have had two or three people a year as a practice who successfully committed suicide. Onewas my patient. She was on family benefits and quite an ill person. My impression of the lastyear of her life … she had lots of medical problems, drug abuse problems … she was constantlybringing in these forms and the benefits were being eroded and she was trying to get this andthat, and having to advocate for her all the time.”c) Wife abuse“I think the biggest impact of welfare cuts on women and children is that more women have totolerate abuse, because for them [housing] is very difficult to find... I mean, even though they areon welfare, the welfare money is not sufficient for them to pay the rent … Before, they gave firstand last. …[Now] they do not pay last month rent. So, how can they get a decent place to stay?Especially if they have small children - three to four children.”MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 121
  • exempted from the welfare benefit reduc-tions, the reductions were applied to singlemothers. Moreover, recent immigrants facean additional $100 reduction in benefits iftheir relationship with their sponsor has dete-riorated. These changes may increase the vul-nerability of immigrant women to abusefrom their partners by limiting their financialautonomy. Women, who are most likely tobe the primary caregivers in their families,also tended to bear the burden of cuts tohome care and community support services.Gathering qualitative accounts from com-munity service agency workers was valuablebecause it identified key issues of concern tocommunities that can now guide our popula-tion database analyses.23,24Some impacts ofpolicy changes, such as the increased need foradvocacy and the meanings attributed tothese changes by individuals, are best exploredusing qualitative methods. Importantly, inter-pretation of the data collected from partici-pants must be viewed with an understandingof the conceptual framework that the keyinformants and the researchers were workingwithin.25The service providers’ viewpointrepresents one perspective in the complexrelationship between policy, healthcare andhealth. Further research that includes the per-spective of new Canadians themselves isessential. It may also be the case that theresponses of key informants reflect not merelythe impacts of policy changes on immigrantsand refugees, but also relate to inner-city pop-ulations in general.Our small sample size may have limitedthe generalizability of our conclusions.However, external validity was bolstered bythe maximum variation sampling, sinceshared themes derive their significance fromhaving emerged out of the heterogeneity ofour sample.12Our key informants’ interest inpolicy or activism may have influenced theirwillingness to participate and could be asource of bias. However, only two individualswe approached refused to participate in thestudy; in both cases, the reason stated waslack of time and not lack of interest.A recent qualitative study by Raphael et al.explored the concept of government policies asa threat to health in Toronto communities.26The authors argued that public health workersshould be involved in policy development atthe planning stage rather than focussing onprograms meant to ameliorate the effects ofpolicy decisions. Our study, while focussingon immigrant and refugee groups, lends fur-ther support to Raphael’s recommendations.On many levels, changes to health and socialpolicy were seen to have had a detrimentaleffect on the health of new immigrant andrefugee groups. Health care providers in theinner city of Toronto are finding it challeng-ing to meet the increasing health needs of thispopulation in the face of increasingly strainedresources. In keeping with the principles ofpublic health, government agencies shouldensure that policy changes promote ratherthan threaten the public health goal of univer-sal and equitable access to the basic conditionsthat are necessary to achieve health.REFERENCES1. Statistics Canada. Profile of Census Divisions andSubdivisions in Ontario, Part B. Ottawa: 1996.2. The Metropolis Project. Facts and Figures -Immigration Overview: Toronto Profile. [cited 2000Jun 1], Available on line at http://canada.metropo-lis.net/research-policy/f&f/ 2h.html.3. Chen J, Ng E, Wilkins R. The health of Canada’s immi-grantsin1994-95.HealthRep1996;7(4):33-45,37-50.4. Burke MA. Canada’s immigrant children.Canadian Social Trends 1992;24(Spring):15-20.5. Dunn JR Dyck I. Social determinants of health inCanada’s immigrant population: Results from theNational Population Health Survey. Soc Sci Med2000;51:1573-93.6. Beiser M, Hyman I. Southeast Asian Refugees inCanada. In: Al-Issa I, Tousignant M, (Eds.),Ethnicity, Immigration and Psychopathology. NewYork: Plenum Press, 1997;45-56.7. Kinnon D. Canadian Research on Immigration andHealth: An Overview. Ottawa: Health Canada,1999. Catalogue No. H21-149/1999E.8. Glazier RH, Cohen MM, Badley E, Badgley R,Patychuk D, Purdon L, et al. The Health Effects ofReductions in Welfare Payments and HospitalClosures on Immigrant Populations in SoutheastToronto. Research in progress funded by the JointCentre of Excellence for Research on Immigrationand Settlement. (CERIS) Toronto, 1999-2000.9. Glaser BC, Strauss AL. Discovery of GroundedTheory: Strategies for Qualitative Research. Chicago:Aldine, 1967.10. Strauss A, Corbin J. Basics of Qualitative Research:Grounded Theory Procedures and Techniques.Newbury Park, CA: Sage, 1990.11. Miles MB, Huberman AM. Qualitative DataAnalysis: A Sourcebook of New Methods, 2nd Ed.Beverly Hills: Sage, 1995.12. Patton MQ. Qualitative Evaluation and ResearchMethods, 2nd Ed. London: Sage, 1990;381-89.13. Torjman S. Health Care/ Caring for Health.Caledon Institute of Social Policy, 1998 [cited 2000Feb 20]. Available on line at http://www.cale-doninst.org/full92.htm.14. Mackinnon D. Restoring Public Confidence inOntario’s Health Care System. 1999 pre-budgetsubmission to the honourable Ernie Eves, Ministerof Finance and Deputy Premier. Toronto: OntarioHospital Association, March 23, 1999.15. Social Planning Council, City of Toronto & MetroCommunity Services Toronto. Profile of aChanging World. 1997.16. Mwarigha MS. Issues and Prospects. The Fundingand Delivery of Immigrant Services in the Contextof Cutbacks, Devolution and Amalgamation. JointCentre of Excellence for Research on Immigrationand Settlement. [cited 2000 Sep 22] Available online at http://ceris.metropolis.net.17. George U, Nichalski J. A Snapshot of ServiceDelivery in Organizations Serving Immigrants.Toronto: Centre for Applied Social Research,University of Toronto, 1996.18. Citizenship and Immigration Canada. OperationsMemorandum 1P-98-16. Interim Federal Health(IFH) Program. December 1998.19. Ontario Works Act, 1997. Ontario Regulation134/98. Amended to O. Reg. 614/00 Section51(2).20. Halifax Daily News. Apr 18, 95. Daily Edition.Pg. 14.21. Regulations under the Ontario Drug Benefit Act.GENERAL O. Reg. 201/96. ONTARIO REGU-LATION 201/96. Amended to O. Reg. 495/00Sect. 3(4).22. Wallace J. Elderly hit by $2 fee for drugs. TheToronto Sun 1996;Jul 14:3.23. Sofaer S. Qualitative methods: What are they andwhy use them? Health Serv Res 1999;34(5 Pt2):1101-18.24. Green J, Britten N. Qualitative research andevidence-based medicine. BMJ 1998;316(7139):1230-32.25. Hughes LC, Preski S. Using key informant meth-ods in organization survey research: Assessing forinformant bias. Res Nurs Health 1997;20(1):81-92.26. Raphael D, Phillips S, Renwick R, Sehdev H.Government policies as a threat to health: Findingsfrom two Toronto community quality of life stud-ies. Can J Public Health 2000;91(3):181-85.Received: January 24, 2001Accepted: November 15, 2001POLICY CHANGES AND IMMIGRANT HEALTHRÉSUMÉContexte : Il y a eu de profonds bouleversements des politiques sanitaires et sociales de l’Ontarioau cours des cinq dernières années, mais on en a très peu mesuré les incidences sur la santé. Notreétude porte sur les opinions de prestateurs de services quant aux incidences de quatre grandschangements d’orientation sur la santé des nouveaux immigrants et réfugiés des quartiers déshéritésde Toronto.Méthode : Entretiens semi-directifs avec des informateurs clés.Résultats : Selon nos informateurs, les compressions dans les budgets de l’aide sociale, deshôpitaux et des organismes communautaires ont eu des effets importants sur la santé des nouveauxarrivants : érosion des déterminants sociaux de la santé, restriction de l’accès aux soins, besoinaccru de défense des intérêts, détérioration de la santé mentale et augmentation de la violenceconjugale.Conclusions : Dans plusieurs domaines, les changements d’orientation auraient eu des effetsnuisibles sur la santé des immigrants et des réfugiés nouvellement arrivés. Les résultats de l’étudepeuvent éclairer les décideurs, les planificateurs des quartiers déshérités et les chercheurs quimènent des études représentatives sur la santé des immigrants.122 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 93, NO. 2