Executive Summary

Perceptions from Official Language Minority Communities : Access to Health Services in the Official Language of Choice

2020

Submitted to
Health Canada

Prepared by
Leger

Contract number: HT372-194222/001/CY
POR #077-19
Contract Value: $78,411.83 (HST included)
Awarded 2020-01-27
Delivery Date : 2020-03-31
2020-03-31

Leger
507 Place d'Armes, Suite 700
Montréal, Québec
G1R 2K2
Phone: 514-982-2464
Fax: 514-987-1960

For more information on this report, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca
Ce rapport est aussi disponible en français.

Perceptions from Official Language Minority Communities Access to Health Services in the Official Language of Choice

Executive Summary
Prepared for Health Canada
Supplier Name: Leger
March 2020

This public opinion research report presents the results of a web survey and online focus group discussions conducted by Leger Marketing Inc. on behalf of Health Canada. The research was conducted with Canadians living in an official language minority situation.

Cette publication est aussi disponible en français sous le titre : Perceptions des communautés de langue officielle en situation minoritaire (CLOSM): accès aux services de santé dans la langue officielle de son choix 2020.

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB
200 Eglantine Driveway, Tunney's Pasture
Jeanne Mance Building, AL 1915C
Ottawa, Ontario K1A 0K9

Catalogue Number:
H14-348/2020E-PDF

International Standard Book Number (ISBN):
978-0-660-34698-4

Related publications (registration number: POR 077-19):
Catalogue Number: H14-348/2020F-PDF (Final Report, French)
ISBN 978-0-660-34699-1

^©Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2020.

1. Executive Summary

Leger is pleased to present Health Canada, and its Official Language Community Development Bureau (OLCDB), with this report on findings from the qualitative and quantitative surveys on the barriers and enablers that Official Language Minority Communities (OLMCs) may encounter in accessing health services in the official language of their choice.

This report was prepared by Leger who was contracted by Health Canada (contract number HT372-194222/001/CY awarded January 27, 2020).

1.1 Background and Objectives

Health Canada, through the OLCDB, supports the implementation of activities to enhance the vitality and developments of OLMCsas well as the full recognition and use of English and French in Canadian society. One of the OLCDB's key objectives is to improve access to health care services for OLMCs in the official language of their choice.

To document this issue, Health Canada undertook a quantitative and qualitative data collection project to better understand the barriers that OLMCs may encounter in accessing health services in the official language of their choice, as well as enablers that facilitate this access. The results of this study will document the lived experience of OLMCs in accessing health care services in their official language of choice and will help identify key gaps and enablers.

Specific research objectives include, but are not limited to, the following:

• To measure the degree of ease with which a person was able to obtain health services in his or her official language of choice;
• To seek a better understanding of the barriers and enabling factors that had an impact on this access;
• To assess whether access improved over the last few years.

1.2 Methodology - Hybrid Research

To achieve the study objectives, a research plan based on a hybrid method, with qualitative and quantitative components, was developed. The two phases of the research were conducted in parallel: one phase being independent on the results of the other. The target population for this whole research project is comprised of two main groups of Canadians adults aged 18 and over:

• French-speaking adults living outside the province of Quebec
• English-speaking adults living in the province of Quebec

1.2.1 Quantitative Methodology

The quantitative research component was conducted through online surveys, using Computer Aided Web Interviewing (CAWI) technology. The online survey was conducted from February 27, 2020, to March 15, 2020. The participation rate for the survey was 25%. Calculation of the Web survey's participation rate is presented in Appendix A. A pre-test of the survey questions was carried out by conducting 28 interviews in both official languages (20 in English, 8 in French). The pre-test was completed on February 27, 2020. Survey interviews lasted 10 minutes on average.

A total sample of 1,125 Canadian adults were surveyed in all regions of the country.

Special attention was given to ensure a distribution of respondents that provides a sufficient sample size to support analyses in the subgroups of the sample. The following table shows the effective sample collected by Leger in the different regions of the country:

Based on data from Statistics Canada's 2016 national census, Leger weighted the results of this survey by age, gender, region, language (mother tongue) and the education level. Since a sample drawn from an Internet panel is not probabilistic in nature, the margin of error cannot be calculated for this survey.

Details regarding the weighting procedures can be found in Appendix A.

Below is the calculation of the survey's participation rate.

As a member of the Canadian Research and Insights Council (CRIC), Leger adheres to the most stringent guidelines for quantitative research and acts in accordance with the Government of Canada requirements for quantitative research and Standards of the Conduct of Government of Canada Public Opinion Research. The details of the methodology and more information on Leger's quality control mechanisms are presented in Appendix A. The questionnaire is available in Appendix D.

1.2.2 Qualitative Methodology

Leger conducted a series of four online discussion sessions with French-speaking Canadian adults living outside of the province of Quebec (3) and English-speaking Canadian adults living in the province of Quebec (1). Conducting the discussion sessions online offered the opportunity to regroup people from all the regions in Canada. One session was held in English with participants from Quebec and three sessions were held in French with participants from the other provinces of Canada. For each online discussion session, ten participants were recruited by our professional recruiters. A total of 26 recruits participated in the online focus groups (see Table 3 for details). All participants in the focus group received an honorarium of $100.

Online discussion sessions were conducted using the itracks video chat software to facilitate moderation and to ensure an optimal interface between moderator and participants. itracks' Video Chat service is a video-based online discussion session that combines the convenience of the Web with the comfort of an in-person discussion. Participants can see each other and the moderator as they speak.

Each group session lasted approximately 90 minutes. Every session was recorded for analysis purposes. All groups used streaming methodology to allow for remote viewing by Leger and Health Canada observers.

Locations and dates

Groups were held in the following regions on the dates specified in Table 3.

1.3 Overview of Quantitative Study Findings

The overview of the results is divided into three sections: the quantitative section with English-speaking respondents in Quebec, the quantitative section with French-speaking respondents outside Quebec, and finally the qualitative section with Canadians living in minority language situations from various regions of the country.

This overview details the main highlights of the study and shows points of convergence as well as points of divergence between the results of the different sections of the study.

English-speaking respondents in Quebec

• Almost every respondent had consulted a health care provider over the last year (97%). Pharmacists, family physicians, dental professionals and nurses/nurse practitioners were the most consulted health care providers. The clinic was the most common location where the English-speaking respondents received health services. Most of the respondents received all or some of their health services in their official language, but respondents from eastern and central Quebec were less likely to receive it in English than the other respondents in the province of Quebec.
• Family physicians (70%), dental professionals (68%), psychologists/psychiatrists (57%) and pharmacists (53%) are the health-care providers who were able to provide services completely in English to more than half of English-speaking respondents who consulted them over the last year. While a significant proportion of respondents have received health services in their official language of choice in the past year, English-speaking respondents from Montreal, Laval and the peri-urban area are more likely to have observed a decrease in health services in English in the province of Quebec over the past 10 years, while respondents from eastern and central Quebec are more likely to have witnessed an increase of the health services in English.
• Almost eight out of ten (79%) English-speaking respondents indicated that they are very confident in their ability to clearly communicate their health care needs in their first official language. Only three out of ten (32%) are very confident to do the same in French. Respondents from Montreal, Laval and the peri-urban area are less likely to feel confident with their ability to clearly communicate their health care needs in French. More than half of them (55%) are very confident in the ability of the health care providers to clearly understand their needs in English, but only a third of them (36%) are very confident that health care providers can understand their health care needs in French. These results are consistent with the fact that most English-speaking respondents prefer to receive health care services in English (85%) while a minority of them (15%) would rather receive them in French.
• Family physicians are seen by most respondents (74%) as the health care service that should absolutely be provided in the first official language of the patients. This result is well ahead of the results of psychologists/psychiatrists (43%), pharmacists (32%) and personal support workers (30%).
• Six respondents out of ten (62%) think it is very important to receive health care services in their first official language spoken and one out of four (24%) think it is somewhat important. English-speaking respondents living in the Montreal and Laval area (71%) are more likely to think it is very important. On the contrary, respondents living in eastern and central Quebec are more likely to think it is somewhat unimportant (19%) or not important at all (10%). However, these latter respondents are more likely than others to find it very important for children to receive services in English. Respondents who are caregivers for other people than their child(ren) are largely of the opinion that receiving services in English for their family or friend is very important (66%).
• More than half of English-speaking respondents (57%) found at least one health care provider speaking English, while four out of ten (43%) did not find any. Family physicians (48%), dental professionals (44%), pharmacists (38%) and psychologists or psychiatrists (28%) are the most sought-after English-speaking health care providers. It is in the Montreal and Laval region that respondents have had the most success in their research (66%). In the eastern and central region of Quebec, they have had less success (43%). Most providers were found through the Internet (22%), recommendations from friends and family (14%) and word of mouth (11%).
• The main barrier to obtaining health services in English is the lack of health care providers who can speak English (36%). However, the fear of receiving a lower quality health service (33%) and the use of unilingual forms and documentation (29%) are barriers that distinguish Quebec's linguistic minorities from those in other Canadian provinces. The three main obstacles that prevent parents from finding health care providers who speak their children's first official language are: place of residence (26%), availability of providers who speak the minority language (23%), and poor second language skills on the part of health care providers (20%).
• In general, respondents ask to receive health services in their first official language spoken. English-speaking respondents in Quebec are more likely (51%) to request it than French-speaking respondents in the rest of the country (39%). Respondents in the Montreal and Laval region are the most likely (59%) to make this type of request, while those living in the eastern or central part of the province are less likely to do so (43%). Those who do not ask to receive health services in their first official language spoken consider themselves comfortable enough in the other language not to have to ask (57%), that health care providers do not speak the minority language (21%), or fear comprehension problems (11%).
• From a very general point of view, English-speaking respondents receive positive responses when they request health services in their language (very 29%; somewhat 29%). Those living in the Montreal and Laval region are more likely than others to receive a very positive response (35%), while those living in the Montreal suburbs are more likely to receive a somewhat (20%) or very (8%) negative response. Respondents in eastern and central Quebec are more likely to never make such a request (39%).
• More than one out of four (27%) English-speaking respondents in Quebec have received health services by phone or through other forms of virtual care or services. Respondents in eastern and central Quebec are more likely to have already done so than other respondents (40%). Telephone consultations are by far the most used "technological" health service (80%), well ahead of online and virtual appointment booking (24%) and text/email (12%). These technological health services were conducted mainly in English for the phone consultations (62%), texts/emails (75%), and online/virtual appointment booking (81%). Respondents consider that technology can be really (30%) or somewhat (25%) useful for getting health services in their first official language and a large proportion think it is very (40%) and somewhat (40%) effective in doing so. It is for visits to family physicians, pharmacists, and nurses that this type of technology appears to be most useful to respondents.
• Respondents would like to be informed via the Internet (50%), to be referred by another health care provider (49%) and by word of mouth from family and friends (47%) about health care services available in English. Respondents made several suggestions to improve the availability of health services in both languages. The most popular suggestions are enforcing bilingual services (10%), hiring more bilingual staff (8%), and doing more publicity about the services (7%).

French-speaking respondents outside Quebec

• Almost every respondent has consulted a health care provider over the last year (98%). Pharmacists, family physicians, dental professionals and nurses/nurse practitioners were the most consulted health care providers. The clinic was the most common location where the French-speaking respondents living outside Quebec received health services. One third of the respondents received health services completely in French, while one third received some of their health services in French and another third received no health services in their first official language. People from the Western region of Canada are less likely than the people from the other regions of Canada to have received health services completely in French.
• Even if only a third (34%) of the French-speaking respondents outside Quebec received health services in their first official language from all their health care providers during the last year, they are more likely than English speakers in Quebec to have observed an increase over the last ten years in regard to health services provided in their first official language. Respondents from Ontario (23%) are more likely to have witnessed an increase of the offer of health services in French than respondents from the other regions of Canada.
• Almost seven out of ten (69%) French-speaking respondents living outside Quebec indicated that they are very confident in their ability to clearly communicate their health care needs in their first official language. Only half of them (49%) are confident to do the same in English. Respondents from the Western region (61%) and Ontario (52%) are more likely to feel confident with their ability to clearly communicate their needs in English than the respondents from the Atlantic region (36%). About half of French-speaking respondents living outside Quebec (50%) are confident in the ability of the health-care providers to clearly understand their needs in French and about the same (51%) are confident that health care providers can do the same in English. These results are consistent with the fact that most French-speaking respondents outside Quebec mentioned that they prefer to receive health care services in English (60%) while the others (40%) would rather receive them in French.
• Family physicians are seen by most of the respondents (65%) as the health care services that should absolutely be provided in the first official language of the patients. This result is well ahead of the results of psychologists/psychiatrists (35%), paramedics (30%), pharmacists (28%) and personal support workers (26%).
• About three out of four (74%) of French-speaking respondents think it is very important or somewhat important to receive their health care in their first official language. French-speaking respondents from the Atlantic provinces (55%) are more likely to think it is very important. Four out of ten (43%) French speakers in Ontario share the same opinion while those living in Western Canada are less likely to have that opinion (32%).
• About half (48%) of the parents of children outside Quebec think it is very important that their children receive health services in their first official language spoken, but they are more likely to think that it is not important at all (21%) than English speakers in Quebec. This is especially true for parents from Ontario (31%). Only one out of five parents (18%) in the Western provinces and 8% in the Atlantic region share this opinion.
• Family physicians (47%), dental professional (38%) and pharmacists (31%) are the most sought-after French-speaking health care providers. About six out of ten French-speaking respondents living in the Atlantic region (61%) found at least one health care provider speaking French, while less than half of those living in Ontario (47%) found one. People living in Western Canada (27%) are less likely than the others to have found a French-speaking health care provider.
• The main barrier to obtaining health services in French is the lack of health care providers who can speak French (45%). However, the fear of having to wait longer to get the service (26%) and the lack of information on where these services are available (25%) are also major barriers to get health services in French in Canadian provinces outside Quebec. The three main obstacles that prevent caregivers from finding health care providers who speak French are the same.
• In general, only four out of ten (39%) respondents ask to receive health services in their first spoken language. Respondents from the Atlantic region are more likely (51%) to request it than French-speaking respondents in the rest of the country: Ontario (41%) and Western Canada (16%). Those who do not ask to receive health services in their first official language spoken consider themselves comfortable enough in the other language not to have to ask (56%), believe that health care providers do not speak the minority language (33%), or fear comprehension problems (15%).
• From a general point of view, Francophones received positive responses when they request health services in their language (very 23%; somewhat 23%). Those living in the Atlantic region are more likely than others to have received a very positive response (38%) than those living in Ontario (22%) and in the Western provinces (4%).
• More than one out of four (24%) French-speaking respondents have received health services by phone or through other forms of virtual care or services. Telephone consultations are by far the most widely used technological health service (73%), well ahead of online and virtual appointment and booking (20%) and text/email (14%). These technological health services were conducted mainly in French for the phone consultations (54%), texts/emails (53%), and online/virtual appointment and booking (56%). Respondents consider that technology can be very (26%) or somewhat (23%) useful for getting health services in their first official language and some respondents think it is very (27%) and somewhat (41%) effective in doing so. It is for visits to family physicians, pharmacists and nurses and nurse practitioners that this type of technology appears to be most useful to respondents.
• Respondents would like to be informed via the Internet (49%), to be referred by another health care provider (42%) and by word of mouth from family and friends (44%) about health care services available in French. Respondents made several suggestions to improve the availability of health services in both languages. The most popular suggestions are making more publicity about the services available in the minority official language (11%), hiring more bilingual staff (10%) and enforcing bilingual services (8%).

1.4 Overview of Qualitative Study Findings

• Accessibility to health services in people's first official language seems to be strongly influenced by where people live. Participants living in the Montreal and Laval regions said they had no problem receiving health services in English; but the reality is quite different in other regions of Quebec. Participants living in certain areas of Ontario (e.g. the Ottawa region) and those living in the French-speaking regions of New Brunswick said that it was somewhat easy to get health services in French, but those living elsewhere in Canada said it was much more difficult.
• There are differences in terms of access and availability to health-care services in the minority official language for people living in Canada's large urban areas and those living in rural areas. Urban areas appear to offer more opportunities for people to get health services in their first official language spoken.
• In principle, receiving health services in one's first official language is important for the vast majority of participants, regardless of where they live. Even for bilingual participants and those comfortable in the other official language, it was perceived as a safety issue to properly understanding diagnoses, treatments, as well as dosages, handling, and storage of medications. The issue of clarity of communication and understanding is amplified by the use of medical and technical terms, generally unknown to the public, in discussions with health care providers. However, depending on their region of residence, many said they knew that it would not be possible to receive care in their first official language. This is particularly true for French-speaking Western Canadians participants.
• Seeking health services often means being vulnerable or feeling pain. That is why some participants pointed out that health issues are not a matter of trivial communication. Communication should be as smooth as possible. Some expressed a certain anxiety about their ability to clearly communicate their health needs in the other official language. In serious or urgent situations this can become a real issue. Most participants thought that being able to communicate clearly in their first official language is reassuring.
• Although many participants said that they do ask to be served in the official language of their choice, not all participants were comfortable asking to be served in their first official language spoken; mostly Anglophones in the province of Quebec, outside the Montreal and Laval area, and the French speakers in Western provinces. Those who tend to be reluctant to ask also tended to be from regions where they believe access is very limited. As well, these participants' reluctance to ask was out of fear of being judged negatively for asking. This was not because of their minority language status but rather about the fact that they consider that asking would be an issue or a problem for the health care provider. Many have had the experience of being asked to wait while someone would look around for a solution. These participants do not want to "create a problem." Participants from the province of Quebec outside of the Montreal region, as well as participants from the Atlantic region (excluding New Brunswick) and participants from the Western part of the country were the most inclined to adopt this attitude towards requesting services in their first official language.
• Other participants mentioned that they did not request to be served in their first official language because they know their health care provider well enough to know that he or she cannot serve them in their official language of choice. Those participants consequently consider it futile to ask for services in the official language of their choice knowing in advance that it would not be available. Here again, the regional cleavage in access was central to participants' experience. Participants residing in Ontario or Western Canada are generally more likely to have such an attitude toward requesting services in French. Many participants in the West would rather speak in the official language of the health care provider mainly because they are quite comfortable using that language, but also because they have no confidence in the health care provider's ability to express themselves effectively in the other official language.
• The respondents' willingness to ask for services in their first language will vary depending on the type of health care provider consulted and the place where the service is provided. Expectations for the pharmacy or a small clinic are not the same as for a large hospital, for example. People will adapt their demands based on expectations when it comes to level of service.
• Bilingualism is also an important dimension in health seeking behavior in the minority official language. While most participants expressed a general preference for receiving health services in their first official language spoken, some participants did not see it as a major issue because they are bilingual. Receiving health services in either official language made no difference to them.
• As one participant noted, New Brunswick is a bilingual province, and there are regulations in place to ensure that people are aware that they must provide service in both languages. In Western Canada, in Ontario (with the exception of Ottawa and Toronto), and in the Atlantic (except New Brunswick) very few participants mentioned this type of effort by health care providers.
• There is a shared feeling among many participants that health care providers will try their best to make an effort to communicate with users in the official language of their choice, even though limited in some places. Some providers allowed users to write their requests in the language of their choice and tried, to the best of their ability, to respond in the first official language chosen by the user. However, the level of bilingualism of health care providers can vary greatly across the country.
• Participants encountered several barriers in seeking or accessing health services in their first official language spoken: the lack of awareness of health services available in their first official language in their region, the additional delays or longer waiting times before receiving a service and the distance they have to travel to obtain health services in the official language of their choice. The area of residence of the participants greatly influences barriers such as availability, waiting time, and distance. Residents of major urban areas across the country appear to have fewer barriers than participants living outside of major urban centres. Edmonton, New Brunswick, the Montreal region in the province of Quebec, and the cities of Ottawa and Toronto in Ontario are places that are more likely to have health services available in both official languages.
• Very few participants were actually offered alternatives, such as interpreters or system navigators. Only a minority of participants have ever had access to those services. Moreover, those alternative services are mostly unknown.
• Some participants made use of technology to assist them with access to health care services. Technology is used mainly to help translate and understand medical and technical terms, to renew prescriptions, to book appointments, to exchange text messages with health care providers and in fewer cases, to attend a virtual medical consultation.
• The majority of users were very open to the idea of using technology in health services. They were also pleased to see the potential for these technological tools to improve access to health services in their first official language spoken by making it possible to work faster, freeing up employees and reducing waiting and travel times.

1.5 How the Results Will Be Used

This project will provide Health Canada and the Government of Canada with first-hand information on needs, barriers and possible enablers to access health services in the patient's preferred official language. Findings will be made public at Library and Archives Canada and shared with stakeholders. Collecting more and better information on the possible barriers as well as the factors that enhance access to health services for OLMCs will benefit Canadians in that it could provide insights into how to make health care systems across Canada more responsive to the needs of all users, irrespective of their official language of choice.

1.6 Statement of Limitations

The quantitative portion of the research is based on a web-survey methodology. Respondents for this survey were selected from among those who have volunteered to participate/registered to participate in online surveys. The results of such surveys cannot be described as statistically projectable to the target population. The data have been weighted to reflect the demographic composition of the target population. Because the sample is based on those who initially self-selected for participation, no estimates of sampling error can be calculated.

The qualitative portion of the research provides insights into the opinions of a population, rather than providing a measure in percent of the opinions held, as would be measured in a quantitative study. The results of this type of research should be viewed as directional only. No inference to the general population can be done with the results of this research.

1.7 Notes on Interpretation of Research Findings

The views and observations expressed in this document do not reflect those of Health Canada. This report was compiled by Leger based on the research conducted specifically for this project. This research is not probabilistic; the results cannot be inferred to the general population of Canada.

1.8 Political Neutrality Statement and Contact Information

I hereby certify as Senior Officer of Leger that the deliverables fully comply with the Government of Canada's political neutrality requirements outlined in the Policy on Communications and Federal Identity and the Directive on the Management of Communications- Appendix C (Appendix C: Mandatory Procedures for Public Opinion Research).

Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate, or ratings of the performance of a political party or its leaders.

Signed:

Christian Bourque
Executive Vice-President and Associate
Leger
507 Place d'Armes, bur 700
Montréal, Québec
H2Y 2W8

cbourque@leger360.com

Additional information

Supplier name: Leger
Contract Number: HT372-194222/001/CY
Contract Award Date: 2020-01-27

The cost of this research was $78,411.83 (HST included).

To obtain more information on this study, please email: hc.cpab.por-rop.dgcap.sc@canada.ca