Corps de l’article

Introduction

Research on health in official language minority communities (OLMCs) has gained remarkable momentum as a result of the action plans and roadmaps of the Canadian federal government. Since 2003, Health Canada and the Official Language Community Development Bureau (OLCDB) have provided funding to the Consortium national de formation en santé (CNFS) and Société Santé en français (SSF), which allocate a portion of their funding to research. The research component of the CNFS, through the National Secretariat and the Université de Moncton, the University of Ottawa, Laurentian University and the Université de Saint-Boniface components, fund start-up projects, pilot studies and scholarships. This has led to the development of Francophone university health research hubs across the country. Two OLMC health catalyst programs under the aegis of the Canadian Institutes of Health Research (CIHR) have also contributed to health research, the first from 2004 to 2012 and the second since 2021.

Research networks have emerged, research groups formed and research chairs awarded, with the specific objective of studying health in Francophone minority communities (FMCs) and the access of this population to French-language health services, such as the Réseau de recherche interdisciplinaire sur la santé des francophones en situation minoritaire au Canada (RISF) (CIHR 2006–2011); the Réseau de recherche appliquée sur la santé des francophones de l’Ontario (RRASFO), an initiative of the Ontario Ministry of Health and Long-Term Care (MOHLTC) (2009–2015); the Groupe de recherche sur la formation et les pratiques en santé et service social en contexte francophone minoritaire (GReFoPS) at the University of Ottawa; the Groupe de recherche et d’innovation sur l’organisation des services de santé (GRIOSS) at the Université de Moncton; the Research Chair in Population Aging at the Université de Moncton; the University of Ottawa/Institut du Savoir Montfort Joint Chair on the Health of Francophones in Ontario; and the Canadian Francophonie Research Chair in Health. Other research groups and chairs, while not focusing on FMC health as their primary objective, have also carried out a number of studies on the same theme, some of these include the International Francophonie Research Chair on Digital Health Technologies at the University of Ottawa; the Research Chair on International Francophonie and the Health of Immigrants and Refugees from Francophone Sub-Saharan Africa at the University of Ottawa; the Centre for Rural and Northern Health Research at Laurentian University; the Institut du Savoir Montfort Research Chair in Medical Education; the Institut du Savoir Montfort Research Chair in the Organization of Health Services; and the Institut du Savoir Montfort Research Chair in Family Medicine.

Scientific production on the subject has grown considerably. Sauvageau (2018) had counted some 60 publications between 1990 and 2001, and some 235 between 2002 and 2016. Today, nearly 600 references on FMCs can be found in the bibliography of our research chair’s knowledge mobilization site (https://sante-closm.ca/en/).

One key issue driving researchers and knowledge users alike is the need to understand and assess the impact of minority language on the health of populations and on the quality and safety of health services. A few research postulates emerge: belonging to an FMC is a determinant of health; language concordance between service providers and recipients is a determinant of the quality and safety of care; linguistic insecurity and the fear of not receiving services in a timely manner impact the demand for services in the minority official language; and the active offer of minority official language services is an equity policy.

This thematic issue presents a review of the knowledge produced to date, highlighting its strengths and limitations and identifying future research needs. It stems from the symposium The Health of Francophones in a Minority Language Context: 20 Years of Research, held at the 89th Acfas Congress in May 2022. The call for proposals targeted five main areas of research from the analytical framework for research on OLMC and health of the University of Ottawa/Institut du Savoir Montfort Joint Chair on the Health of Francophones in Ontario, entitled Organizing Knowledge on the Health of OLMCs: language laws and health policies, health and its determinants, the provision of services, human resources, and the experience of care and services. We will report on research findings in these different fields.

Preliminarily, Bouchard and Lizotte’s article examines the availability of linguistic data in national and provincial health information systems, and their strengths and limitations for health research and planning. Methodological issues related to the definition of the francophone population, the use of linguistic variables, small sample sizes, and the potential impact of these issues on the robustness of results are discussed. A number of best practices for improving the analytical capacity of FMCs and producing better data are also presented, including database linking, the inclusion of linguistic identity on the health card, and the creation of new databases.

Research on health laws, regulations and public policies

Access to health care services in French remains a challenge, even in provinces with language laws governing the health sector.

Forgues and Maillet’s study examines the effectiveness of these language laws. It aims to develop a better understanding of the social, legal, organizational and psychological dimensions that may influence compliance with language laws in the healthcare sector in Canadian provinces that have such legislation. The article analyzes the perceptions of health facility staff regarding various aspects that can influence the provision of health services in French. It shows that there are often significant differences between Anglophone and Francophone respondents, and between those working in Anglophone and Francophone hospitals. The results suggest that efforts must continue to be made to achieve greater effectiveness of language laws in the health sector. Notably, knowledge of these laws and the obligations they entail must be improved, as must the understanding of the role that the organization, colleagues and immediate superiors can play in respecting language legislation or in offering services in French (or in both official languages).

In a similar vein, Landry et al. examine the opinions of the province’s population regarding bilingualism in New Brunswick’s healthcare system. Their study measures the effects of various sociodemographic variables, political orientation and opinion of the “privileged” status of Francophones in the province, on the perception that bilingual services are sufficiently developed in the health sector. While the province’s Francophone residents overwhelmingly support official bilingualism, positions opposed to official bilingualism and improved bilingualism in health services are prevalent among New Brunswick’s mother-tongue English-speaking population. Among the variables studied, conservative party (Progressive Conservative or People’s Alliance) voting intentions are the most strongly associated with this position.

Finally, the last article of this theme reports on the pivotal work carried out by the Groupe de recherche et d’innovation sur l’organisation des services de santé (GRIOSS) at the Université de Moncton on the governance of French-language health services, their organization and management, as well as professional strategies and relational dynamics in a “system of networked players.” Using a historical narrative approach, Collin et al. retrace the evolution of the action research programming of the GRIOSS. The article shows how the knowledge generated by this research has fuelled joint reflection and led to lasting social change within FMCs.

Research on health and its determinants

Communication—an essential component of the therapeutic relationship—can be hampered when culture and language differ. In the Francophone minority context, this problem is particularly acute in the field of mental health.

Van Kemenade, Bouchard et al. review the current state of knowledge on the subject of mental health in the Francophone minority context. Their analysis of 59 research papers published between 2000 and 2022 reveals a number of key findings. The deinstitutionalization of psychiatric services has intensified the demand for French-language services and led to the implementation of language policies in mental health in Ontario. Data from national health surveys have only partially contributed to improving knowledge of mental health conditions and their determinants. Exploring the association between cultural and linguistic identity and mental health provides a better understanding of phenomena such as the effect of the minority/majority relationship and language insecurity on mental health. Lastly, access to mental health services in French remains a challenge for FMCs, and the impact of this lack of access on health outcomes is poorly documented.

Research on the provision of services

Research into the provision of services in minority official languages has focused on care models, access, availability, quality and safety.

The Groupe de recherche sur la formation et les pratiques en santé et service social en contexte francophone minoritaire (GReFoPS) presents a review of its research on access to and continuity of French-language services in FMCs (S. Savard et al.). Their article synthesizes nearly twelve years of research on facilitating factors and obstacles to the provision of health services in French. The GReFoPS studies have highlighted certain organizational or interorganizational mechanisms that have led to the emergence of innovative practices to improve the provision of French-language health services in community and institutional settings. The authors also describe tools created to help the managers of these services identify measures and mechanisms to meet the needs of minority Francophone users. They observe that in organizations serving a low density of Francophones, a strategy of small steps is perceived more favourably.

While many studies highlight the more rapid aging present in FMCs compared with the Canadian population as a whole, and that home support has long been described as a winning strategy for responding to an aging population, there is paradoxically very little written specifically on home support in FMCs. In her article, Dupuis-Blanchard summarizes the results of 14 studies identified by a scoping review. Most of these studies were conducted as part of the Université de Moncton’s Research Chair in Population Aging, held by the author. The studies focus on the living conditions of Francophone seniors in New Brunswick, their perceptions of the barriers and facilitators to aging in place, their access to home support services and the low availability of French-language services in this field, due in part to the difficulty of attracting and retaining bilingual human resources in care attendant positions. The article suggests some innovative ways of improving the situation, such as the Nursing Homes Without Walls project and raising awareness of health careers in Francophone high schools.

The lack of access to prevention, diagnostic, support and care services in French for people with neurocognitive disorders in Francophone communities in western and northern Canada is analyzed by van Kemenade, Tremblay et al. Their article presents the results of the project L’Abécédaire d’un cerveau en santé – Sensibilisation à la démence dans l’ouest et le nord. Firstly, the study identifies good practices in dementia prevention and awareness, and support for caregivers. It also identifies the limited research that has demonstrated the impact of language barriers on dementia diagnosis and support. Secondly, the study presents the perspectives of Francophone front-line workers and family caregivers in three provinces and one territory regarding access to services, the impact of not receiving services in French, and their need for information.

Scullion et al. present an inventory of the availability of French-language health services in Ontario, based on data collected by OZi, established by the Réseau des services de santé en français de l’Est de l’Ontario. OZi is an information system that measures the supply and distribution of health services in relation to the level of responsibility of healthcare facilities vis-à-vis French-language services, the language skills of health professionals in these facilities, and the distribution of Francophone patients by care sector. Between 2017 and 2020, OZi, supported by the Ontario Ministry of Health and Long-Term Care (MOHLTC), conducted province-wide data collection and analysis of French-language services. The analysis identified gaps in services for Francophones in different health regions and in certain care sectors, as well as deficiencies in the distribution of Francophone human resources in relation to the needs of the population.

Since physicians in Canada are generally self-employed and not employed by healthcare facilities, other means are needed to study the availability of physicians who can provide services in French. Carr et al. cross-referenced available physician data from Ontario College of Physicians registration and OHIP billing with population data from the 2016 census to examine potential access to French-speaking family physicians for Francophones residing in 1,643 aggregate dissemination areas (ADAs) in Ontario. The analysis highlights an inequitable distribution of Francophone physicians (who can offer services in French based on their registration with the College): the ratio of Francophone physicians to the Francophone population is lower in rural areas with a higher density of Francophones. These results point to areas where efforts should be made to improve potential access to language-concordant care.

Finally, a research group at the Institut du Savoir Montfort has conducted a series of retrospective studies to identify the link between, on the one hand, language concordance and, on the other, the quality and safety of care provided in primary care, hospitals and long-term care homes to cohorts of Francophone, Anglophone and Allophone patients included in Ontario’s home care and long-term care databases. Reaume et al. present a synthesis of these secondary analyses, showing that Francophones and Allophones in language-discordant situations have poorer clinical outcomes than Anglophones who are usually served in their own language. This finding underscores the importance of referring people to a care provider who speaks their language. In light of Ontario’s French Language Services Act, more Francophones could be directed to designated care settings. Allophones, on the other hand, would benefit from more interpreting services or referral to culturally-sensitive long-term care.

Research on human resources, training and active offer professional practices

In his report evaluating the impact of the Consortium national de formation en santé, Leblanc (2008) highlighted major shortcomings in the training of future health and social service professionals called upon to work with FMCs. J. Savard et al. report on research into the teaching of the active offer[1] of services in French to future health and social service professionals that resulted from this observation. The article reviews studies carried out since 2008 aimed at developing an educational framework for training in active offer and the needs of FMCs, supporting the preparation of educators who teach this content, testing strategies to integrate the training into existing courses and internships, and developing validated learning assessment tools. The findings point to the progress made in active offer training for Francophone learners and other health and social service professionals, despite certain challenges encountered around systematizing this training. The impact of training on the use of this skill by professionals working in predominantly Anglophone healthcare environments, and on access to French-language healthcare services by members of FMCs, remains to be assessed.

Research on the experience of care, services and language barriers

Sauvé-Schenk et al. present an overview of research on the experience of Francophones who have received health and social services in a minority language context. The studies identified address perceptions regarding health and social services, demand for and experiences of accessing health services in French, language barriers and navigating the healthcare system. It shows that while a majority of Francophones find it important to be able to obtain health services in French, far fewer actually request them. There are many reasons why people prefer, request or do not request services in French. The perceived impact of a lack of access to linguistically-adapted services is reported in several studies, including the impact on the quality of the therapeutic relationship and on access to timely and appropriate care. The article also considers the perspectives of current research, in particular to better understand and integrate the measurement of French-speaking users’ perceptions into the ongoing evaluation of French-language healthcare services, including perceptions of the use of health technologies.

Grosjean et al. continue this line of inquiry into the use of digital health technologies. Their study on the needs and expectations of Francophone Ontarians shows that the accessibility and acceptability of health technologies to support the provision of virtual care depend on several factors, including their perceived usefulness, their integration into existing uses, and the range of technologies available in French, from their design to the assistance offered to support their use. The authors invite us to consider the communication challenges involved in using health technologies to support the provision of care.

What can we take away from these twenty years of research?

Through these 14 articles, many of them syntheses, covering the five research themes of the analytical framework for research on OLMC and health, this issue paints a relatively representative picture of the state of knowledge on health in Canada’s francophone minority context.

This review of 20 years of FMC health research demonstrates the progress that has been made. The combined results of qualitative and quantitative studies have made it possible to grasp the multiple perceptions of Francophones in minority communities regarding the importance of receiving health services in French and the possibility of requesting them, as well as their ongoing perceptions of the difficulties in accessing such services (Sauvé-Schenk et al.; van Kemenade, Tremblay et al.; Dupuis-Blanchard; S. Savard et al.). Similarly, the research has shed light on the perceptions of various stakeholders on the subject, whether it be the perception of the relevance of bilingual services within populations that can influence public policy (Forgues and Maillet; Landry et al. ), the perceptions of health service managers on how to deal with the obstacles they encounter in their efforts to improve access to French-language health services (S. Savard et al.; Collin et al.), or the perceptions of health educators on how to raise awareness of the needs of FMCs among future service providers (J. Savard et al.). A more recent area of study concerns the use of technology to improve access to French-language health services (Grosjean et al.).

Quantitative studies have attempted to map the provision of health services in French in Ontario using a data platform created specifically for this purpose (Scullion et al.), or to compare the geographic distribution of family doctors who speak French in a given area with the size of the region’s French-speaking population (Carr et al.), all of which represent important advances in addressing the glaring absence of data on the organizational capacity to offer services to Francophones. Others have highlighted the impact of language discordance on the quality and safety of care (Reaume et al.). An aspect less studied in this issue concerns the health status of FMCs and their determinants, with only one article addressing the determinants of mental health (van Kemenade, Bouchard et al.). This theme has already been analyzed in nearly forty quantitative studies listed in our sante-closm.ca/en/ knowledge base, many of which have used data from censuses and various waves of the Canadian Community Health Survey (CCHS) to establish comparative portraits of the living conditions and health status of Francophone minority communities compared with the majority group. The article by Bouchard and Lizotte in this issue discusses some of these studies from the perspective of the strengths and limitations of health databases in documenting health and health services for FMCs.

What does the future hold for research in the Francophone minority context?

This overview of two decades of research also leads us to reflect on the future of FMC health research and the challenges it faces.

A first observation is the paucity of studies on Francophone minority populations in Canadian provinces other than Manitoba, Ontario and New Brunswick. The concentration of Francophone populations and bilingual or French-language universities in these three provinces may explain this state of affairs. However, we need to think about ways to better document the needs of Francophones in provinces where the Francophone population is growing and often immigrant, such as Alberta and British Columbia.

As highlighted in the article by Bouchard and Lizotte, a second gap is the inability of national information systems to adequately document health, access to services, quality and safety of care—all relevant indicators for evaluating the performance of health systems. Even in major national surveys, Francophone populations outside of the Quebec province often remain too small to study the health needs of administrative regions or population sub-groups (such as seniors), making them difficult to use for planning French-language health services for FMCs.

Beyond the data providing information on the availability of care providers who can speak French, we note an absence in administrative databases of variables on the language of communication actually used in interactions between service providers and patients, as well as a difficulty in studying this communication qualitatively due to the confidentiality clause, which limits our ability to better grasp the impact of language discordance on the quality and safety of care.

To improve health research capacity in the Francophone minority context we believe that a number of avenues need to be explored. Firstly, the initiative taken by OZi to build an innovative data collection system on organizational capacities to offer health services to Francophone communities is proving to be an indispensable tool for research, but above all for better health planning. This new database fills the gap left by the lack of data on services, and we hope that its continued existence can be assured.

Secondly, to overcome the impossibility of documenting small populations through national information systems, it is important to consider targeted primary data collections, particularly in provinces and regions where Francophones are poorly represented in national surveys. For this, a survey infrastructure is needed (either to build surveys or in partnership with polling firms).

Thirdly, because of the way it is funded, research in the Francophone context is often confined to exploratory studies or pilot projects, which have certainly led to significant advances, but have the drawback of being less far-reaching. Substantial funding is needed to ensure a better understanding of the needs and health status of the Francophone minority population, and to study the implementation of care models best suited to this population.

Fourthly and lastly, we need to increase knowledge translation activities, which implies ongoing processing and communication of information using a variety of synthesis products. We believe that a Francophone minority health observatory would consolidate a genuine network of collaborative research and knowledge translation that would provide a solid foundation for the future.