Introduction
he increasing diversity of Canada’s population due to immigration poses significant challenges and opportunities for its healthcare system [1-5]. Immigrants, particularly those who have experienced trauma, such as war injuries, often face unique healthcare needs and barriers that may not be adequately addressed by existing health services [5-9]. This study focused on the health service experiences of war-injured immigrant populations in Canada, exploring how their specific circumstances influence their access to, and interactions with, the healthcare system.
Research has consistently shown that immigrants face multiple barriers to accessing healthcare, which include linguistic challenges, cultural differences, and lack of familiarity with the healthcare system [5, 8-11]. These barriers are exacerbated for immigrants with physical disabilities or those who have suffered war-related injuries, as their needs are often more complex and require a multidisciplinary approach to care [7, 12-14]. Moreover, the healthcare challenges faced by immigrant populations are not solely limited to physical health needs but also include significant mental health concerns, often stemming from the trauma associated with their migration experiences [15-17]. 
The need for culturally competent healthcare services that can effectively address these diverse needs is critical. Studies have highlighted the importance of cultural competence in improving healthcare access and satisfaction among immigrants [18]. Moreover, the role of patient-provider communication is a recurring theme, with evidence suggesting that improved communication can significantly enhance the healthcare experience for immigrants [19]. 
This study is situated within this context, drawing on the theoretical framework of access barriers as outlined by Dahal et al. and the patient-identified solutions to these barriers [20, 21]. By integrating these perspectives with direct narratives from war-injured immigrants, this research contributes to a more nuanced understanding of the health service experiences within this unique population. Specifically, it addresses the gaps identified by Kalich et al. regarding the healthcare access barriers experienced by immigrants in Canada and builds on the findings of Maio and Kemp, who documented the deterioration of health status among immigrants, emphasizing the need for tailored healthcare interventions [10, 22]. 
Furthermore, the study leverages insights from related research on health literacy among Nepalese immigrants in Canada [23], which underscores the critical role of health literacy in navigating the healthcare system effectively. Health literacy can be particularly crucial for war-injured immigrants, as it directly impacts their ability to understand and engage with healthcare services, ultimately influencing their health outcomes. In addition to highlighting the importance of health literacy, this study emphasized the necessity of qualitative research in this field. Qualitative methods provide a deeper understanding of the complex, nuanced experiences of war-injured immigrants, capturing the personal and contextual factors that quantitative data might overlook. Through detailed personal narratives and thematic analysis, qualitative studies can uncover the specific barriers and facilitators encountered by this vulnerable population, offering rich insights that can inform targeted interventions and policy development. By focusing on the Richmond Hill immigrant community, this study not only addresses the specific issues faced by war-injured immigrants but also contributes to the broader discourse on healthcare accessibility and quality for immigrant populations across Canada. Thus, this study aimed to provide knowledge that can inform policy and practice, enhancing the responsiveness of Canada’s healthcare system to the needs of its diverse immigrant population. By doing so, it contributes to the ongoing efforts to achieve health equity, ensuring that all residents of Canada, regardless of their origin or the challenges they face, have access to the care they need. 

Methods

Study design
This study employed a qualitative research methodology to explore the health service experiences of war-injured immigrant populations residing in Richmond Hill, Ontario in 2023. Given the complex and personal nature of healthcare experiences, qualitative methods were deemed most suitable for gaining deep insights into the participants’ perspectives and the subtleties of their interactions with the healthcare system. This approach is well-documented in the literature as being particularly effective for exploring complex, context-dependent phenomena, especially in health research [24-28].

Participants
Participants were recruited using a purposive sampling method from the immigrant community in Richmond Hill, Ontario, with the specific inclusion criterion of having sustained severe physical injuries in war conditions prior to their resettlement in Canada. Recruitment was conducted through community centers, local non-governmental organizations (NGOs), and social media platforms catering to immigrants. Efforts were made to ensure a diverse sample in terms of age, gender, country of origin, type of injury, and duration of residence in the research area. 
The participants had lived in Richmond Hill for varying periods, ranging from six months to five years. This diversity in the length of residence allowed for a comprehensive understanding of how long-term and recent immigrants navigate the healthcare system. Additionally, the frequency and extent of their use of health services were considered, with participants reporting their interactions with healthcare providers and services from initial contact to ongoing care.
The study explicitly focused on severe physical injuries, distinguishing between acute and chronic conditions. Acute injuries often require immediate and intensive medical attention, whereas chronic injuries involve prolonged and continuous interaction with the healthcare system. The study also acknowledged the significant mental health challenges faced by war-injured immigrants, such as post-traumatic stress disorder (PTSD) and depression, which necessitated specialized mental health services. 

Data collection
Data collection was based solely on semi-structured interviews, which allowed for the collection of detailed personal narratives while providing the flexibility to explore emerging themes. The interview guide was developed to cover topics, such as initial access to health services, quality of care received, communication with healthcare providers, and overall satisfaction with the services. Interviews were conducted until theoretical saturation was achieved, where no new information was observed in the data. 

Data analysis
The collected data were transcribed verbatim and analyzed using thematic analysis. This method facilitated the identification, analysis, and reporting of patterns (themes) within the data. Initial codes were generated and then combined into potential themes, which were reviewed and refined to ensure they accurately represented the dataset. To enhance the credibility and reliability of the findings, several strategies were employed. Peer debriefing was conducted periodically throughout the data analysis process to challenge emerging themes and ensure a comprehensive understanding of the data. Moreover, participants were given the opportunity to review and comment on the findings (member checking), which provided additional validation of the interpretations. The qualitative software NVivo, version 15 was utilized to assist in the organization and analysis of the data. 

Results 
In this study, a total of 26 war-injured immigrants residing in Richmond Hill, Ontario, participated. There were 15 males (57.7%) and 11 females (42.3%). The age distribution was as follows: Six participants (23.1%) aged 18-30 years, 10 participants (38.5%) aged 31-45 years, and ten participants (38.5%) aged 46-60 years. The participants originated from a variety of countries, with the largest groups being from Syria (7 participants, 26.9%), Afghanistan (6 participants, 23.1%), and Iraq (5 participants, 19.2%). The remaining participants were from various other countries affected by war, each represented by one or two individuals (Table 1).



In the thematic analysis of semi-structured interviews with war-injured immigrant populations in Richmond Hill, Ontario, four main themes were identified: Access to health services, quality of care, patient-provider relationship, and health outcomes and satisfaction. Below, we detail these themes, subthemes, and associated concepts derived from participant narratives (Table 2). 



Access to health services
Initial contact: Many participants (over half) highlighted issues, such as language barriers and a lack of awareness about available services. For instance, Participant 7 mentioned, “I didn’t even know where to start when I first arrived; everything was so confusing and nobody spoke my language.”
Navigation challenges: A majority cited the complexity of the healthcare system, with complaints about a lack of guidance and difficulty in transportation to healthcare facilities. Participant 12 said, “Getting from one appointment to another without any help makes it even harder for us who are still figuring out public transport.”
Financial barriers: Significant concerns over insurance coverage and healthcare costs were expressed by most participants. Participant 4 explained, “Every time I visit, there’s a new expense; it’s overwhelming.”
Waiting times: Many participants (almost half) reported extended waiting times for emergency services and specialist consultations. Participant 10 recounted, “I waited months just to see a specialist; in that time, my condition only got worse.” 

Quality of care
Professional competence: Participants had mixed experiences, with some praising the accuracy of diagnosis and treatment effectiveness, while others criticized misdiagnoses. Participant 15 commented, “When they get it right, it’s great, but a misdiagnosis can set you back so much.”
Patient-centered care: Respectful treatment and cultural sensitivity varied widely among participants. Participant 8 noted, “It makes a huge difference when they actually take the time to understand where you’re coming from.”
Communication: Clear explanations and the provision of language services were crucial for most participants. Participant 20 explained, “It’s essential that I understand what’s happening in my treatment; otherwise, it’s just more anxiety.” 

Patient-provider relationship
Trust building: Establishing trust was critical, with confidentiality and empathy playing key roles for many participants. Participant 3 stated, “I need to feel like I can trust my doctor with my history and my fears.”
Cultural competence: The acknowledgment of cultural specifics, such as religious practices and dietary needs, was important to most participants. Participant 18 mentioned, “When my dietary needs are considered, I feel respected.”
Communication quality: Effective listening and empathetic communication were highlighted by a majority of participants. Participant 5 shared, “A doctor who listens is a doctor who cares.”
Continuity of care: The importance of having a consistent caregiver was stressed by many. Participant 9 expressed, “Seeing the same doctor each time helps; they know my history.”
Patient advocacy: Assistance in navigating healthcare processes was appreciated by several participants. Participant 24 remarked, “My nurse helped me understand my rights and what I can ask for—that was empowering.” 

Health outcomes and satisfaction
Recovery experience: Descriptions of the healing process and access to rehabilitation services were mixed. Participant 1 enthusiastically shared, “The rehab program they put me on has been life-changing.”
Satisfaction with care: Participants varied in their overall satisfaction, with many indicating that their expectations were either met or unmet. Participant 17 said, “I am happy with the care I received; it’s much better than what I expected.”
Improvement in health status: Most participants noted improvements in symptoms, mobility, and psychological well-being. Participant 25 explained, “I can walk better and feel less pain now; it’s a big step forward for me.” 

Discussion 
The analysis of the semi-structured interviews with war-injured immigrants in Richmond Hill, Ontario, yielded four main themes that encompassed the complexity of their health service experiences. These themes were access to health services, quality of care, patient-provider relationship, and health outcomes and satisfaction. Each theme consisted of several categories, which further break down into specific concepts, providing a detailed insight into various aspects of the healthcare experiences of these immigrants.
The theme of access to health services captures the initial and ongoing challenges faced by war-injured immigrants as they navigate the Canadian healthcare system. The categories under this theme included initial contact, navigation challenges, financial barriers, and waiting times. Initial contact was often hindered by language barriers and a lack of awareness of available services. Navigation challenges involved the complexity of the healthcare system and insufficient guidance, which was particularly daunting for newcomers. Financial barriers encompassed issues, like unclear insurance coverage and unexpected out-of-pocket costs, while waiting times for services significantly affected the timely receipt of necessary medical care. 
Quality of care was identified as crucial in shaping participants’ overall health service experiences. This theme included the categories of professional competence, patient-centered care, and communication. Professional competence involves the accuracy of diagnoses and the effectiveness of treatments provided. Patient-centered care highlights the importance of respectful treatment, cultural sensitivity, and attention to individual healthcare needs. Communication focused on the clarity of explanations provided by healthcare providers, the availability of language services, and the quality of dialogue between patients and providers.
The patient-provider relationship theme emphasized the significance of the interpersonal dynamics between healthcare providers and immigrant patients. Categories under this theme included trust building, cultural competence, communication quality, continuity of care, and patient advocacy. Trust building was vital for creating a safe environment for sensitive health disclosures. Cultural competence was necessary for acknowledging and integrating cultural and religious needs in care plans. Communication quality stressed the need for empathetic and effective communication strategies. Continuity of care was appreciated for maintaining a consistent treatment approach, and Patient Advocacy helped patients navigate the healthcare system more effectively. 
Finally, health outcomes and satisfaction reflected the end results of the healthcare process as experienced by the participants. This theme consisted of categories, such as recovery experience, satisfaction with care, and improvement in health status. Recovery experience involved the process and effectiveness of rehabilitation programs and other treatments. Satisfaction with care captured the overall contentment with the healthcare received, and improvement in health status noted tangible benefits, such as symptom relief, enhanced mobility, and improved psychological well-being.
The first major theme identified, access to health services, resonates with findings from Kalich et al., who documented that immigrants often struggle with navigating the Canadian healthcare system due to its complexity and a lack of culturally sensitive guidance [10]. Participants in our study expressed similar frustrations, citing navigation challenges and language barriers as significant obstacles. This aligns with McKeary and Newbold, who noted that language barriers compound the difficulties faced by immigrants, impacting their ability to seek and receive adequate healthcare [11]. 
Moreover, the financial barriers identified in this study echo the concerns noted by Dahal et al., who reported that economic constraints significantly hinder access to necessary health services for Nepalese immigrants [20, 21]. Our participants’ experiences of insurance coverage confusion and out-of-pocket costs highlight critical areas where healthcare accessibility could be improved for immigrants, especially those with complex health needs such as war-related injuries.
Regarding quality of care, our findings suggest that professional competence and patient-centered care are pivotal in shaping health outcomes for immigrants, which is supported by Guruge et al. They emphasize the need for healthcare providers to adopt more culturally competent care practices to effectively serve Canada’s diverse immigrant populations [18]. Participants valued healthcare providers who demonstrated cultural sensitivity and effective communication, suggesting that these elements are crucial for enhancing patient satisfaction and trust, a sentiment that is strongly supported in the literature [19]. 
The patient-provider relationship emerged as a fundamental component of the healthcare experience for our participants. Trust building, highlighted by our study’s participants, is crucial and reflects the findings of Woodgate et al. (2017), who argued that trust and mutual understanding are essential for the effective delivery of mental health services to immigrant mothers. Additionally, continuity of care, which our participants identified as important, has been shown to improve health outcomes and satisfaction in immigrant populations [29].
Finally, the theme of health outcomes and satisfaction relates closely to the study by Simich et al., who discussed how mental distress and economic hardship affect immigrants’ perceptions and experiences of life in Canada, including their health service experiences [17]. The improvement in health status and satisfaction with care reported by our participants suggests that when access and quality barriers are addressed, positive health outcomes are achievable, supporting the findings of Dahal et al. regarding the health literacy and self-reported experiences of Nepalese immigrants [20, 21]. 

Conclusion
This study explored the health service experiences of war-injured immigrant populations in Richmond Hill, Ontario, identifying key themes related to access to health services, quality of care, patient-provider relationship, and health outcomes and satisfaction. Participants highlighted significant barriers, including language difficulties, system navigation challenges, and financial constraints, which impacted their access to necessary health care. Despite these barriers, positive interactions characterized by professional competence, culturally sensitive care, and effective communication were noted to significantly improve patient satisfaction and health outcomes. Trust and continuity of care within the patient-provider relationship were also crucial in enhancing the healthcare experience and facilitating better health management.
The insights from this research underscore the complex interplay of factors that influence the health service experiences of war-injured immigrants. It is evident that while there are substantial challenges, there are also achievable solutions that can lead to improved care. These findings contribute to a broader understanding of how healthcare systems can adapt to better meet the needs of diverse immigrant populations, particularly those with complex health histories like war injuries. 

Limitations of this study
This study has several limitations. First, the sample size was relatively small and limited to one geographic area, which may affect the generalizability of the findings to other immigrant populations or regions. Second, the study relied solely on qualitative interviews, which, while rich in detail, might be influenced by participants’ willingness to share personal experiences and their recall of healthcare interactions. Additionally, the study did not capture longitudinal data, which could provide insights into changes in healthcare experiences over time. 
To mitigate these limitations, several measures were taken. Efforts were made to ensure a diverse sample in terms of age, gender, country of origin, and type of injury, providing a broad perspective on the healthcare experiences of war-injured immigrants. To enhance the reliability of the data, peer debriefing was conducted periodically, and member checking was employed, allowing participants to review and validate the findings. Although longitudinal data were not collected, the study’s rich qualitative insights provide a strong foundation for future research that can explore these experiences over time. Furthermore, the findings were compared with existing literature to contextualize and support the results, enhancing the study’s credibility.

Recommendation
Future research should aim to include a larger and more diverse sample to enhance the generalizability of the findings. Longitudinal studies could be particularly beneficial to understand how health service experiences evolve as immigrants adjust to their new country. Moreover, comparative studies involving different immigrant groups or different regions within Canada could shed light on specific factors that impact healthcare access and satisfaction across various contexts. Incorporating quantitative measures could also complement the qualitative insights, providing a broader perspective on the issues identified.
The findings suggest several practical implications for healthcare providers and policymakers. Enhancing cultural competence training for healthcare providers is critical to improving communication and care delivery to diverse populations. Healthcare systems should also consider implementing more robust support systems to help immigrants navigate the complex healthcare landscape, such as through community health liaisons or multilingual resource centers. Finally, policies aimed at reducing financial barriers and improving insurance coverage for immigrants, particularly those with pre-existing conditions or complex health needs, could significantly enhance access to necessary healthcare services. By addressing these key areas, healthcare services can become more inclusive, responsive, and effective for all members of the community. 

Implications for policymakers
Enhancing cultural competence training: Developing and mandating comprehensive cultural competence training programs for healthcare providers to better address the specific needs of war-injured immigrant populations.
Improving language access services: Increasing the availability of translation and interpretation services within healthcare settings to mitigate language barriers that hinder effective communication and care.
Streamline access to care: Implementing policies to simplify the healthcare navigation process for war-injured immigrants, including dedicated support services and streamlined procedures to reduce waiting times and bureaucratic hurdles.
Financial support initiatives: Introducing financial assistance programs or subsidies specifically for war-injured immigrants to alleviate the economic burden of healthcare expenses.
Patient-centered care models: Encouraging the adoption of patient-centered care models that prioritize building trust, effective communication, and continuity of care to enhance patient satisfaction and health outcomes.

Implications for public
For the general public, understanding the healthcare challenges faced by war-injured immigrants is crucial. This population often encounters significant barriers such as language difficulties, financial constraints, and complex healthcare navigation. These obstacles can lead to delayed or suboptimal care, affecting their overall health outcomes. Public awareness and advocacy can drive support for policies aimed at improving access to culturally competent and patient-centered healthcare services. Additionally, fostering an inclusive community that supports and understands the unique needs of war-injured immigrants can contribute to their successful integration and recovery, promoting a more equitable healthcare system for all.

Ethical Considerations

Compliance with ethical guidelines
This research was conducted in accordance with the ethical guidelines and approval provided by the KMAN Research Institute (Code: KEC.2023.6A6). Prior to the commencement of the study, all participants were informed about the research objectives, the confidentiality of their responses, and their right to withdraw from the study at any point. Written informed consent was obtained from all participants. Measures were taken to ensure the anonymity of participants, and personal identifiers were removed or altered in the transcription. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization and supervision: James Ma; Methodology and data collection: James Ma and Seyed Alireza Saadati; Data analysis: Jiatang Yang; Investigation and writing: All authors; Funding acquisition and resources: Maura McDonnell.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to express their gratitude to all individuals who assisted them with this project. A special thank you to KMAN Research Institute and York Rehab Center for their invaluable support and encouragement.



References