Strategies for Reducing Barriers to Cancer Screening

Mobilizing Newcomers and Immigrants to Cancer Screening Programs Funded by Public Health Agency of Canada (PHAC) The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada (PHAC)

Presenter(s)

_______________ not had in the past 3 years, a financial interest, arrangement or affiliation with one or more organizations that could be perceived as a direct or indirect conflict of interest in the content of this presentation Conflict of Interest Disclosure

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1.Know about immigrant experience and accessing health care 2.Apply the ABCDE model as a framework for communication 3.review some case studies 4.Consider factors affecting cross-cultural communication Objectives

Why This is Important 24 % of family physician practice is related to cancer care 23 % of population in Ontario are immigrants and growing Participating of immigrant communities in cancer screening programs is low

What is required goes beyond mere tolerance or sympathy or sensitivity- emotions which can be willed into existence by a generous soul. True cultural sensitivity (competence) is something far more rigorous and even intellectual than that. It implies readiness to study and learn across cultural barriers, an ability to see others as they see themselves - Aga Khan Cultural Competence

Creating the same opportunity for positive health outcomes for all Health Equity Terminology

Objective 1: Immigration and the Immigrant Experience

The Health of New Immigrant

Skilled workers and professionals They are selected based on their education, work experience, and other criteria Family Class A Canadian citizen or permanent resident may sponsor her/his spouse, partner or dependent children to come to Canada Canadian Experience Class A temporary foreign worker or a foreign student who graduate in Canada may apply to get a permanent residency Investors, Entrepreneurs and self-employed persons Business immigration program to attract business people to Canada Refugee Refugees are individuals fleeing their homeland due to fears of persecution New Immigrants

Community Evidence-Based Barrier Language Information is not in their language Information is not easy to understand meaning is lost in translation. Not having physicians who speak the same language Negative connotation of cancer as word - that advertising depicts

There are many brochures but they do not answer my questions. In our Latino culture we are more personal. I would like the information in person where I could ask in my own language. We do not want to read those and then look on websites or call that number - S panish participant Community Evidence-Based Barrier

Knowledge Meaning of cancer and cancer risk Prevention: Cancer screening can prevent some cancers Do tests before any symptoms

Community Evidence-Based Barrier Lack of knowledge What types of cancer can be screened What the tests are for cancer screening Tests need to be done regularly How to access screening No cost with OHIP

Why does the doctor ask if I have relatives with cancer? Is it because it is contagious? Could I infect others? Nepalese participant Barrier

If I have an abnormal pap test or if I have cervical cancer, my husband should leave meI would be disowned by my husband. I will not go I have 4 kids - Arabic participant Barrier

Community Evidence-based Barrier Accessibility it is a long process understanding the health care system clinics are available only during office hours Information not from family physicians Not having a female doctor Fear to know

My mom had a medical appointment, so I had to go with her to be an interpreter. When we were in, I asked for a breast screening test a mammogram for my mom The answer was you need to book another appointment to talk about it I do not have time and get permission it is not easy it is another barrier Spanish participant Barrier

Iceberg Concept of Culture and Cancer Festivals Clothing Music Food Literature Language Rituals

2 different cultures in one family Kids growing up in Canada and parents from different countries Intergenerational issues

Immigrant Experience about Cancer Death Fear Suffering Pain No cure It is your fate Loss of independence Loss of control Anxiety Expensive treatments

We, immigrants, have overcome so much to come to this country, to settle and make a life, it would be a shame to then succumb to something like cancer just because we didnt know about or understand screening Dharshi Lacey Cancer Screening/ Immigrant Experience

Objective 2: The *ABCDE Model A framework for cross-cultural communication *Developed by Sick Kids Hospital

ABCDE model CulturalCompetence AAffective BBehavioural CCognitive DDifference EEquity Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008

Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 Often seen as the critical first step in the cultural competency journey Reflects an intentional respect for cultural differences and having an accepting attitude. Cultural awareness and Sensitivity: 1.Curiosity, perceptiveness, respect and desire to connect with the patient and family. 2.Self-awareness refers to own values and biases 3.Awareness of others as cultural beings and of multiple worldviews and ways of being Affective A

Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 Behavioural Cultural skill that enables the health care provider to learn about patients cultural values, beliefs and practice to determine appropriate goals and interventions. Because the behavioural domain requires awareness, knowledge and skill, it is difficult to translate in practice. B

Cognitive Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 C Identifies that cultural competence is not simply an attitude; it is knowledge-based care. Cultural knowledge can be divided in two categories: 1.Generic knowledge is initial knowledge of cultural issues (e.g. communication styles, effects of immigration and resettlement) 2.Specific knowledge is in-depth knowledge of particular cultural groups that can be built through interactions with patients and families

Difference Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 D The concept of privilege is a key concept in the dynamics of difference: providers need to understand their own privilege and use it to challenge barriers that result in inequities in health care Understanding the dynamics of difference at two levels: 1.Difference of power that represents different cultural identities (physician vs. patient) 2.Understanding the impact of systemic oppression, discrimination and racism

Equity Adapted from Srivastava, R. H. The ABCDE of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 E Equality provides the same opportunity for positive outcomes- outcomes that may require very different processes to achieve Focus on creating the same opportunity for positive health outcomes for all, not on providing the same processes for all Equal healthcare for all results in health disparities, while equitable care reduces health disparities The notion of equity as distinct from equality is a fundamental attribute of cultural competence.

What would you do in these cases? Case One An Afghani Muslim woman lived in a refugee camp and then immigrated to Canada a couple of years ago. She has just been matched with a male family physician through Health Care Connect. She is here to see her doctor for a scheduled intake history and physical. She brought her 21 year old daughter in to interpret for her. The doctor offers the woman a Pap test. The woman is not sure that she needs this test given that her Muslim faith prohibits pre-marital sex and it is unlikely she has been exposed to HPV.

ABCDE model CulturalCompetence AAffective BBehavioural CCognitive DDifference EEquity Adapted from Srivastava, R. H. The ABD (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 - Differences between genders - Premarital sex - Topic is very private - Images used to explain the test - She could feel vulnerable and embarrassed when the daughter translates questions and explains the procedure - Parenting (kids vs. parents) - This topic is very private - Be aware if gender differences - Respect of the authority (physician) - She is saying yes and possible smile - Offer to arrange a new appointment with a female nurse or doctor to take the test if the patient agrees - Offer information about the procedure in her language - Offered a professional interpreter - Book next appointment before she leaves

What would you do in these cases? Case Two: A 62 year old man from Honduras is in a family physician office for his physical exam. The patient does not speak English, so he brought his 17 year old daughter to interpreter. During the physician assessment, the doctor asked for GI symptoms and the patient replied he had none. However, the patient stated, he had a positive family history for colon cancer. When the doctor started talking about colonoscopy, he noticed the patient is uncomfortable

ABCDE model CulturalCompetence AAffective BBehavioural CCognitive DDifference EEquity Adapted from Srivastava, R. H. The ABD (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 - Many Latino communities men are considered authority - Machismo - Men are providers and strong person - They deal with finances, work and education - Do not like to be perceived as a weak person - Men do not ask for help - Father does not discuss any issues with his children - Authority (kids vs. parents) - Respect of the authority (physician) - He is saying yes and possible smile - He will not stop that physician disrespect even he is feeling totally uncomfortable - Should be offered information about the procedure in his language - Offered a professional interpreter - Book next appointment before the patient leaves

Case Three A 56 year old woman from Nepal came to see her family physician. She has not seen a physician other than twice for febrile illness in a refugee camp. She was seen by a midwife for the delivery of her three children. There is no known past medical or surgical history. She does not take any medications. During a visit for a cough, it is suggested that she should have screening mammography by her family physician. She states, "Whatever is destined will happen." What would you do in these cases?

ABCDE model CulturalCompetence AAffective BBehavioural CCognitive DDifference EEquity Adapted from Srivastava, R. H. The ABD (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1 (1), 27-33, 2008 -Many of people from Bhutan have lived in refugee camps - Not having a health system - Not having a preventative care concept -Believe in Karma/fate - Illiterate in their language - Doctor might offer to book another appointment to explain the procedure and its importance -Not having prevention health care concept - Not knowledge about health care system - Not having the knowledge about body parts - Respect of the authority (physician) - She is saying yes and possible smile - She could think that something is wrong in her breast - Increase anxiety - Offer information about the procedure in his language using a lot of images - Offered a professional interpreter - Book next appointment before the patient leaves

Objective 3: Cross Cultural Communication

People dont get along because they fear each other. People fear each other because they dont know each other. People dont know each other because they dont communicate. Dr. Martin Luther King Jr. Cross Cultural Communication

Definitions Individualism Collectivism Focus on the I Goal of autonomy Values - Personal choice Emphasize - Goals focus on the individual preferences, rights and pleasure Most of the information is made verbally explicit i.e. North American culture Focus on the We Promote relatedness and interdependence Values - Connection to the family - Respect and obedience Emphasize - Goals focus on the group Communication is less explicit; most of the message is in the physical context or internalized in the person i.e. Asian and Latin American cultures Tamis-LeMonda, Way & Hughes, 2008, Srivastiva, 2007

Communication Continuum Collectivism Individualism

Assigning Meaning Discuss at your tables: What it means to me What it might mean to another Not making eye contact Often saying YES Spending time on small talk Arriving late for an appt Needing to consult family

Common Assumptions is Everyone who looks & sounds the same... is the same Being aware of cultural commonalities is useful as a starting point BUT Drawing distinctions can lead to stereotyping Making conclusions based on cultural patterns can lead to desensitization to differences within a given culture (Garcia Coll et al., 1995; Greenfield, 1994; Harkness, 1992; Ogbu, 1994)

The danger of a single story Chimamanda Ngozi Adichie Common Assumptions

Things to Consider Power Dynamics Experience and Expertise Communication Styles

Assume differences Listen to stories Share your intent, your purpose, your thinking Ask for clarification Be sincere and respectful Acknowledge your own ethnocentrism Take risks and be prepared to apologize Cross-Cultural Communications Strategies

Examine your own values, beliefs and assumptions Recognize conditions that exclude people such as stereotypes, prejudice, discrimination and racism Reframe thinking to better understand other world views Become familiar with core cultural elements of diversity communities Actions that Support Cultural Competence

Develop a relationship of trust by interacting with openness, understanding and a willingness to hear different perceptions Create a welcoming environment that reflects and respects the diverse communities that you work with and that you serve Actions that Support Cultural Competence

Language barrier

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Strategies for Reducing Barriers to Cancer Screening