Strategies for Reducing Barriers to Cancer Screening
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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)
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Presenter(s)
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_______________ 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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There is no financial interest, arrangement or affiliation with
one or more organizations that could be perceived as a direct or
indirect conflict of interest in developing of this project Program
Disclosure of Commercial Support
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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
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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
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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
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Creating the same opportunity for positive health outcomes for
all Health Equity Terminology
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Objective 1: Immigration and the Immigrant Experience
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The Health of New Immigrant
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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
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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
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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
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Knowledge Meaning of cancer and cancer risk Prevention: Cancer
screening can prevent some cancers Do tests before any
symptoms
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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
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Why does the doctor ask if I have relatives with cancer? Is it
because it is contagious? Could I infect others? Nepalese
participant Barrier
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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
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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
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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
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Iceberg Concept of Culture and Cancer Festivals Clothing Music
Food Literature Language Rituals
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2 different cultures in one family Kids growing up in Canada
and parents from different countries Intergenerational issues
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Immigrant Experience about Cancer Death Fear Suffering Pain No
cure It is your fate Loss of independence Loss of control Anxiety
Expensive treatments
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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
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Objective 2: The *ABCDE Model A framework for cross-cultural
communication *Developed by Sick Kids Hospital
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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
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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
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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
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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
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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
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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.
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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.
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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
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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
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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
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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?
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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
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Objective 3: Cross Cultural Communication
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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
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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
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Communication Continuum Collectivism Individualism
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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
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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)
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The danger of a single story Chimamanda Ngozi Adichie Common
Assumptions
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Things to Consider Power Dynamics Experience and Expertise
Communication Styles
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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
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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
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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