1. Strategies for Reducing Barriers to Cancer Screening

2. 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)

3. Presenter(s)

4. _______________ 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

5. 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

6. 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

7. 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

10. “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

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

12. Objective 1: Immigration and the Immigrant Experience

13. The Health of New Immigrant

14. 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

15. 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

16. “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

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

18. 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

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

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

21. 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

22. 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

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

24.  2 different cultures in one family  Kids growing up in Canada and parents from different countries Intergenerational issues

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

26. “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 didn’t know about or understand screening” Dharshi Lacey Cancer Screening/ Immigrant Experience

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

28. 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

29. 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

30. 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 patient’s 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

31. 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

32. 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

33. 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”.

34. 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.

35. 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

36. 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

37. 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

38. 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?

39. 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

40. Objective 3: Cross Cultural Communication

41. “People don’t get along because they fear each other. People fear each other because they don’t know each other. People don’t know each other because they don’t communicate.” Dr. Martin Luther King Jr. Cross Cultural Communication

42. 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

43. Communication Continuum Collectivism Individualism

44. 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

45. 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)

46. The danger of a single story Chimamanda Ngozi Adichie Common Assumptions

47. Things to Consider  Power Dynamics  Experience and Expertise  Communication Styles

48.  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

49.  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

50.  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

51. Language barrier

52. “I had no idea she did not understand until I asked her to teach it back to me. I was so wrapped up in delivering the message that I didn’t realize it was not being received." Provider from the University of Washington Medical Center

53.  Health Literacy is “the ability to access, understand and act on information for health” (Canadian Public Health Association)  It “involves the ability to obtain, process and understand basic health information” (Ratzan and Parker, 2000)  Canadians with the lowest literacy scores are two and a half times as likely to see themselves as being in fair or poor health (Rootman & Gordon-El-Bihbety, 2008) Health Literacy

54.  It involves appropriate use of translated materials and resources such as interpreter services  It is not enough to give the family a pamphlet in their own language Healthy Literacy

55. A literature review described inequitable care with regard to three specific factors:  Adverse events - Patients who do not speak English are more likely to experience serious medical errors  Inappropriate tests and procedures  Lack of or inappropriate hospital utilization (Access Alliance, 2009) Costs of Not Providing Interpretation in Healthcare

56. Availability of interpreters  Interpreters are sometimes unavailable  Strategies are always needed to support effective communication, even when interpreters are unavailable (ex. Language Line) Trained versus untrained interpreters  Trained interpreters were 70% less likely to make medical translation errors than untrained interpreters (Gany et al., 2010) Things to Consider…

57. Things to consider when assessing for an interpreter Barriers  What language family speaks at home  Explore with the family when having an interpreter may be helpful  Ask the family to tell you their understanding of what was discussed  Continue to assess the need for an interpreter on an ongoing basis Assessing  Confidentiality  Privacy  Fear/shame to disclosure some private topics  Fear to be seen different or difficult

58. Interpreter Services and Language Line

59. Across Languages www.acrosslanguages.org  (519) 642-7247  On-site interpreting  telephone interpreting  24/7 Language Services

60. Across Languages  Delivery of spoken language services for more than a 100 languages and dialects  Victims of domestic violence, sexual violence and human trafficking have the service for free Language Services

61. Canadian Cancer Society Cancer Information Service  1-888-939-3333 (TTY 1-886-786-3934)  Monday to Friday from 9 a.m. to 6 p.m. in English and French  For other languages, CCS can access an interpreter service Language Services

62.  Information about: cancer treatment and side effects clinical trials coping with cancer emotional support services Prevention screening programs help in the community complementary therapies Language Services

63. Cancer Care Ontario Cancer screening fact sheets  Different languages  Cancer Screening Fact sheets  Breast Screening Program - Resources Breast Screening Program - Resources Language Services

64. Cultural Competency is an integral component of service excellence as it acts to:  Create organizational flexibility and change and improve organizational climate  Continuously reduce costs and improve productivity by enhancing patient safety  Create an attitude toward improving information services  Improve the quality of care Conclusion

65. Health Ethics, Equity and Human Dignity  Global Health ethics is concerned with organization financing and delivering health care.  In this respect, ethics is a bridge between health policy and values, where values are recognized as guides and justifications people use for choosing goals, priorities and measures.  Ethics examines the moral validity of the choice Prof. Mamdouh Gabr http://www.humiliationstudies.org/documents/GabrHealthEthics.pdf

66. Acknowledgement to Sick Kids Hospital, Toronto By providing Cultural Competence Train the Trainer Manua l

67. Immigration is the sincerest form of flattery Jack Paar

68. Questions?

69. Thank you