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)
Presenters
 Dr. Jan Owen. BA, MSc, MD, CCFP, FCFP
Primary Care Lead, South West Regional Cancer Program
 Dr. Bhooma Bhayana. MD, CFPC.
Adjunct Professor of Family Medicine Department,
University of Western Ontario
 Dr. Adriana Diaz. MD
Project Coordinator, South West Regional Cancer Program
International Medical Graduate . OB-GYN.
Conflict of Interest Disclosure
Dr. Jan Owen has 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
Dr. Bhooma Bhayana has 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
Dr. Adriana Diaz has 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
Program Disclosure of
Commercial Support
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
Objectives
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
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
Percentage not reporting mammogram in past two
years, by years since immigration, female household
population aged 50 to 69, Canada, 2008
70
Percentage
60
50
57.4
40
34.92
30
29
20
25.8
10
0
0-9
10-19
20 - more
Non immigrant
Years since immigration
Statistics Canada, 2009, "An update on mammography use in Canada", Health Reports, Vol. 20, No. 3, catalogue number 82-003-X.
Percentage reporting having fecal occult blood test in past
two years or colonoscopy or sigmoidoscopy in past five years,
by years since immigration, household population aged 50 or
older, Canada, 2008
45
Percentage
40
42.8
35
30
39.9
32.2
25
20
22.2
15
10
5
0
0-9
10 - 19
20 or more
Non immigrant
Years since immigration
Statistics Canada, 2009, "Colorectal cancer testing in Canada–2008", Health Reports, Vol. 20, No. 3, catalogue number 82-003-X.
Cultural Competence
“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
Health Equity Terminology
Creating the same opportunity for
positive health outcomes for all
Objective 1:
Immigration and
the Immigrant Experience
The Health of New Immigrant
How would you describe the health status of new
immigrants upon arrival in Canada?
New immigrants arrive with better health scores than
average Canadians. Five years later their health scores
are lower than those of the general population
New Immigrants
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
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
Community
Evidence-Based Barrier
“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”
-Spanish 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
Barrier
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 me…I would
be disowned by my husband.
I will not go… I have 4 kids
- Arabic participant
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
Barrier
• 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
Iceberg Concept of Culture and
Cancer
Festivals
Clothing
Music
Food
Literature
Language
Rituals
Intergenerational issues
 2 different cultures in one
family
 Kids growing up in Canada
and parents from different
countries
Immigrant Experience about
Cancer
Death
No cure
Fear
It is your fate
Anxiety
Suffering
Loss of
independence
Expensive
treatments
Pain
Loss of control
Cancer Screening/ Immigrant
Experience
“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
Objective 2:
The *ABCDE Model
A framework for
cross-cultural communication
*Developed by Sick Kids Hospital
ABCDE model
A
Affective
E
B
Equity
Behavioural
Cultural
Competence
D
C
Difference
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
Affective
A
 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
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
B
 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.
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
Cognitive
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
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
Difference
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
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
Equity
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”.
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
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
- 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
A
- Differences between genders
- Premarital sex
Affective
E
B
Equity
- Respect of the authority
(physician)
- She is saying yes and possible
smile
Behavioural
Cultural
Competence
D
C
Difference
Cognitive
- 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
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
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
A
- Should be offered
information about the
procedure in his
language
- Offered a professional
interpreter
- Book next appointment
before the patient leaves
- Many Latino communities men are
considered authority
- Machismo
Affective
E
B
Equity
- 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
Behavioural
Cultural
Competence
D
C
Difference
Cognitive
- 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)
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
What would you
do in these cases?
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."
ABCDE model
A
- Offer information
about the procedure in
his language using a lot
of images
- Offered a professional
interpreter
- Book next appointment
before the patient leaves
Affective
-Many of people from Bhutan have lived
in refugee camps
- Not having a health system
- Not having a preventative care concept
E
B
Equity
Behavioural
Cultural
Competence
- Respect of the authority
(physician)
- She is saying yes and possible
smile
- She could think that something is Difference
wrong in her breast
- Increase anxiety
D
C
Cognitive
-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
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
Objective 3:
Cross Cultural Communication
Cross Cultural Communication
“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.
Definitions
Individualism
 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
Collectivism
 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
Individualism
Collectivism
Assigning Meaning
Discuss at your tables:
Not making eye contact
Often saying “YES”
Spending time on small talk
Arriving late for an appt
Needing to consult family
What it means
to me
What it might
mean to
another
Common Assumptions
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)
Common Assumptions
The danger of a single story
Chimamanda Ngozi Adichie
Things to Consider
 Power Dynamics
 Experience and Expertise
 Communication Styles
Cross-Cultural Communications
Strategies
 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
Actions that Support Cultural
Competence
 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
Language barrier
“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
Health Literacy
 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)
Healthy Literacy
 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
Costs of Not Providing
Interpretation in Healthcare
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)
Things to Consider…
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 when
assessing for an interpreter
Assessing
 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
Barriers
 Confidentiality
 Privacy
 Fear/shame to disclosure some
private topics
 Fear to be seen different or
difficult
Interpreter Services and
Language Line
Language Services
Across Languages
www.acrosslanguages.org
 (519) 642-7247
 On-site interpreting
 telephone interpreting
 24/7
Language Services
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
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
 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
Cancer Care Ontario
Cancer screening fact sheets
 Different languages
 Cancer Screening Fact sheets
 Breast Screening Program - Resources
Conclusion
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
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
Acknowledgement to Sick Kids Hospital, Toronto
By providing Cultural Competence
Train the Trainer Manual
Immigration is the sincerest
form of flattery
Jack Paar
Questions?
Thank you