Transcript Giving New Subjects a ‘Voice’

Giving New Subjects a ‘Voice’
Cultural Diversity in the
Healthcare System
Giving New Subjects a “Voice”
is funded by the Volkswagen Foundation
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Project Partners
Dr. Patrizia Nanz
University of Bremen, Germany
Dr. Elmar Brähler
University of Leipzig
Dr. Carlo Ruzza
Università di Trento
Dr. Oliver Schmidtke
University of Victoria
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Canadian Team
Dr. Oliver Schmidtke
University of Victoria
Dr. Saime Ozcurumez
McGill University
Lloy Wylie
University of British Columbia
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Rationale for the Research
Increasing international mobility
The need for integration of immigrants into
existing social and political structures
Efforts to devise policies that are more
responsive to cultural differences
Increased political organisation of
immigrants that articulate political demands
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Focus of Research
Empirically grounded investigation of
formal and informal institutional measures
for a culturally sensitive integration of
immigrants
Integrates the fields of multiculturalism and
cultural diversity with public deliberation
and political mobilisation
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Research Context
Pressure for Change from Immigrant
Organisations
Evolving Conflicts

disagreements over the status of cultural and religious identities in
public life
Multiculturalism vs Assimilation
Political and Scholarly Controversy
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
universal. individually-based rights vs
public recognition for minorities and protection of cultural rights
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Institutions and Voice
institutional arrangements - opportunities to
engage in public debate and policy-making
institutional strategies and channels for
articulating the needs of immigrants;
Dialogue leads to an intercultural validation of
social institutions. their norms and practices.
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Immigrant Organisations as
Knowledge Brokers
important role as cultural mediators between
the institutions and immigrants
facilitators of communication
Work to attain a more equitable delivery of
health-care services to specific ethnic groups.
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Why the Health Care System?
Health-care is chosen as a critical test case
It is a sector of public services which immigrants
are heavily dependent upon.
It is dominated by rules and practices often alien
Pro-immigrant organisations and anti-racism
activists have repeatedly voiced and politicised
cultural demands on the health-care system.
This has given rise to a lively political and
academic debate about immigrants’ access to
health-care and responsiveness of institutions to
their needs.
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Access
result of many factors
participatory practices aimed at the inclusion of
immigrants into the health-care system play a
prominent role.
an equitable and effective distribution of health
services has to take into account the needs and
demands of recipients of these services, including
those deriving from cultural differences and
experiences of immigration and relocation.
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Cultural Diversity and Common
Standards of Healthcare
Tension between

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commitment to meet immigrants’ needs and demands
(which sometimes requires revising accepted practices)
duty to ensure certain standards of health which are
widely established in the receiving society.
Can be resolved through
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Institutionalised inter-cultural dialogue
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could strike a balance between the incorporation of cultural
diversity and the need to maintain common standards of
healthcare.
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Levels of Analysis and Questions
Level
Focus
Questions
Macro
State-level
federal legislation
 structures
 strategies
Meso
Institutional practices
cities
 Decision Making
models
 participation
mechanisms
Micro
Organisations
(e.g. health care, immigrant
associations)
 Issues
 services
intercultural dialogue
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Focus
maternity care
first contact with the healthcare system in the
receiving country for most immigrant women
 context in which cultural values, traditions and
sometimes prejudices play an important role

mental health
need for culturally sensitive inclusion
 recognition of the stressful experience of
resettlement and exclusion

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Focus on Urban Centres
Germany (Bremen and Leipzig)
Italy (Bologna and Napoli)
Canada (Vancouver and Montreal).
Recognition of the decentralized structure
of the healthcare system and the role of
local level initiatives.
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The Logic of Comparison
Aim at finding the best and most successful
practices and policies for integration, public
deliberation, and mutual learning.
Healthcare systems in these countries are similar
in their commitment to universal inclusion and
access to services.
National contexts reveal significant variation with
regard to the political and legal provisions,
cultural standards and policy initiatives.
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Aims of the Study Group
comprehensive picture of the obstacles and
opportunities for immigrants to find a voice in
health policy-making
Identification of innovative practices and policies
exchange and deliberation between academics.
Practitioners, immigrant organisations and policy
makers
Promotion of intercultural dialogue
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Preliminary Results
Interviews in Vancouver and
Montreal
Changing Demographic Profiles
increasing numbers of immigrant patients of
the population in 2001
Montreal 28%
 Vancouver 37.5%

slower increase in the numbers of people
working in the hospitals from ethno-cultural
communities (other than in the cleaning and
food services).
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Countries of Origin – Top 10
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Permanent Residents % of population
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By Province
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New borns withe mothers born
outside of Canada.(5)
%
New borns with at least one parent born
outisde of Canada.(6)
%
Ahuntsic
45.9
54.1
Nord-de-l’île
68.6
76.4
Côte-des Neiges
69.3
81.6
De Rosemont
35.1
42.8
Des Faubourgs
39.9
47.7
La Petite Patrie
38.1
48.2
LaSalle
33.4
43.2
Métro
65.8
73.6
Montréal-Nord
46.2
53.7
NDG/Montréal-Ouest
44.6
57.4
Olivier-Guimond
30.7
38.1
Parc-Extension
89.4
93.2
Pierrefonds
35.1
45.1
Pointe Saint-Charles
31.0
36.9
René-Cassin
54.9
65.9
Saint-Henri
42.4
51.0
Saint-Laurent
69.4
77.8
Saint-Léonard
48.8
57.8
Saint-Louis-du-Parc
37.7
58.7
Saint-Michel
68.0
74.7
Villeray
49.7
58.6
Birth Registration
Estimates for populations in CLSC territories between 1998 and 2000 :
MSSS. Service du développement de l’information
CLSC
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Legal Regulations
Federal Level: no legal regulations in place for improving
access other than in the Canada Health Act, which does not
outline any requirements other than vague principles.
Provincial Level: Quebec - Health and Social Services Act
– fosters (to the extent allowed by the resources) access to
health services in their own langauges for members of the
various cultural communities
Since 1986 - legal regulation for access in the native
language, and increased activities since 2002 to improve
cultural competences in different organisations
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Relationship between Government and
Community - Montreal
Quebec has recently established a Committee for advising
the government on multicultural issues.

The committee members were appointed by the government from a
list of people nominated by different community groups.
ACCÉSSS (Alliance des Communautés Culturelles pour
l’Égalite dans la Santé et les Sevices Sociaux) engaged in
the reform of the health services network

an association bringing organizations of ethnic communities
around the goal of improving equality of access to health care and
social services across Quebec.
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Institutional Changes to Promote
Access Montreal
Interpretation services
multicultural program at Montreal Children’s
hospital is a leader in multicultural care,
celebrating its 20th anniversary.
Well-established intercultural training of managers and
workers in McGill teaching hospitals network (facilitated
by MCH)
Regular presentations take place – often at the request of
the facility or professional group via l’Agence de
developpement de reseaux locaux de services de sante at
de services sociaux
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Interpretation Use in Montreal
(Source: Inter-regional Interpreters Bank Report 2003-2004)
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Mental Health
Mental health of immigrants not a priority in government
policy
committee on mental health created in fall 2005 – no
representatives of non-European ethnicities
Report did not see diversity as a major question, and there
is no new resources put to mental health programs for
diverse communities
growing availability of psychiatric therapy for refugees
that were torture victims and post-traumatic stress disorder
ACCESSS has report on mental health
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Maternity care
some local establishments, i.e. Montreal
Children’s Hospital, do great work around
maternity care for immigrant women
A project started ten years ago to recognize
midwifery (but no major progress in the
recognition of midwives).
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Limitations to services
Not every Agence and not every part of Quebec
has interpreters, some use volunteer interpreters
qualification of the interpreters, need to able to
interpret language, and know enough about health
care so that the translation does not miscommunicate the diagnosis or symptoms
the main stumbling block in Quebec is that these
changes are highly de-centralized, so great
practices in one place are not replicated in others
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Programs to Promote Access Vancouver
Interpretation Services: Vancouver Coastal
Health Authority has interpreters. which are
requested by the doctor.
 Usually an interpreter is available within 24
hours.
 Written material is provided in a variety of
languages. and over 100 languages are available
through the Nurseline (telephone service).
Cultural Brokers
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Programs to Promote Access
Vancouver con’t
pilot projects on mental health
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with the Punjabi community
initiated by the Provincial Health Services Authority
Vancouver General has a successful transcultural
psychiatry program
pilot projects on maternity care
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South Vancouver Birthing Project that offers midwifery
and dula services to pregnant women.
There was a project for Somali women’s maternity care.
but that is no longer operating.
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Relationship between Government and
Community - Vancouver
Vancouver Coastal Health Authority has a
Community Engagement Department that
maintains ongoing advisory committees with
numerous members of ethno-cultural
communities.
In Vancouver AMSSA is an association that brings
together multicultural societies throughout BC.
AMSSA participates regularly in the advisory
committees of VCH.
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Vancouver
Children’s hospitals noted as one of the leaders in
facilitating access for ethno-cultural communities.
Bridge Health Clinic that is there to serve
immigrants and refugees for at least their first year
in Vancouver.
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This organization also works to connects people with
the rest of the health care system
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acquiring health care cards
family doctors
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Challenges –
Montreal and Vancouver
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Lack of consistent funding resources and need to reapply for funds on a regular basis
Limited staffing resources in immigrant associations
Intercultural training among staff is ad hoc and
generally staff feel too overworked to participate.
Most of the coordinated intercultural training takes
place in hospital setting – but use of community health
centres are high, so training needs to take place there as
well.
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Unequal Access:
groups and locale
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Largest communities that are well established fare better
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Vancouver: Chinese and Punjabi communities.
Montreal: English and Chinese
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Smaller and newer ethno-cultural groups (e.g. African, Eastern
European) have problems in both Vancouver and Montreal
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Vancouver has very good access to interpreters, whereas North Vancouver and
other parts of the province there are no publicly funded interpreters and very few
practitioners from ethno-cultural communities
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Montreal: Through Inter-regional interpreters bank, but access to trained medical
interpreters is limited in other parts of Quebec
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Perception of Current Status
Immigrant associations as more skeptical of
effectiveness of the initatives
general sense that the numbers of patients from ethnocultural communities will grow, and policy makers will
need to respond to service needs
general sense that the numbers of practitioners from
ethno-cultural communities will expand, but there is no
policy in place to facilitate affirmative action hiring or
to develop quotas.
Need regulation to make sure that access to
interpretation is guaranteed and resourced
if the system in general was more accessible and
representative of the diversity of the population living
in Canada, immigrant specific services would not be
required.
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Strategies to Overcome Barriers
engaging ethnocultural groups effectively and
increasing their participatory role in decisionmaking
adequate resources for community associations
of immigrants
training of health care professionals on
intercultural health care provision
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Ways Forward
dedicated staff time to participate in ongoing
training
Hiring policies to increase representation ethnocultural communities
Data collection on ethno-cultural groups’ service
utilization for service planning/resources
Recognition of professional accreditation from
outside Canada
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Resources
Vancouver
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http://www.vch.ca/
www.amssa.org
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Links to numerous affiliate members
Montreal
http://www.santemontreal.qc.ca
 www.accesss.net
National Transcultural Health Conference: Advancing
Knowledge, Strategy and Connectedness in Working
Across Cultures
Montreal May 9-11, 2007.
www.nursing.utoronto.ca/immigrationguide
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Contacts
Dr. Oliver Schmidtke
University of Victoria
[email protected]
Dr. Saime Ozcurumez
McGill University
[email protected]
Lloy Wylie
University of British Columbia
[email protected]
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