Giving New Subjects a

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Giving New Subjects a Voice

• Cultural Diversity in the Healthcare System

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• 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
• 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
• 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
• Institutionalised inter-cultural dialogue
• 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

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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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CLSC 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-lîle 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 linformation
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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 lÉgalite 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 Childrens
  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
  lAgence 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
  Childrens 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
  mis-communicate 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 cont

• pilot projects on mental health
• with the Punjabi community
• initiated by the Provincial Health Services
  Authority
• Vancouver General has a successful transcultural
  psychiatry program
• pilot projects on maternity care
• South Vancouver Birthing Project that offers
  midwifery and dula services to pregnant women.
• There was a project for Somali womens 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

• Childrens 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.
• This organization also works to connects people
  with the rest of the health care system
• acquiring health care cards
• family doctors

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Challenges Montreal and Vancouver

• Lack of consistent funding resources and need to
  re-apply 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 Accessgroups and locale

• Largest communities that are well established
  fare better
• Vancouver Chinese and Punjabi communities.
• Montreal English and Chinese
• Smaller and newer ethno-cultural groups (e.g.
  African, Eastern European) have problems in both
  Vancouver and Montreal
• 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
• 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
  ethno-cultural 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
  decision-making
• 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
  ethno-cultural 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
• http//www.vch.ca/
• www.amssa.org
• Links to numerous affiliate members
• Montreal
• http//www.santemontreal.qc.ca
• www.accesss.net
• National Transcultural Health Conference 
  AdvancingKnowledge, Strategy and Connectedness
  in Working Across CulturesMontreal May 9-11,
  2007. 
• www.nursing.utoronto.ca/immigrationguide

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Contacts

• Dr. Oliver Schmidtke
• University of Victoria
• ofs_at_uvic.ca
• Dr. Saime Ozcurumez
• McGill University
• saime.ozcurumez_at_mcgill.ca
• Lloy Wylie
• University of British Columbia
• lloy_at_interchange.ubc.ca