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Working with the Marshallese Community in Cancer Care & Prevention

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Amanda Tran

on 7 December 2012

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Transcript of Working with the Marshallese Community in Cancer Care & Prevention

Cultural Perspectives Cultural Relativity e.g. aspect of time, humor as coping mechanism, pain stoicism, concept of group over individual, fatalistic about cancer, reciprocity = important Cultural Environments & Contexts There is no oncologist in the Marshall Islands and medical care is limited. Because of this, and a difficulty obtaining medical insurance in the U.S., Marshallese are often inexperienced regarding medical care and treatment. Socio-Cultural Networks e.g. Family Dynamics Traditions & Taboos e.g. touching, height positioning, gender and topic restrictions, women: showing breasts/bodies Spirituality/Religion Public expressions of pain are not demonstrated, and stocism ragarding pain is common. Marshallese are not individualistic, and tend to make decisions based on what’s best for their family, then their community. In Micronesia, women are usually advisors and health promoters. e.g. lack of adequate medical care in MI, no oncologist in MI “Many Micronesians belong to family, church, and community groups and can be reached through these venues. Women usually congregate separately from men, and women usually help each other with child care and other tasks and give each other advice about health and daily living.” Family takes precedence over personal needs, and women particularly are expected to focus on the home and family. It is good to take the context of their family’s well being into discussions about treatment and health. Marshallese tend to be fatalistic about Cancer and may see it as God’s will Modesty is a large concern for women, and sensitive topics regarding female body parts can be extremely embarrassing. Sensitive topics include sex, reproductive body parts and elimination - especially when an opposite sex is present. Social taboos include mixing of genders when addressing sensitive topics. A same-sex doctor is strongly preferred in these cases, and family may need to leave the room during exams. Communication Cancer Care & Prevention Suggestions & Resources Brief Historical Context Nuclear weapons testing occurred in the Marshall Islands 1946-1958, exposing people and the environment to radiation. Due to several factors, there is still limited understanding about how cancer and the weapons testing are related. When do the Marshallese seek care? Marshallese migrants do not seek health care until they perceive their illness as a health crisis. To the Marshallese a health problem is normally only considered a crisis when there is an indication of pain. The will to go to a doctor is only established when their pain is unbearable. Minor pain is often ignored and the absence of pain indicates wellness. Seeking care will often stop once this absence of pain is achieved regardless of what stage of their illness this belief is particularly stronger in the older generations. Seeking Care cont. The Marshallese won’t seek care when their network cannot provide for them to go there. The Marshallese people have strong family and community ties and often will not take themselves to a doctor but will rely on other people in their network to get them there. The Marshallese are less likely to seek care when an interpreter is not present. Under the instruction of lay educators the Marshallese have shown to increase attendance to health screenings. A woman with cancer came in for treatment and her husband accompanied her. The husband had a slight limp to his walk and the health service provider asked if he had his limp checked out. The man said that he was fine but the health service provider insisted on checking. She found that a hole on the bottom of his foot from severe diabetes. She was shocked and learned that the Marshallese may say they are fine when in other cultures this would not be the case. Example from a bilingual health service provider when working with the Marshallese: Why Non-Compliance? The Marshallese people have a particular view point of time as being in the present. This leads them to not plan for the future with follow-up appointments. The Marshallese do not have a concept for preventative care in the Marshall Islands because of the lack of health care there. When coming to the United States the Marshallese must be taught the importance of preventative care. The Marshallese will not go to appointments they have made if they do not have another person in their community take them there. Doctors may see this as noncompliance but in the Marshallese culture they heavily rely on people in their community. Independence is not such an admired trait as it is in American culture. The Marshallese people are not provided insurance that covers numerous amounts of treatment. Marshallese may want to have treatment but their insurance does not cover it so they will not schedule further appointments. If the Marshallese are told to eat healthier to manage their diabetes or cancer they may not eat healthier due to the fact that they normally have very low incomes and are only provided $13 week in food stamps. This low amount of money to spend on food forces them to buy cheaper foods which are typically unhealthy such as preserved foods not fresh produce. Economical Aspect is Key Language no common language Language barrier does not only prevent the Marshallese from communicating with their doctors, but it also hinders the Marshallese from following up on their appointments because they don't have the language proficiency that is necessary to acquire a driver's permit. Medical terminology complicates the process; it may obscure a condition's true meaning or effect. During medical appointments or checkups, Marshallese patients might nod and agree, when in reality, they don't understand what the doctor is trying to tell them. Not only are some terms unknown to the Marshallese, but some individuals can be uncomfortable when talking about cancer. It is a sensitive topic for them. Since certain terms do not exist in the Marshallese language, the Marshallese people attribute certain diseases to magic rather than medical conditions for which they don't have terminology. Certain terms do not exist When misunderstanding occurs, it is recommended that the physicians repeat themselves and use simpler, more direct words. Some anatomical references cannot be literally translated into the English language. Those who lack language and cultural skills, turn to their networks for assistance. Due to to their limited knowledge and education about the language and culture, clinic setting may be uncomfortable and stressful for the Marshallese patients. Because of their limited language skills, many Marshallese are more comfortable when interpreting services are offered. Lack of healthcare infrastructure and trained medical personnel contributes to the Marshallese people's lack of understanding and education about health care. Lack of education plays a significant role in the quality of health care that the Marshallese receive. Inability to navigate the health care system (because of lack of knowledge or language skills) might keep the Marshallese from seeking out resources or services related to health care. Education Power/Social Dynamics Marshallese culture emphasizes respect, and as such, because of the respect for authority they may be be disinclined to ask questions. Even though some Marshallese might be able to speak English, they will feel uncomfortable speaking it in a clinical setting. Working with the Marshallese Community in Cancer Care & Prevention Data Compiled and Presented By
Amanda Tran, Jenny Hooker, Hanna Dinh,
Christi Quilligan, Yulia Arbuzova Works & References Cited People tend to give priority to the moment and many operate on “island time” which can be difficult regarding health care settings. Marshallese culture is one based on reciprocation and mutual respect. Taking time to learn a little about their culture is greatly appreciated. Illness and suffering are often accepted as inevitable experiences in life, and this outlook can influence decisions to seek care. Most migrants learn about health care system norms and rules from their social networks. They learn how to make appointments, fill out applications and arrange transportation services for them. Christianity is a large part of Marshallese culture and much of their community is based around it.
Some Marshallese work with magic and/or prayer to influence outcomes. In contrast, disease can also be seen as originating from supernatural causes. 'imi hale - native hawaiian cancer network. (2008). Retrieved from Williams, D., & Hampton A. (2005). Barriers to health services Aitaoto, N., Braun, K. L., Estrella, J., Epeluk, A., & Tsark, J. (2012). Design Carucci, L. M. (1993). Medical magic and medicinal cure: Manipulating Buenconsejo-Lum, L. (2010, September 30). Improving the health of Pacific regional comprehensive cancer control plan 2007-2012. (2007, Choi, J. (2008). Seeking health care: Marshallese migrants in Hawai'i. perceived by Marshallese. Journal of Immigration Health, 7, 317-26. Ethnicity & Health, 13(1), 73-92. doi:10.1080/13557850701803171 http://www.imihale.org/education_materials.htm meanings with ease of disease. Cultural Anthropology, 8(2), 157-168. Retrieved from http://www.jstor.org/stable/656468 Pacific Islanders: Leveraging resources through communityacademic partnerships. (2010). Retrieved from http://www.americantelemed.org/files/public/MemberGroups/PICATA/PICATA_Buenconsejo-Lum_-_Improving_the_health_of_Pacific_Islanders_-_9-30-10.pdf March). Retrieved from http://cancercontrolplanet.cancer.gov/state_plans/Pacific_Regional_Cancer_Control_ Plan.pdf and results of a culturally tailored cancer outreach project by and for Micronesian women. Prev Chronic Dis, 9(100262), doi: http://dx.doi.org/10.5888/pcd9.100262 Marshallese focus groups and individuals have suggested ways to enhance communication and build trust and compliance:
Examples of visual aids: http://www.imihale.org/pubs/brochures/Shower%20cards/Marshallese.pdf
http://www.imihale.org/pubs/brochures/Cancer%20Brochures/BeadNecklace.pdf Have only same-gendered staff discuss personal or taboo information, and apologize for having to use “offensive” language.
Conduct home visits for health education and discussing sensitive issues
Patience, lack of judgement and taking time with the patient shows respect.
Due to financial and logistic reasons, offer samples of prescriptions and follow-up appointments over the phone
Aim to make healthcare education programs and materials available in the native, Marshallese language Example: http:///www.imihale.org/education_materials.htm Provide translators and interpreters. Ideally someone with understanding of the culture. Speaking in short phrases with minimal jargon will get the message across best and quickest. Visual aids can also be helpful.
Incorporate patient-navigators in hospitals and clinics By definition, individuals from the patients’ own culture or community that went through the same health experience or has been very involved in or understand the healthcare system that will be able to explain the health processes to the patients “if an individual needs medical care or advice, they will first go to someone they feel they can trust and provide interpretation services, rather than first seek Western medical care” i.e. a known community leader or pastor
Culturally Health Tailored Care In essence, education and health programs will be more effective when they are culturally appropriate for the population that is being served.

To create a fitting program, healthcare providers must be able to identify and describe cultures/subcultures and understand how each relates to health behavior, and then apply this knowledge in planning and developing of appropriate activities.

There are five categories for creating a culturally appropriate health care plan: peripheral, evidential, linguistic, constituent-involving, and sociocultural categories.

Peripheral strategies seek to give programs or materials (healthcare) an appearance of cultural appropriateness by packaging them into ways that would be ideal and likely to appeal to a certain group. For example, colors, images or pictures of group members might be useful and influential tools. When this material seems familiar to the patient, it will make them feel more comfortable. Unlike text, there are no linguistic barriers, and such images can be perceived instantly. It also establishes credibility with the chosen cultural group. By matching and making an effort to be culturally sensitive, the group will be more receptive and accepting of the treatment, and any of the healthcare messages might be enhanced.

Evidential strategies enhance and make medical information more relevant by presenting evidence to the group. Most of the time, the evidence is epidemiological or other data that relates to the specific group (20% of Marshallese women are affected by cancer, for example). These statements will raise awareness, and make the data more relevant, and will cause the patients to think seriously about the healthcare problem that they might be experiencing, and encourage them to take preventive action.

Linguistic strategies aim to make healthcare education programs and materials more accessible by providing them in native language. At the very least, this may involve having an interpreter or a translation program.

Constituent-involving strategies are those that draw on the experience of the same member of the group. Training of professionals or “natural helpers” that can provide valuable insights into the cultural characteristics that are not as obvious as language.

Sociocultural strategies involve discussing health related issues in the context of a broader social and/or cultural values. Using this approach, the group's cultural values, beliefs, and behaviors can be recognized with ease and reinforced and built upon. In addition, it will allow the extraction of useful and meaningful information and messages about a given health problem or behavior.

Subgroup that takes into account characteristics shared by the subgroup’s members. For example, people feel more comfortable talking about cancer to those who shared their views on it, talked similarly about it, and who even looked like them.
"Whenever I translated, it seemed that the doctors were always impatient and in a hurry. Sometimes it seemed like they wanted the session to be over quickly. It's understandable because they're busy and have more patients to see. Interacting with a non-English speaking patient is hard, and they see it as more work"
To complicate things, there is a third individual—the interpreter—and building trust between three people is rather hard. However, as an interpreter, I provided relevant information that helped the doctor communicate with the patient and build trust. That way, it becomes easier to work with the patient.
http://www.imihale.org/education_materials.htm
http://www.imihale.org/pubs/brochures/Cancer%20Brochures/BeadNecklace.pdf
http://www.imihale.org/pubs/brochures/Shower%20cards/Marshallese.pdf
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