Knowledge Hub 06: Cultural Considerations in Care

Learning Objectives

By the end of this Knowledge Hub, you will be able to:

1. Improve understanding of the concept application of cultural considerations in care
2. Understand how to use cultural assessment tools.
3. Specify effective support for patients with a language barrier.
4. Reflect on one’s practice of cultural competence and cultural safety.

Introduction to Cultural Considerations

Culture is an incredibly important part of care for all patients. In this hub, we will look at the various components of culturally competent care and explore how to achieve an expansive skillset of reflection techniques to improve one’s cultural awareness through assessment tools. We will also discuss the barrier of language across different populations and how this can affect the level of care a patient receives (CNA, 2018; Campinha-Bacote, 2018).

1. Improve understanding of the concept application of equity, diversity, inclusion and Indigeneity

1.1 Define culture and cultural diversity in Canada.

According to 2016 census data, 22% of Canadians have a first language other than English, French, an Indigenous language, or American sign language (Brosseau & Dewing, 2018).

Culture can be defined as “a specific individual’s beliefs, values, norms, and lifeways that can be shared, learned, and transmitted, which can influence people’s thinking, decisions, and behaviours” (CNA, 2018). Culture is an evolving and complex process that is shaped by each individual’s own experiences and can change over time (CNA, 2018).

Cultural diversity can be defined as the presence of different cultures in Canadian society. Currently, there are over 250 varying ethnic groups across Canada (CNA, 2018; Li, 2000).

1.2 Provide statistics figures of diverse populations in Canada.

More than 2 million people in Canada report having Aboriginal ancestry and First Nations was the largest group with 1.5 million people (Statistics Canada, 2017). Chinese, East Indian and Filipino ancestry are some of the most common Asian origins seen in the Canadian population and close to 70% of those who reported Asian origins are foreign-born (Statistics Canada, 2017).

1.3 Illustrate the social determinants of health.

The social determinants of health (SDOH) are a range of personal, social, and economic factors that influence health outcomes (WHO, 2023). SDH accounts for roughly 30-55% of health outcomes and includes social norms, political systems, and conditions in which someone: works, lives, and was born (WHO, 2023). Examples include income, education, food insecurity, housing, childhood development, access to healthcare services, culture and gender.

Refer to prevention at http://www.bccancer.bc.ca/health-info/prevention (BC Cancer, 2024).

1.4 Illustrate the social determinants of Indigenous health.

Healthcare providers can identify the modifiable factors and encourage healthy public policy that provides an adequate social safety net (D’Souza & Leslie, 2022). Racism, discrimination, and intergenerational trauma are important social determinants of health for Indigenous health (Government of Canada, 2023). The loss of land, culture, and language affects the conditions that an Indigenous individual lives in and alters how they experience life. Vulnerability in childhood development is 2 times higher in that of Indigenous children (Government of Canada, 2023). Lack of access for people living in remote areas also heavily affects the SDH of Indigenous peoples (Government of Canada, 2023).

1.5 How do social determinants of health impact the experience of people living with cancer?

Recognizing and attending to the risk factors, including those associated with unconscious bias and systemic factors, are critical attributes of cultural competence and cultural safety (D’Souza & Leslie, 2022). Social determinants of health can influence the cancer risk in individuals as exposure to carcinogens may be increased. For example, cigarette smoking can cause cancer in many different places in the body: rates are higher in those with a lower education level (CDC, 2023). Obesity is linked with 13 different types of cancer: adults in poor or rural communities may have less access to healthy and affordable foods (CDC, 2023). Not getting screened for cancer: people may have limited access to screening services or are unable to afford screening (CDC, 2023).

1.6 Illustrate cultural safety, cultural desire, and cultural competency for healthcare professionals in Canada.

Cultural care preservation/validation, cultural care accommodation/negotiation, and cultural care reframing are approaches that can be utilized to enhance trust, collaborate with patients and families, and tap into both provider and patient expertise (Srivastava & Mawhinney, 2022). Cultural care preservation, cultural care accommodation, and cultural care reframing are approaches to enhance interprofessional collaborative practice (D’Souza, M. S., & Leslie, 2022), diversity and inclusive practice (D’Souza, M. S., & Leslie, 2022) and intercultural communication and relationship (D’Souza, M. S., & Leslie, 2022).

Cultural safety focuses on the dedication of the healthcare system to address power imbalances that lead to the absence of racism and discrimination, so patients feel safe receiving care (Government of Canada, 2023). Over 42% of Indigenous peoples reported racism in the past 2 years, which influences the safety and quality of care they receive (FNHA, 2016).

Cultural desire can be described as the healthcare worker’s motivation to “want” in the process of cultural awareness and expanding their knowledge regarding different cultures (Campinha-Bacote, 2018). Asking questions is important, by asking questions healthcare team members can receive an insight into individual client perspectives which allows for tailoring specific care plans. The process of cultural awareness can look like a healthcare provider actively seeking out different backgrounds and wanting varying cultural experiences. The process of cultural desire is necessary to provide culturally safe care (Campinha-Bacote, 2018).

Cultural competency is one’s ability to reflect on their own culture and values and understand how this affects how one provides care as well as view other perspectives on cultures and continually expand their knowledge (Government of Canada, 2023). This includes the healthcare provider respecting the values, beliefs and attitudes of people from other cultures and their ability to incorporate these into their care without judgment (Government of Canada, 2023). Cultural competence in the healthcare design framework is informed by an understanding of culture as patterns and power (Srivastava, 2022) and contextual impact on health outcomes. This process is complex and lifelong as healthcare providers can never be truly “competent” in another culture (CNA, 2018). Cultural competency uses five different constructs: cultural desire, awareness, knowledge, skill, and encounters (CNA, 2018; Campinha-Bacote, 2018). Cultural competence is to identify values, beliefs, and agendas that may be influencing decisions in particular contexts, or policies and processes that can be exclusionary and unfavourable to specific individuals and groups (Srivastava & Mawhinney, 2022).

This video highlights culture and the respect that is involved in maintaining a culturally safe environment for patients.

1.7 Illustrate cultural awareness and cultural reflection.

Cultural awareness is the healthcare providers’ acknowledgment and observation of cultural differences. This process does not consider political or socioeconomic factors and does not include reflection on one’s culture (Government of Canada, 2023).

Cultural reflection: An example of practicing cultural awareness would be using the College of Nurses of Ontario guide to reflective questions Consider possible areas where cultural variations in beliefs and values frequently occur. In your role as a nurse, would the choices you make be different for yourself or someone you care about? Do you believe your patients have the same priorities? How do these values impact your relationships with patients? (CNO, 2018).

1.8 Illustrate cultural knowledge and cultural skills.

Cultural knowledge is the act of expanding and growing your knowledge base on different cultures and ethnic groups to help gain a broader perspective of others’ worldviews (Campinha-Bacote, 2018). Thus it is important to use such cultural knowledge to inquire into patients’ needs and preferences and not make assumptions (D’Souza & Leslie, 2022). Cultural knowledge is both knowledge of other cultures and knowledge of legacies, structures, and systems that continue to perpetuate health inequities. Healthcare providers need to develop generic cultural knowledge that applies across populations and knowledge that is focused on specific cultures or clinical populations (Srivastava, 2022).

Cultural skills include being able to engage in the appropriate collection of cultural data. This skill set requires having learnt about the cultural beliefs, values, physical, and psychological state of the patient and what they require from this assessment to be respected in their culture (Campinha-Bacote, 2018). Healthcare providers need to ensure that they share their expert clinical knowledge with the individuals and remain open to learning about the cultural strengths of families (D’Souza & Leslie, 2022).

2. Understand how to use cultural assessment tools.

2.1 Describe the assessment tools for cultural awareness.

Informed and patient-centred decision-making needs to be at the forefront of care to improve prenatal care satisfaction across cultures and ensure equitable outcomes (D’Souza & Leslie, 2022).

Cultural Safety Self-Evaluation Tool

This cultural safety tool was created by the Central Vancouver Island Multicultural Society to help improve and expand the cultural awareness of healthcare workers. The tool includes a questionnaire for individuals to complete which helps to reflect on their cultural safety and then offers information as well as information education of each section of the tool (Siddel et al., 2014). Sections covered include personal cultural self-awareness, cultural sensitivity and humility, developing personal ability, and personal motivation.

2.2 Describe the cultural framework.

Culture is a pattern commonly understood as learned traditions and unconscious rules of engagement (Srivastava, 2022). Cultural safety and cultural competence frameworks include recognizing the need for humility and inclusivity, understanding the unique history, traditions, and beliefs of individuals and groups, considering the impact of the social determinants on health, and communicating in respectful, culturally appropriate ways (Srivastava, 2022). Cultural competence and equity work can be integrated within the toolkits for practice development and approaches to achieve the needed transformation for care that is culturally congruent and equitable (Srivastava & Mawhinney, 2022). The culture framework developed by the Palliative Care Network of Wisconsin to encourage providers to collect a “cultural history” to better understand a patient’s needs (Lum, 2012) includes communication, unique cultural values, locus of decision-making, translators, understanding the patient, ritualized practices and restrictions, and environment at home.

2.3 Describe cultural encounters.

Cultural encounters are the provider’s effort to engage and interact with diverse patients to increase their knowledge and perspectives (Campinha-Bacote, 2018). This helps create a diverse environment and avoid “othering.” There can be multiple barriers to cultural encounters, such as language barriers.

2.4 Describe the cultural and language barriers between patients and family members.

Culture and language are incredibly intertwined, and barriers can arise for those who do not speak an “official” language (Bowen, 2001). This could be recent migrants to Canada, Aboriginals who face discrimination, or people who come from isolated communities (Bowen, 2001). Language is the basis of understanding and is vital for communication between both the patient and provider (Bowen, 2001). Patients who experience language barriers in the healthcare setting are more at risk of adverse health outcomes, such as at risk for misinterpretation of information, not being able to ask appropriate questions etc.. There is an incredible barrier to health promotion and prevention and barriers to first contact of care (Bowen, 2001). Patients could experience poorer satisfaction, poorer health outcomes, and the inability to discuss necessary medical interventions (Bowen, 2001).

2.5 Describe strategies to improve cultural and language-appropriate care for patients and family members with examples.

The Government of Canada recommends multiple strategies to decrease the effects of language barriers in healthcare:

1. Assess the feasibility of using other official languages to collect health data for accuracy
2. Promote training on the effects of language barriers and how to work with interpreters and translators
3. Use the teach-back method, previously discussed, to assess understanding
4. Develop healthcare initiates’ in Aboriginal and immigrant languages

3. Specify effective support for patients with a language barrier.

3.1 Describe the role of professional language translators and interpreters.

Professional interpreters are individuals who have proficiency in both target language and source languages, training that is recognized by professional accreditation, and can accurately communicate from one language to another (PHSA, 2023). Through their expert skillset, they can listen to a message in a language (source), interpret this message and communicate it in the target language between speakers (PHSA, 2023).

Professional translators provide the rendering of written language from the target language correctly in a source language or vice versa (PHSA, 2023). They can offer services in revising translated documents, voiceover, narration, website translation, and audio-visual materials (PHSA, 2023).

Refer to resources at http://www.bccancer.bc.ca/screening/health-professionals/breast/resources (BC Cancer, 2024).

3.2 Illustrate cultural humility and cultural safety application for healthcare professionals.

Cultural humility is a dynamic process that is based on self-reflection and individual critique. This process differs from cultural competence as it focuses on the broader life-long commitment, addresses power imbalances, and requires an attitude of openness as well as a nurturing self-evaluation of one’s knowledge base of culture (Campinha-Bacote, 2018).

3.3 Illustrate cultural sensitivity and cultural resources.

Cultural sensitivity requires an understanding of culture, as patterns and as power, and recognizes that learning “who I am” is the first step toward developing cultural competence (Srivastava, 2022). Cultural sensitivity focuses on respect, humility, awareness, and understanding—not only about our values and reactions to difference, but also how we might be perceived by others (Srivastava, 2022). Culturally sensitive care revolves around recognizing the need and importance of respecting cultural differences and making choices that are respectful of the values and opinions of others that are based on their culture (Saskatchewan Health Authority, 2016). For example, a healthcare provider with culturally sensitive care attributes would work to create solutions to adjust diet choices in the hospital to the patient’s culture and provide more food choices (Saskatchewan Health Authority, 2016). Cultural resources need to be developed at the individual as well as the organizational level (Srivastava, 2022).

3.4 Describe health disparity and inequity

Patients of Black, Indigenous and People of Colour (BIPOC), and, more specifically, Indigenous and Black patients are most likely to experience racial injustices and health disparities when accessing care (D’Souza & Leslie, 2022). Health disparities are “differences in health status that occur among population groups defined by specific characteristics” such as determinants of health (culture, economic status, gender) (PHAC, 2005). Health disparity consequences affect the entire community directly and indirectly by pushing the excess burden of illness to the already disadvantaged and also damages the cohesiveness of a society (PHAC, 2005).

4. Reflect on one’s practice of cultural competence and cultural safety.

4.1 Describe equity, diversity, inclusion, and Indigeneity framework for cultural considerations in care to patients and families.

An Equity, Diversity, Inclusion and Indigeneity lens is a way to discuss unconscious and conscious bias to reflect and support the wide range of diversity across our communities (City of Ottawa, 2018). By using this lens, you can become increasingly aware of the diversity around you, create a positive environment free of judgement, and address systemic barriers and inequities of different populations (City of Ottawa, 2018). Some populations who can be addressed and supported through an equity diversity inclusion and Indigeneity lens are Indigenous, Blacks and People of Colour (IBPOC), 2SLGBTQIA2+, neurodivergent challenges and disabilities (City of Ottawa, 2018). Many factors affect health equity and patients who do not have a positive experience with the healthcare system and healthcare providers, are unlikely to trust and seek appropriate healthcare (D’Souza & Leslie, 2022). The three elements of cultural sensitivity, cultural knowledge, and cultural resources are needed to assist healthcare providers in identifying key cultural values that affect the clinical encounter (Srivastava, 2022).

To utilize an incredible handbook and tool for using the EDI lens please visit the City of Ottawa PDF for additional tools.

Equity, Diversity, Inclusion PDF

4.2 Introduction to Populations

The following statistical tables represent specific pieces of cancer information.

• Incidence refers to the number of new cases of cancer in a specific group of people in a set period (BC Cancer Agency, 2011).
• Mortality refers to the total number of deaths that occur from cancer (BC Cancer Agency, 2011). Age-standardized mortality means cancer deaths that occurred in a specific region, or period and from a specific form of cancer. (BC Cancer Agency, 2011).
• Prevalence means people had a diagnosis of cancer earlier in life, and are now living in a population of others with cancer (BC Cancer Agency, 2011).
• Survival refers to the amount of people who are living after their diagnosis, it is common to use a five-year mark for this statistic (Canadian Cancer Society, 2023f).

Hwee & Bougie (2021) report that ethnic populations will initially experience a decrease in the likelihood of being diagnosed with cancer. This protection will fade the longer an ethnic person resides in Canada. The specifics of cancer reporting for ethnic populations in Canada is lacking. Women from Europe have the greatest incidence of cancer. The lowest incidence has been found in South Asians. Breast cancer for all ethnic females was in the top three cancers most likely to be experienced. For ethnic males prostate cancer had the highest likelihood of being experienced. To view the incidence and mortality statistics for ethnic populations from 2006-2016, follow the link below.

Hwee & Bougie, 2021,

Do cancer incidence and mortality rates differ among ethnicities in Canada? (statcan.gc.ca)

Racine et al. (2021) report that refugees come from countries that experience significant incidence and mortality of cancer. When these people arrive in Canada screening does not happen as often as non-refugee people. Advanced cancer is found in ethnic minority women with a higher prevalence in comparison to non-ethnic minority women in Canada. This same population of ethnic minorities has a reduced 5-year survival rate and a greater likelihood of mortality. There is a decreased likelihood of a woman who originates from an Arabic-speaking country to be screened for breast cancer, in comparison to other ethnic populations. Arabic women have been linked to an increased likelihood of being diagnosed with breast cancer at a younger age, in comparison to women from Western Europe. This may be attributed to cultural differences, where healthcare is sought out when a woman is demonstrably ill. To view the statistical findings of the Racine et al. (2021) study, follow the link below.

Racine et al., 2021

Examination of Breast Cancer Screening Knowledge, Attitudes, and Beliefs among Syrian

Woods et al. (2022) discuss that in a sample of women from British Columbia who had immigrated from 1985 onward. Immigrants from India were found to have lower rates of breast cancer. Other immigrant groups in comparison had higher rates of breast cancer. While it was found that immigrants from India and some other countries develop higher rates of cancer with increased time lived in Canada, other immigrants from other countries do not have a clear association with length of time as a resident and specific breast cancer diagnostic stages. It was found that immigrants from India and China, Macau, Hong Kong and Taiwan are different in terms of cancer risk compared to other immigrants.

See Woods et al., 2022

For more information on staging specifics of breast cancer that looked at women from Indian, Philippines and other originations, visit the link below.

https://link.springer.com/article/10.1007/s10903-022-01378-w

Lofters et al. (2019) explain breast cancer is the most common type for women to develop across Canada. Those who have immigrated from South Asia are linked to a later diagnosis, while those from China have been connected to an earlier diagnosis. An early diagnosis is connected to a better outcome. The majority of immigrants stay in British Columbia and Ontario. A woman that is between the ages of 50-74 that is considered at an average risk for cancer is recommended to access mammography screening services twice a year. Women from East Asia and the Pacific were more likely to be diagnosed with either stage 1 or 2 breast cancer. Specific regions that included South Asia, Latin America and Central Asia had a lower likelihood of a stage 1 or 2 diagnosis if they lived in Ontario. In this study time spent as a resident was not a significant factor for a cancer diagnosis for those that lived in Ontario and British Columbia. There was a decreased likelihood of having screening mammography in both of these provinces for immigrant women. It does not appear to be an access issue for decreased screening, as the proportion of visits to primary care is similar across new to long-term residents. However, there is variability across different immigrant populations that can be further explored by accessing the link below.

See Lofters et al., 2019

https://bmccancer.biomedcentral.com/articles/10.1186/s12885-018-5201-0

Mortality

Cancer Research UK (2019) explains that there is currently a known relationship between being trans or non-binary and a greater chance of having cancer in comparison to people from the general population.

Specific cancers and group

Cochran et al. (2001) explain that older lesbians have a greater likelihood of developing both breast and endometrial cancer (as cited in, Roberts et al., 2022). Gay and bisexual men have an increased risk of developing anal cancer and non-Hodgkin’s lymphoma.

Canadian Cancer Society (2023ae) explains that members of the LGBTQ (lesbian, gay, bisexual, transgender (trans) and queer populations should seek out cancer screening just as much as heterosexual people. There may be many barriers in the way of effective screening, and this can contribute to a greater likelihood of death caused by cancer. While there are certain populations not explicitly named in the previous LGBTQ acronym, it is important to acknowledge that there are other diverse orientations and identities. Hereon the term 2SLGBTQIA+ will be used for inclusivity Canadian Cancer Society (2023ae).

Barriers to Palliative Care

There is a concern that people with diverse orientations would have to modify their living spaces to be cared for (Roberts et al., 2022). There are many issues associated with how staff members treat their patients. Thinking that one has to worry about how others may react to their physical expressions of love with someone else. The traditional form of a family may be different for people with diverse orientations, and some staff members may not be prepared to understand. Staff members may be ignorant about how to address their patients respectfully. Other categories of issues include but are not limited to, mistreatment, fragmented relationships with biological families, and challenges with decision-making (Roberts et al., 2022).

Collection of Sexual Orientation and Gender Identity Data

SGM population is a term that represents sexual and gender identities that do not align with traditional norms (Schabath et al., 2017). By not asking about identities people of the SGM population may not receive the timely care that is required to talk about psychosocial challenges. Schabath et al., (2017) discuss that sex at birth and gender in the present day are two features of what gender identity is comprised of. Asking for a pronoun can help patients feel at ease. Does not appear to be a standardized way to collect data from the SGM population (Schabath et al., 2017). The fluidity that exists with sexual orientation and gender identity increases the complexity of data collection (Schabath et al., 2017).

2SLGBTQIA++ Populations

The lack of age stratification makes it challenging to know how infertility concerns affect adolescent and young adult members of the 2SLGBTQIA++ population (Russell et al., 2016). Asking about identity can start with how one identifies, and possibly lead to how someone would describe their orientation if listed identities are accurate for them. Russell et al. (2016) found cancer survivors were hesitant to tell people they were dating about their diagnosis and treatment. Some decided to disclose earlier, others later, while others were concerned about their self-esteem regarding the changes their body had undergone. Heterosexual individuals saw parenthood as coming from natural conception. 2SLGBTQIA++ survivors had different degrees of desiring parenthood, with about half of Russell et al. (2016) participants reporting they wanted a family. After a cancer diagnosis Russel et al. (2016) found it was only heterosexual individuals who changed their perception of having a family, 2SLGBTQIA+ persons maintained their beliefs. Heterosexual survivors had varying opinions on fertility, some felt it brought them closer to their partner, and for others, it was a divide. Young 2SLGBTQIA+ persons commonly were not looking to start a family at that the current time. Other 2SLGBTQIA++ person did not find that fertility was a concern for their relationship, it was just something to discuss. Both heterosexual and 2SLGBTQIA++ persons found that fertility was not commonly discussed during their treatment time, making it difficult to navigate afterwards. Some found that their doctors were not comfortable when they brought up the subject of fertility. Overall if a doctor did not start the conversation on fertility, it was 2SLGBTQIA+ persons that were less likely to initiate a talk. For all participants, the most reported reason for choosing to not preserve fertility was an absence of time and information guiding a choice. 2SLGBTQIA++ persons also reported they did not have an interest in fertility preservation. Across many participant groups, loss and happiness followed infertility. 2SLGBTQIA++ however was affected by this news. Survivors recommended that patients advocate for their health decisions by thinking ahead. Patients are advised by heterosexual persons to consider what they want in the future, and the possible infertility could affect their likelihood of becoming a parent. It was found by the survivors that it would have been beneficial for doctors to take the time to explain what infertility means, and what can be done. Russell et al. (2016) note that a discussion on infertility may not happen with individuals who have started a family, and a talk on biological parenthood may miss 2SLGBTQIA+ persons if they do decide to talk about their orientation (Russell et al., 2016).

Unhoused Populations

Festa et al. (2019) wanted to understand why women who are homeless experience greater barriers and delays in care. There were different categories of homelessness, which focused on life-changing events creating the need for temporary shelter, which means somebody was on the street for fewer than twelve months and less than four total episodes, and finally chronic homelessness means somebody has been on the street for more than twelve months and has suffered from four episodes in three years. Festa et al. (2019) found it was a common occurrence to have women be diagnosed with cancer, or receive a first treatment, and then become homeless. If a woman moved from shelter to shelter, it was common for the longest of delays to be experienced by this individual. Comorbidities and mental health challenges were linked to appointments being unattended even before a cancer diagnosis and subsequent plans were made. Reducing delays is a way to improve outcomes for breast cancer, but it appears that the homeless are consistently suffering from delays. Those that are chronically homeless are more likely to experience delays than those that are temporarily or episodically homeless. Women who shift into chronic homelessness quite quickly are possibly in an even riskier place before they are even diagnosed, as they are at an even greater likelihood of experiencing delays (Festa et al., 2019).

Lawrie et al. (2020) looked at homelessness in Canada and found that this population compared to the rest of the people has a four times greater likelihood of having cancer. People who are homeless are two times more likely to have cancers affecting the bronchus and lungs, perhaps a large proportion of these cancers are due to smoking. Low health literacy is a characteristic of understanding that could lead to cancer being discovered in a form that is in later development. Accessing necessary health care is dependent on a person being able to use their health literacy to navigate the system. Screening information about cancer occurs when a person comes in contact with the healthcare provider for issues that are not as serious. This does not happen for homeless people who do not make contact. Lower health literacy is related to comfort with receiving healthcare. Access to healthcare may be impacted by experiences of discrimination and stigmatization as discouragement can happen. While medical advisement can provide a series of instructions, healthcare providers may predict the inability to adhere, leading to a decision to underserve the population. Yet it is factors such as transportation and social stress that can prevent a homeless person from following medical directions (Lawrie et al., 2020)

Indigenous Populations

Indigenous populations refer to the First Nation, Inuit and Metis peoples of Canada (Brock et al., 2021). Cancer is a major concern, as it has increased to a point where it is acknowledged to be a major cause of death for Indigenous peoples. Social determinants of health are behind all interventions which include looking at cancer screening, the lifestyles of individuals and cancer survival rates. The lived experiences of Indigenous populations, particularly when it comes to colonization and its associated challenges, are not always included in data that investigates cancer. It is a challenge to accurately understand the health of Metis persons, which limits cancer surveillance. Metis people report that finding cancer care is a challenge, as they do not have a family physician, reside in a remote location, and face discrimination (Brock et al., 2021). Ultimately diagnosis, improper treatment, and follow-up issues are some of the issues that Indigenous Peoples face when it comes to cancer care (Horrill, 2022). Some examples of social determinants of health that are involved include income, access to healthcare and social context. On top of the challenges of accessing cancer care, politics and jurisdiction add additional layers of issues. Understanding how structure impacts the experience of Indigenous Peoples, and providing policy advocacy to create change are important steps that oncology nurses can take. Action that seeks to reduce inequities, to provide culturally safe care in a tailored manner will help to create relationships where change can happen (Horrill, 2022). Witham et al. (2021) report that cancer is being detected later in First Nations, contributing to a disparity in survival rates compared to the general population. Obtaining healthcare is a complex process that affects the cancer journey of Indigenous peoples. Some of the barriers affecting care include living remotely, having costs associated with care at the beginning of cancer care, and having an experience that loses the familiarity of home. Western medicine is different than the worldview of Indigenous ideas of health and illness. This difference can cause people to undervalue the culture of Indigenous Peoples, creating a gap in the provision of care that is culturally informed. British Columbia has Indigenous patient navigators who are recognized as a nexus for helping patients bridge the gap between understanding and embracing cultural needs (Witham et al., 2021).

Persons with Disabilities

Agaronnik et al. (2021b) explain that persons with disabilities (PWD) report they did not receive complete care because it was difficult to transfer them onto a piece of equipment. PWDs have found that their healthcare providers do not appreciate the time it takes to accommodate a disability. Some reported that their concerns about the possibility of cancer were interpreted by healthcare providers as an emotional reaction to the presence of a chronic health challenge. Delays for testing were experienced when healthcare providers saw the signs and symptoms of cancer as a manifestation of a disability. Agaronnik et al. (2021a) state that a PWD will have had interactions with the healthcare system that inform their decision-making in their cancer treatment. Some found that the form treatment setting did not easily accommodate a disability, such as lacking mechanical lifts. Others described healthcare providers are fearful of PWD, even recommending less aggressive treatments when perhaps there are other options (Agaronnik et al., 2021a). Sakellariou et al. (2020) explain that PWD do not have the same access to cancer care that others would have. A lack of consultation between different professional specialties before starting cancer treatment was discussed by Sakellariou et al. (2020) at inappropriate times. The challenges that PWD face during care have been attributed to discrimination based on disability (Sakellariou et al., 2020).

Rural and Remote Populations

Baldwin-Medsker et al. (2020) explain that access to care for a cancer journey can be impacted by the distance of a rural community to where care is physically located. There can be delays in treatment because of the trips that must be made. Distance impacts both ends of the care continuum, as healthcare providers also struggle with issues presented by distance (Baldwin-Medsker et al. (2020). Even when a community is not located relatively too far from treatment, the need to use public transportation can greatly increase the time needed to get to an appointment. Living in a rural community is also associated with a greater chance of falling within the population labelled as impoverished. Baldwin-Medsker et al. (2020) have discussed that implementing eHealth strategies is a way to get rid of gaps. For example, attending a clinic can happen via online services instead of in-person. While some patients may not be comfortable with online models of care, the transition into this area of services needs an overall culture to change. Optimal online care requires a private space for the client, and the healthcare professional to carefully observe non-verbal communication, consent for the meeting also needs to be expressed by the client to ensure privacy is protected (Baldwin-Medsker et al., 2020).

Black, Immigrant and Refugee Populations

Nnorom et al. (2021) discuss that addressing barriers to care is an optimal way to reduce the inequities that some people experience regarding their cancer journey. These barriers include feeling stigmatized, being fearful of screening, and feeling unimportant. Nnorom et al. (2021) focused on immigrant and Black populations in Canada. It was found that refraining from using the word “cancer” was an ideal way to communicate screening information over the phone. This was deemed to be upholding culturally safe care. When the diverse individual entered the clinical setting, it was then deemed appropriate to use the word “cancer” during an educational conversation. When it comes to providing culturally safe education, it was found by Nnorom et al. (2021) that using different approaches at the same time can be effective. Nnorom et al. (2021) found when screening was promoted in an inclusive manner, where the people being represented in the campaign reflected an Afrocentric approach, there was greater uptake. Lewis-Thames et al. (2022) identified that among Chinese-American immigrants, screening rates can be lower when health literacy and the ability to use English are lower. This is related to the inability to follow available screening guidelines. Navigators who were partnered with female Chinese Americans were able to bridge the gaps in language and culture that have historically reduced patient outcomes (Lewis-Thames et al., 2022).

Dunn et al. (2017) reported that screening for cervical and breast cancer has resulted in populations that are inequitably receiving this service. Examples of specific populations affected include people originating from South Asia, women who are new to Canada, and those marginalized by other factors. Dunn et al. (2017) explain that newcomers have trouble accessing screening, have less knowledge, and do not know how to find services to bridge language gaps. Dunn et al. (2017) implemented an intervention that focused on Pap and mammography screening. Screening was found to have significantly increased based on exposure to the educational procedures ( Dunn et al., 2017).

Summary

Culture is a dynamic and ever-changing process that is influenced and shaped by each individual’s experiences and surroundings. Factors that influence health and culture are known as social determinants of health, which can range from personal, social, and economic factors. These factors can determine how healthcare is accessed, and which populations are at risk for poor health outcomes due to their own SDH. Indigenous health has specific SDHs that are tied to trauma, racism, and deep-rooted discrimination that affect their vulnerability and healthcare experiences (CNA, 2018). Cultural competency is one’s ability to reflect on their cultural values and understand how their culture affects the way one provides care. As well as this competency is enhanced by viewing other perspectives on cultures across various groups. The basis of cultural competency focuses on 5 principles: cultural desire, awareness, knowledge, skills and encounters. The Cultural Safety Evaluation Tool and the Culture Framework can be utilized to assess the level of cultural competency and encourage self-reflection and motivation to continue to learn about culture. Healthcare professionals need to be equipped with culturally sensitive care approaches that create an environment of respect and value for other cultural perspectives. This can be achieved by using translators, an EDI Lens, and committing to the process of cultural humility (Campinha-Bacote, 2018; City of Ottawa, 2018; CNO, 2018).

References

1. Bowen, S. (2001). Language Barriers in Access to Health Care. Government of Canada. https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-accessibility/language-barriers.html
2. Canadian Nurses Association [CNA]. (2018). Position Statement.
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Resources

1. BC Cancer. (2024, April). prevention. Provincial Health Services Authority, BC Cancer, British Columbia. http://www.bccancer.bc.ca/health-info/prevention
2. BC Cancer. (2024, April). resources. Provincial Health Services Authority, BC Cancer, British Columbia.

http://www.bccancer.bc.ca/screening/health-professionals/breast/resources

Videos

Northen Health BC. (2017). Cultural Safety: Respect and Dignity in Relationships. [Video]. https://youtu.be/MkxcuhdgIwY?si=2bfPzbu6UOPgIkwl . Youtube.

Images

Ben Mason. (2009). [Diversity]. Flickr. https://flic.kr/p/69dmcG