health services infrequently, and incur higher costs when they do seek care (Tsai & Lee, 2016). This study also pointed out “the importance of health literacy as a critical dimension in devising policies and intervention programs to improve health conditions of immigrant women in Taiwan, and in other host countries. Our study also demonstrates that the health literacy framework contributes a new lens for the examination of immigrant health issues” (Tsai & Lee, 2016. P 73). Interpreting services have been recognized as an important tool to provide safe and effective health care for immigrant populations (Britigan et al., 2009). Studies have provided insights into the importance of professional interpreters to promote effective communication, patient comprehension and satisfaction (Karliner et al., 2007). However, few studies have examined patients’ insights into interpreter services (Karliner et al., 2007).
Health literacy issues of immigrants in non-English-speaking countries have received limited attention. Current research focuses mainly on health literacy matters of immigrant groups in native English-speaking countries, for example Canada, the US, the UK and Australia (Tsai ; Lee, 2016). There is a need for research to explore the specific language and communication issues experienced by immigrant populations in countries where the first language is not English (Tsai ; Lee, 2016).
Nutbeam claims that although the widely held assumption is that health literacy is ability to understand and use health information, it is really a narrow perspective. He developed a conceptual model of health literacy that comprises three levels: “functional literacy,” “interactive literacy” and “critical literacy” (Nutbeam, 2000). The primary level, functional literacy, is present in everyday settings; at this level, individuals can successfully read and write (Nutbeam, 2000). The second level is interactive literacy, in which people acquire unconventional knowledge and skills and are able to apply both to different life conditions (Nutbeam, 2000). The third and the advanced level is the critical level. At this level, individuals can critically appraise information and have control over situations (Nutbeam, 2000). Nutbeam proposed that health literacy is a powerful tool that individuals can greatly benefit from to control their health (Nutbeam, 2008).
Health Seeking Behaviour (HSB). According to Mahmood, Iqbal, and Hanfil (2009), health-seeking behavior is an action taken by patients when they feel that they need to medical treatment. Jaramillo (1998) writes that health-seeking behaviour is a “multi-dimensional concept” that goes further than biomedical concerns and include cultural, social and organizational factors. Mackian, Bedri and Lovel (2004) found that health-seeking models are critical for designing social interventions aimed at empowering individuals to adopt ‘healthy choices’. Thus, in order to plan and deliver appropriate health care services, it is necessary to understand HSB (Chauhan et al., 2015). Health Care Seeking Behavior (HCSB) refers to a “decision or an action taken by an individual to maintain, attain, or regain good health and to prevent illness” (Chauhan et al., 2015, P 118). HSB is affected by multiple factors such as age, sex, type of illness, and affordability and availability of services (Chauhan et al., 2015).
Chauhan et al. conducted a community-based descriptive study in a rural coastal area in India to evaluate HSB in a rural population (Chauhan et al., 2015). The study found that HSB determined predominantly by people’s perceptions about the quality of health care services. The study also identified factors that drove healthcare seeking behaviour among the rural population in the coastal area. These included income, type of illness, and availability and cost of services (low-cost services were more frequently accessed) (Chauhan et al., 2015). In other studies, HSB was found to be associated with various factors, for example gender of the person seeking care, area of residence, education and the health care provider (Pillai et al., 2003).
In the US, poor access to health care and a lack of information may be associated with the deterioration of health among Latino immigrants (Garcés, Scarinci & Harrison, 2006). Factors such as low income, low education, language barriers and fear of deportation among undocumented groups have been found to keep people from seeking health care services and information (Garcés, Scarinci & Harrison, 2006). Latino immigrants maintain their cultural health beliefs and practises when they arrive in the US (Garcés, Scarinci & Harrison, 2006). The most commonly reported health practises among immigrants from Latin America were the use of herbs, chiropractic treatments, dietary supplements and home remedies (Garcés, Scarinci & Harrison, 2006). The immigrant Arab population in the US also reported a significant use of alternative medicine (Lazar, 2008). However, there is limited information regarding HSB of the Arab community in North America (Lazar, 2008). In the context of this study, it appears that the HSB of Arab immigrant women is influenced by diverse factors such as cultural beliefs, the perception of diseases and whether or not they have the available disposable income to access health care. For example, as seen earlier, in communities, diseases such as cancer are seen as a form of a cultural curse (Adnan et al., 1999). If a woman contracts such a disease, it becomes difficult for her to seek care as she will likely believe only traditional charms can cure her (Adnan et al., 1999). To better understand someone’s HSB, it is necessary to understand the culture that he or she comes from (Rought, Duaibis ; Hussain, 2010).
Multiculturalism. Canada has a long history of welcoming immigrants from around the world. However, Challenges for new immigrants is transitioning from their previous cultural practices into the host country’s culture (Adnan et al., 1999). According to Flores (2004), health issues touch on different human experiences and the migrants from diverse foreign cultures have many different experiences.
Culture plays a fundamental role in the perception of health and access to health care services (Tan & Li, 2016). One of the ways in which culture can be defined is “as a group of individuals who have similar attitudes, beliefs and values, both in the group and when on their own” (Tan & Li, 2016, P 112). Different background languages, social norms, religions, beliefs and health care structures were found to be barriers to accessing health services for immigrants and ethnic minorities (Tan & Li, 2016).
Cultural diversity is a reality and a controversial issue within health care (Tan & Li, 2016). In the UK, it is becoming more challenging for the National Health Service (NHS) to provide outstanding medical services because of the growing diversity of the population (Tan & Li, 2016). Many culture issues complicate healthcare, among them the religious beliefs of both practitioners and patients. For example, patient rejects treatment on a religious basis and physicians’ perceptions of end-of-life care (Tan ; Li, 2016).
Nichols, Horner and Fyfe (2015) have showed that a lack of understanding of cultural diversity influences not only the patient-physician relationship, but also the relationship between health care professionals. They found different experiences in the workplace. Some health care practitioners reported finding respect and satisfaction, whereas others reported finding negativity and discrimination (Nichols, Horner ; Fyfe, 2015). Health care providers from ethnic minority groups were more likely to experience delays in their career paths (Nichols, Horner ; Fyfe, 2015). The study also highlighted the importance of preparing and training health care providers to be able to see patients in a holistic way and focus on both biological and psychosocial aspects (Nichols, Horner ; Fyfe, 2015).
Multiculturalism affects patients and health care providers. For example, according to Nichols, Horner and Fyfe (2015), if there is a language barrier, or if the patient feels the physician is culturally insensitive, the patient may not continue seeking health care. Some communities consider female genital mutilation to be a “rite of passage” (Amin, 2008). It is important for health care professionals to recognize cultural diversity and that their patients may have different beliefs (Nichols, Horner ; Fyfe, 2015).
In a critique of multiculturalism in the NHS, Culley (1996) discussed the way in which health care is constructed and delivered to people from minority ethnic groups. Culley’s paper highlighted the limitations of the cultural attitude of health professionals and the impact of racism on access to quality health care. Culley pointed out large gaps in the awareness of health providers and their approaches towards the needs of people from ethnic minorities. These health workers claimed that they did not receive any training for working in multicultural settings (Culley, 1996). Pearson (1986) also argued that knowledge on culture is the most important component for enhancing quality health care. Pearson also stated that cultural variations are not disputed. What is contested, however, is the power imbalance between ethnic groups (Pearson 1986). Fruitful communication can be hindered when one providers and patients are ignorant about each other’s differences (Culley, 1996). Pearson described those difference as “deviant, alien and stubborn”. Black people, for example, are not only viewed as different, but are seen as secondary and inferior, Asian- American girls are “caught between two cultures”, and Muslim women in western societies often find themselves having to defend their choice to wear a veil (Pearson 1986). Such cultural views are deeply rooted in societies and organizations and play a key role in access to quality health care by minority populations ((Pearson 1986).
There is a need for research that will evaluate the complexity of different issues surrounding multiculturalism in health care from the perspective of patients and healthcare providers (Nichols, Horner ; Fyfe, 2015). Patients report different health care experiences. While some patients were happy and satisfied with their care, other reported discrimination, and a lack of respect for their needs and beliefs (Nichols, Horner ; Fyfe, 2015). It is important to build trust and have open discussions with patients, and provide more information to ensure that “the patient is viewed as a person, in a pluralistic society” (Nichols, Horner ; Fyfe, 2015, P 113).
Previous Immigrant Research on Breast Cancer (approaches and issues)
Qualitative methods have been widely used in the literature to address breast cancer and screening disparities among women from minority groups. An ethnography approach has been adopted in many studies in Western countries. For example, Zhao et al. (2010) applied a focused ethnographic approach to explore Chinese-born immigrant women’s beliefs about breast cancer screening and mammography in the US. They found that these women, who are highly influenced by their community, believe that the absence of signs and symptoms indicates health, which may perpetuate low screening rates.. They suggested that a community-based culturally competent health education program may be beneficial in improving Chinese-born immigrant women’s usage of health care services. However, a major weakness in this study was that the authors didn’t differentiate between Asian-born, Asian-American, and Asian immigrants, which creates confusion about the differences in cultural beliefs between these three groups. One of the issues in cross-cultural research is a lack of knowledge about the variations among subgroups (Aziza, 2014). This ignorance may lead to misunderstanding and mistrust between the researcher and the study population (Aziza, 2014). It may also lead to inaccurate conclusions regarding the cultural beliefs of different groups (Zhao et al., 2010).
Research shows that Latino women with breast cancer underuse recommended follow-up chemotherapy, which reduces their survival rates (Kreling, 2008). A focused ethnography study was conducted in the US to explore how cultural beliefs and perceptions impact decision-making processes for Latino women regarding breast cancer treatment (Kreling, 2008). The amount and quality of data that have been obtained from this study allow comprehensive understanding of Latino women’s perspectives and experiences with regard to breast cancer treatment (Kreling, 2008). The outcomes from this study are expected to accelerate social change by shedding light on cultural diversity in health decision making (Kreling, 2008). However, one of the limitations of this study is the researcher’s experience. As a breast cancer survivor, Kreling’s personal experience could have influenced her interpretation and analysis of the data. Different results might emerge if this study had been conducted by a researcher with no history of breast cancer. On the other hand, this personal experience might be beneficial as the researcher has a unique understanding of cancer patients which could positively affect the way she conducts interviews and potentially make discussions easier. It might also be easy for her to gain the study participants’ trust (Dwyer & Buckle, 2009). In addressing insider-outsider issues, Ogilvie et al.(2008) proposed that when exploring immigrant health, integrating different researchers from inside and outside can produce innovative thinking.
Focus group methodology was also conducted to study Emirati women’s attitudes and beliefs about breast cancer and screening in United Arab Emirates (UAE) (Abdulbari et al., 2002). The method worked well in this setting (Abdulbari et al., 2002). The study produced in-depth descriptions and rich data regarding determinants of participation in breast cancer programs, including factors that positively influence the screening practices as well as factors that discourage participation (Abdulbari et al., 2002). A critical ethnographic approach was also used to expose the social and cultural factors that affect breast cancer screening practices of Arab Muslim women in Qatar (Hwang et al., 2015). Beliefs about health and illness, religious practises and gender relations were the main themes identified (Hwang et al., 2015). The study also showed that Arab Muslim women’s health attitudes cannot be recognized in isolation from their sociocultural context (Hwang et al., 2015). In addition, interventions to address poor participation in breast cancer screening services must address the context and not be narrowed to the individual (Hwang et al., 2015). Abdulbari shares a language with the study population, which was not the case in the Hwang study. This brings us to issues of language differences in conducting cross-cultural health research. Research participants are usually more comfortable, more informative and more accurate when using their native language, and sometimes researchers know little or nothing about their language (Ogilvie, Burgess-Pinto, & Caufield, 2008). Similarly, a researcher who is familiar with the participant’s native language is more capable of building rapport (Dwyer ; Buckle, 2009). Sometimes the researcher can be the translator if he/she is fluent in the language of the study participants (Ogilvie et al., 2008). Different methods have been suggested to overcome language differences in immigrant health research. Yang (2015) discussed in depth several methods that other researchers used to collect data. Among these methods were back-translating and hiring bilingual interviewers. Yang also examined the limitations of these methods and explained how to overcome them.
The community-based participatory approach has been adopted in many studies. For example in Dallas, Texas, a community based-participatory study to reduce breast cancer inequalities among low-income African American women was conducted (Cardarelli1 et al., 2011). This project was successful in enhancing knowledge, improving uptake of mammography and breast self-examination, and increasing the community’s capacity for prevention and sustainability of the program (Cardarelli1 et al., 2011). Another community-based intervention in the US was conducted to improve the use of breast cancer screening among underserved African-American women (Electra et al., 1999). Results of this project showed that the percentage of women reporting regular use of mammography increased in the intervention city (Electra et al., 1999). Different approaches were applied in the intervention city, including clinic in-reach (e.g., in-service meetings and counselling) and community outreach strategies (e.g., lectures, media and events) (Electra et al., 1999). The outcomes from this study showed that screening rates in underserved groups can be enhanced by using a multidimensional intervention (Electra et al., 1999). Community-based participatory research (CBPR) is a collaborative process to empower and improve the health of a community (Springett, 2017). In Canada, community-based participatory research is a phrase that refers to participatory health research studies (Springett, 2017). CBPR is a partnership approach to research that engages different partners (e.g., community individuals with common issues or goals, research, and expertise), and each partner’s skills and knowledge should be valued and respected (Minkler ; Wallerstein, 2008; Israel, Schulz, Parker, Becker, Allen, ; Guzman, 2008; Springett, 2017). The interest in this approach is growing in Canada, particularly in aboriginal health research (Springett, 2017). Yang (2015) argued that this approach can productively lead immigrant health research even though there is a deficiency in the related literature. Khalema and Shankar reported that community-based participatory approach can not only contribute health promotion knowledge transfer in immigrant health research, but can acts as an intervention for community change, as it emphasises the need for community engagement in immigrant health promotion research (Khalema ; Shankar, 2009). However, community-based participatory research is time- and resource- consuming. For these reasons, I did not adopt this approach for this study.
In summary, the literature has revealed the significant gaps in existing research. Society views the meaning of health as subjective. Different groups and MENA, in particular, have different definitions of health. Few people take an interest in understanding these differences. It is clear in this chapter that there is a significant relationship between health care services and HSB, multiculturalism, individual perceptions of the meaning of health and the utilization of and access to quality healthcare. Much needs to be done in the province , as little research has been done in the communities where immigrants settle. Moreover, the cultural practices of immigrants are seen to highly impact HSB and the utilization of health care services. It is therefore of importance to understand these cultural practices to incorporate them or be able to understand the immigrants’ points of view in regards to HSB.