Dialogue Report. November 30, 2012

Transcription

1 Dialogue Report November 30, 2012 Report prepared by Dr. Joanna Ashworth February 2013

2 Report prepared by Dr. Joanna Ashworth With Jacinthe Boulanger, Research Assistant, SFU, Annie Carnot and Helene Rasmussen, The Provincial Language Service Table of Contents 1.0 Overview of Dialogue Event 1.1 Background Goals and Objectives Overview of Event Process Morning Dialogue: Perceptions and Challenges 2.1 Findings from Community Consultation with Francophone Newcomer Families Dialogue One: Perceptions and Challenges Youth Experiences Afternoon Dialogue: Promising Opportunities for Change 3.1 Findings from Community Consultation and Research into Promising Practices Dialogue Two: Promising Opportunities for Collaboration and Change Reflections and Summary 4.1 Listeners Panel Graphic Recording of Dialogue Closing Circle Acknowledgements 14 Appendices

3 1.0 Overview of Dialogue Event 1.1 Background On Friday, November 30th, 2012, more than 75 health care professionals, community agencies, newcomer parents and youth gathered to explore the findings and implications of a Provincial Language Service (PLS) initiative, Community Engagement for Well-Being: Addressing the Health of French-Speaking Newcomer Families with Children and Youth. This initiative aimed to better understand the experiences and perspectives around health and well-being that underlie many Francophone immigrant and refugee families expectations and patterns of accessing the health system. During the course of the project, a community consultation process was held with over 100 French-speaking newcomer parents and youth from select communities across the province. To build on the findings of the consultation process and accompanying research, PLS, a program of the Provincial Health Services Authority, hosted a day of dialogue: Healthcare, Wellbeing and Newcomer Families. This event launched a broader conversation about newcomers experiences with healthcare: to explore what can be learned from the perceptions and experiences of Francophone newcomers within the BC health system and to discuss ideas and strategies that address issues raised through the consultation. The event was designed for maximum participation in an environment that encouraged vibrant, respectful and collaborative discussion. It was held at Harbour Centre, Simon Fraser University. To encourage a diversity of perspectives and facilitate deep conversation, the dialogue event was organized around a blend of plenary presentations, small group dialogue and plenary reporting. The ideas shared in plenary and small group sessions have been synthesized in this report. 1.2 Goals and Objectives Create an open and informed exchange around issues and gaps that impact the health, wellbeing and access to health services of newcomer communities, viewed through the lens of Francophone immigrant and refugee families in BC. Explore strategies for collaboration and change to support equitable access and culturally-sensitive patient centred care to newcomer families. Strengthen cross-sectoral linkages between stakeholders from diverse sectors including health authorities, immigrant settlement agencies, Francophone organizations, family physicians, government, and newcomer parents and youth. Guidelines for Dialogue: Listen to understand Shift from blaming to learning Stay open by being curious Speak personally, rather than generalizing or speaking for others Ask questions Joanna Ashworth Establish a dialogue environment that is inviting and comfortable for all participants. 1

4 1.3 Overview of Event Process Healthcare, Wellbeing and Newcomer Families was designed using a dialogue model and an inclusive approach to provide opportunities for a constructive exchange of different perspectives. Participants were assigned to diverse groupings at tables of 7 to 8 people, with a host at each table to support participation and note taking of key ideas. Simultaneous interpreting in French and English was offered throughout plenary sessions, with options available to participate in the language of choice during small group discussions. Co-Facilitating the session were Dr. Joanna Ashworth, a dialogue and engagement expert from Simon Fraser University s Centre for Sustainable Community Development, and Annie Carnot, Coordinator of Francophone Services and Special Initiatives at PLS. To set the stage, Suzanne Barclay, Executive Director of PLS, welcomed attendees and provided a brief background on the project. Ms. Barclay encouraged all who attended to be open to each other s ideas and suggestions and thanked the sponsors of the event for their contributions, including the financial support of Health Canada and RésoSanté Colombie-Britannique and the provision of in-kind support from the Provincial Health Services Authority. As well, Ms. Barclay recognized the work of the Steering Committee for this event. Steering Committee Members Paola Ardiles, Project Manager, Research & Knowledge Exchange, BC Mental Health and Addiction Services, PHSA Joanna Ashworth, researcher and planner with Simon Fraser University Tannis Cheadle, Provincial Manager, Population & Public Health, PHSA Jeanne Nzeyimana, Outreach Case Manager, Moving Ahead Program, Settlement Services, Burnaby Family Life Kemi Odegbile, former Provincial Manager, Population & Public Health, PHSA With leadership from: Annie Carnot, Francophone Services and Special Initiatives Coordinator Elisabeth Kyle, Manager, PLS Programs (Translation and Francophone Services) Helene Rasmussen, Special Project Coordinator France-Emmanuelle Joly, a board member of RésoSanté Colombie-Britannique, provided opening remarks and recognition of the work done to date, noting how important it is to support newcomers to Canada, and in particular Francophone newcomers, in their access to healthcare. 2

5 To open the day s activities in keeping with the theme of wellbeing and as a way to build new connections among attendees, participants joined in an art-based small group activity to explore their understandings of wellbeing. Getting to know each other more personally from a values perspective was a good opening to spending the day in dialogue. Two small group dialogues took place during the event, the first focused on challenges and obstacles in meeting the needs of newcomers within the BC health system, and the second on promising opportunities for collaboration and change. To set the context for each dialogue session, Helene Rasmussen, Special Project Coordinator for PLS, provided an overview of related consultation findings. Following each small group discussion, there were plenary sessions during which participants were invited to share their key ideas. Through this process, areas of consensus were identified. The morning program was anchored by a presentation of the project Youth Working Group, led by Josiane Anthony, who shared personal experiences within the health care system through story-telling and spoken word. These moving stories of the newcomer experience put a human face on the issues. A Listeners Panel was invited to offer perspectives on key themes that emerged from the day. Panelists included Lydia Drasic, Executive Director, Population Health Strategic Planning & Provincial Initiatives, Provincial Health Services Authority; Chris Friesen, Director of Settlement Services, Immigrant Services Society of BC; Dr. Patricia Gabriel, Family Physician, Clinical Faculty of International Medical Graduate Program at UBC, Primary Care Researcher, and Dr. Victoria Lee, Medical Health Officer, Fraser Health Authority. Drummer Kesseke Yeo provided the heart beat of the dialogue, working closely with the facilitators to call the session to order and alert small groups to move to plenary session. In the afternoon, Kesseke kept the attendees energized with a participatory call and response song and a lively dance. The dialogue as a whole was captured in visual form by graphic recorder Sam Bradd. The two posters that emerged throughout the day provide a synthesis of the dialogue, and a visual tool to continue the conversation. The agenda for the event can be found in Appendix 1. 3

6 2.0 Morning Dialogue: Perceptions and Challenges The morning program focused on widespread perceptions and challenges of immigrant and refugee families in relation to health, well-being and accessing the BC healthcare system. Context was first provided through a presentation of key themes from the PLS community consultation with Francophone newcomer parents and youth, followed by a small group dialogue that asked attendees to share their own reflections and experiences working in the healthcare sector, community sector or as a newcomer accessing the healthcare system. 2.1 Findings from the Community Consultation with Francophone Newcomer Families Several key themes related to perceptions and challenges around health and the BC health system emerged during PLS community consultation with over 100 Francophone newcomer families. Participants in the consultation shared understandings and expectations of healthcare that differed significantly from common practices of the BC system. They spoke of coming from societies in which care is provided within a tightly-knit web of community relationships that includes health providers. Their expectations of active intervention at each medical appointment and few institutionalized controls around access to resources and scope of physician visits were frequently out of sync with practices they encounter here. Understandings around the health provider/patient relationship were similarly divergent from the patient as partner model common in the BC system. The consultation also revealed a diverse range of challenges encountered by immigrant and refugee families including socio-economic stressors, disruptions due to immigration, and difficulties navigating and adjusting to norms of the system that impact the health of newcomers. A widespread perception was that the BC system lacks compassion and cultural competence, leaving newcomers feeling unsupported, misunderstood, demeaned and/or disrespected. Language issues, including a lack of French-speaking health professionals and gaps in interpreter services, especially in family practice, limit communication, often resulting in inappropriate use of others (such as youth or community members) to take on this role. These challenges contribute to heightened anxiety, distrust in the health system, and underutilization of health services. Power Point Slides of the presentation can be found in Appendix 2. 4

7 2.2 DIalogue One: Perceptions and Challenges Following this overview of consultation findings, the attendees were invited to share their ideas and experiences in response to two related questions. Question 1: How do these perceptions and challenges resonate with your experience working in the health sector, community sector or as a newcomer accessing the health care system? Question 2: In your view, what are some of the constraints and obstacles in meeting the needs of newcomer families? The consensus themes that emerged from the morning small group dialogue validated to a great extent the consultation findings, confirming that they relate not only to Francophone newcomers but to newcomers in general, as well as other more vulnerable populations. KEY THEMES related to constraints and challenges included the following: a. Systemic Constraints Time, Trust and Compassion Constraints in the healthcare system impact the ability of providers to adequately meet the needs of newcomers and inhibit the kind of communication that may be necessary to identify and bridge cultural gaps between physicians and patients. Examples include: The pressure for efficiency in the current healthcare system gets in the way of providing appropriate and compassionate care. Participants expressed the feeling that there is no time for compassion, relationship building or explanation of how the healthcare system works. Patients have no time or are not permitted to talk about more than one issue at a time. There is a lack of flexible scheduling. Many patients receive healthcare from multiple sources operating in a fragmented and siloed manner. b. Fragmentation of Care Many attendees spoke of experiences where the patient s holistic needs - psychological, physical, social and even at times spiritual - were not addressed in their encounters with health services. It was frequently observed that that a more integrated, holistic approach to health should be taken into account. Addressing this issue would involve bringing care into the community, to mixed-use centres where childcare and other services would also be provided. 5

8 c. Build Capacity in Cultural Competency Participants spoke about a perception of unconscious bias on the part of physicians, impairment of provider/ patient communication, and lack of cultural sensitivity and competence on the part of physicians and other health care workers. Clinical decision-making is sometimes affected by the projection of stereotypes onto individual patients. Many participants underlined the need to understand each other from a cultural perspective in order to build compassion and enhance the ability to work together. It was also noted that patients need to know their rights and also their responsibilities, such as arriving on time for their appointments. d. Patient-Provider Communication Attendees reported disparities faced by patients due to communication barriers. They spoke to the necessity for increased language supports, both in the specific Francophone context and for newcomer communities in general, particularly in regards to interpreting services at family physician and specialist appointments. The lack of such resources puts tremendous pressure on newcomer families, and particularly on youth, as parents often rely on their children as mediators and interpreters in their dealings with community agencies and health care professionals. Some suggested that a focus on patient-centered communication would help health care providers be more aware of the potential barriers created by using medical jargon. e. The Politics of Health Care Participants spoke to the need for the health care system to address the social determinants of health. Attendees were challenged by a participant to consider the question, How do we change the health care system? This participant added, It s going to require direct action. We need to push for change. Summary Reflections Attendees widely recognized the need to better bridge the gap between the needs of newcomer communities and the healthcare system. Themes that emerged included the lack of knowledge amongst newcomers of how the health system works in British Columbia; a general mistrust of the system amongst many newcomers, some of it related to past experiences perceived as discriminatory; and the concerning observation that [newcomers] do not feel cared for. The consensus in the room was clear, for vulnerable newcomers, the 10 minute appointment with a health practitioner isn t enough. It was further recognized that many challenges (such as appointment times and referral processes) are conditions of the health care system and part of the structures within which health care providers practice medicine. As one attendee noted; the system is mismatched to the needs of people. Participants reflected that newcomers who want a holistic approach will be disappointed by the system as it is not set up for that. The system is sickness oriented and not wellness oriented, it was observed. While challenges with the system are shared with many British Columbians, they clearly have heightened implications for newcomers facing a complex set of difficulties and language obstacles. 6

9 2.3 Youth Experiences Youth perspectives were an important focus of the dialogue sessions. To help illuminate these perspectives, the project Youth Working Group, led by facilitator Josiane Anthony, was invited to share their experiences with accessing healthcare. Their stories put faces and names to challenges and provided a powerful reference point for attendees with regard to where opportunities and solutions are possible. Each storyteller crafted a thoughtfully presented story and gave it a phrase that captured its essence: Josiane Ignorance and Discrimination ; Nkechi Solving Problems with the Right Resources ; Daniella and Yao Broken Trust ; Alexandrine Empathy and Going the Extra Mile ; Stanley Minimizing the Pain and Unsupportive. The presentation concluded with a spoken word poem, written and performed by Josiane. 3.0 Promising Opportunities for Change 3.1 Findings from Community Consultation and Research into Promising Practices Helene Rasmussen (Coordinator, Special Projects, at The Provincial Language Service) prepared attendees for the afternoon small group dialogue by presenting project findings that offer promising opportunities for change. Five key areas in which participants in the community consultation made suggestions were highlighted: tools to navigate the health system, a compassionate and responsive system of care, language services, programs to support newcomer families, and building on community capacity. Key themes that came out of research into innovative approaches from other jurisdictions were also presented. Elements that underpinned many of these promising practices included a focus on culturally sensitive care, responsiveness to newcomer needs and life circumstances, a holistic and multi-disciplinary approach, recognition of the need for structured resources to help newcomers navigate the health system, and involvement of immigrant community members as cultural brokers. Power Point Slides of the presentation can be found in Appendix 3. 7

10 3.2 Dialogue Two: Promising Opportunities for Collaboration and Change This presentation on project findings set the stage for an insightful and productive afternoon of small group dialogue and plenary discussion. Two questions were posed to the small groups and their responses were captured in the plenary that followed. Specific ideas for action are noted below. Question 1: From your perspective, what do you think are the most promising opportunities for collaboration and change? Question 2: In your view, what role can community agencies, community members, health care professionals and others play? KEY OPPORTUNITIES FOR COLLABORATION AND CHANGE that emerged from the afternoon small group dialogue included the following: a. Cultural Literacy is a Two Way Street Participants observed that both healthcare providers and newcomer patients need better access to information and training to address the gaps in understanding and communication that exist. This requires increased cultural competency training for health professionals and better education on the British Columbia health care system for newcomers. Opportunities exist in the classroom, both in ESL classes and medical school curriculums. Education is needed for everyone in the health care system the professional and the patient. There is so much more we can learn about each other. b. Community-Based Primary Care Community-based services such as those currently offered in limited settings should be more widely offered within the community to include nurses, social workers, pharmacists, dieticians, public health practitioners, physicians and others. This patient centered approach would be responsive to economic, social, cultural and gender differences and address the need for a more holistic medical practice, while building trust and consistency. c. Build on Community Capacity It was suggested that international credentials be recognized. This could be achieved through mentorship programs where BC health professionals ensure foreign health professionals are knowledgeable with provincial standards. 8

11 d. Offer more (French) Language Services Approaches to increase language supports and services were proposed. Suggestions included the wider provision of phone interpreting for medical visits and strategies to ensure that all healthcare professionals able to provide services in French be listed as such in the BC medical directory. e. Offer Community Programs and Workshops Participants spoke of the need to provide programs in the community that welcome newcomer families and build knowledge of how the BC healthcare system works and what services are available. Such programs would respond to a broad range of needs related to language and health care system navigation, while offering an opportunity for networking. These programs, to include youth mentoring, should be brought to diverse sites including churches, community centers, homes and schools. f. Consider Legal Action A suggestion was put forward that champions are needed to make a class action legal suit in order to ensure that interpreting services are treated as a human rights issue around access to medical care. Comments related to the roles community agencies, community members, health care professionals and others can play, beyond those covered above, included: Support continuity of care by reducing the frequent staff turnover in service settings in order to build relationships based on trust and understanding. Build better communication between community agencies and healthcare providers to identify and address issues that arise. Integrate services to reduce the time and energy required to access different services and build a stronger network of services. 9

12 4.0 Reflections and Summary 4.1 Listeners Panel Many important ideas came out this day of dialogue. To bring closure to the proceedings, the Listeners Panel representatives provided their reflections on key messages and opportunities for change. Lydia Drasic, Executive Director, Population Health Strategic Planning & Provincial Initiatives, PHSA, provided her reflections on the morning program. She noted that it is important to address the social determinants of health and to recognize that issues around poverty and education are also part of health care. Given the complexity of the health system, there is a need for dialogue to understand each other and the system we are dealing with. I believe it is important to remind ourselves that if we were in another health care system, what would it be like for us to navigate [that different system]? She suggested that this kind of empathy reminds us of how difficult it can be for newcomers to navigate the health care system and that relationships are so important to doing this well. She noted in conclusion that this dialogue allowed participants to move forward together; to understand each other s perspectives and through this understanding, find the much needed compassion and energy for creating change. Chris Friesen, Director of Settlement Services, Immigrant Services Society of BC, opening up the afternoon portion of the listeners panel, observed that immigration will continue to play a significant role in British Columbia; By 2031, 59 per cent of the population will be born outside of Canada. The challenges and solutions identified at this event are relevant for all newcomers, not just Francophones. Mr. Friesen noted that solutions must be multi-pronged and led from both communities and institutions; there must, however, also be political will to create the needed changes to the health care system. He suggested that more attention to prevention and health promotion would improve outcomes for all newcomers. Communication and language services are vital for accessing health care, access being a universal right. And while the human touch and interpersonal relationships are important, Mr. Friesen reminded attendees that they are in a digital age and therefore social media may be part of the response and provision of services. He noted that many people attending the dialogue agree that education is a dual responsibility, a two way street that includes the host society and the newcomer. Each must find ways to learn about the other. He remarked that the medical profession is made up not just of doctors, but also nurse practitioners and social workers as well as those who work in immigrant services. He questioned why it is that funding cuts to critical services for newcomers continue when, as participants at the dialogue pointed out, there are many innovative practices doing excellent work, such as Bridge Clinic and other integrated health services in the community. It s not about doing something different it s about finding the political will to enlarge what we re doing well and supporting that. 10

13 Dr. Patricia Gabriel, family physician, Clinical Faculty at the International Medical Graduate Program of UBC and primary care researcher, opened her reflections by saying it is evident health is important to newcomers health understood in a broader sense that includes physical, emotional and spiritual dimensions. But there are clearly gaps in our system and challenges for newcomers in accessing health care. There is not enough empathy and compassion. She asked, Why is this happening? and pointed to a lack of awareness of each other s constraints as well as differing expectations about what is being offered. Dr. Gabriel noted that there is a lot of enthusiasm for change in terms of education, cultural literacy and language resources, as well as for services based on greater community outreach and integration. Similarly, there are promising practices in terms of mentoring and promoting attachments. Speaking from the health care provider perspective, she said that it is important for professionals to approach their work with newcomers from a virtues and values perspective -- to be more humble. Such an approach would have health care providers be more aware of their power. In terms of creating change, she concluded by saying that We can all be champions; every one of us has a role to play. Dr. Gabriel committed to sharing with her peers what happened in this dialogue and the consultation that informed it. She also invited anyone who is interested to become involved in two projects that she is currently working on one related to language use in primary care, and the other to the formation of a team approach to interdisciplinary care for newcomers. Dr. Victoria Lee, Medical Health Officer, Fraser Health Authority, expressed her appreciation for the opportunity to add her final observations. She noted that this dialogue explored the systemic barriers to health care services that relate not just to Francophone newcomers but all newcomers, and in many cases, to all British Columbians. Building relationships is a good start to addressing these barriers and it makes sense to build on the promising practices that are already underway, including cultural competency training. However, a long-term vision is needed to switch the focus from an illness-based model for the health care system to a wellness-based model. Promising practices can be introduced to enhance what is already in place, but it might be time for a paradigm shift. This would mean designing innovative forms of practice to break down the institutional silos and fill the gaps in our current system. It would also mean investing more in prevention and health promotion, to transform the way we look at health and the way we build our practice. We seem to have all the right ingredients the pot has been seasoned and now it s just a matter of turning them into actions both short and long term. Advocacy and system change are all part of this process. By changing the I to We, ILLNESS becomes WELLNESS. 11

14 4.2 Graphic Recording of Dialogue To open the last portion of the event, Sam Bradd reflected on the images that he captured in his role as graphic recorder, representing key themes that emerged throughout the day s discussions on supporting the health and wellbeing of newcomers. The posters on this page and the next were created during the course of the dialogue event. 12

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16 4.3 Closing Circle Participants were invited to share their responses to the day what resonated and what actions were they inspired to make as a result of their participation in the dialogue? What resonated? Participants noted that there seems to be agreement among the attendees that there is a gap in services to meet the healthcare needs of newcomers. Attendees appreciated hearing ideas about how to build on what works in terms of increased integration of programs and services, including liaison and collaboration between healthcare services and settlement and community agencies, particularly around education and cultural competencies. Most consistently, participants mentioned the value they heard fellow attendees place on relationship building. Many referred to this as building bridges through hearing the perspectives of both patients and healthcare providers. The importance of compassion in healthcare and interpersonal relationships resonated for participants. Action Inspired by the Dialogue Participants said that they were inspired to: Be a champion for a more responsive system. Keep working to make things better. Contribute to political action. Be more present in the community and collaborate more with the community sector. Advocate for a new billing code that would allow for the billing of interpreting services to MSP. Advocate through the Divisions of Family Practice for changes to the complex care fee code to include newcomer patients with limited English skills, thus ensuring care that is less rushed and better addresses cultural considerations. 4.4 Acknowledgements Elisabeth Kyle, Manager, PLS Programs - Translation and Francophone Services, concluded the day by expressing her sincere thanks and gratitude all who participated in the collaborative dialogue. Community participants and youth representatives were recognized for sharing their stories so openly. The patient voice is critical to system change, and we are grateful that you used your voice today to work towards improvement. Health Canada, RésoSanté Colombie-Britannique and the Provincial Health Services Authority, as well as partners at the Francophone Affairs Program of the Intergovernmental Relations Secretariat, were recognized for their support and collaborative approach. 14

17 Appendices 1 Dialogue Event Agenda November 30, novembre 2012 Harbour Centre, SFU Vancouver Welcome to a day of collaborative dialogue among health care professionals, community agencies, newcomer parents and youth to explore the findings and implications of a two-year project on the health of newcomer families, viewed through the lens of Francophone immigrants and refugees in BC. This event aims to explore your ideas on issues and gaps that impact the health, wellbeing and access to health services of newcomers and to identify ideas and strategies for change. Bienvenue à cette journée de dialogue empreinte de collaboration réunissant des professionnels de la santé, des organismes communautaires, des parents et des jeunes nouvellement arrivés. Le dialogue portera sur les résultats et les implications d un projet de deux années sur la santé des familles nouvellement arrivées, selon l'optique des immigrants et des réfugiés francophones de la C.-B. Il a pour but d explorer vos points de vue sur les problèmes et les lacunes qui touchent la santé, le bien-être et l accès aux services de santé des nouveaux arrivants et de définir des pistes et des stratégies pour changer les choses. We would like to thank our funders for their generous contributions to this event. Today s dialogue has been made possible through the financial support of Health Canada and RésoSanté Colombie-Britannique, and the provision of inkind contributions by the Provincial Health Services Authority. Nous tenons à remercier les partenaires qui ont contribué à cet événement. Le dialogue d aujourd hui a été rendu possible grâce à du financement provenant de Santé Canada et de RésoSanté Colombie-Britannique et à des contributions en nature de la Régie provinciale de la santé. 15

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21 2 Presentation: Community Consultation Findings on Perceptions and Challenges Community Consultation with Francophone Newcomer Families Community Engagement Helene\engaging.jpg 19

22 Key Themes Key Perceptions and Expectations 20

23 Challenges Facing Newcomer Families Voices from the Consultation Photos 21

24 3 Presentation: Project Findings on Promising Opportunities for Change Promising Opportunities for Change Suggestions offered by participants in the community consultation Promising practices from our research Suggestions from the Community Consultation Research on Promising Practices Elements common to many of these practices include: Focus on culturally and linguistically sensitive care Responsiveness to needs and life circumstances e.g. home and group visits Holistic and multi-disciplinary approach Recognition of need for structured tools and resources to support newcomers in understanding and navigating the health system Involvement of immigrant community members as cultural brokers 22

25 The development of this dialogue has been made possible through the financial support of Health Canada and RésoSanté Colombie-Britannique, and the provision of in-kind contributions by the Provincial Health Services Authority. The views expressed herein are from the participants of the dialogue event and the community consultation and do not necessarily represent the views of Health Canada, la Société Santé en français, RésoSanté Colombie-Britannique or the Provincial Health Services Authority. 23