1

Culturally Appropriate Communication for the

Asian Americans, Native Hawaiians and Pacific Islanders

Presented by: Mavis Nitta, MPH, CHES

Advisory Committee on Breast Cancer in Young Women Meeting September 21-23, 2011

2

AAs and NHPIs in the U.S. are Diverse Populations

• ~30 distinct Asian ethnic and cultural groups1

• 60% of Asians in U.S. foreign born in 20092

1U.S. Census: The Native Hawaiian and Other Pacific Islander Population: 2000, Census 2000 Brief, issued December 2001; Asian & Pacific Islander American Health Forum, 2000. 2U.S. Census 2009 Estimates. 3Boeree CG: The Language Families of the World, http://webspace.ship.edu/cgboer/languagefamilies.html. 4AAPCHO: Asian Americans, Native Hawaiians and other Pacific Islanders (AA and NHOPIs), http://www.aapcho.org/site/aapcho/section.php?id=10950.

• ~50 distinct Native Hawaiian and Pacific Islander ethnic and cultural groups1

• 12% of NHPIs in U.S. foreign born in 20092

• >2,000 distinct Asian and Pacific languages and dialects3

• >100 Asian or Pacific Island languages/dialects commonly spoken in the U.S.4

3

Who areAsian Americans

and how do they differ?

4Graphic Maps, 2005, http://worldatlas.com/webimage/countrys/as.htm

SOUTH ASIA

Map of ASIA

5

ASIANS Persons “having origins in any of the original peoples of the Far East,

Southeast Asia, or the Indian subcontinent”.1

FAR EAST (“ASIA”)

SOUTHEAST ASIA INDIAN SUBCONTINENT(“South Asians”)

Iwo-JimanJapaneseKoreanChinese

MongoliaTaiwaneseTibetan2,3

Burmese2 Malayan Bornean Mien Cambodian Mongolian Hmong Nepali2 Indochinese Filipino / Pilipino Indonesian Singaporean Javanese Thai Laotian Vietnamese

Asian IndianBangladeshiBhutaneseMaldivesNepali2

PakistaniSri Lankan

Afghanistani2Burmese/Myanmar2

Tibetan2,3

1U.S. Census definition. 2These groups are sometimes included in a broader definition of South Asian or South-east Asian; although they are not always identified as being of “Asian origin”. 3Although the People’s Republic of China claims sovereignty over the Tibetan people, Tibet maintains its independence as a government-in-exile. Officially, the U.S. government considers Tibet to be part of China. However, Tibet’s exiled spiritual leader, the Dalai Lama, has many supporters in the U.S. and the Congress, and Tibet’s political status remains controversial in the U.S.

Asian American Network for Cancer Awareness, Research & Education, 2000, http://aancart.org/whoareasianamericans.html; Leadership Education for Asian Pacifics, Inc. (LEAP), 2000; South Asian Public Health Association (SAPHA), 2002; U.S. Census, 2000 and 2004; U.S. Department of State: Background Notes: Taiwan, U.S. Relations, Oct 2009, http://www.state.gov/r/pa/ei/bgn/35855.htm#relations.

6

Who are

Native Hawaiians and Pacific Islanders

and how do they differ?

7WorldAtlas.com (http://worldatlas.com/aatlas/infopage/oceans/pacificocean.htm); Pacific Resources for Education and Learning (http://www.prel.org/pacserv/pacserv_top.asp)

THE PACIFIC

8

NATIVE HAWAIIANS andPACIFIC ISLANDERS

Persons “having origins in any of the original peoples of Hawai`i, Guam, Samoa, or other Pacific Islands”

POLYNESIAN MICRONESIAN MELANESIAN

Cook IslanderFrench Polynesian

MaoriNative Hawaiian

NiueanSamoanTonganTahitian

Tokelauan

Bikini Islander Marshall IslanderCarolinian MarshalleseChamorro/Guamanian PalauanChuukese/Trukese Pohnpeian / Enewetak Islander (Ponapean) I-Kiribati SaipaneseKosraean Tinian Islander Kwajalein Islander YapeseNorthern Mariana Islander

FijianNauruan

New CaledonianNi-Vanuatu /

Vanuatu IslanderPapuan

Papua New GuineanSolomon Islander

Tuvaluan

U.S. Census: The Native Hawaiian and Other Pacific Islander Population: 2000, Census 2000 Brief, issued December 2001; Asian & Pacific Islander American Health Forum, 2000

9

US Total Non-Hispanic White

Latino / Hispanic

African Am/ Black

Asian American American Indian/

Alaska Na-tive

Native Hawai-ian/ Pacific Is-

lander

0

50,000

100,000

150,000

200,000

250,000

300,000

350,00028

1,421

.9

216,9

31.0

35,30

5.8

36,41

9.4

11,89

8.8

4,119

.3

874.4

308,7

45.5

231,0

40.4

50,47

7.6

42,02

0.7

17,32

0.9

5,220

.6

1,225

.2

2000 2010

U.S. Census by Race/Ethnicity Inclusive Population in Thousands, 2000 and 2010

U.S. Census 2000 and 2010

Popu

latio

n in

Tho

usan

ds

46% 40%

10

Im/migrant Populationsare more likely to:

• Be socially isolated– Holding on to their native cultures – Often exacerbated by language isolation

• Experience significant language barriers– Non-English speaking– Limited English Proficient (LEP)

• Be socioeconomically disadvantaged– High poverty rates– Medically uninsured

• Despite being employed full-time (often working 2 or more full-time and/or part-time jobs)

Impact of AA and NHPI Culture• Causes of physical illness: – Sins of past life– Physical ailment is

caused by the “supernatural”

• Home and folk remedies (CAM): – Herbal and plant

medicines common– Use of massage

• Faith:– Look to religion for

assistance– Praying as a cure– Medicine healers to

treat illness• Stigma of cancer• Fatalism• Fear of knowing• Social & cultural

obligations (i.e. funerals)

11

Structural Challenges Faced by AAs and NHPIs

• Lack of health insurance• Undocumented status• Low socioeconomic

status• Distorted conclusions

from being categorized with API– Data– Cultural beliefs

• Lack of Asian and Pacific Islander interpreters

• Need for health navigation

• Lack of culturally competent health care providers

12

13

Culturally and Linguistically Appropriate Messages

• Use positive pictures and messages– Connection with family– Pictures of their people, relatable – Cancer survivor’s story to put a face to the issue– Eye catching photos – Respectful tone

• Positive feeling, happy message, nothing scary or not directing blame at individual

14

Culturally and Linguistically Appropriate Messages

• Message affirms belief that mammograms can be lifesaving

• Encourages responsibility to take care of self in order to care for family– Consider using this message with a family photo

• Clear message on when you should get mammograms

• Messages need to be direct, but not too detailed

15

Language issues

• Chinese:– Mandarin vs Cantonese– Simplified vs Traditional

• Filipinos:– Tagalog vs English vs

Ilocano

• Terminology:– Layman’s terms vs

medical terminology– Word for cancer may not

exist in Asian or Pacific Islander language

– Mammogram is difficult to translate in various Asian or Pacific Islander languages (description is needed)

16

Examples of Educational Materials

17

Examples of Educational Materials

18

Breast Cancer Awareness for Tongans Project

3 media messages were used for project:1. Life is a gift, Take good care of it, Get a

mammogram

2. A woman’s good health is her most precious gift to her family. Remember your annual mammogram.

3. Educate & motivate. Screening saves lives.

19

Filipino Breast Cancer Project

5 print media messages using family, individual Filipina, health provider images and messages:

1. Do it for yourself, Do it for your family.2. Taking care of yourself is showing love to your

family3. Take care of your health now, so you can be there

for your family later.4. Mammograms…Not just once, but for a lifetime5. Ate, Get your mammogram. It could save your life.

20

Work with Community to Outreach and Maintain Communication

• Use ethnic and mainstream newspapers, radio, and television

• Use community lay health workers

• Work with church leaders

21

Chinese Radio Station

Photonovella in Bengali

Print ad in Vietnamese

22

Messenger

• Trusted member of the community– Physician vs nurse vs public health navigator/lay

health worker– Minister vs minister’s wife

• Male vs Female • Women they can relate to– Age/generation– Color of skin– Cancer survivors

23

Take Home Messages

• One size doesn’t fit all approach• Get feedback from community• Tailor and adapt • Evaluate effectiveness of the message