Health promotion and research in the Chinese community in Montreal: A model of culturally appropriate health care

Abstract

In the past three decades, rapidly changing demographic characteristics have been witnessed in western society. Concurrently, numerous culture-related studies have attested to the disparity in health services among different ethnic groups. Reports have shown contributing factors that can render main stream services inaccessible to immigrants include cultural and language barriers, adaptation difficulties, racial discrimination and lack of culturally appropriate psychosocial services. Inadequate training of health professionals regarding cross-cultural issues may hinder patient compliance and therapeutic alliances. In a paediatric practice in Montreal, prevalent health problems among Chinese families were identified to be related to cultural beliefs and psychosocial factors. These included a low breastfeeding rate (8%) among Chinese newborns, prevalent iron deficiency anemia (12%), nursing caries, social isolation, delayed diagnosis of developmental delay, learning disabilities and psychosocial problems. The participation in community research and advocacy, the development of health promotional projects with an interdisciplinary approach and the preparation of Chinese health information such as perinatal programs, infant nutrition, dental hygiene and immunization, were described. Subsequent studies in this population illustrated an increased breastfeeding rate (48%), decreased incidence of iron deficiency (2.8%) and improved self-health maintenance practices. More culturally appropriate allied health services, including the Multiculturalism Department in the Montreal Children’s Hospital, have subsequently been developed for the community.

In summary, identifying prevalent health problems of ethnic propensity may be the initiatives needed to develop research and health promotional projects for a target population. Comprehensive health care to different ethnic groups requires health professionals to incorporate cross-cultural issues in their services.

As a result of the rapidly changing demographic characteristics of major cities in North America and western Europe in the past three decades, cross-cultural issues have surfaced in every facet of western society. Much debate on the accessibility to conventional health and psychosocial services by different ethnic minority groups has resulted in a vast amount of culture-related research and health promotion (1–3). Psychiatrists and anthropologists have begun to emphasize the link between anthropological data and the biomedical processes of illness (4–7). Community groups, health professionals and educators have recognized that the psychosocial, medical and educational services available to mainstream society often do not serve the ethnic populations effectively, especially newer immigrants (8,9). Contributing factors include cultural and language barriers (10), adaptation difficulties, lack of awareness of existing health and social services (eg, perinatal courses [11], daycare services for preschool children [12] and services for the elderly [13]), and even racial discrimination (14). Inadequate training of health and education professionals regarding cross-cultural issues results in health policy decisions that fail to incorporate culturally appropriate services, creating impediments to patient compliance and the development of therapeutic alliances (15–17).

Because cultural evolution is a dynamic phenomenon, each individual, regardless of his or her genetic makeup, has a unique cultural identity. A caring physician needs to be aware of the cultural differences between the health care giver and the patient. Physicians serving multi-ethnic communities, especially in the primary care paediatric setting, should be acutely aware of cultural factors influencing particular modes of illness presentation and the health-seeking behaviour of their clients (6,17,18).

Preventive health care in paediatrics involves both developmental surveillance, as advocated by the major western paediatric organizations (19,20), and early identification of biomedical and psychosocial risk factors and illnesses (21,22). Developmental monitoring of children of immigrant families can be complex because of their very different health-seeking behaviours and psychosocial characteristics. The acculturation process can be a source of psychological disturbance among these children. Culture-related health beliefs and psychosocial factors often intertwine with the process of illness presentation and account for certain prevalent health problems. For example, Chinese women who believe in the Ying-Yang concept of health often refrain from drinking cold milk or juice and eating vegetables and fruits on the postpartum ward. Such practices are often associated with constipation, difficulty in lactation and a low breastfeeding rate among these women (23). The traditional Chinese infant weaning food is rice congee (porridge). Meat has high iron bioavailability, but in the Ying-Yang concept it is believed to have excessive ‘heat’ and is not appropriate to be fed to infants. Congee that has been cooked with meat is fed to the infant only after the meat is removed. Iron deficiency anemia can develop when an infant is fed with such weaning food while only being breastfed or receiving whole cow’s milk (24). The present paper illustrates observations of these phenomena in my paediatric practice in Montreal over the past three decades, the importance of physicians’ involvement in community and hospital settings, and the effect that advocacy of research and health-promotional services has had on the Chinese community. Such services have facilitated comprehensive health care delivery by health professionals, raised patients’ awareness and improved their ability to access health and social services.

In 1973, in a paediatric clinic opened one half day per week at the Montreal Chinese Hospital, I observed prevalent nutritional and psychosocial problems among immigrant Chinese families. These included a very low breastfeeding rate (8%) among Chinese newborns (23), iron deficiency anemia (12%) and thalassemia trait (6.7%) among young Chinese children (24), nursing caries (25) and social isolation (18). Although breastfeeding promotion and perinatal programs had become standard services for expectant couples in Montreal since the early 1980s, a pilot survey of Chinese clienteles at prenatal clinics revealed only 2% had attended any form of prenatal education. A young Chinese woman with postpartum depression committed suicide despite intervention by the conventional social support system. This intervention did not address the cultural needs and traditions of this Chinese family (18). New immigrant Chinese families experience parenting difficulty because of their busy lifestyle and because the language-appropriate counselling services available to them are inadequate. Adolescents, in particular, experience cultural and maturational identity crises (18). Developmental delay and school problems with or without specific learning difficulties were often not diagnosed, and such children would eventually present with secondary behavioural problems (12). Routine prenatal screening for hepatitis B virus to prevent longitudinal transmission of the virus to neonates by carrier mothers became universal in Canada in the mid 1980s. Although Asian immigrants are known to have a high carrier rate of hepatitis B (26,27), there have been no systematic education or routine screening programs for this target population in Montreal. Where carriers have been identified, they were often lost to follow-up because of language barriers.

In the early years of my community practice, culture-and language-specific psychosocial services for the Chinese community had not been developed. As a paediatrician, I constantly faced the challenge of having to provide psychosocial counselling and individual education to many Chinese families. It soon became apparent to me that individual effort was not a cost-effective way of helping an at-risk population, and comprehensive and patient-centred health care required the collaborative effort of interdisciplinary health professionals. Beginning in the late 1980s, paediatric literature dealing with psychosocial medicine coined the term ‘new morbidity in paediatrics’ (28), prompting practitioners to recognize the psychosocial factors that contribute to health problems and the manifestations of disease. Concurrently, the ethnic composition of communities, both provincially and nationally, had changed rapidly. The recognition of, and publicity given to, the reality that mainstream health care, psychosocial and education services were largely inaccessible to immigrants led to numerous conferences, research activities, and publications on multiculturalism and health.

I joined action groups promoting the development of the Chinese Family Services of Greater Montreal in the 1970s, participated in workshops and symposia on health issues pertaining to immigrant families in Montreal and at national and international levels. I also developed health research and promotional projects for the Chinese community. With funding from the Montreal Chinese Hospital Foundation, a breastfeeding promotional campaign was undertaken. Information pamphlets were prepared in Chinese on a variety of topics, including healthy nutritional practices, breast-feeding, dental care, thalassemia and hepatitis B screening. These were made available to the Chinese community. The breastfeeding rate rose from 8% (23) to 48% (11) as a result. A prospective study (29) of Chinese children from birth to age two years revealed that iron deficiency anemia decreased from 12% (24) to 2.8% (29).

In 1986, I collaborated with colleagues at the Montreal Children’s Hospital in the development of a Multiculturalism Department created to facilitate the delivery of medical services to different cultural communities. Since then, the department has been providing essential ancillary services to different ethnic groups as circumstances and needs arise. From 1988 to 1991, I participated in a study group on multiculturalism and mental health funded by the Quebec Government’s Le comité de la santé mentale du Québec, which led to the publication of a book titled, La santé mentale et ses visages : Un Québec pluriethnique au quotidien (18). This collaborated effort helped me personally to become more effective in exploring and integrating family dynamics and cultural factors in patient care.

In recent years, cultural psychiatry has become a distinct discipline (30). A clinical study on the psychological functioning of children of immigrant families seen in my office practice was undertaken in collaboration with colleagues from the Psychiatry Department of McGill University. Our data indicate that children’s social competence and self-esteem are influenced by both parental and child acculturation styles, and that parental acceptance of the majority culture is associated with healthier psychological functioning (31). This study has provided useful guidelines for physicians in counselling immigrant families. The importance of psychosocial assessment of immigrant children and youths has also been emphasized by the Canadian Paediatric Society (CPS). Serving on the Psychosocial Paediatric Committee of the CPS has proven to be invaluable. The variety of experiences enabled me to contribute the chapter on psychosocial assessment of immigrant families to Children and Youth New to Canada: A Health Care Guide, a publication by the CPS (32).

The development of the first perinatal program for Chinese-speaking families at the Montreal Chinese Hospital (a project cofunded by the Hospital Foundation and the Federal Department of Multiculturalism from 1989 to 1992), was a significant contribution to culture-specific health services to the Chinese community. Initially, a Chinese-speaking nurse was provided by the Hospital to coordinate the clinic. Prenatal courses were originally given in Cantonese, and later, as more immigrants began to arrive from mainland China, in Mandarin. As the program became better known, it offered consultation services to regional postpartum home visiting nurses who encountered language or cultural barriers with Chinese-speaking clients. Research data from this project revealed that prenatal class participants had higher breastfeeding initiation rates, were more likely to ask the regional postpartum visiting nurses pertinent questions and more likely to receive postpartum help from their husbands. Prenatal course discussions on hepatitis B and thalassemia screening also raised the awareness level of these issues. Clearly, the Chinese culture-specific program has been successful in promoting family-centred, pre- and postnatal care to the community (11). Consistent positive feedback has also been received from the clients. A perinatal manual titled Family-Centered Childbirth and Infant Care (text in Chinese) (33) was published in 1995 to further support the services of this program. A revised edition appeared in 2002. Free copies have been distributed to health centres across Canada and are available on request to the Montreal Chinese Hospital (Mrs Sylvie Genest, Montreal Chinese Hospital, 189 Viger Street East, Montreal, Quebec H2X 3Y9).

In summary, health care delivery to ethnic populations can be improved by providing culturally appropriate services. Furthermore, different ethnic groups may have higher prevalences of certain health problems which need to be recognized. Physicians need to work with other health care professionals and community groups to develop research and health promotional projects adapted to local needs. Such community efforts are likely to lead to more comprehensive and cost-effective health care services.