Culturally Appropriate Communication for the Asian Americans, Native Hawaiians and Pacific Islanders Presented by: Mavis Nitta, MPH, CHES 1 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 groups 1 60% of Asians in U.S. foreign born in U.S. Census: The Native Hawaiian and Other Pacific Islander Population: 2000, Census 2000 Brief, issued December 2001; Asian & Pacific Islander American Health Forum, U.S. Census 2009 Estimates. 3 Boeree CG: The Language Families of the World, 4 AAPCHO: Asian Americans, Native Hawaiians and other Pacific Islanders (AA and NHOPIs), ~50 distinct Native Hawaiian and Pacific Islander ethnic and cultural groups 1 12% of NHPIs in U.S. foreign born in >2,000 distinct Asian and Pacific languages and dialects 3 >100 Asian or Pacific Island languages/dialects commonly spoken in the U.S. 4

3 Who are Asian Americans and how do they differ?

4 Graphic Maps, 2005, 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-Jiman Japanese Korean Chinese Mongolia Taiwanese Tibetan 2,3 Burmese 2 Malayan Bornean Mien Cambodian Mongolian Hmong Nepali 2 Indochinese Filipino / Pilipino Indonesian Singaporean Javanese Thai Laotian Vietnamese Asian Indian Bangladeshi Bhutanese Maldives Nepali 2 Pakistani Sri Lankan Afghanistani 2 Burmese/Myanmar 2 Tibetan 2,3 1 U.S. Census definition. 2 These 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”. 3 Although 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, 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,

6 Who are Native Hawaiians and Pacific Islanders and how do they differ?

7 WorldAtlas.com ( Pacific Resources for Education and Learning ( THE PACIFIC

8 NATIVE HAWAIIANS and PACIFIC ISLANDERS Persons “having origins in any of the original peoples of Hawai`i, Guam, Samoa, or other Pacific Islands” POLYNESIANMICRONESIANMELANESIAN Cook Islander French Polynesian Maori Native Hawaiian Niuean Samoan Tongan Tahitian Tokelauan Bikini Islander Marshall Islander Carolinian Marshallese Chamorro/Guamanian Palauan Chuukese/Trukese Pohnpeian / Enewetak Islander (Ponapean) I-Kiribati Saipanese Kosraean Tinian Islander Kwajalein Islander Yapese Northern Mariana Islander Fijian Nauruan New Caledonian Ni-Vanuatu / Vanuatu Islander Papuan Papua New Guinean Solomon 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 U.S. Census by Race/Ethnicity Inclusive Population in Thousands, 2000 and 2010 U.S. Census 2000 and 2010 Population in Thousands  46%  40%

10 Im/migrant Populations are 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

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 13

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 14

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) 15

Examples of Educational Materials 16

Examples of Educational Materials 17

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. 18

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 family 3.Take care of your health now, so you can be there for your family later. 4.Mammograms…Not just once, but for a lifetime 5.Ate, Get your mammogram. It could save your life. 19

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 20

Chinese Radio Station Photonovella in Bengali Print ad in Vietnamese 21

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 22

Take Home Messages One size doesn’t fit all approach Get feedback from community Tailor and adapt Evaluate effectiveness of the message 23