Self-management, health service use and information seeking for diabetes care among recent immigrants in Toronto.

INTRODUCTION: Our objective was to explore self-management practices, health services use and information-seeking for type 2 diabetes care among adult men and women from four recent immigrant communities in Toronto. METHODS: A structured questionnaire was adapted for the Canadian context and translated into 4 languages. A total of 184 participants with type 2 diabetes-130 recent immigrants and 54 Canadian-born-were recruited in both community and hospital settings. RESULTS: Recent immigrants were significantly less likely than the Canadian-born group to perform regular blood glucose and foot checks and significantly more likely than the Canadian-born group to be non-smokers, participate in regular physical activity and reduce dietary fat. Recent immigrants were significantly less likely than the Canadian-born group to use a specialist, alternative provider and dietician and less likely to report using dieticians, nurses and diabetes organizations as sources of diabetes-related information. Important differences were observed by sex and country of origin. CONCLUSION: Findings suggest that diabetes prevention and management strategies for recent immigrants must address linguistic, financial, informational and systemic barriers to information and care.

[Cultural diversity in Montreal: a range of public health challenges]. / La diversité culturelle montréalaise: une diversité de défis pour la santé publique.

Increasing immigration to Quebec has brought to the surface the need for adapting its public health systems and services, particularly in the area of primary care. The challenge is to take the heterogeneous nature of the population into account and to integrate diverse values, experience and know-how into the development of programmes and delivery of services, whilst simultaneously respecting the values of the various care providers and the norms of the institutions in the host country. This article addresses the question of adaptation strategies for health services, and namely the development of prevention and heath promotion programmes in public health within the framework of primary health care services within the intercultural context of Montreal. The issue of adaptation falls within the perspective and mandate of the Quebec government's policy on health and well-being (La politique de santé et du bien-être, 1992). Furthermore, it is a response to frequent demands from various health professionals and groups concerned with the adaptation of public services with respect to intercultural relationships confronted with the emerging realities associated with immigration. The article provides a reflection on specific ways of adapting prevention and health promotion initiatives targeting cultural communities and those who are undergoing immigration procedures or transitions. It also examines the development of ethno-cultural or other indicators which make it possible to capture migration experiences and their health impact. Since the Quebec health and social services system is currently in the process of major reform, it is hoped that it will seize this opportunity in order to make health and social service centres accountable for the adaptation of their programmes and services to the diversity of the populations they serve.

[Migration, ethics and public health in Quebec]. / Migration, éthique et santé publique au Québec.

This article analyses the ethical issues of migration in relation to public health in Quebec. There are two objectives: to describe the progression of analysis of the migration phenomenon in public health over the last thirty years and to state the ethical debate it raises. The progression of analysis of the migration phenomenon has been characterised by various approaches: intercultural, acculturation, transcultural, and migratory journey. Although these approaches have contributed to the development of knowledge about the reality of immigration, they have also, in spite of themselves, generated stigmatisation, discrimination and the proliferation of prejudices. Generally, findings that have emerged when migration is taken into account indicate an imbalance of power. For some, to focus on the phenomenon of migration promotes the power imbalance while for others, to disregard it masks the issue.

[Intercultural communication in the clinical context: a question of partnership]. / La communication interculturelle en contexte clinique: une question de partenariat.

This article is intended to promote reflection on the intercultural competence of nurses and other health professionals. It discusses the different types of interpretation used to communicate with patients who do not speak English or French, legal and ethical consequences, and impact on health-care quality. The authors offer recommendations for both research and clinical nursing, as well as the health-care system in general, and highlight the challenges faced by nurses in a pluralist society. The literature review reveals an inherent complexity in the use of diverse types of interpreters. Finally, the authors argue that the intricacy of the cross-cultural communication trio is intensified by a lack of adequate preparation of nurses and other health professionals and interpreters regarding cross-cultural communication.

[New immigrant women and health]. / Les nouvelles immigrantes et la santé.

The Canadian health care system serves an increasingly ethnically diverse clientele, especially in major urban centres. Sustained inflows of immigrants demand that social and health care services partially revise their mission to help these newcomers maintain their health following arrival in Canada, since their health generally tends to deteriorate over time. This poses a special challenge for women who have immigrated recently, because their health is often jeopardized by vulnerability linked to their socioeconomic status. Responding in a culturally appropriate way to each person's needs entails a choice of health promotion and disease prevention strategies. While this choice is based on specific definitions of the concepts, it also must reflect immigrant women's perceptions of what constitutes promotion, prevention and health. The purpose of this study was to develop a profile of their perceptions and use of preventive social and health care services. Our respondents reported that health is the absence of psychological and physical problems and that health promotion is associated primarily with a good diet, physical exercise, control of stress, and continuing to lead an active life (work, education). They believe that disease prevention lies primarily in overcoming financial problems and gaining access to a healthy diet and medical care. These views are similar to North American concepts. Research could confirm the similarities and differences between immigrant women and host populations. Nursing interventions would support culturally appropriate comprehensive action that addresses the individual, family, community and social aspects.

[Health promotion for immigrant women in Quebec]. / Promotion de la santé en faveur des femmes immigrant au Québec.

Over the past fifteen years, the Canadian population has undergone increasing cultural diversification. Many researchers have investigated the role of culture with respect to social and health services. Most studies confirm the fact that increased cultural diversification related to immigration challenges the public health system in many ways. Certain groups, such as economically challenged immigrant women, may pose even greater problems to the health system. While these individuals are in relatively good health upon arrival to Canada, there is a need to ensure that adequate health promotion as well as disease prevention strategies are instituted. It is important to examine the concepts of health promotion and disease prevention through a cultural perspective. Little research has been done in this area. Concepts of promotion and prevention as they are understood by immigrants may not always coincide with North American or European definitions. Therefore, it is essential to consider life conditions that surround potential health promotion and prevention behaviors of immigrants. Empowerment, economic integration and acculturation are among the many factors that need to be taken into account when studying immigrants' health promotion behavior. Here, we present a critical analysis of current knowledge in this field. This is followed by research recommendations aimed at facilitating the development of health promotion and prevention strategies that are appropriate to the needs of Canadian, and more specifically of immigrant women in Québec.

[The interpreter in an intercultural clinical milieu]. / L'interprète en milieu clinique interculturel.

The public's diversified language profile means that nursing practice must adjust to provide the same quality of care to all clients, no matter what language they speak. To improve quality and quantity of information exchanged in the nurse-client-interpreter triangle, the authors have investigated the type of information likely to be filtered and studied the various factors underlying the interpreter's choice to filter information. The authors also analyzed the values interpreters assign to information and the factors that form the background for filtering, including mistrust. The authors suggest adequately preparing interpreters; using interpreters' expertise; and developing an appropriate training program for intercultural interpreters to enable them to better function within health care institutions.

Impact of immigration on tuberculosis infection among Canadian-born schoolchildren and young adults in Montreal.

We conducted a cross-sectional tuberculin survey among non-BCG-vaccinated Canadian-born schoolchildren in grades 6 and 10, health professional students, and young adult workers, to estimate the association of tuberculin reactions with indices of contact with tuberculosis. Participants underwent simultaneous tuberculin testing with PPD-T (standard) and PPD-B (from M. intracellulare). Exposure was estimated from questionnaire responses, group, aggregate census, and tuberculosis incidence data. Of 3,710 participants, 88 (2.4%) had positive tuberculin reactions, i.e., of 10+ mm. Positive tuberculin reactions were rarely associated with larger reactions to PPD-B, but were associated with older age (adjusted odds ratio for each 5 years: 1.5 [95% confidence interval, 1.3, 1.8]), household contact (4.2 [1.4, 12.7]), and population group (health professional versus all others: 0.6 [0.3, 1.0]). Estimated annual risk of infection declined by 3% per year. Tuberculin reactions were not associated with any indices of contact in school, work or neighborhood settings with foreign-born from tuberculosis endemic areas, nor with tuberculosis in Canadian-born. There was no evidence of transmission of tuberculosis from affected high risk sub-groups in Montreal to the general population working or attending school.

Transcultural nursing and a care management partnership project.

This paper aims to illustrate how Leininger's Theory of Culture Care Diversity and Universality has influenced the research process of a study that emerged from a care management partnership between Canadian nursing teachers and Tunisian nurses. The purpose of the study was to investigate the meanings of care as viewed by university hospital-based Tunisian nurses. The qualitative analysis of data gathered through observation-participation and interviews highlights recurrent patterns and reveals three major professional care themes. For Tunisian nurses care means to secure the patient's cooperation towards the medical regimen within established rules in the hospital; to contribute to curing the patient by using current technology as well as by maintaining their technical skills and improving their medical knowledge; to take charge of the patient to assist the physician in treating disease. This study showed that Tunisian nurses emphasize curing rather than widely shared community values such as interdependence, intercommunication, understanding, presence and responsibility for others. Discussion of the study's findings draws upon the perspective provided by Freire's Oppressed Group Theory. In order to promote cultural congruence within the Care Management Partnership Project in Tunisia, the three predicted modes of care within Leininger's theory guide the decisions and actions for future nursing research and partnership activities.

Utilization of health services among rural women in Gujarat, India.

This study examined the effects of four sets of factors on use of curative health services among rural women living in Gujarat, India. The sets of factors analyzed were as follows: (1) the demographic characteristics of the women; (2) the characteristics of the household in which they lived; (3) the characteristics of the environment in which they lived; and (4) the price and convenience of care. The study focused on rural married women aged 17-45 who had at least one child. Nested multiple logistic regressions were computed on cross-sectional data to assess the simultaneous influences of the independent variables on (1) reports of episodes of illness (2) use of curative services among rural women who reported an illness and (3) use of a specific service. Four types of service were examined as outcomes of interest, namely, private doctors, Aga Khan Health Services centres, government health centres, and traditional healers. Other things being equal, women's education, income, family structure and kinship affiliation were significant predictors of use of service. Women seemed to be more sensitive to travel time to the health service and its associated costs (purdah restrictions, transportation and time costs) than to the direct costs of service. Factors such as women's occupation and sanitation facilities, while associated with use of service in the expected direction, were not significant predictors of use of service. Implications for health planning are offered, including initiatives to implement health promotion and disease prevention programs in addition to increasing access to the existing health services. Avenues for future studies are suggested, particularly in regard to decision-making processes affecting the health-seeking behavior of rural women. It is recommended that such policies and studies should consider the cultural environment in addition to the existing pluralistic health system.

The booster effect in two-step tuberculin testing among young adults in Montreal.

OBJECTIVES: No consensus exists regarding the definition and interpretation of a significant boosting reaction after sequential tuberculin testing. The booster phenomenon is thought to represent remote tuberculous infection where tuberculin reactivity has waned, but it has also been described among persons with previous exposure to other mycobacteria or Bacille Calmette-Guérin (BCG) vaccine. We studied the factors affecting the booster phenomenon among Canadian-born young adults to determine the definition that would maximize sensitivity and specificity of a positive booster reaction in these persons. DESIGN: Point-prevalence survey of initial tuberculin reactions and response to repeated tuberculin testing after 1 to 4 weeks. SETTING: Community-based study of all students entering health professional training programs at six post-secondary institutions. MEASUREMENTS: In 1989, 1990, and 1991, students completed self-administered questionnaires, underwent two-step tuberculin testing with purified protein derivative-tuberculin (PPD-T), and had their childhood BCG vaccination status verified. In 1991, students were also tested with purified protein derivative-Battey (PPD-B) (for Mycobacterium intracellulare). RESULTS: Overall, 74 students (5.2%) had positive booster reactions, which were significantly associated with older age (P < 0.001), larger initial tuberculin reactions (P < 0.001), previous BCG vaccination (P < 0.001), older age when vaccinated (P < 0.02), longer interval from vaccination to testing (P < 0.01), and sensitivity to PPD-B (P < 0.001). Boosting was not associated with the number of BCG vaccinations, sex, or risk factors for tuberculous infection. The pattern, mean, and mode of the frequency distributions of booster reactions among those with BCG vaccination and sensitivity to PPD-B were similar to those with assumed tuberculous infection. CONCLUSIONS: In young adults, booster reactions due to previous tuberculous infection are uncommon and cannot be distinguished from false-positive reactions due to past exposure to other mycobacteria.

Factors associated with compliance in treatment of tuberculosis.

The most important cause of failure of antituberculosis therapy is that the patient does not take the medication as prescribed. To assess this problem, a retrospective review was conducted, using medical and nursing records, of adult patients treated at the tuberculosis clinic of the Montreal Chest Hospital in 1987-1988. In all, 352 patients were identified, of whom 59% were judged to have completed therapy. Completion of therapy was recorded in 92% of those with culture-positive disease, 76% of those with active but culture-negative disease and 54% among the 300 prescribed preventive therapy (P < 0.001). Compliance with preventive therapy was highest among those who had been in contact with an active case, and lowest among those identified through a workforce screening survey (P < 0.01). At the time of the first follow-up visit, patients identified to have suboptimal compliance were more likely to fail to complete therapy (P < 0.001). Compliance was higher among those initially hospitalized, those assessed to have better understanding (P < 0.05), those prescribed 6-9 rather than 12 months of therapy (P < 0.01), and those who returned for follow-up within 4 weeks of initiation of therapy (P < 0.01). Compliance could be improved by enhancing patient understanding, closer follow-up, and shorter therapy, particularly for those at lower risk of reactivation. As well, additional compliance enhancing interventions can be targeted to those patients with suboptimal compliance who can be accurately identified early in the course of therapy.

Factors associated with tuberculin reactivity among the foreign-born in Montreal.

Because tuberculosis among the foreign-born is of increasing importance in North America, it has recently been recommended that newly arriving immigrants be tuberculin tested and preventive therapy given to all those with significant reactions. The factors affecting the prevalence of tuberculin reactions were assessed in a community-based tuberculin survey among foreign-born schoolchildren and young adults. Of 1,198 foreign-born who were tuberculin tested, 32.4% had significant tuberculin reactions. False-positive tuberculin reactions due to sensitivity to purified protein derivative (PPD)-B (for Mycobacterium avium) were uncommon and those due to BCG vaccination of importance only among immigrants from countries with low tuberculosis rates. Tuberculin reactions of 10+ mm were associated with tuberculosis rates in the country of origin (p less than or equal to 0.001), age when immigrated (p less than or equal to 0.001), bacillus Calmette-Guérin (BCG) vaccination (p less than or equal to 0.01), and residence in poorer neighborhoods in Montreal (p less than or equal to 0.001), but not with number of years resident in Canada. The booster phenomenon, seen in 16% of those undergoing two-step testing, was most strongly associated with prior BCG vaccination (p less than or equal to 0.001) and also with tuberculosis rates in the country of origin (p less than or equal to 0.08), age of immigration (p less than or equal to 0.01), and number of years resident in Canada (p less than or equal to 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bacille Calmette-Guérin vaccination on tuberculin reactivity.

The effect on tuberculin reactivity of bacille Calmette-Guérin vaccination (BCG-V) given 10 to 25 yr earlier was measured among schoolchildren and young adults in Montreal. Of a total eligible population of 8,264 persons, 5,952 were tuberculin tested (72%). The BCG-V status could be verified for 4,629 of 4,969 (93%) participants born in Quebec. Of these, 1,511 (33%) had received BCG-V, 66% of whom had been vaccinated once only in infancy, 23% of whom had been vaccinated once but after infancy, and 11% of whom had been vaccinated twice. Among those vaccinated in infancy, 7.9% had significant tuberculin reactions, compared with 18% among those vaccinated between 1 and 5 yr of age, and 25.4% among those vaccinated after the age of 5 (p less than 0.001). Among those receiving BCG-V in infancy, the prevalence of tuberculin reactions of 10 mm was similar to the nonvaccinated subjects, after accounting for differences in age and socioeconomic status. Among those vaccinated after infancy, tuberculin reactivity was not significantly affected by interval from BCG-V until tuberculin testing nor by repeat BCG-V. We conclude that after an interval of 10 to 25 yr the most important determinant of effect of BCG-V on tuberculin reactivity is age when vaccinated. A significant tuberculin reaction among those who have received BCG-V should be interpreted in light of the age when vaccinated and the expected prevalence of tuberculous infection in the population tested.