Hepatitis C Ethnocultural Education, Outreach and Social Marketing Program

What is the Program?

CATIE’s Hepatitis C Ethnocultural Education, Outreach and Social Marketing Program is a hepatitis C awareness and educational outreach program for immigrants and newcomers in Ontario. The program works with four communities (Chinese, Pakistani, Punjabi and Filipino) and in four languages (Simplified Chinese, Urdu, Punjabi and Tagalog). The program’s immediate goal is to increase knowledge and awareness of hepatitis C and increase testing among immigrants and newcomers in Ontario; its ultimate goal is to increase capacity in immigrant and newcomer communities to address hepatitis C.

This program was initiated as a four-year provincial pilot in 2010, funded by the AIDS and Hepatitis C Programs of the Ontario Ministry of Health and Long-term Care. It became an ongoing program with provincial funding in 2014. The Public Health Agency of Canada provides funding to print and distribute resources for use outside of Ontario.

The program addresses the information needs of immigrants and newcomers. In the program’s first four years, CATIE developed and implemented a multi-level strategy across four communities in Ontario: Chinese, Pakistani, Punjabi and Filipino. The strategy includes three major interconnected areas of work:

Education and outreach
Development and distribution of multilingual education resources
Media campaigns

The program takes a community development approach, which includes meaningful community involvement; engagement and partnerships with settlement, community and religious organizations; and a commitment to health equity.

Although hepatitis C is the main subject of the program, CATIE has taken a broader approach to immigrant and newcomer health rather than focusing only on this single health issue. This approach acknowledges the various factors that affect people’s overall health, including the social determinants of health, settlement stress, health literacy and access to healthcare.

The program started with one full-time program coordinator. A team of 16 bilingual facilitators representing the four priority communities and community advisory councils have been critical to guiding the program and delivering outreach and educational activities. In the first three years, an education and outreach coordinator was hired for six months of the year. This position became full time in the fourth year of the program.

Why Was the Program Developed?

The Hepatitis C Ethnocultural Education, Outreach and Social Marketing Program was developed in response to a need identified by the AIDS and Hepatitis C Programs of the Ontario Ministry of Health and Long-term Care. This is the government body responsible for developing Ontario’s HIV and hepatitis C strategies and a provincial funder of community-based programs.

In Canada, immigrants and newcomers are disproportionately affected by hepatitis C and hepatitis B. Immigrants and newcomers are estimated to represent 35 percent of all past or present hepatitis C infections in Canada.¹ The primary mode of transmission for this group is unsafe medical practices outside of Canada, including transfusions of contaminated blood and reuse of unsterilized medical or dental equipment. Hepatitis C is not routinely screened for during the immigration process, so many immigrants may not know they have the virus.

Once someone arrives in Canada, there are a host of factors that contribute to their need for health information, especially relating to hepatitis C. Although immigrants typically arrive healthier than their Canadian counterparts,² research has shown the longer a person resides in Canada the more their health status comes in line with that of the general population, and sometimes their health declines further. Immigrants and newcomers access healthcare services less than people born in Canada and they often face cultural and linguistic barriers to services.

Upon receiving funding, CATIE completed an environmental scan to set the groundwork for this program. On the basis of this environmental scan, immigrants and newcomers from four countries were identified for the development of awareness campaigns and information resources: China, India, Pakistan and the Philippines. Therefore, CATIE’s education and resource development work began in the following languages: Mandarin (Simplified Chinese), Punjabi, Urdu and Tagalog.

Trubnikov M, Yan P, Archibald C. Estimated prevalence of hepatitis C virus infection in Canada, 2011. Canada Communicable Disease Report. 2014 Dec 18;40(19). Available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-19/surveillance-b-eng.php
Gushulak B, Pottie K, Roberts J et al. Migration and health in Canada: health in the global village. CMAJ. 2011 Sep;183(12):E952-E958.

How Does the Program Work?

A community development approach

This program used a participatory community-led approach. Community leaders were engaged from the beginning and work was undertaken in spaces where the community was already engaged. Partnerships with organizations serving immigrants and newcomers are a core aspect of the Hepatitis C Ethnocultural Education, Outreach and Social Marketing Program. Strong evidence suggests that health promotion activities in cultural and ethnic minority communities should use this approach.

CATIE used a number of strategies to support health promotion activities in each of the communities. CATIE set up community advisory councils with representatives from each of the four communities to guide the program at all stages. For more information on the community advisory councils, please see the “Building partnership with communities” program element. In addition, CATIE engaged and trained facilitators who were bilingual in English and one of the four languages of the program to deliver workshops, attend community events and be the face of the program in their communities; developed relationships with bilingual medical and community reviewers to ensure that the educational resources were appropriate and accurate; engaged community members in a critical dialogue about the media; and piloted its workshops with community members to ensure they resonated with them.

Education and outreach

The program’s education and outreach activities include two core workshops (Immigrant Health and Hepatitis C and Media Literacy and Health Literacy), community outreach events and a partnership with the Toronto Public Health AIDS and Sexual Health Information Line, which has provincial reach and makes referrals to testing sites across Ontario in 16 languages, including the four priority languages of the program.

Workshops

CATIE has developed and delivered two core client workshops as part of this program: Immigrant Health and Hepatitis C and Media Literacy and Health Literacy. Workshops are organized by CATIE’s program coordinators in collaboration with CATIE’s community partners.

Food, transit fares and childcare subsidies are always available to participants to encourage broad involvement that includes women, families and youth. Workshops are hosted in community spaces and organizations that are familiar to clients. They are delivered in Simplified Chinese, Urdu, Punjabi and Tagalog by bilingual facilitators.

Workshops: a focus on health literacy

It was important to CATIE to consider the context in which its education and outreach work reached people. Throughout the planning of the project, CATIE recognized that improving health literacy involves more than the transmission of health information, although that remains a fundamental task for awareness-raising.

Health literacy is generally best achieved through personal forms of communication and through community-based education outreach.¹ Initiatives to improve health literacy integrate participatory approaches with communication and address structural inequalities. Participatory approaches to health communications involve a number of activities:²

involving and empowering vulnerable and at-risk groups in health communication efforts
developing inter-organizational partnerships to support intervention efforts
providing appropriate training and support for both consumers and providers
designing culturally appropriate messages and materials for communication efforts
focusing on the family and the community for delivering and reinforcing messages
providing consumers with choices and options for promoting their health

In its discussions about health literacy and its work to build health literacy capacity, CATIE emphasizes the fact that health literacy helps people develop the confidence to act on health information and gives them the ability to ask for support, screening, or to work with, educate and help others.³ CATIE recognizes that the people it reaches through its work may end up in positions to self-advocate for a test, treatment or support.

Understanding health literacy among immigrants and newcomers is challenging because it means accommodating different cultural views of the world, science and health. These different views may result in different interpretations of risk and stigma surrounding an illness. Many health resources available to immigrants and newcomers to Canada focus only on Western medicine, without acknowledging other cultures of care and healing. Health literacy promotion involves understanding “different realities” among service providers and immigrants and finding the best way to communicate between them.

CATIE has acknowledged throughout the project that a community knows what is best for itself and, once provided with resources and information, community members can move forward where and when they are ready.

The role of bilingual facilitators

Over four years, the program has engaged 16 bilingual facilitators from the four communities to offer the two primary workshops and to be present at community events. The bilingual workshop facilitators are important, engaged cultural brokers in the program. They bring culturally sensitive health information to diverse spaces in each community.

The program facilitators and bilingual medical and community reviewers receive honoraria for their work. The project primarily engages facilitators who are immigrants and newcomers and who may be precariously employed, deskilled (not able to use the skills for which they have been trained) or no longer working in a job that matches their education. Skilled pay is offered for skilled work. This is an important opportunity for facilitators to continue using their education and for CATIE to offer them some Canadian work experience and a reference.

Potential bilingual facilitators are recruited from partner organizations and through the provincial settlement job posting website.

Ongoing capacity building for bilingual facilitators

Successful candidates for facilitator positions are invited to an annual CATIE-led train-the-trainer workshop held over two days. Returning facilitators join the group on the second day to share their experiences and receive information updates. During the training, the core curriculum of the Immigrant Health and Hepatitis C workshop is delivered with an explanation and discussion about the choices CATIE made about content, sequence, approach, word choice and the primary learnings from each activity. The facilitators are also given time to work on their personal introductions to frame their experience and explain why they do this work. A session on personal disclosure while facilitating workshops, specifically how they may share their lived experiences—as immigrants, as people living with an illness, around sexual health or substance use, or other personal experiences—is facilitated by a CATIE educator living with HIV with extensive experience with this kind of peer-based work.

One session during this training is dedicated to preparing the facilitators to respond to the sensitive issues of sex, sexual health, substance use and harm reduction. The facilitators are given analogies of risk management and prevention, then they are provided with time to reflect and relate to these ideas in their own ways. Often they come up with their own stories, talk about things they wish they had known sooner about sexual health and substance use, relate these ideas to their own religious practices and discuss how they manage risk and take control of their health in their own lives. With the help of this training, the facilitators have been able to discuss difficult topics in religious contexts with Muslim, Sikh and Christian members of their communities.

After attending the training, new facilitators begin by co-facilitating at least two workshops with an experienced facilitator. The program coordinators attend every workshop to provide feedback to the facilitators. Once new facilitators are facilitating alone, interpreters are hired if the CATIE program coordinators do not speak the language in which the workshop is being delivered. Their presence also allows the program coordinators to assist the facilitators in answering questions beyond the facilitators’ knowledge level. When interpreters are used, they professionally translate questions for attendees and for the program coordinators. Evaluations provide feedback and the coordinator debriefs with the facilitator after every workshop.

Sex, substance use and stigma in ethnocultural communities

The four communities that are the focus of this program are socially and culturally conservative. Practices around sex and drugs are often not openly discussed within families or in their communities.

This makes it more difficult to discuss sex and substance use in the Immigrant Health and Hepatitis C workshop. The role of CATIE’s bilingual facilitators becomes valuable in this context. As members of the same cultural communities and native speakers of the language, the facilitators are uniquely positioned as cultural brokers to discuss safer sex and substance use issues without being offensive to their community’s cultural sensibilities. CATIE also delivers separate workshops to men and women when appropriate.

Every year when the annual training is organized for CATIE’s bilingual facilitators, one session is dedicated to preparing the facilitators to respond to these issues appropriately.

Immigrant Health and Hepatitis C workshop

The Immigrant Health and Hepatitis C workshop was pilot tested with a number of partner community organizations and their clients. Through this process it became clear that it was necessary to address larger issues, including settlement stress, immigrant health and access to healthcare as they relate to hepatitis C.

A discussion addressing the realities of settling in Canada and the possibility that participants may need to take some time for their health was found to be much more engaging than a simple hepatitis C information session. The workshop spends an hour on immigrant health and then an hour on hepatitis C. Both parts of the workshop are grounded in case studies and discussion. For more details on the workshop content, please see the Program materials section of this case study.

The content of Immigrant Health and Hepatitis C was approved by the community advisory councils for this project. Although the hepatitis C information does not change from one workshop to another, the program coordinators and the bilingual facilitators work with the organizations hosting the workshop to tailor the information to the needs of the target community.

Media Literacy and Health Literacy workshop

During the development of the media campaign (see the section below on the media campaign), Media Literacy and Health Literacy workshops were held to build each community’s capacity to critically examine media and their messages. This gave community members a unique opportunity to think about how their community is appealed to as a market and how their own health is marketed to them through products. Commercials and public service announcements from the community’s home country as well as from Canada were played for the group. Persuasion tools such as flattery, repetition, fear and humour were identified in the health messages and examined critically.

After attending the workshops, the participants indicated that they preferred health messages with a focus on direct action like getting tested and building community and family, rather than an approach that was fear-based or focused on the consequences of long-term chronic illness. This informed the development of the media campaign.

Community outreach events

As part of the education and outreach activities, opportunities are identified to set up outreach tables at community events to provide hepatitis C information one-on-one to community members. The tables are staffed by CATIE’s bilingual facilitators so that information is provided to community members in their first language. These events are great opportunities for creating awareness about hepatitis C.

Partnerships for education and linkage to services

CATIE’s program is important in raising awareness in the four priority communities, but it is not set up to provide referrals to health services or to field inquiries in other languages. Once people attend a workshop, read one of CATIE’s pamphlets or see one of CATIE’s ads, they need a place to follow-up if they want to get tested or ask more questions.

The program formally partnered with the Toronto Public Health AIDS and Sexual Health Information Line to ensure continuity of referral and information. This infoline provides Ontario-wide free and anonymous counselling on HIV, hepatitis and sexual health. With staff who can offer services in 16 languages, this service is an additional support for community members who have questions after being exposed to the program’s media campaign, resources and workshops. The infoline staff can also refer people to testing sites across the province.

Focused capacity-building opportunities in ethnocultural communities

CATIE also organizes targeted capacity-building opportunities with key community partners to build relationships and to work with specific populations. These kinds of opportunities have built CATIE’s relationships within the four communities and have supported organizations to integrate some health or hepatitis C content into their work.

In 2014, CATIE held a peer training session to build capacity around hepatitis C for clients and staff from Toronto’s ethno-specific AIDS service organizations. In 2015, a Filipino community forum was organized in partnership with three community organizations. It was an opportunity to give newcomers information about research and issues central to that community in Canada and relate the information to health outcomes and prevention.

Future plans for capacity building include conferences for South Asian and Chinese service providers in Ontario.

Development and distribution of multilingual health education resource

CATIE has also developed linguistically and culturally tailored online and print resources as part of this program. CATIE’s multilingual website includes information on hepatitis C prevention, transmission and testing. CATIE also developed “What you should know about hepatitis C,” a print-based brochure that outlines basic information about hepatitis C prevention, transmission and testing. A hepatitis A, B and C puzzle was developed as an interactive workshop tool to give participants multiple ways to piece together the differences between hepatitis A, B and C. The puzzle has information, colour and spatial cues to provide a number of ways for a person to solve it.

Although the education and outreach component of the program is only offered in the four priority languages (Simplified Chinese, Urdu, Punjabi and Tagalog), CATIE offers its health education resources and website information in seven other languages (Hindi, Bengali, Tamil, Vietnamese, Spanish, French and Arabic) in addition to English. For more information on the translation process CATIE follows to ensure content accuracy, please see the “Translation and review” program element.

Media campaign

As part of the program, CATIE developed a media campaign to broaden awareness about hepatitis C among the four priority communities.

CATIE worked with an advertising agency to develop the health messages for the initial media campaign. These messages were pretested with the community advisory councils as well as Media Literacy and Health Literacy workshop participants. CATIE’s initial media campaign focused on direct health messages and messages appealing to community and family, specifically avoiding fear- or shame-based messaging.

The campaign has run a series of print, radio and online campaigns each year since 2012, and it has been adapted and updated. Editorial content was also produced for the four communities, including articles, radio interviews and TV programs.

Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2006;15(3):259-267.
Kreps G, Sparks L. Meeting the health literacy needs of vulnerable populations. Patient Education and Counseling. 2008;71(3):328-332.
Zanchetta MS, Poureslami IM. Health literacy within the reality of immigrants culture and language. Canadian Journal of Public Health. 2006 May;92(2):S26-30.

Required Resources

Two full-time coordinators with a focus on program development, partnership, recruitment, training and media production.
Sixteen casual bilingual facilitators to deliver workshops and do outreach in the languages of the community.
Partnership with provincial and national networks.
Connections to frontline services and community organizations serving newcomers and immigrants.

Challenges

Demand is high for workshops and translated health information across many communities and languages.
There is lack of uptake from the settlement sector because of other more immediate chronic health conditions.
Topics of sex and drugs are stigmatized in many cultural communities.
The rapidly changing landscape of hepatitis C treatment requires ongoing translation and updates.

Evaluation

Workshop evaluation

As of March 2015, 43 workshops have been delivered to 877 people. Evaluations in the clients’ first language are collected after every educational and training activity. The workshop evaluations for the Immigrant Health and Hepatitis C workshops have been overwhelmingly positive. In 2013–2014:

98% of workshop attendees reported the workshop was useful for them
97% of workshop attendees were satisfied or very satisfied with the workshop
99% of workshop attendees agreed or strongly agreed that the workshop was appropriate for them
97% of workshop attendees agreed or strongly agreed that the workshop was relevant to them
99% of workshop attendees agreed or strongly agreed that they would recommend the workshop to others

CATIE also collects key information to determine if the hepatitis C workshops are meeting their objectives. Overall, CATIE’s workshops have been shown to be very effective:

97% of workshop attendees agreed or strongly agreed that the workshop increased their knowledge of hepatitis C
the average knowledge of participants increased from 4.4 to 8.0 on a 10-point rating scale; 83% of participants reported an increase in knowledge-based on this scale
100% of workshop participants agreed or strongly agreed they will use/apply the knowledge gained at the workshop in their work/life
97% of workshop participants agreed or strongly agreed that the workshop increased their capacity to respond to hepatitis C within their communities/personal life

Resource distribution

Pamphlets: From 2013 to 2015, 16,623 “What you should know about hepatitis C” pamphlets have been distributed in the four priority languages: 4,239 in Simplified Chinese, 4,018 in Urdu, 3,842 in Punjabi and 4,524 in Tagalog.

Puzzles: Over 1,500 puzzles were distributed in the first two years. An additional 7,000 puzzles were printed in 2014–2015.

Website traffic: CATIE’s website maintains information in 12 languages (including English) and receives over 1,000 visits monthly.

Lessons Learned

Community ownership of the process helps create culturally appropriate and sensitive resources.
Working with faith-based groups and religious places helps the program reach out to the wider community.
Gender-segregated sessions can facilitate knowledge transfer especially among female participants.
There is no single way to understand stigma; it varies in different cultural contexts.
Meaningful partnership, community engagement and a strong interest in raising awareness of hepatitis C within newcomer and immigrant communities contribute to the program’s success and improve its reach.
The strong response to the program’s available resources online and in print highlights the need for more multilingual health work and information.
Targeted outreach and campaigns are important for newcomer and immigrant communities that don’t receive a lot of health promotion and prevention messaging.
Information on sexual health and drug use is available in the program’s workshop curriculum and resources after community review despite the stigma that exists around these topics. This means CATIE has found an acceptable way to address these topics.
The facilitation program has been a great opportunity for newcomers and immigrants with similar community or work backgrounds to connect around credentials and seeking work.

Program Materials

Other Useful Materials

Information found on the CATIE website

Resources

Hepatitis C Information for Immigrants and Newcomers

Contact Information

Hywel Tuscano, Coordinator, Hepatitis C Ethnocultural Education and Outreach Program
416-203-7122 ext. 246
htuscano@catie.ca