Proposing an Addition to the PAPM to Facilitate Access to Culturally Competent Health Care for Immigrants, Newcomers and Refugees
Precaution Adoption Process Model
The precaution adoption process model (PAPM) is a stage progression model tracking the achievement of sustainable behavior change in the health promotion field. Following the transtheoretical model of change, this is the second “major” stage theory used to approach behavior change. This evolutionary theory is separated into 7 stages and has distinct differences from the TCM.
Stages of PAPM
Stage 1 of the theory is described as “unaware of health risk”. In this stage a person has no information concerning a particular health risk, at this point it is likely that they also do not have an opinion about the risk. People are often reluctant to provide an opinion of the behavior during this stage. Stage 2 of the theory is described as “unengaged by the health risk”. At this stage a person may have some awareness of a health risk but do not have knowledge about how engaging in this behavior may affect them. Perceived susceptibility differentiates someone that is unaware of a health risk versus being unengaged by it. Here there is a higher likelihood that someone believes that there is a probability of experiencing a health threat as a result of a certain negative health behavior, or the absence of a positive behavior. (DiClemente et al., 2018)
Stage 3 of the theory is described as “deciding about acting” At this stage a person may have had personal experience with the health risk, there then needs to be a distinction between people who have thought about acting and people who have never thought about taking action to change the behavior. Stage 4 of the theory is described as “decided not to act”. This is an endpoint in the stage progression and includes a person that has considered information available concerning behavior change, but does not feel that protective action is necessary. Stage 5 of the theory is described as “deciding to act”. At this stage, a person who has taken information available into consideration and decided to take action in moving towards a sustainable behavior change. Stage 6 of the theory is described as “acting”. At this stage implementation of the behavior change process occurs. Information that a person is provided with determines how they choose to go about the change. Detailed information is provided at this stage. Stage 7 of the theory is described as “maintenance”. This stage is similar to the TMC, in that at this point behavior change has already occurred. It is in the process of being made a sustainable change. Stage 7 is the second endpoint of the PAPM. (DiClemente et al., 2018)
Development of the Theory and Differences from TMC
According to Weinstein and Sandman (2002) there are four basic elements of stage progression theories of behavior change. These are
- “A classification system to define stages
- An ordering of stages
- Stages that are defined such that common barriers to change are faced by people in that same stage
- Stages that are defined such that different barriers to change are faced by people in different stages “
The last two points are where the PAPM and TMC differ. In the PAPM, there is an important distinction to be made between the first two stages, “unaware of health risk” and “unengaged by health risk” whereas this is combined into the precontemplation stage in the TMC. Optimism bias is an important concept that creates this distinction and is a defining concept of stage 2 of the PAPM. It describes the common occurrence of people not perceiving themselves to be as vulnerable to adverse consequences of a health-risk behavior than their peers also engaging in the behavior. This is key for creating targeted interventions for populations in these separate stages. If people in stage 2 are facing common barriers, interventions can be targeted more specifically and will have a better chance of being effective. This will not hold for people that are both “unaware” and “unengaged” in the precontemplation stage of the TMC. The difference in barriers that people face in this stage could make interventions unfocused. (DiClemente et al., 2018)
The TMC moves people that relapse back into the precontemplation stage to progress through that model. This is different in the PAPM, where a person who attempts a behavior change and then rejects action is placed in stage 4, “decided not to act”. People who have attempted behavior change and have not been successful are facing different barriers than those in the precontemplation stage, therefore interventions aimed towards these populations should be unique to their needs. Aligning a behavior change model with the basic elements of stage progression identified by Weinstein and Sandman (2002) is essential to create stage-matched interventions for recipient populations.
Moving Through Stages
Facilitating internal and external motivation, providing sufficient knowledge and removal of barriers are important aspects of creating interventions that allow people to progress from stage to stage in the PAPM. Specific intervention strategies are identified for stage progression.
Stage 1 Stage 2: Enhancing exposure to information about health risks of a behavior will be effective in transitioning someone into stage 2 of the PAPM. This can be done through media campaigns and other forms of knowledge translation.
Stage 2 Stage 3: During this transition, making health risks and consequences personal, and identifying impacts it can have on a person as an individual is important. Messages from social supports are important here, as well as having experience with the risk behavior or adverse outcomes associated with the behavior.
Stage 3 Stage 4 or 5: Here, enhancing perceived efficacy to perform protective health behaviors is extremely important. Levels of perceived susceptibility to health consequences and perceived severity of these consequences is essential to a personal risk evaluation that can motivate someone to decide whether or not to act. Ensuring that social norms are supportive of action is important movement out of stage 3 as well as reducing perceived barriers to behavior change.
Stage 5 Stage 6: Interventions to provide someone with the tools and resources to act and engage in the behavior change process require significant time, effort and the dissemination of knowledge. Cues to action and social support are also extremely important here to provide continuous motivation and encouragement to engage in positive health behaviors and avoid ones that involve risk.
As is evident, identification of a person’s progression through these stages is important in creating target interventions. In order to remove barriers and promote healthy behaviors, needs and challenges of populations need to be identified. PAPM, a stage progression model allows for this.
Health Behavior: Accessing Culturally Competent Mental Health Care Services for Newcomers, Immigrants and Refugees in Canada
The ability of immigrants, newcomers and refugees to access culturally competent mental health care services is a public health concern that is highly relevant in Canada’s social and political climate today. There are several systemic and social barriers that could inhibit someone in this population group from seeking mental health care. In this section, the scope of this issue will be explored as well as both effective and ineffective practices that are currently in place to mitigate this problem.
Description of Problem
In 2016 Canada accepted 296 000 new permanent residents, 62 000 of which were refugees. (Government of Canada, 2017) Studies of mental health in immigrant populations show little to no difference in the prevalence of mental health issues between immigrants and non-immigrants, however there are inequities in the ability of newcomer populations to access mental health care. (Volleberg et al., 2005) When looking at this population group it is important to acknowledge that needs across the group are not particularly uniform. Within this category there is great diversity (in terms of country of origin, life experiences, and residency status). (McKenzie et. al, 2010) To affect the most significant change a systemic approach recognizing cultural competency is necessary to remove barriers that prevent these groups from accessing relevant and impactful mental health care.
Cultural competence in health care is important in creating a system that can deliver equitable and quality care to all patients. This care should not be inhibited by a patient’s culture, race, ethnicity or the language(s) they speak. (Bentancourt et al., 2005) Canada is a haven to people fleeing war and conflict from many regions around the world, and a home to many seeking a better life for themselves and their families. As a country with a publicly funded health care system, there is a responsibility to provide accessible care. When there is meaningful communication between a health care provider and a patient, there is known to be greater adherence to instructions from a care provider as well as better overall health outcomes. (Stewart et. al., 1999) This shows that providing culturally competent mental health care should be a priority while attempting to improve population health outcomes.
Specific to refugees, there has often been a significant amount of exposure to violence, trauma, loss and separation. (Mental Health Commission of Canada, 2016) These people face unique challenges that can put them at risk for mental health issues. The Canadian Pediatric Society’s guide for mental health promotion for newcomers’ highlights that these challenges should be addressed early on in order to promote wellbeing and resiliency. Support during the initial transition into a new environment will contribute to better performances in school. (Canadian Pediatric Society, 2018) Protective factors that address the social determinants of health can be helpful in taking a proactive approach to reducing the risk of mental health issues. These can include ensuring newcomers have a stable living environment and are connected to social supports in the community. Protective factors, as well as risk factors for developing a mental health issue occur at the individual, community or family level as well as a broader environmental and systemic level. The table in Appendix I illustrates some of these factors that may be present in the newcomer population.
Individual, Community and Systemic Barriers to Accessing Care
As is known, interventions that take on a preventative approach will be most effective in reducing the prevalence of mental health problems in this population. However, there is a need to access culturally competent care when mental health issues do arise. Language can be a significant barrier for a newcomer looking to access resources. Awareness of this issue by care providers is important to expand their reach and cater to newcomers. Ability and willingness to communicate without fear of judgement can also create barriers in a person seeking care’s ability to explain how they are feeling, symptoms they are experiencing and what they need.
Typical social determinants of health are applicable to migrants and contribute to barriers in accessing mental health care, but migrant status and settlement is in its own way a social determinant. Government policy plays a big role in removing systemic barriers to accessing care as well as in promoting and mandating culturally competent care. Special attention needs to be paid to the clarity of residence statuses, affordable and safe housing, access to job and education opportunities and connections to community. (Cleveland and Rousseau, 2013) As part of a plan to integrate newcomers into Canadian life, it is necessary to incorporate their unique needs into planning and delivery of care. (Mental Health Commission of Canada, 2016)
At an individual level, the age at which people are moving to Canada for the first time can have strong impacts on their health outcomes. Younger children are found to have similar health statuses as Canadian peers of similar age, however adults that are facing challenges accessing education and maintaining job security will have additional contributors to mental health stressors. Young adults also face unique challenges as they are building an identity for themselves, while having to navigate a new culture. They may have extra responsibilities in helping facilitate their parents transition. (Khanlou & Guruge, 2008) Gender, cultural background and religious or spiritual identity were also noted as important factors that affect access to mental health care at the individual level for newcomers. (McKenzie et al., 2010)
Current practices in place and Failure to Solve the Problem
Accepting refugees and migrants into Canada is not new in this country and in 1988 a national task force investigated mental health outcomes of immigrants and refugees. The findings of this investigation recognized that exposure to a new culture, country and way of life does not necessarily have to take a toll on mental health. The task force suggested three principles that would prioritize mental health and well-being for newcomers:
- “Risk factors must be mitigated, and remedial services made universally accessible”
- “Prevention and treatment of emotional distress in immigrants and refugees involve persons with whom migrants come in contact with as much as they do the migrants themselves. Sensitizing Canadians – immigration officers, settlement workers, teachers, neighbors, health care personnel – to the ways culture can affect encounters with newcomers helps eliminate sources of distress for migrants and facilitates effective mental health care”
- “For newcomers to adapt and integrate into Canadian society, their strengths, needs and perspectives must be taken into account by decision-making bodies at each level of government, by planners and service providers.” (Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees, 1988)
27 specific recommendations were made by the task force for Citizenship Canada, Immigration Canada and Health Canada. The work these federal bodies do with newcomers are imperative to prevent mental health issues and improve the mental health upon arrival and settlement. 6 of these 27 recommendations have been implemented to this date.
Currently, practices in place to mitigate this issue seem more informational, available in the form of a long list of resources for newcomers to sort through to find a mental health care service. There is not significant work being done in terms of individual capacity building or removal of barriers to accessing treatment. The gap between providing people with knowledge of resources and providing care givers with cultural competency knowledge, needs to be filled by introducing feasible methods of facilitating access to resources.
Adding to the PAPM and Operationalizing the Model
In this section I will propose additions to the PAPM that could provide ease in transitions between stages and target interventions to a culturally diverse population with various needs.
Rather than applying a medicalized or psychiatric approach to remedying this issue, I will focus on removing barriers to accessing care and building capacity and self-efficacy in individuals. The new addition I am proposing will integrate the social-ecological framework of health promotion to tackle the problem at all levels. It is my hope that special attention to this framework will help to build a better integrated intervention system that can more easily facilitate persons transitions between stages in the PAPM model. I will refer to this new model as the ecoPAPM and a detailed diagram is included for reference in Appendix II.
Stage 2 to Stage 3 – Building individual capacity through health literacy (Individual level) Between stage 2 and 3 I have added “building individual health literacy” during the transition between these stages. While navigating completely new social systems, newcomers to Canada also need to learn about how health services operate in their new home. At the individual level, building health literacyis important to be able to transition from being “unengaged by a health risk“ to “deciding about acting”. In this case action would look like taking preventative measures to maintain good mental health, being aware of what can put themselves at risk for a mental health issue, and have the knowledge and tools needed to access culturally competent care. (King, 2007) The Canadian Public Health Association recognizes that immigrants are coming to Canada largely with high education levels, but 2003 IALSS the International Adult Literacy and Skills Survey (IALSS), results revealed that 60% of immigrants were falling below the minimum level of literacy that is needed to “cope with the demands of everyday life and work in a knowledge economy”. English proficiency was identified to be an important determinant of the prevalence of depression in immigrants from southeast Asia, as well as a determinant of employment security. (Beiser & Hou, 2001) Implementing initiatives that are focused on individual needs in improving health literacy will help transition someone into stage 3 of deciding about acting because they will be able to better understand and appraise information they are being given. They can then move into the decision-making process depending on what they perceive their needs to be. This will build individual capacity and give power to people trying to navigate the mental health care system.
Stage 3 to Stage 4 – Removing Structural Barriers to Health Literacy (Systems level) Health literacy can also be improved at a systemic level. I have added the “removal of structural barriers to health literacy at a systems level” in the transition between stage 3 and 5. As a concept, health literacy is often thought of in terms of only verbal skills, and how these are perceived by health care providers but this neglects various cultural contexts of communications. In many cultures’ authority is perceived differently, faith can have a large role in values and therefore communication as well as many other factors that need to be addressed by care providers and people planning interventions. (McKenzie, 2010) If cultural competency is taught to all health care professionals, and there is recognition and empathy of the difficulties newcomers are facing, interactions with them in a patient context will be more positive.
Stage 4 – Including an evaluation/reflection stage at all levels of the ecological model (Systems, community and individual level) Including an evaluation and reflection stage at this endpoint (stage 4) in the ecoPAPM model is essential to recognizing the reason behind an individual deciding not to act. We can evaluate whether it was a failure at a systems level, a community level, a lack of self-efficacy or perceived capacity at an individual level or whether or not a person needs to take action and seek mental health care services (or any other health behavior). Adding this in will provide a holistic perspective of how the ecoPAPM operates and can identify things that do not seem to be working earlier on in the model. At this stage if an issue is recognized that can be addressed or fixed, then this can be done to move someone along the model if they are willing.
Stage 5 to Stage 6 – Removing Structural Barriers to Accessing Care services (Systems level) Between the decision to act and acting (stage 6) I have included removing structural barriers to accessing care services. This can include the provision of culturally competent care services that are not already readily available, transportation to services and more. Through policy we can mandate the provision of programs, providing funding and investment in resources to get newcomers started off well will eventually pay off when they are able to further their education, find employment and contribute to the Canadian economy while also enriching our diverse communities. Ensuring government and industry are aware of the benefits that investing in the wellbeing of newcomers will bring to Canadian society is important in providing them with incentive to act. When there are fewer structural barriers to accessing mental health care, newcomers will be more likely to seek out these services and maintain this behavior.
Stage 5, 6 and 7 – Creating and maintaining social support networks (Community and systems levels)Creating and maintaining social support networks is essential for people moving through the action and maintenance stages of the ecoPAPM. The most impact in terms of intervention at this stage can occur at the community level, with support from government and industries. Creating community programs and groups that can help newcomers form social connections with each other, community resources and Canadian citizens can help in them finding a place and sense of belonging in their new home. (Canadian Pediatric Society, 2018) A sense of belonging has been shown to be very important during transitional periods, and can contribute to all aspects of wellness and maintenance of good mental health. Social support can be used to encourage people to seek out mental health care, find stable housing or employment and build a network of people that can help throughout the settlement process. Social support is also essential to adherence with medical care plans. (Lloyd, 2014)
Conclusion
The creation of the ecoPAPM is meant to work to the remove barriers that inhibit immigrants and newcomers accessing mental health care and build capacity in individuals. These recommendations come from a multi-level systems perspective. As is recognized in the ecoPAPM, individuals at different stages in the model have different needs and many of these needs can be addressed by different levels on the ecological model of the broader health system. I have focused on intervention’s applicability at the individual, community and systemic/policy level. I believe that specification approaches the problem from a broader lens and allows for a further reach with intervention initiatives. Depending on the needs of an individual, a more targeted approach would be more effective but in terms of this particular public health issue there is a lot that can be done from the top down to remove barriers to accessing culturally competent mental health care.
Cultural competency should be an important consideration in any health promotion intervention, or health behavior model development but especially one as personal as facilitating access to mental health care. A lot of behavior change models were created with a general population in mind, however this not account for unique needs that someone unfamiliar with Canadian culture and language might face. There are nuances in navigating the health care system that we are familiar with but take for granted that it is something people are always aware of. Creating a system that is accessible to all is important and focusing on building cultural competency at all ecological levels in the health promotion framework will ensure that interventions and programs are adaptable and effective.
APPENDIX I
APPENDIX II
Diagram of ecoPAPM : Using the ecological framework of health promotion to facilitate stage transition in the Precaution Adoption Process Model
References
- Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence and health care disparities: key perspectives and trends. Health affairs, 24(2), 499-505.
- Beiser, M., & Hou, F. (2001). Language acquisition, unemployment and depressive disorder among Southeast Asian refugees: a 10-year study. Social science & medicine, 53(10), 1321-1334.
- Canadian Pediatric Society. (2018). Caring for kids new to Canada: A guide for health professionals working with immigrant and refugee children and youth. Retrieved from https://www.kidsnewtocanada.ca/mental-health/mental-health-promotion
- Canadian Task Force on Mental Health Issues Affecting immigrants and Refugees (1988). After the door has been opened: Mental health issues affecting immigrants and refugees in Canada. Ottawa: Multiculturalism and Citizenship Canada
- Cleveland, J., and C. Rousseau. (2013). Psychiatric symptoms associated with brief detention of adult asylum seekers in Canada. Canadian Journal of Psychiatry, 58(7): 409-416.
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- Government of Canada. (2017). Parliament annual report on immigration. Retrieved from https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/annual-report-parliament-immigration-2017.html
- Khanlou, N., & Guruge, S. (2008). Chapter 10: Refugee youth, gender and identity: On the margins of mental health promotion. In: Hajdukowski-Ahmed M, Khanlou N, & Moussa H (Editors) Not born a refugee woman: Contesting identities, rethinking practices. Oxford/New York: Berghahn Books (Forced Migration Series).
- King, J. 2007. Environmental Scan of Interventions to Improve Health Literacy: Final Report, National Collaborating Centre for Determinants of Health, St. Francis Xavier University, Anti- gonish, Nova Scotia.
- Lloyd, A. (2014). Building information resilience: how do resettling refugees connect with health information in regional landscapes–implications for health literacy. Australian Academic & Research Libraries, 45(1), 48-66.
- Mental Health Commission of Canada. (2016). Supporting the mental health of refugees to Canada. Retrieved from https://ontario.cmha.ca/wp-content/files/2016/02/Refugee-Mental-Health-backgrounder.pdf
- McKenzie, K., Hansson, E., Tuck, A., & Lurie, S. (2010). Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups. Canadian Issues, 65.
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