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The Challenges of Engaging Young Black Women and Women of Colour in Health Care Service Delivery Systems, Including Community Health Centres

I Introduction

‘Really want me here, welcome me': engaging racialized young women in a holistic discussion on health and well-being   
        

"So if I were supposed to come to a centre for women of colour, I'd expect to see like a place that we can just sit around like something like this. Like couches, just sit around to relax and you can just feel open to talk about your problems to each other. And that people (young women) will be there to help you no matter what your situation is."

-Participant, young women's focus group, Women's Health in Women's Hands Community Health Centre, 2007

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II Overview

Engaging young women in discussions on their own health and well-being is challenging. It becomes even more challenging with regards to young black women and women of colour due to racialization/marginalization and a general lack of culturally relevant services, often due to a parochial understanding of cultural competence on the part of the providers which result in a lack of trust and faith in the health care system (Women's Health in Women's Hands Community Health Centre (WHIWH-CHC) Young Women's Focus Group, 2007). The purpose of this article is to acknowledge these challenges and offer some recommendations for greater and more effective participation of young racialized women in taking ownership of their health. The recommendations are based on three "conversation circles" with 19 young women from racialized populations in the city of Toronto.

This article includes an overview of WHIWH-CHC, followed by an explanation of why the conversation circles were planned, the methodology, the results and finally, the learning we gleaned from this process. While the focus of this brief article is to share strategies to engage young racialized women, it will also touch on some of the structural barriers to health identified by the participants, At the onset, it should also be acknowledged that the suggestions/recommendations presented here are more applicable to large metropolitan centres (in this case, the Greater Toronto Area) as issues facing young racialized women in remote and rural communities are beyond the scope of this article. 

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Women's Health in Women's Hands Community Health Centre: who we are and what we do

WHIWH-CHC is a pro-choice, anti-racist, multilingual, participatory community health centre for women of diverse backgrounds in Metropolitan Toronto and surrounding municipalities. We are committed to providing primary health care to Black Women and Women of Colour from the Caribbean, African, Latin American and South Asian communities in Metropolitan Toronto and surrounding municipalities. We are committed to working from an inclusive feminist, pro-choice, anti-racist, anti-oppression, and multilingual participatory framework in addressing the issue of access to healthcare for our mandated priority populations encompassing all the determinants of health caused by gender, race, class, violence, sexual orientation, religion, culture, language, disability, immigration status and socio-economic circumstances. 

We acknowledge women as experts in their own healthcare and incorporate the biological, socio-cultural, psychological and spiritual dimensions of women's lives in offering health care services.

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III Rationale and Methodology for the Conversation Circles and Methodology

Since Toronto is witnessing a growing number of young and racialized youth populations, we recently decided to explore the possibilities of offering services for young women from our priority populations. An initial focus group was conducted in 2007 with young women from African and Caribbean communities. These young women drew our attention to a general lack of youth-specific programs and also, to the fact that there is a wide range of social, cultural, familial pressures that young women live with that impact their ability to take care of their health and/or access services. Our decision to explore these issues further with young women from African, Caribbean, Latin American and South Asian communities led to a series of consultations in the summer of 2008. Pierrette Walker and Gabriela Agatiello were hired to co-facilitate this project.

More than two million women, or 14% of the total female population, are members of a visible minority. They are centered largely in Toronto and Vancouver.

While developing a methodology to explore matters pertinent to young women, we were mindful of their interests and socializing practices. Many WHIWH-CHC staff shared various previous considerations in sustaining youth focused programming at the centre. While there was no dearth of creative ideas, there were shortcomings in the strategies to actually get the youth to participate in the planning and execution of initiatives. With this history of challenges in engaging youth, we consulted community organizations such as Centre for Addiction and Mental Health (CAMH), New Heights Community Health Centre, and the Alliance for South Asian AIDS Prevention (ASAAP) who shared their programming successes, barriers and considerations. Thus a participatory framework recognizing young women as experts in their lives, needs and lifestyles and respectful of their cultural considerations, age and interests informed the conversation circles. In order to be truly engaging and youth-friendly, we modeled a creative and interactive atmosphere that allowed participants to have ample room for expressing their ideas, experiences, and specific concerns about their health/available services. The consultations had the following components:

  • The Health Continuum - exploring young women's sense of health and well being
  • Post It! - exploring individual health needs
  • Word on Da Street! - effective outreach strategies for young women
  • If I Could Dream Dream Dream this is What it Should Be - young women's vision of ideal health care setting

Participants were encouraged to choose the direction of the session while the staff limited themselves to facilitating roles only. This proved to be an effective strategy for locating common interests and concerns.

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IV Key Questions and Results

The participants were asked to identify overarching and specific issues impacting their health and their service/program/advocacy needs. The following key questions were integrated within the four components of the conversation circles:  

  • What are the issues currently affecting young women in their communities?
  • What barriers do young women face in accessing health care/programs and what types of services/programs can address those?
  • What outreach strategies/elements are meaningful for young women?
  • What needs or considerations should a Community Health Centre take into account when creating facilities, programs and services for young racialized women?

A range of issues were identified as crucial for young women's health promotion. These were both systemic/structural and social/familial. The participants however, demonstrated an understanding that these factors are often interdependent and, in order for them to maximize their health outcomes, a holistic model of care needs to be promoted. The following points summarize their thoughts:

  • Racism/sexism, family and relationship issues, poverty and low income and, exposure to violence at many levels were affecting young women's health and well-being. Participants noted lack of access to anti-oppressive, anti-racist healthcare providers with adequate understanding of these structural determinants as their major concern.  
  • The most commonly identified barrier in accessing health care were associated with religious and moral beliefs, and socio-economic factors (e.g., lack of transportation money, especially for those without status).
  • Privacy and family pressure were two other major concerns that the participants shared.
  • Young racialized women often are not aware of their rights in health care and would appreciate greater understanding of the social determinants of health, susceptibility to infectious diseases and, self care to promote mental health etc.
  • While health promotion and education (through workshops etc.) are worthwhile, young racialized women also need informal sharing circles, mentoring programs and access to employment for their well-being. These programs should help young women with self-esteem, self-care and, life skills building etc.; all with the end goal of promoting empowerment. Expressive arts were recommended as a particularly engaging method for promoting young women's health and well-being.     
  • There needs to be more youth specific community health centres, services for queer youth and non-status youth etc. Accessible health care settings that are welcoming and receptive to young women's needs are crucial as well.

Since there is only a slim body of research on young racialized women's health needs it would also have been appropriate to exclusively discuss the health issues identified by the participants. But the purpose of this article is also to outline strategies to engage young women more effectively, and, therefore, the following section includes their thoughts on effective outreach strategies and their visions of an ideal health care setting.

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Youth Friendly Outreach/Engagement Strategies

According to the participants, specific factors should be considered while planning programs and services for young women and envisioning them in any space as clients, participants etc. Their recommendations were with regards to community health centers. They suggest that community health centres be rigorous about researching, planning and executing young women's programs and services. For instance, the following should be considered:

  • Age and potential parental control/pressures that may exist in their surroundings.
  • Location/accessibility of health facility (including its visibility), a careful confidentiality maintenance plan.
  • Youth friendly atmosphere (e.g., bright colours, music, open door/walk-ins), such as a youth lounge filled with relevant educational materials, computers, condoms, and a television etc. was suggested.
  • Visiting middle and high schools to facilitate educational workshops on issues related to young women's health was suggested as well.
  • It was strongly recommended that services and programs consider the precarious situation of non-status women and recognize that their lack of legal status in the country is a significant determinant of their health/quality of access to health.

Participants also advised that promotional materials/advertisements must adapt quickly to the information age. Existing outreach strategies have serious limitations. Community health centres need to utilize the Internet, websites and portals that youth frequently access, e.g., Facebook. Current promotional materials often are too wordy, rely on print media and, fail to use diverse images etc. Participants recommended more vibrant colours, appealing graphics, relevant and to the point messaging and different media (TV, Facebook, Billboards, real people telling their stories) and incentives to effectively engage young women. Community health centres also need to make themselves more visible to youth by advertising services through the radio, Internet, Facebook, word of mouth and, creating satellite centres that are more easily accessible to youth living outside the downtown core. Finally, programs should be sustainable financially and organizationally.

Insights from some of the young women around how they could be engaged:

If you...
"get my attention, I may come"
"add colour to your poster"
"were cheerful"
"have it (activities like this)"
"get me an appointment"
"gave me free stuff and got my friends involved"
"accompany me/tell me about it"
"give me options for date and time, I could figure out a good time for me"/ "Give me something relevant to relate with"
"open up the age and race group"
"were exciting and easily relatable" (issues related to me as a black women)
use "facebook," have " diverse people," "promote interesting topics affecting young people today", "make things more informative"
"make it interesting and directly relate it to me by making it look attractive and informative"
"have individual classes where I could share my health issues in private"
"really want me here, welcome me."

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V Lessons Learned

Barriers embedded within the health care system strongly influence how one experiences health and how one is treated by the health care system. At WHIWH-CHC, our goal is to strategize to remove these barriers and address the issue of access to health care from a systemic advocacy stance. These conversations with young racialized women form part of our ongoing engagement with the communities of women we work with and will inform future programming and service delivery plans. We learned that young women need to be reached out into their comfort zones and in ways that make sense for them. We also learned that contrary to popular beliefs, these women are well aware of their health needs and would access services that are relevant, engaging and youth-friendly. Their marginalization based on their age, youth stereotypes, racialized/minoritized status and finally, their financial barriers create a cycle of multiple physical and emotional needs which however, remain unmet because of these very barriers. Community health workers promoting young and racialized women's health, therefore, need strategies to break this cycle. Programs that address systemic barriers are imperative, as are up-to-date outreach messages. Youth advisory boards would be beneficial as well provided they become platforms for mentoring and learning.