For many people, the word cancer carries the connotation of fear, hopelessness, living with pain, and thoughts of death. Because it is recognized as a chronic disease in developed countries, it means living with the disease and its treatment over a continuous period of time. It is also a disease that not only affects the person, but involves family, friends, colleagues, and the community.21
The diagnosis of cancer brings with it the cultural beliefs of each individual. Cultural elements are learned and shared by families. What people believe in, what is important to them, and what they value differ among the many diverse cultures of the world. Thus, how each culture approaches the belief in the prevention of the disease, responds to the diagnosis once made, or addresses survivorship and quality-of-life issues will not be the same.21
Cancer has long been believed to be fatal-that once given the diagnosis, it is a death sentence. It is a perception that persists even today in many parts of the globe despite advances in earlier diagnosis and treatment and individuals living longer, and well, with their disease. An early study in the United States by the American Cancer Society (1981) is a good example of the view that is held by many-that once diagnosed with cancer it is a death sentence.22 The study of 750 African Americans highlighted the disparities between them and Caucasians regarding knowledge of cancer and health behaviors. Many of the factors identified in the study such as cancer incidence, and pessimism about the future and hope for cure, can be found in the multiple cultures of the global community.23
Over the course of the 15 years of the 9 National Cancer Institutes of the USA-funded Cancer Prevention and Control Workshops, the 140 participants from 71 countries represented a diverse mix of gender, race, and ethnicity. It created a challenging learning environment of cultures. The representation from the WHO regions and countries provided a unique opportunity for sharing common beliefs that are invaluable in fostering an appreciation for the cultural dimension each one brings to the experience.
The primary premise of the cancer control and prevention workshops was to provide scholarly and factual information about cancer, as well as its prevention and control, culled from the scientific literature and the personal experiences of the distinguished faculty. The faculty supported the belief that a prerequisite for decreasing health disparities throughout the world was dependent on culturally sensitive interventions.24,25 It would be incumbent on all who attended to adapt the information learned to their individual learning needs and cultures.
The recognition of their knowledge of the beliefs and attitudes that each participant brought with them was necessary for taking the first step in application to practice. They also brought knowledge about the patients and groups with whom they worked in their own settings and about ways to integrate that knowledge into practice-the second step required for application for practice. Negotiation, the third step in application to practice, could then begin as the individuals worked with the various communities within their setting to adapt the knowledge and information they gained and could share.26
The world is now globally interactive. Individuals are a bridge or a catalyst between their own world of traditional cultures and commonalities that may become the norm for all. Computers, television, movies, and the ever-changing influence of the mobile global community have accelerated the number of other influences each is involved in.27
It was critical for the integrity of the learning process and the cohesiveness of the group necessary to facilitate learning that the multicultural perspective as written by Kluckhohn and Murray 28 was a focus.
"Every (person) is in a certain respect
a. like all other (people),
b. like some other (people), and
c. like no other (person)."
The role of the faculty was a challenging one. We had to acknowledge that the learners came from varied levels of educational background and cancer expertise and that we had to help them move from being a passive, or traditional, learner to an active learner who could critically look at themselves and their culture and alter their own behavior and then the behavior of others.24
Inherent in the design of the program was establishing a process for the participants to reflect on the learning they brought to the workshop and to decide if what they were learning was justified in their present situation. As Mezirow and associates point out, this is a critical part of the learning process that educators all too often fail to incorporate in program design.29
Shared knowledge and power between equal, but different, cultures facilitates co-learning through individual and group interactions. According to Mezirow and associates,
Perspective transformation is the process of becoming critically aware of how and why our presuppositions have come to constrain the way we perceive, understand, and feel about our world, of reformulating these assumptions to permit a more inclusive, discriminating, permeable, integrative perspective, of making decisions or acting upon these new understandings.29
All program participants were selected for the program on the basis of the following:
* Expressed motivation to learn, from the program faculty and from each other,
* A willingness to change personal behavior as appropriate,
* A desire to transfer learning through mentoring others and role-modeling personal health behaviors, and
* Transfering the knowledge gained to all avenues appropriate to their individual cultural setting.
There are many examples of the cultural considerations and issues addressed by the participants in the Cancer Prevention and Control Workshop in order to implement programs in their own countries. Selected individual reports are located in the "Program Outcomes" section. One example is listed below-An example of program implementation sustained, over time. Majda Slajmer Japelj, Director of WHO Collaborating Centre, Slovenia (former Yugoslavia), attended the first and second Cancer Prevention Workshops in 1986 and 1988. Despite having lost contact with her for several years, we have once again established communication with her. In response to our request for an update of her "apple" story, she submitted the following:
I was very glad to receive your message, as the education through which I was going attending your workshops, was most useful and very original in approach. I was and am again lucky that I was in position to transfer all what I was allowed to learn, to younger generations of colleagues in my country.
As our Centre is involved into the development of nurses in "transition" countries, we are again using the acquired knowledge for the work in the countries and for the workshops organized in Maribor for them. Therefore the idea with apples is very vivid again-nurses from southern European countries and from Central Asian countries are namely still very strong smokers, so educating them is very important.
How Has It Started?
After working with you and attending the education in New York and in London, it was clear to me that we have to do something, which would activate nurses for the anti smoking campaign. But how can you teach with fingers brown from tobacco? I knew that just prohibition does not help and that we have to offer something as replacement. People have always complained that when they stop smoking, they gain in the weight, because they feel hungry and are eating more sweets.
At the same time in our part of the country which has many apple orchards, farmers were complaining that they do not have market big enough for selling of their products and were looking for new forms of advertisement. So we have approached their Association and have offered them following: if they donate apples for all our workshops and meetings, we shall write the names of donors and will include the themes about healthy nutrition (including fruit) into our agendas.
It happened, we have and are still receiving apples from farmers and our slogan is as always: take an apple instead of the cigarette. It is helpful. During the last years we had groups of nurses from former Yugoslavia in our workshops; they wanted also to save some given pocket money for shopping and we have advised them to take apples with them during the lunch time-what is health, does not cost anything and the need for cigarettes will be smaller. They were later telling us that they have taken apples with them also in the evening and have eaten them instead of the last cigarette in the evening.
We are using also the old folks saying: an apple a day is taking the doctor away. They are returning now to Maribor for additional learning or when we are visiting them in their working places, they feel very embarassed, if other colleagues are smoking and some of head nurses have told us, that smokers are not invited to be health educators in schools or in the local community as long they do not stop smoking. This is very hard, because they are poorly paid and health educational programmes are offering them often additional income.
Now I can look back to a longer period of this cooperation with fruit producers and the results are very positive. For the arrangement of working room and places for coffee breaks we do not need flowers the baskets with colourful apples are the most beautiful decoration. The "Apple" idea was also taken over by some colleagues who have been visiting our courses and we are glad, that it happens.
Just to mention: There was also an interesting action during the war in Bosnia, when we had many female refugees also in Maribor. We wanted to use the time also for the education and have instructed them about the self-examination of breasts. It did not raise big interest. But as they had poor equipped rooms and were missing also mirrors, some of shops/producers have given us beautiful framed mirrors and we have presented them to those women who showed the interest for self-examination and this group was growing. After the war I have met the woman to who I have brought a beautiful mirror from my mother in law and she said to me that she has brought the mirror with her back to Bosnia and whenever she looks into it in the morning, she would feel guilty if she would not follow our advice-she wordly said that the mirror is telling her what she has to do.
You see, that we are working in very different conditions and therefore the way how your education was conducted, was an excellent example for our work. I wish you further a lot of possibilities for this work.