Toronto’s 2-1-1 Healthcare Services forImmigrant Populations

Andrea A. Cortinois, PhD, MPH, Richard H. Glazier, MD, MPH, Nadia Caidi, PhD,Gavin Andrews, PhD, Mary Herbert-Copley, BA, Alejandro R. Jadad, MD, DPhil

Background: Although access to information on health services is particularly important for recentimmigrants, numerous studies have shown that their use of information and referral services islimited. This study explores the role played by 2-1-1 Toronto in supporting recent immigrants.

Purpose: The study objectives were to (1) understand whether 2-1-1 Toronto is reaching and supportingrecent immigrants and (2) gain a better appreciationof the informationneeds of this population group.

Methods: A phone survey was conducted in 2005–2006 to collect information on 2-1-1 users’characteristics and levels of satisfaction. Survey data were compared (in 2006) with census data toassess their representativeness. To achieve Objective 2, semistructured qualitative interviews wereconducted and analyzed in 2006–2007, with a subset of Spanish-speaking callers.

Results: Recent immigrants were overrepresented among 2-1-1 callers. However, the survey pop-ulation was substantially younger and had higher levels of formal education than the generalpopulation. Health-related queries represented almost one third of the total. The survey showed veryhigh levels of satisfaction with the service. Many interviewees described their fırst experiences withthe Canadian healthcare system negatively. Most of them had relied on disjointed, low-qualityinformation sources. They trusted 2-1-1 but had discovered it late.

Conclusions: Results aremixed in terms of 2-1-1’s support to immigrants. A signifıcant percentageof users do not take full advantage of the service. The service could become the information “entrypoint” for recent immigrants if it was able to reach them early in the resettlement process. Proactive,community-oriented work and a more creative use of technology could help.(Am J Prev Med 2012;43(6S5):S475–S482) © 2012 American Journal of Preventive Medicine

BackgroundIn Mexico, I was blind. In Canada, I became blind,deaf and mute.1

(Jimena, aged 30 years)

Toronto is one of the most multicultural cities inthe world.2 In 2006, according to the NationalCensus of Canada, 2.3 million people, or 45.7%

of the population living in the TorontoCensusMetropol-

From the Centre for Global eHealth Innovation, University Health Net-work andUniversity of Toronto (Cortinois, Jadad), the Faculty of Informa-tion, University of Toronto (Caidi), the Institute for Clinical EvaluativeSciences (Glazier), Centre for Research on Inner City Health, St. Michael’sHospital and University of Toronto (Glazier), Family and CommunityMedicine, St. Michael’s Hospital (Glazier) Toronto, Department of Health,Aging and Society, Faculty of Social Sciences, McMaster University(Andrews), Hamilton; and Policy and Stakeholder Relations, UnitedWayof Canada (Herbert-Copley), Ottawa, Ontario, Canada

Address correspondence to: Andrea A. Cortinois, PhD, MPH, Centrefor Global eHealth Innovation, Toronto General Hospital, R. Fraser ElliottBldg., 4th Fl., 190 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.E-mail: a.cortinois@utoronto.ca.

0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2012.08.010

©2012American Journal of PreventiveMedicine. All rights reserved.

itan Area (CMA) were foreign-born. Immigrants camefrom more than 200 countries and spoke nearly 150 lan-guages. Half of them (49.5%) spoke English as a secondlanguage, a substantial barrier to the navigation and ne-gotiation of an already unfamiliar healthcare system.3

Although adequate access to information on health-related services would be particularly important for im-migrants,4–12 numerous studies have shown that they areone of several nondominant groups in society who usehealth information and referral services the least.13–23

The present study focuses on the role played by 2-1-1Toronto in supporting immigrants, with emphasis onboth clinical services and other services that this popula-tion group needs to use when facing health problems.Information on “health-related services,” such as childcare and elder care, transportation services, homemak-ing, insurance and legal support services, counseling,spiritual support services, and many others, is often notavailable through healthcare providers. (Defınitions of“health-related services” vary. Many defınitions draw at-

tention to the perceived and evaluated needs of a specifıc

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patient population to emphasize the complex issues re-lated to caring for such population.24–26 This paperadopts a loose and inclusive defınition.)Therefore, services such as 2-1-1 have the potential to

bridge an important gap. In Toronto, 2-1-1 was launchedin 2002 and, at the time of the study, employed 31 coun-selors who answered in excess of 30,000 phone calls amonth in more than ten languages.27

PurposeThe two objectives of the study were to (1) understandwhether 2-1-1 Toronto is used effectively by recent im-migrants, defıned as immigrants who, at the time of thestudy, had spent less than 5 years in Canada; and (2) gaina better appreciation of the information needs of recentimmigrants struggling to navigate and negotiate an unfa-miliar healthcare system.

MethodsTo achieve the fırst objective, a phone survey of 2-1-1 Torontocallers was conducted. The survey included an initial interview,completed at the time callers fırst contacted the service, and afollow-up interview with users who had been seeking health-related information. Initial interviews were conducted over a pe-riod of 6 weeks, between July and September 2005.A sample of 2-1-1 Toronto users, selected by systematically

inviting every eighth caller, was surveyed. Inclusion criteria in-cluded speaking English well enough to understand the recruit-ment script and the survey questions; being aged �18 years; livingwithin the boundaries of Toronto CMA; and being an information“end user,” not a community agency worker calling on behalf ofclients. Questions included demographic descriptors; respondentethnic background; history of migration; knowledge of languages;socioeconomic activities; sources of health information; andknowledge/use of 2-1-1 Toronto services.Survey data were compared with Toronto CMA data extracted

from the Census of Canada 2001, the most recent available at thetime of the study, to assess their representativeness. To match thesurvey inclusion criteria, only information for individuals aged�18 years was included. Data from the long form of the censusquestionnaire, which includes 53 questions on topics such as edu-cation, ethnicity, mobility, income and employment, were used.3

Follow-up interviews with participants who had been seekinghealth-related information and had given consent to be contactedagain were conducted in July and August 2006. The 10-monthinterval was considered suffıcient to assess the contribution of2-1-1 to the solution of even complex queries. The questionnairefocused on whether 2-1-1 solved callers’ problems and their satis-faction with 2-1-1.Quantitative data analysis was conducted in 2006 using SAS/

STAT software.28 Univariate and bivariate analyses, includingmeasures of central tendency, distribution, and shape, were con-ducted. In addition, ten variables were compared between surveyand census: age, gender, marital status, highest level of formaleducation achieved, legal status inCanada, personal andhouseholdincome, mother tongue, and language most commonly spoken at

home and at work. All variables were categoric with the exception

f age andpersonal income,whichwere recoded as categoric beforeomparison because (1) they were not normally distributed, mak-ng the t-test inapplicable; and (2) the census data at the individualevel were not available, preventing the use of a nonparametric test.n all cases, therefore, data were compared using �2 statistics.Callers’ queries were analyzed, classifıed as health-related/non-

health-related, and organized into 16 thematic groups. Querieswere considered to be health-related when they were about specifıcdiseases/conditions, health providers/services, therapies anddrugs, administrative aspects of health care, and health needs ofspecifıc population/patient groups. Queries also were classifıedinto two groups depending on whether they related to simple,factual information needs, such as a phone number or address, orcomplex needs. Counselors for 2-1-1 are highly experienced pro-fessionals trained to analyze complex problems and would be un-derutilized if they responded only to factual queries.To achieve the second objective, between August 2006 and

March 2007, a small number of digitally audio-recorded, 60–120-minute, semistructured interviews were conducted with 2-1-1 To-ronto callers who were recent immigrants and had sought health-related information. The interview schedule included 55 questionsorganized around three thematic areas: participants’ personal his-tories of migration; their experiences with health-related servicesbefore and after migration; and the “information pathways” theyfollowed after their arrival in Canada to learn about local services.A convenience sample of participants was recruited by a 2-1-1counselor who invited participation after addressing callers’ initialqueries.Data review and analysis (2006–2007)were developed in parallel

with data collection tomonitor thematic saturation. Only Spanish-speaking immigrants were invited to do these interviews, as bothinterviewers spoke Spanish fluently and were therefore able tointerview participants in their mother tongue. This ability wasessential to explore participants’ experiences in their ownwords, inthe form of a life narrative, using images and metaphors of theirchoice, and to provide description of information use and effect ina more vital and meaningful way.28 Eight interviews were con-ducted face-to-face and two via telephone.Immediately after each interview, a health professional who

spoke Spanish as a fırst language transcribed it. The transcriptswere then independently read, coded, and organized using NVivo,and codes were reduced to a number of key themes. Analyzers meton aweekly basis to compare and supplement each other’s analyses.

ResultsSurveyIn all, 1766 callers were invited to participate in the sur-vey. Of these, 1058 accepted (59.9%), and of these, 699matched all inclusion criteria (66.1%). Of the 699 in-cluded individuals, 656 participants (93.8%) completedthe questionnaire. Of these, 305 were born in Canada(46.5%); 321 had moved to Canada after birth (48.9%);and 30 did not answer the question on their status regard-ing Canadian residence (4.6%). Of the 321 participantswho had moved to Canada after birth, 185 had spent�5 years in the country (57.6%); 87 were recent immi-grants (27.1%); and 49 did not answer the question on tim-

ing of immigration (15.3%). Table 1 shows a comparison of

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Table 1. Survey/census comparison of demographics, citizenship, and language knowledge variables: general population

Variable Survey, nSample from 2-1-1

Toronto, n (%) Census, nToronto census,

n (%)

Survey/censuscomparison

(�2 test; p-value)

Age, years (M) 629 39.4 95,924 44.2 0.0001

Gender 656 95,924

Female 473 (72.1) 49,881 (52.0) 0.0001

Male 178 (27.1) 46,043 (48.0)

Missing 5 (0.8)

Marital status 656 95,924

Single 298 (45.4) 24,557 (25.6) 0.0001

Married 222 (33.8) 58,897 (61.4)

Divorced 49 (7.5) 4,604 (4.8)

Separated 46 (7.0) 2,782 (2.9)

Widowed 22 (3.4) 5,084 (5.3)

Missing 19 (2.9)

Formal education 656 95,243

Less than high schoola 87 (13.3) 22,954 (24.1) 0.0001

High school 120 (18.3) 13,144 (13.8)

High school � x � universitydegreeb

222 (33.8) 30,954 (32.5)

University degree 137 (20.9) 5,904 (6.2)

Above university degree 57 (8.7) 22,287 (23.4)

Missing 33 (5.0)

Legal status 656 95,921

Canadian by birth 305 (46.5) 44,507 (46.4) 0.0001

Canadian by naturalization 182 (27.7) 37,889 (39.5)

Landed immigrant 111 (16.9) 12,278 (12.8)

Nonresident 28 (4.3) 1,247 (1.3)

Missing 30 (4.6)

Personal income in Can$ (M) 349 27,340 95,924 32,661 0.0001

Household income ($) 656 95,672

�30,000 204 (31.1) 16,073 (16.8) 0.0001

30,000–�60,000 81 (12.3) 23,057 (24.1)

�60,000 63 (9.6) 56,542 (59.1)

Missing 308 (47.0)

Mother tongue 656 95,921

English 381 (58.1) 53,332 (55.6) 0.0001

Other 272 (41.5) 42,589 (44.4)

Missing 3 (0.4)

(continued on next page)

ecember 2012

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demographic, citizenship, and language knowledge vari-ables for the survey and census. Table 2 presents the samevariables and comparisons for the subpopulation of re-cent immigrants.

Demographics. Both landed immigrants and nonresi-dents were more numerous among 2-1-1 survey partici-pants than in the general population (21.2% compared to14.1%). Citizen by birth and by naturalization, together,were less numerous in the 2-1-1 survey than in the census(78.1% and 85.9%). In spite of the fact that these resultsrepresent a conservative estimate of the true differencebetween the two populations, as non-English speakerswere excluded from the survey, these differences are sig-nifıcant (p�0.0001).Callers closely matched the linguistic heterogeneity

and variety of geographic origins of immigrants living inToronto. The 2-1-1 survey population was younger thanthe Toronto population, both in general and in the re-cent-immigrant subcategory (p-values of 0.0001 and0.015, respectively). Also, in the recent-immigrant sub-population, 2-1-1 callers had higher levels of formal edu-cation than the general population (p�0.0001). All butone survey/census income comparison (recent immi-grants’ personal income; p�0.99) showed that 2-1-1 call-rs were on average poorer than Toronto’s generalopulation.

nalysis of callers’ queries. Information on a total of650 queries was collected. More than half of them (955,r 57.8%) were factual. Health-related queries were al-ost one third of the total (489 or 29.6%). Complexueries were more common (p�0.0001) among health-elated queries (45.1%) than among other types of queries33.3%). Finally, the percentage of health-related queries

Table 1. Survey/census comparison of demographics, citize(continued)

Variable Survey, nSample from

Toronto, n

Language at home 656

English 482 (73.

Other 167 (25.

Missing 7 (1.0

Language at work 656

English 599 (91.

Other 22 (3.4

Missing 35 (5.3

ncreased with age (p�0.01), going from 28.3% in the h

group aged 18–39 years, to 31.5% in the group aged40–64 years, and to 55.2% in the group aged �65 years.

Effectiveness of 2-1-1 and satisfaction with the ser-vice. Of the 234 callerswho contacted 2-1-1with health-related queries and were invited to participate in thefollow-up interview, 153 (65.4%) accepted. Of them, 73(47.7%) were interviewed again. Most other callers werelost because they had moved or changed phone numbersduring the time between the two interviews, whereas onlysix (3.9%) refused to participate when contacted again.Of the 73 participants, 62 (84.9%) said that they had

solved their original problem, and 56 respondents(76.7%) said that 2-1-1 had been either helpful, very help-ful, or the single-most helpful source of information. For29 respondents (39.7%), 2-1-1 had been the only sourceof information. A total of 49 participants (67.1%) saidthey were either satisfıed or highly satisfıed with the ser-vice. When asked whether they had any suggestions forimproving 2-1-1 Toronto, the most common answer,given by 16 participants (21.9%), was tomake advertisingmore widespread and effective.

Qualitative InterviewsTen interviews were conducted. Table 3 presents demo-raphics and immigration-related variables for partici-ants. The following section describes the most notablemerging themes, with illustrative quotes.

ersonal histories of migration. Most participantsaid that the decision to move to Canada had been theesult of a sudden crisis and admitted that they knewirtually nothing about life in Canada when they arrived.hey felt that the little information they had found on thenternet, in the media, or through friends and relatives

ip, and language knowledge variables: general population

1Census, n

Toronto census,n (%)

Survey/censuscomparison

(�2 test; p-value)

95,921

67,432 (70.3) 0.006

28,489 (29.7)

71,780

68,765 (95.8) 0.025

3,015 (4.2)

nsh

2-1-(%)

5)

5)

)

3)

)

ad often been misleading.

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Table 2. Survey/census comparison of demographics, citizenship, and language knowledge variables: recentimmigrant subpopulation

Variable Survey, nSample from 2-1-1

Toronto, n (%) Census, nToronto census,

n (%)

Survey/censuscomparison

(�2 test; p-value)

Age, years (M) 87 35.1 8457 37.4 0.015

Gender 87 8457

Female 43 (49.4) 4431 (52.4) 0.73

Male 44 (50.6) 4026 (47.6)

Marital status 87 8457

Single 28 (32.2) 1708 (20.2) 0.016

Married 55 (63.3) 6089 (72.0)

Divorced 1 (1.1) 220 (2.6)

Separated 3 (3.4) 169 (2.0)

Widowed 0 (0.0) 271 (3.2)

Formal education 87 8326

�High school 1 (1.1) 1649 (19.8) 0.0001

High school 9 (10.3) 1016 (12.2)

�High school but �university degree 22 (25.3) 1765 (21.2)

University degree 31 (35.7) 607 (7.3)

�University degree 24 (27.6) 3289 (39.5)

Legal status 87 8457

Canadian by naturalization 5 (5.7) 1894 (22.4) 0.0002

Landed immigrant 65 (74.8) 6563 (77.6)

Nonresident 15 (17.2)

Missing 2 (2.3)

Personal income in Can$ (M) 46 19,036 8457 17,962 0.99

Household income ($) 87 8444

�30,000 38 (43.7) 2711 (32.1) 0.0001

30,000–�60,000 7 (8.0) 2635 (31.2)

�60,000 3 (3.4) 3098 (36.7)

Missing 39 (44.9)

Mother tongue 87 8457

English 15 (17.2) 1269 (15.0) 0.37

Other 72 (82.8) 7188 (85.0)

Language at home 87 8457

English 32 (36.8) 2089 (24.7) 0.001

Other 55 (63.2) 6368 (75.3)

Language at work 87 6218

English 76 (87.4) 5428 (87.3) 0.039

Other 4 (4.6) 790 (12.7)

Missing 7 (8.0)

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Some people told me they were working for the [Ca-nadian] embassy but they wanted money. (Gladis,aged 41 years)

All respondents described migrating as a disorientingand disempowering experience. Jimena’s experience wasparticularly dramatic. She was a 30-year-old, legally blindwoman from Mexico. When she came to Canada, sherealized that

. . . in this country I wasn’t just blind, I was also deafandmute. Iwouldwalk in the streetwithout being ableto understand what people said, and without beingable to speak, because it wasn’tme speaking, it was likebirds speaking. . .

She relied on her 6-year-old son towalk her fromhome to

Table 3. Demographics and immigration-relatedariables for participants in the qualitative interviews,(%) unless otherwise noted

Variable Values

Total participants, n 10

Gender

Female 9 (90)

Male 1 (10)

Age, years

Range 28–56

M 42

Marital status

Married 4 (40)

Divorced 4 (40)

Widowed 2 (20)

Formal education

High school degree 18 (80)

University degree 22 (20)

Immigration category

Refugee 9 (90)

Sponsored relative 1 (10)

Time spent in Canada

Recent immigrant 9 (90)

Long-time immigrant 1 (10)

Country of origin

Mexico 6 (60)

Colombia 3 (30)

Ecuador 1 (10)

his school. For the fırst week, she sat in the school lobby

and waited until the end of classes because she could notgo back home on her own. She knew nothing aboutschool buses and services for people with physicaldisabilities.Language was one of the key factors contributing to thefeeling of disempowerment. For all participants, not be-ing able to speak English was the obstacle with the great-est impact.

For a long time we ate only soup because we didn’tknow anything else, we didn’t understand anything atthe grocery store! (Emilia, aged 31 years)

Despite the challenges, most participants were happy tolive in Canada and appreciative of the opportunities theyfound.

In Canada, I learned not to get surprised about any-thing.Whenmy common sense suggests that a certainservice should not exist, there it is! Like 2-1-1 forexample! Here, if one has a problem, there is always asolution! (Indira, aged 35 years)

Experience with health and health-related ser-vices. Before migrating, none of the respondents wasfamiliar with the gate-keeping role of family doctors,the only professionals in Canada who can refer pa-tients to specialists. For some of them, fınding a familydoctor was particularly diffıcult because of their con-dition as refugees.

Many don’t want to work with people who have thebrownpaper [The document identifying a personwhohas applied for refuge in Canada]. (Indira, aged 35years)

One half of respondents described their fırst encounterwith a health professional in negative terms.

We went to a doctor who used to attend people fromthe refugee shelter. The doctor didn’t care at all aboutus. It was clear that the only thing he really wantedwasfor us to leave. (Flor, aged 44 years)The doctor didn’t want to explain anything to me

about my daughter’s condition. He was in a rush andgot irritated when I asked more questions. He wasalready standing by the door. (Indira, aged 35 years)

Providers’ negative attitudes were reported as the mostimportant problem. Beyond language, other cultural fac-tors and idiosyncrasies complicated the patient–providerrelationship.

My feeling about doctors in Canada is that they arecolder, don’t show interest, are very distant. I feel likeI am an object. (Flor, aged 44 years)I guess that in Colombia we get spoiled. There,

when you go to the doctor for a cold or a flu he givesyou antibiotics. Here they don’t care, they don’t pre-

scribe anything! (Beatriz, aged 56 years)

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Only two respondents described positive fırst interactionwith health services.

[Back at home] physicians know nothing about au-tism! Leaving. . . was a lucky coincidence because assoon as the doctor saw my son he said: “This child isautistic!” And I thought: “Thank God!” He visited myson very carefully. He treated him well. (Emilia, aged31 years)

“Information pathways.”.Doctors and other healthcareproviders had been, for most respondents, the mainsource of health-related information in their countries oforigin. In Canada, none of them had identifıed a single,outstandingly important source.

I learned about various services a bit at a time andfrom many different sources, out of necessity and bydirect experience, trial and error. (Ana, aged 52 years)I learned about all the bureaucratic stuff on my

own, by doing. The only thing I was told at the refugeeshelter is that I had to fınd a family doctor. They didnot say why or how. (Gladis, aged 41 years)

When looking for information,virtuallyall respondentshadbeen helped by people they had met by accident. Carla, forexample, had been lucky enough to meet a woman whoworked for 2-1-1 Toronto and spoke Spanish at a bus stop,soon after her arrival. Often, “information chains” wouldspontaneously develop among immigrants attending Eng-lish courses or in similar settings. With one exception, helpat community centers and shelters was limited.Relying on disjointed information sources had nega-

tive consequences. In Carla’s words:

When you get information from all sides, distinguish-ing good and bad information is diffıcult.

Some participants had met people who had taken advan-tage of them.For all respondents, printed materials, the radio, TV,

and the Internet had played a secondary role, particularlybecause of language barriers. Six respondents mentioned2-1-1 as one of the most important sources of informa-tion. However, with two exceptions, participants hadlearned about 2-1-1months or years after arriving.All tensaid that fınding the service had been diffıcult becausethey had never experienced anything similar and couldnot even conceptualize its existence. Also, after learn-ing about 2-1-1 and sometimes even after using itseveral times, most participants did not know verymuch about the richness of information available. Allrespondents, however, had had very positive experi-ences with 2-1-1 and trusted counselors, particularlybecause they could communicate in Spanish and were

friendly and respectful.

ecember 2012

DiscussionEvaluation of 2-1-1Toronto showsmixed results in termsof its support to immigrants. This group, which is over-represented among users, presents problems that the ser-vice seems to be able to solve effectively. Recent immi-grants who use the service fınd it very useful and arehighly satisfıed with it. On the other hand, the elderly andthe less educated are under-represented among 2-1-1callers. After experiencing other phone-based services,they might be afraid of having to negotiate, in English, acomplicated automated answering system. Also, a sub-stantial percentage of users do not take full advantage ofthe service, as suggested by the high percentage of callers’factual queries. Clearly, as confırmed by the qualitativeinterviews, the value of 2-1-1 is not fully appreciated, evenby repeated users.The qualitative interviews offer some insight on the

role information and referral services can play in sup-porting immigrants. They come to Canada knowingnothing about everyday life here and face, all at the sametime, major and inter-related problems. They have to gothrough a vast amount of disorganized, often confusing,sometimes misleading information. Recent immigrantswho, soon after arrival, are lucky enough to learn about2-1-1, often accidentally, fınd it very helpful, trust it, andshow high levels of satisfaction with the service.Recent immigrants could be supported more effec-

tively by 2-1-1 Toronto if they were offered informationas early as possible in the resettlement process, with a goalof becoming the information “entry point” for newcom-ers. To achieve this, 2-1-1 Toronto should increase mul-tilingual advertising and promotion activity specifıcallyaimed at recent immigrants and, even more importantly,move beyond the existing reactive model to develop amore proactive, community-oriented one, to build andexpand on the excellent work counselors are alreadydoing.Information and communication technologies could

be usedmore extensively by 2-1-1 Toronto. In particular,a “triage” could be set up for users, online, directing thosewith factual queries to a database of frequently askedquestions while referring those withmore complex prob-lems to information counselors. It also could support avirtual community, built on theWikipediamodel, to helpimmigrants share “survival tips” and learn collectively,instead of individually.

LimitationsThe study has four important limitations. First, non-English speakers were excluded from participation in thesurvey. As a result, fındings are not generalizable to 2-1-1

callers who do not speak English, a potentially important

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subgroup likely to face different challenges. Although acomprehensive multilingual survey would have beenideal, it was not feasible given the resources available atthe time, and may have been futile, given the very largenumber of languages spoken in Toronto.Second, the response rate at 10-month follow-up was

low (48%). High rates of attrition are not uncommon in2-1-1 samples. To understand whether the 73 follow-upparticipants were systematically different from the initialsurvey sample, the two groups were compared along 18variables. No differences were found.Third, only Spanish-speaking participants were in-

cluded in the qualitative interviews. Although the experi-ences of recent immigrants from non-Spanish-speakingorigins easily could differ from the ones reported in theinterviews, it is reasonable to believe that there are manyuniversal hurdles shared by all recent immigrants whosefırst language is not English. Finally, working across cul-tures presents unique challenges that could not be elimi-nated completely. However, language barriers were low-ered as interviews were conducted, transcribed, andanalyzed in Spanish, a language common to both partic-ipants and researchers. Final results were then translatedinto English.1

Publication of this article was supported by funding from theNational Cancer Institute (NCI) and the Offıce of Behavioraland Social Science Research (OBSSR) of the NIH(HHSN261201100469P).Andrea Cortinois was supported by the Canadian Institutes

of Health Research (CIHR) through a Doctoral ResearchAward offered by the Institute of Health Services and PolicyResearch and through a Doctoral Fellowship in Health Care,Technology, and Place awarded by the Knowledge TranslationBranch, Institute of Health Services and Policy Research andInstitute of Gender and Health.No fınancial disclosures were reported by the authors of this

paper.

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