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Caring Needs Among Different Cultures

Monday March 22, 2004
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Culturally competent healthcare must incorporate
each individual's unique values and beliefs. What do nurses
need to do to succeed in this endeavor?

Almost one-third of the female population in the US belongs to racial and ethnic minority groups.1 The incidence of illness, disability, and premature death is greater among these women, yet they use fewer health services. Not only are there formidable cultural and economic barriers to care, but our healthcare system itself has also become exceedingly complex to access and use, even for native-born citizens.
As immigration and growth in the racial and ethnic minority populations continue, current Euro-American healthcare practices will be inadequate. Culturally competent healthcare will need to incorporate each individual's unique values and beliefs. Healthcare providers knowledgeable in the health practices of diverse groups will be better able to address their needs.
Disparities Among Ethnicities
Disparities in health status are apparent in morbidity and mortality statistics. Although heart disease and cancer are the leading causes of death for all women in the US, African-American women are more likely to die from HIV, and American Indian/Alaska Native women are at risk for accidents, chronic liver disease, and cirrhosis. Hispanic American/Latina women are more likely to die from chronic liver disease and perinatal conditions. Hypertension is among the top 10 causes of death only in the Asian-American/Pacific Islander and Native Hawaiian women.2
"Compared with non-Hispanic whites, Hispanics are less likely to have Pap smears, blood pressure monitoring, screening for high cholesterol, prenatal care in the first trimester, all recommended childhood vaccinations for children 19-35 months, and influenza vaccination for people 65 and older," says Rachel Zachariah, RN, MS, DNSc, associate professor of nursing at the Bouvé College of Health Sciences at Northeastern University, Boston. "In addition, Hispanics have higher hospitalization rates for complications of diabetes. Hispanics also report greater difficulty obtaining access to care. They are less likely to have health insurance or a source of ongoing care. They have problems getting referrals to specialists, and they report less overall satisfaction with healthcare."
Violence is a major cause of injury for all American women aged 15 to 54, including intimate partner violence and sexual assault. However, American Indian/Alaska Natives are most at risk, with the reported incidence of rape and stalking much higher. Despite this, both Asian American and Hispanic women are less likely to report rape and stalking.3 Screening and appropriate intervention are important nursing considerations in the care of patients with depression, substance abuse, contusions, fractures, burns, hypertension, and sexual diseases.4
Variances in Adolescents
The health issues of adolescent minority women are primarily psychosociocultural in nature, according to Virginia A. Graves, RN, CMS. In her roles as president of DoubleSunrise: Young Women's Health, nurse practitioner for adolescent girls, and occupational health nurse, Graves applies contemporary women feminist theories to the health of young women. Through her focus groups, health website, and speaking engagements, she hears "the same questions, concerns, and feelings, and very similar threads from group to group."
"The statistics will tell you there is a difference, but the lines are getting blurry," explains Graves. "You used to be able to say that girls with eating disorders are white, and girls of color have better body images and self esteem, because they are surrounded by aunts and mothers who tell them they're beautiful just the way they are. However, as these women move up in socioeconomic class, they tend to be at higher risk, and as they climb the corporate ladder they are very attentive to what is accepted, including thinness."
Acculturation, or the adoption of Anglo-American behavior patterns, may affect the health of minority women in both beneficial and adverse ways. The risks for diabetes, heart disease, cancer, alcoholism, drug abuse and psychological disorders vary within the populations, relative to the degree of acculturation. "In the Puerto Rican society, as you get older you spend more time with adults, and those girls are at lower risk for pregnancy, drugs, alcohol," says Graves. "As sex education courses are being dropped all over the country, it's a cultural norm the rest of us could learn from, rather than staying in the periphery for fear of not using the right words."
When Graves works with women of color, she is always amazed at the nurturing environments they create. "Some contemporary developmental psychologists say that developing a healthy relationship like this with at least one adult is the most important task of adolescence. However, media messages threaten that with images of girls who are thin, scantily dressed, and overtly sexual, implying this is how to get what you need. This separates the girls from the older women."
The Language Barrier
In 1990, 14 percent of US residents, or 31.8 million people spoke a language other than English at home.5 Lack of English proficiency is a frequent barrier to optimal care, resulting in delays in scheduling appointments and potential serious misunderstandings at every point of the medical interview, examination, and treatment. Written materials in the native tongue may be helpful, assuming that the patient possesses basic reading and writing skills.
"If you do health education, be sure that you review the literature yourself carefully," says Graves. "I have seen beautiful pamphlets and magazines sent by the box load to doctors' offices with subliminal messages that we may not agree with."
Through their clinical positions as staff nurses, nurse practitioners, and midwives, nurses may directly impact the health of minority women. "I try to give them hope that there are trustworthy people out there," says Graves. "I explain the cycle of violence and paint a different picture of where they can go. Our therapeutic relationship is very powerful and we can support women who are making tough decisions."
Let Your Voice Be Heard
In the community, nurses may have an even greater role in addressing healthcare needs. "When nurses stand up and talk at the PTO meeting, people listen," says Graves. "We can address that the soda machine will bring in a lot of money, but at what cost. We can ask how much advertising we want in our schools, and whether we really want to raise funds through magazine sales. We need to understand how powerful the voice of a nurse can be, at the town meeting or via a letter to the editor."
As US citizens, nurses may voice their concerns that 44 million Americans are uninsured, with Hispanics and African Americans more likely to lack insurance than whites. Liaisons with larger organizations, both professional and civic, at the local, state, and national levels, can provide necessary leverage. Statewide collaborative efforts, such as the Statewide Partnerships in Women's Health program of the Health Resources and Services Administration and the Center for Disease Control and Prevention provide an integrated approach to improving healthcare for those women with unique cultural and linguistic needs.1,4
At the national level, the Office of Minority and Women's Health of the US Department of Health and Human Services Bureau of Primary Health Care promotes policies and programs to improve the health outcomes for vulnerable women and minorities. Recognizing that care must be responsive to cultural and linguistic needs, a holistic approach to comprehensive health care that incorporates cultural, behavioral, environmental, and spiritual aspects is recommended.
Strategies to improve access to care, resource sharing between private and public-sector organizations, and dissemination of health information. are being developed. Their "Models that Work" competition recognizes women's service programs that address issues beyond reproductive health and provide enabling services such as extended hours, child care, and links to other community services.4
Be Proactive
According to Zachariah, nurses should be on the lookout for materials from national organizations and professional associations that document the crisis of healthcare disparities and the responsibilities of nurses in the workforce. "Nurses are called to action not only to read and gain knowledge, but also to take the bold, courageous, next steps in bringing about changes in the systems within organizations, institutions and community settings. These changes will more fully address the need for providing accessible, affordable, and acceptable care for all minority women."
Women of minority populations who have these unique medical and psychosocial needs often put their own needs last. Elimination of healthcare disparities will be an enormous undertaking, requiring providers and institutions across society to work together.
"As nurses in the work force, we need to find innovative ways to reach minority women," says Zachariah. "These women need help and support during life transitions to find positive ways of meeting the challenges. Nurses collectively will have the power and authority to fix systemic and organizational problems. Minority women need supportive resources to build on their strengths and resilience to actively participate in their healthcare."