At a special ceremony during its 10th Annual Carnegie Nursing Research Conference on Eliminating Health Disparities (see article on page TK), Howard University’s Division of Nursing honored a group of 20 outstanding nurse scientists from across the nation as Emerging Nursing Stars in Health Disparities Research. These researchers studied a broad spectrum of critical minority health issues affecting vulnerable populations at all stages of life--from low-income parents and at-risk minority children to senior citizens and menopausal African-American women.
Here’s an in-depth look at five of these dedicated nurse researchers and their pioneering efforts to improve health outcomes for Americans of color. For the complete list of Emerging Nursing Stars in Health Disparities Research, see page TK.
Dr. Hines-Martin, an associate professor at the University of Louisville School of Nursing, was honored for her research study “African-American Mental Health Service Use,” which investigated factors that influence this minority population’s first-time use of mental health care services. The three-year project was funded by the National Institute of Nursing Research (NINR), one of the National Institutes of Health (NIH).
As a nursing student, Hines-Martin recalls, she noticed that much of the information presented in her classes ignored minorities. This inspired the African-American nurse to generate her own research to fill these information gaps. Initially she focused on African-American health issues and nursing but later shifted her focus to mental health.
Part quantitative, her “African-American Mental Health Service Use” study looked at the statistics involving first-time use, including the length of time it took patients to decide to seek help. It was also qualitative, as she talked in-depth to a sub-sample of her 117 subjects to try to determine what factors facilitated treatment and identify barriers to treatment. “I also wanted to know what exactly was the decision-making process that led them to figure out, first, that they had a mental health condition; second, what were their options for treatment; and third, what was the process for accessing services,” she adds.
The research revealed that lack of outreach and lack of information about mental health services in the African-American community were common barriers. Many people delayed seeking treatment because they prioritized jobs and families first. When they did seek mental health care, it was often in-patient. “I saw this to be…[a situation] where they had to deal with many more complications by the time they got to services,” says Hines-Martin. “I wanted to understand exactly what was happening that caused them to choose in-patient [care] rather than out-patient.”
She also found that the decision to seek treatment did not involve much pre-planning, although people had had the problem, on average, for five years before they finally sought help. Often, a crisis triggered a response to get help, and the patients often ended up being admitted to a hospital through the ER.
Even though admission looks voluntary in these cases, Hines-Martin notes, it is generally forced to some degree by a loss of something of value in the patient’s life. “Health care providers need to identify the person’s priority and match that priority with what they [as providers] have to offer,” she continues. “That means you have to try to provide services in a slightly different way.”
Clinicians often try to establish cooperation with mental health patients by telling them that treatment will make them think clearer or feel better. “[Patients] don’t want to hear that,” Hines-Martin contends. “If the care provider can show how being involved and committed in treatment will help the patient achieve whatever goal is most important to them, then you end up with a better collaboration and more commitment from the patient.”
What’s next on her research agenda? She says she would like to compare her work with research on other ethnic groups and see if socioeconomic factors are at play. That answer will allow a better understanding of what must be done to develop more culturally competent mental health services that will better meet minority patients’ needs.
Hines-Martin would also like to see mental health services integrated into primary care or general health settings, since most of her research subjects used that approach first. Her study found a 40% dropout rate between the time people made initial contact for help and their first outpatient clinic appointment. “Why not move the services to where the patients first identify,” she asks, “[so we can] catch them at a point where their illness is not as severe?”
Beatrice Adderley-Kelly, RN, PhD, and Pauline M. Green, RN, PhD
Adderley-Kelly, who is African American, and Green, who is Caucasian, are professors at Howard University’s Division of Nursing and have collaborated as a team for many years. They are on a mission to improve access to care and health promotion among African Americans, with a defining focus on reducing cancer disparities. This commitment led the two nurse researchers to conduct a study on “Colorectal Cancer Knowledge, Perceptions and Behaviors in African Americans,” for which they were honored as Emerging Nursing Stars in Health Disparities Research.
African Americans have the highest incidence of colorectal cancer (CRC) of all racial and ethnic groups. It is the third leading cause of cancer death in black Americans and “the disparity between the minority population and the majority population is widening,” Adderley-Kelly warns. Screening and early detection can save lives, both researchers emphasize.
Their one-year research project, funded by NINR, studied a nonrandom sample of 100 African-American men and women 50 years of age or older, who were recruited from a residential site for seniors in Washington, D.C. Adderley-Kelly and Green administered a survey to look at the extent to which CRC screening may be influenced by demographic, socio-psychological and structural variables, as well as susceptibility, severity, benefits and barriers. Participants were asked about their use of fecal occult blood tests (FOBT), flexible sigmoidoscopy and colonoscopy exams, and double contrast barium enema exams.
The study’s findings revealed an inadequate knowledge of CRC in many of the participants, with a significant difference in mean scores between males and females. “That surprised us,” says Adderley-Kelly. “We thought women would be more knowledgeable, especially African-American women, as they are more attentive to their health [than black men].”
Not knowing how to schedule screening was a perceived barrier for more women (60.3%) than men (40.5%). A higher percentage of women (64.3%) than men (48.3%) were afraid to find out that something was wrong if they had CRC screening, and more females (81%) than males (44.9%) feared screening because they did not know what would be done.
On the other hand, a very high percentage of the subjects were aware of the benefits of screening as a tool for preventing colorectal cancer. Seventy-one percent of the participants agreed that CRC was a possibility for them; 69% were concerned about developing the disease.
In addition, the study found that these older African Americans’ self-report of participation in CRC screening was above the national average. Almost half of the sample reported FOBT home kit use and more than half of the sample reported completion of sigmoid and colonoscopy exams and double contrast barium enema exams.
Adderley-Kelly says this screening behavior could be attributed to where the participants lived--an area that has a number of health care facilities--and the fact that this sample goes for regular physician visits. Payment by Medicare for some of the participants’ screening may have contributed to the large numbers who were screened, Green adds.
The duo hope to expand the study with a larger population to see what impact educational intervention will have on screening behaviors. They also want to do a longitudinal study to determine the screening behaviors of older African Americans. “We have a snapshot picture right now, but we would like to know if participants continue with the recommended guidelines,” Green explains. She adds that it is important to get the message out to health care providers about CRC causes, prevention, detection and the importance of screening.
Dr. Cheryl S. Taylor, director of the Office of Nursing Research and a graduate faculty member at Southern University and A&M College School of Nursing in Baton Rouge, La., has devoted her 26-year nursing career to the health needs of medically underserved populations. She was honored by Howard University for two research projects: “REACH 2010 at the Heart of New Orleans” and “REACH for Health On-Line.”
“When people talk about racial and ethnic disparities, the fact is that we [minorities] are a small percentage of the total U.S population but we experience and die from a significant proportion of the major illnesses and chronic diseases,” says Taylor, who is African American. “I live in the black community and witness disparities on a daily basis. It would be very difficult for me to walk past suffering and do nothing relevant to help alleviate it.”
Taylor is the principal investigator for “REACH 2010 at the Heart of New Orleans,” which targets African-American women in churches to reduce their risk of cardiovascular disease (CVD). The project, which involves a partnership between 40 local churches across 10 denominations, is part of the Centers for Disease Control and Prevention’s Racial and Ethnic Approaches to Community Health (REACH) 2010 initiative, aimed at eliminating minority health disparities in six areas--including cancer, diabetes and CVD--by the year 2010.
“African-American women’s [disproportionately poor outcomes] for cardiovascular disease and diabetes in the state of Louisiana exceed the national average. These women are at the top of the list for death and disabilities,” Taylor says. “Our REACH team conducts community-based intervention research that serves the local parish communities by providing access to quality preventive health screening, counseling, referral and heart health education services.”
There are over 1,100 African-American women enrolled in the study, according to Taylor. “Those women are members of churches where we implement lifestyle interventions,” she adds. “Everyone freely participates in classes on nutrition and increasing physical activity. We target women for survey data, but we don’t discriminate against men when it comes to conducting our health promotion interventions.”
Participants undergo annual health screenings--which include a CVD risk assessment as well as blood pressure, cholesterol and weight checks--at church sites. The churches also serve as sites for seminars, workshops and fitness classes.
The intervention has already begun to make a difference in narrowing the CVD disparity gap for these Louisiana women. “We have raised the awareness of risk factors for heart disease and provided needed access to quality lipid and blood pressure screening,” Taylor reports. “We have helped hundreds of women in churches to take charge of their health, get access to care, start eating better and start fitness programs. Our evaluation data indicates the positive impact our faith-based interventions and targeted actions have had toward building capacity in churches for sustaining health promotion programs on a long-term basis.”
Her other project, “REACH for Health On-Line,” involves a collaboration between her university and the U.S. National Library of Medicine (NLM), part of NIH. Taylor is investigating the impact of online access to health information as a predictor for behavioral change in African Americans from diverse socioeconomic backgrounds.
“The NLM has the most scientifically sound health information in the world,” Taylor explains. “The purpose of this project is to instruct and direct people on how to use MedlinePlus [to obtain health information] and not be seduced by Web sites that don’t have scientifically sound information. Our target [health disparities] are heart disease, cancer, stroke and diabetes, because those are the killers.”
The NLM created and maintains the MedlinePlus Web site (www.nlm.nih.gov/medlineplus) to assist the public in locating authoritative health information. The goal of the one-year REACH project, which has locations in Shreveport, Baton Rouge and New Orleans, is to have at least 5,000 people using MedlinePlus.
This associate professor of nursing at the University of Illinois at Chicago is one of the leading researchers in HIV prevention education for ethnically and culturally diverse populations. Dancy, who is African American, has conducted a number of studies in this area and was honored as an Emerging Nursing Star in Health Disparities Research for this body of work. At the Howard University conference, she presented “HIV Prevention for Low-Income African-American Women,” a study funded by the National Institute of Mental Health, another of the NIH institutes.
A total of 280 black women, recruited throughout the local community and with an average age of 31, participated in the study. They were divided into two groups: an HIV risk reduction curriculum group and a health promotion curriculum group. Each group met once a week for two hours over a period of six weeks.
The HIV risk reduction curriculum included classes on human sexuality and the reproductive system. “We gave them skills to help them be more assertive and to help them make healthy decisions,” Dancy explains. Participants also practiced using these skills through role-playing.
The health promotion curriculum (control group) focused on nutrition, hypertension, diabetes and exercise. “Hypertension, diabetes and breast cancer are big health problems in the African-American community,” says Dancy, “so we wanted to give [the women] skills to help reduce their risks of those disorders.”
The research examined the influence of such factors as knowledge about HIV transmission, self-efficacy for low-risk HIV behavior, perceived HIV vulnerability, social norms related to male-female relationships, attitudes related to condom use, and HIV-related community behavior on consistent condom use over a 22-month period. In the first phase of the study, one group of women received the HIV risk reduction curriculum and the other group the health promotion curriculum. Each woman completed a questionnaire before the start of the classes and six weeks later. They were also tested three, six and nine months later. In Phase Two, the two curricula were switched and the women again completed the questionnaires as they did in Phase One.
“Generally, the results supported that the HIV risk reduction curriculum had some benefits in helping women to reduce their HIV risk behavior,” reports Dancy, whose study is in the process of being published.
Because the rate of HIV infection among African Americans is disproportionate to the size of this minority population in the U.S., she adds, “we need culturally sensitive HIV risk reduction programs for this group. There is a great need for solid information about what will work best to help African-American women develop strategies to reduce their risk for HIV.”
Dancy says her ultimate goal is to develop HIV risk reduction interventions that are family-based, with parents assuming responsibility for teaching their children about HIV prevention. “I think the research indicates that when parents have adequate information themselves, they can be a protective factor for their children,” she notes.
A long-time nurse, Dancy says she chose to focus her career on research because of the need for more empirical evidence on behavior change. Most of her studies have looked at vulnerable populations. She has worked on research projects that focused on family environments, teen-age pregnancies, adolescent fatherhood and promoting exercise to reduce the risk of cardiovascular disease.
Racial and ethnic minorities are underrepresented in nursing research today, she adds. “When you go to conferences, most of the presenters are not minorities. We need minority nurses to get into the field and get their PhDs in research so they can be prepared to become researchers.”
Minority nurse researchers bring a unique perspective to the field because of their first-hand knowledge of their culture, Dancy continues. “Plus, we can serve as role models when we go out into the community,” she says. “When children see people of their own ethnicity doing research, it may inspire them to want to do the same.”