It may be the federal government that launched the national initiative to eliminate racial and ethnic disparities in health by the year 2010, but it’s minority nurses who are taking the ball and running with it.
As part of former President Bill Clinton’s Initiative on Race, the U.S. Department of Health and Human Services (HHS)’s Initiative to Eliminate Racial and Ethnic Disparities in Health seeks to eradicate differences in health outcomes among minority populations in six critical areas:
The first article in Minority Nurse’s two-part series on the so-called “2010 Initiative” focused on the crucial role nurses of color can play in researching the causes of minority health disparities and using that data to design interventions. But the research laboratory and the academic classroom aren’t the only fronts on which nurses can fight the war against unequal health outcomes. There’s also the clinical setting, where nurses can make a difference in “closing the gap” through such activities as community outreach, patient education and more.
Nurses of color have a formidable advantage in working with minority populations because they know—often from personal experience—the cultural and linguistic barriers that can prevent access to health care, as well as the importance of building relationships over time in the communities they serve.
When Elvia Kirkpatrick, RN, the lead nurse for a Kaiser Permanente clinic in East Los Angeles, first came to the facility in 1986, she began teaching diabetes care classes in Spanish. Prior to that, the classes were taught only in English to a patient population that is 96% Hispanic.
“You can see when patients are struggling to speak English and how they relax when you start speaking to them in their own language,” says Kirkpatrick, who is of Hispanic descent.
Speaking their language not only puts minority patients at ease, but is often a first step to building a trusting relationship, agrees Viola Benavente, RN, MSN, CNS, an instructor at the University of Texas Health Science Center in San Antonio. It also increases the chances that the patients will truly understand the information being presented, she adds.
“Otherwise, you tend to find them nodding in agreement with whatever the health care provider says without understanding it,” says the Hispanic nurse, whose specialty is cardiovascular disease. “And they won’t tell you that they don’t understand it, either.”
Benavente says she automatically addresses Hispanic patients in Spanish. “But it’s not only the language,” she stresses. “As a minority nurse, I feel I understand the true meaning of cultural competence. I have grown up with the same values, beliefs and customs as many of my patients. The fact that I experienced these things, instead of just reading about them, makes a big difference.”
Benavente recalls, for example, seeing the ritual of the malojo, or evil eye, being performed on her mother when Viola was just a child. According to a traditional Hispanic folk belief, when a person admires a characteristic or trait of another individual, the latter will become ill unless the admirer touches them. Benavente’s mother suffered from headaches, which she believed were caused by people admiring her eyes. To ease her headaches, the malojo was performed.
The ritual involves sweeping a raw egg over the person’s body as he or she lies down. At the same time, prayers and chants are recited and the sign of the cross is made. The egg is then cracked, dropped into a cup of water and slid under the bed.
“When the egg is cooked in six to eight hours, then you know it has pulled out the evil spirit from the person,” Benavente explains. Her mother always felt better after the ritual was performed.
In December, Benavente is scheduled to attend a conference on cardiovascular health for women as a representative of the National Association of Hispanic Nurses. She intends to tailor the information she learns there into culturally and linguistically competent education programs for her Hispanic female patients. On an even more ambitious level, Benavente plans to develop a health care outreach program in the Latino community along the border of Texas through the Rio Grande River.
“One of the things I will be up against is [patients’] belief in curanderismo, or folk medicine and healing, like the malojo ritual,” she says. “The Latino people tend to believe very strongly in the curandero, or folk healer, who uses prayers, rituals and herbs to heal. Many of them are very hesitant to go to a doctor or clinic.” Benavente even remembers her father going to a curandero and taking her to one because he wouldn’t go to a doctor.
One way she hopes to get around this cultural barrier is to research the herbs used in some of these folk remedies. Benavente has discovered that many of the herbs the curanderos use are also used in today’s modern medicines. Her strategy will be to encourage the patients to start seeing a physician while continuing to acknowledge their need to see the curandero. This will involve convincing them that the doctor or nurses will not take away their herbs or make them stop using their herbal remedies. Benavente believes this compromise is another way to build trust between patient and health care provider.
As part of the outreach program, Benavente also plans to conduct an educational class that focuses on heart-healthy cooking. “Coronary heart disease, high blood pressure and congestive heart failure all fall back on diet and lifestyle,” she says. While Benavente acknowledges that it will be difficult to change years of traditional approaches to cooking, she believes patients can discover, for example, how various herbs and spices can be substituted for salt, a seasoning that is used heavily in Hispanic dishes.
When Kaiser Permanente’s new East Los Angeles clinic opens in April 2002, it too will offer cooking classes geared to the Hispanic diet. “We’ll be teaching how to make traditional foods healthier,” Kirkpatrick says.
For diabetic patients, teaching them how to cut back on lard and tortillas is key. Many Hispanics also believe that eating certain types of cacti will cure diabetes. While eating cacti can help bring down blood sugar levels because it’s filling, Kirkpatrick says she must still make her patients understand that there is no known cure for diabetes.
Athena Philis-Tsimikas, MD, medical director for Project Dulce, a community diabetes care program targeting Latinos in northern San Diego, has also run into the “cactus cures diabetes” myth. Like Kirkpatrick, she doesn’t dissuade patients from eating cacti, but she does object to their substituting it for other forms of treatment, such as medication and a healthy diet.
Another potentially dangerous cultural belief Philis-Tsimikas has encountered is the idea that using insulin worsens diabetes. This misconception, she says, comes from individuals who have developed complications shortly after beginning the use of insulin. In reality, the reason for these complications is often due to patients waiting too long to seek medical care, thus resulting in the diabetes moving to an advanced, more treatment-resistant stage.
Although Philis-Tsimikas, who is a diabetes specialist, learned about some of these cultural beliefs by conducting focus groups in the local community, she acknowledges that minority nurses can be invaluable sources for such information. “They already understand many of the cultural practices and beliefs regarding diabetes,” she says. “They also have a unique awareness of specific barriers to treatment within the minority communities where they work.”
Nurses who have first-hand awareness of cultural barriers to treatment and are able to work around them can help build trust and establish relationships, both of which are key factors when working with Native American populations. So says Regena Dale, a Navajo nurse who is director of public health nursing for the Phoenix Indian Medical Center in Arizona, a service unit of the Indian Health Service.
Language barriers are not a problem with younger Native Americans, because they speak English very well. “But if you really want to make a connection with the elderly, you need to speak their language fluently,” states Dale, who works in a facility that predominantly services communities not of her own tribe.
As an example, she cites the experience of observing one of her staff public health nurses providing foot care to an elderly diabetic couple. “It was evident that the couple, who may have simply nodded in agreement if they had been lectured to in English, were engaged in a dialogue with the nurse because she was speaking in their native language.”
Scheduling doctor’s appointments or medical tests can be another major challenge for nurses working on Indian reservations. In Native American culture, the concept of time is viewed as being flexible and or even unimportant, Dale explains. “At work, it’s unacceptable to show up to a meeting 10 or 15 minutes late. But on the reservation, even if you have a meeting scheduled for a specific time, it convenes when everyone gets there.”
Native Americans’ cultural beliefs also shape their definitions of health and illness. “With diabetes, for example, if a patient can function without pain, even if his blood sugars are at 400, he believes he is okay,” says Dale. “[Many of our patients] seem to define health as being able to carry on day to day. We’re trying to get people to understand the importance of exercise and maintaining a proper weight.”
Obesity is a big problem in Native American communities, Dale continues, because being overweight has been culturally accepted for such a long time. “If a child gets to the point where her height and weight are proportionate, it’s not unheard of for her grandmother to say she’s too skinny,” she notes. However, this view is beginning to change as Indian communities become more aware of the health risks associated with obesity.
Fortunately, Dale doesn’t run into any cultural barriers concerning immunizations for children, which is her primary focus of care. “We explain to the parents that the immunizations are for preventable diseases,” she says. “And while most parents ask questions about the procedure, they do realize it’s responsible behavior on their part to keep their kids well.” In fact, about 86% of the approximately 1,400 two-year-olds in Dale’s unit, which serves five reservations in Arizona, have received all of their required vaccinations.
The people on these reservations truly appreciate public health nurses bringing their preventive educational programs into the community, Dale attests. Many reservation residents are without transportation and would have difficulty getting to the city to receive medical care. “Plus, we try to present our programs at a time when most people are free to attend, usually in the evenings,” she adds. “As with most cultures, providing food adds a social component.”
Sometimes the lack of attendance at such programs can be discouraging for the nurses. Nobody may come to the first class and only a handful of people may come to the second one. But when nurses in her unit become disheartened by the lack of attendance, Dale encourages them to continue what they’re doing, because they will eventually see a change. “In public health, we know that the community is observing us and people do eventually embrace the fact that we’re committed and we’re not just going to give up.”
Clearly, minority nurses throughout the country are adopting that same sense of commitment and perseverance in their efforts to eliminate racial and ethnic disparities in health wherever they find them. “I am so excited about attending [the cardiovascular health conference] because it will enable me to target Latino women and teach them about heart disease and prevention,” says Benavente. “Finally, I get to give back to my community, my people.”