Global Applications of Culturally Competent Health Care: Guidelines for Practice

Marilyn “Marty” Douglas Dula Pacquiao Larry Purnell Editors

123 Global Applications of Culturally Competent Health Care: Guidelines for Practice Marilyn “Marty” Douglas Dula Pacquiao • Larry Purnell Editors

Global Applications of Culturally Competent Health Care: Guidelines for Practice Editors Marilyn “Marty” Douglas Dula Pacquiao School of Nursing School of Nursing University of California San Francisco Rutgers University Palo Alto Newark California New Jersey USA USA

Larry Purnell College of Health Sciences University of Delaware Sudlersville Maryland USA

ISBN 978-3-319-69331-6 ISBN 978-3-319-69332-3 (eBook) https://doi.org/10.1007/978-3-319-69332-3

Library of Congress Control Number: 2018943678

© Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface

There are three areas that heighten the need for culturally competent care: globalization and its resultant increase in population and workforce diversity, global conflicts with consequent displacement of populations, and evidence of health inequities within the same country and across different countries globally. Today, global conflicts have forcibly displaced 65.6 million persons, creating an unprecedented 22.5 million refugees in the world (UNHCR 2018). An influx of this magnitude presents a challenge to nurses worldwide to provide care to persons who may have health beliefs and practices different from their own. In addition, these new groups of refugees and displaced persons augment the local and national racial and ethnic minority populations who are increasingly vulnerable to unequal access to health care and resultant poor health outcomes. This book was compiled as an effort to reduce the effects of social inequities on the health of these populations and to provide healthcare professionals with a resource for providing culturally competent care. Health disparities are the differential consequences on the physical and mental well-being of population groups attributable to social inequalities. These inequities create cumulative disadvantages in human life conditions exposing certain groups to a greater number and intensity of health risks. Health is tied with the social conditions of life. Thus, health promotion should be grounded on the principles of social justice and protection of basic human rights supportive of health. While individual-based care and biomedical approaches to diseases are important, population health achievement is difficult without improving the conditions in which people are born, live, and work. This book attempts to demonstrate culturally competent care as a strategy to achieve health equity. The Guidelines for Culturally Competent Health Care were developed by a task force convened by members of the Expert Panel on Global Nursing and Health of the American Academy of Nursing and also included members of the Transcultural Nursing Society. In preparing the guidelines, the task force members reviewed documents related to culturally competent health care from more than 50 publications and sources from around the world, including healthcare, governmental and nongovernmental organizations. Several versions of the guidelines were sent to global colleagues for peer review to assess global applicability. Eventually, the final version of the Guidelines was endorsed by the International Council of Nurses and distributed to its member

v vi Preface national nursing organizations throughout the world. Nurses in these countries are now left to decide how to implement them. The purpose of this book is to expand on previous work describing the Guidelines (Douglas et al. 2014) and to provide practical, clinical examples of how each of these guidelines can be integrated into practice by practitioners caring for diverse populations from around the world. This book will be useful for multidisciplinary healthcare students, clinicians, advanced practice nurses, administrators, educators, and those who provide community health or population-based care. The first chapter provides the conceptual basis for culturally competent health care and presents a list of ten guidelines along with a few examples of implementation. Then a separate section is devoted to each guideline. Within each section is a chapter with an in-depth discussion of the guideline and its rationale, followed by three or more chapters with clinical case studies of examples of how the guideline was implemented in a particular cultural setting. All case studies follow a similar format and are written by international authors with clinical expertise and work experience in the culture being presented. It is recognized that these guidelines must be adapted to each situation. Within each setting, there are cultural norms embedded in their respective social, economic, and political system in which they exist. Therefore, in conclusion, the guidelines and their accompanying case studies are intended to be examples of how culturally competent care can be delivered. They are not meant to be requirements for professional practice but rather to assist the practitioner, educator, administrator, or researcher in planning care for a culturally diverse population.

Palo Alto, CA, USA Marilyn “Marty” Douglas Newark, NJ, USA Dula Pacquiao Sudlersville, MD, USA Larry Purnell

References

Douglas M, Rosenketter M, Pacquiao D, Clark Callister L, Hattar-Pollara M, Lauderdale J, Milsted J, Nardi D, Purnell L (2014) Guidelines for implementing culturally competent nursing care. J Transcult Nurs 25(2):109–221. https://doi. org/10.117/1043659614520998. Accessed 29 Oct 2017 United Nations High Commissioner for Refugees (UNHCR) Figure at a glance. Statistical yearbooks. http://www.unhcr.org/en-us/figures-at-a-glance.html. Accessed 9 Jan 2018 Acknowledgements

The Co-Editors wish to acknowledge and thank all of our professional colleagues around the world who have made this work possible. In particular, these include the members of the American Academy of Nursing Expert Panel on Global Nursing and Health’s Task Force on Global Standards of Culturally Competent Care. This task force was comprised of the three co- editors of this book plus Lynn Clark Callister, PhD, RN, FAAN, Marianne Hattar-Pollara, PhD, RN, FAAN, Jana Lauderdale, PhD, RN, FAAN, Jeri Milstead, PhD, RN, FAAN, Deena Nardi, PhD, PMHCNS-BC, FAAN, Marlene Rosenkoetter, PhD, RN, CNS, FAAN, and Joan Uhl Pierce, PhD, RN, FAAN. This task force formulated the original Standards of Practice for Culturally Competent Care and published them as Guidelines for Practice, which form the basis of the structure and content for this book. Special acknowledgement must be given to Joan Uhl Pierce, PhD, RN, FAAN, who was the first chair of the task force, and whose initiative was to enlist past presidents of the Transcultural Nursing Society as members of the Academy’s task force on this topic. In addition, we would like to specifically acknowledge Dr. Marianne Hattar-Pollara for her vision of expanding these Guidelines to book form. She was also instrumental in coordinating and participating in the key planning session for this book. Finally, we wish to acknowledge the Transcultural Nursing Society (TCNS), in particular the Transcultural Nursing Scholars, who created the forum for common interest and commitment in promoting culturally competent practices in education, research, and practice. TCNS has its mission “to enhance the quality of culturally congruent, competent, and equitable care that results in improved health and well-being for people worldwide” and a vision “to provide nurses and other healthcare professionals with the knowledge base necessary to ensure cultural competence in practice, education, research, and administration.”

vii Contents

1 Conceptual Framework for Culturally Competent Care �� 1 Dula Pacquiao

Part I Guideline: Knowledge of Cultures

2 Knowledge of Cultures �� 31 Larry Purnell 3 Case Study: Building Trust Among American Indian/Alaska Native Communities—Respect and Focus on Strengths �� 43 Janet R. Katz and Darlene P. Hughes 4 Case Study: An 85-Year-Old Immigrant from the Former Soviet Union �� 49 Lynn Clark Callister 5 Case Study: Caring for Urban, American Indian, Gay, or Lesbian Youth at Risk for Suicide �� 53 Jana Lauderdale

Part II Guideline: Education and Training

6 Education and Training in Culturally Competent Care �� 61 Larry Purnell 7 Case Study: Traditional Health Beliefs of Arabic Culture During Pregnancy �� 77 Jehad O. Halabi 8 Case Study: Perceived Cultural Discord and Possible Discrimination Involving a Moroccan Truck Driver in Italy �� 85 Alessandro Stievano, Gennaro Rocco, and Giordano Cotichelli

ix x Contents

9 Case Study: A Multiracial Man Seeks Care in the Emergency Department �� 89 Marianne R. Jeffreys

Part III Guideline: Critical Reflection

10 Critical Reflection �� 97 Larry Purnell 11 Case Study: Human Trafficking in Guatemala �� 113 Joyceen S. Boyle 12 Case Study: A Young African American Woman with Lupus �� 119 Donna Shambley-Ebron 13 Case Study: Intimate Partner Violence in Peru �� 125 Roxanne Amerson

Part IV Guideline: Cross Cultural Communication

14 Cross Cultural Communication: Verbal and Non-Verbal Communication, Interpretation and Translation �� 131 Larry Purnell 15 Case Study: Korean Woman with Mastectomy Pain �� 143 Sangmi Kim and Eun-Ok Im 16 Case Study: An 85-Year-Old Saudi Muslim Woman with Multiple Health Problems �� 149 Sandra Lovering 17 Case Study: Communication, Language, and Care with a Person of Mexican Heritage with Type 2 Diabetes �� 155 Rick Zoucha 18 Case Study: Stigmatization of a HIV+ Haitian Male �� 161 Larry Purnell, Dula Pacquiao, and Marilyn “Marty” Douglas

Part V Guideline: Culturally Congruent Practice

19 Integrating Culturally Competent Strategies into Health Care Practice �� 169 Marilyn “Marty” Douglas 20 Case Study: Perinatal Care for a Filipina Immigrant �� 187 Violeta Lopez 21 Case Study: Maternity Care for a Liberian Woman �� 193 Jody R. Lori Contents xi

22 Case Study: Care of a Malay Muslim Woman in a Singaporean Hospital �� 197 Antoinette Sabapathy and Asmah Binti Mohd Noor

Part VI Guideline: Cultural Competence in Health Care Systems and Organizations

23 Building an Organizational Environment of Cultural Competence �� 203 Marilyn “Marty” Douglas 24 Case Study: Culturally Competent Strategies Toward Living Well with Dementia on the Mediterranean Coast �� 215 Manuel Lillo-Crespo and Jorge Riquelme-Galindo 25 Case Study: Culturally Competent Healthcare Organizations for Arab Muslims �� 221 Stephen R. Marrone 26 Case Study: A Lebanese Immigrant Family Copes with a Terminal Diagnosis �� 229 Anahid Kulwicki

Part VII Guideline: Patient Advocacy and Empowerment

27 Advocacy and Empowerment of Individuals, Families and Communities �� 239 Dula Pacquiao 28 Case Study: Zapotec Woman with HIV in Oaxaca, Mexico �� 255 Carol Sue Holtz 29 Case Study: Maternal and Child Health Promotion Issues for a Poor, Migrant Haitian Mother �� 261 Joyce Hyatt 30 Case Study: Caring for a Pakistani Male Who Has Sex with Other Men �� 267 Rubab I. Qureshi

Part VIII Guideline: Multicultural Workforce

31 Culturally Competent Multicultural Workforce �� 275 Dula Pacquiao 32 Case Study: Internationally Educated Nurses Working in a Canadian Healthcare Setting �� 287 Louise Racine 33 Case Study: Recruitment of Philippine-Educated Nurses to the United States �� 293 Leo Felix Jurado xii Contents

34 Case Study: Health Care for the Poor and Underserved Populations in India �� 299 Joanna Basuray Maxwell

Part IX Guideline: Cross Cultural Leadership

35 Attributes of Cross-Cultural Leadership �� 307 Dula Pacquiao 36 Case Study: Integrating Cultural Competence and Health Equity in Nursing Education �� 315 Susan W. Salmond 37 Case Study: Cross-Cultural Leadership for Maternal and Child Health Promotion in Sierra Leone �� 323 Florence M. Dorwie 38 Case Study: Nursing Organizational Approaches to Population and Workforce Diversity �� 329 Lucille A. Joel, Dula Pacquiao, and Victoria Navarro

Part X Guideline: Evidence Based Practice and Research

39 Designing Culturally Competent Interventions Based on Evidence and Research �� 339 Marilyn “Marty” Douglas 40 Case Study: Domestic Violence of an Elderly Migrant Woman in Turkey �� 361 Gülbu Tanriverdi 41 Case Study: Sources of Psychological Stress for a Japanese Immigrant Wife �� 369 Noriko Kuwano 42 Case Study: Early Childbearing and Contraceptive Use Among Rural Egyptian Teens �� 375 Azza H. Ahmed 43 Case Study: A Chinese Immigrant Seeks Health Care in Australia �� 381 Patricia M. Davidson, Adam Beaman, and Michelle DiGiacomo Contributors

Azza H. Ahmed, D.N.Sc., R.N., I.B.C.L.C. School of Nursing, Purdue University, West Lafayette, IN, USA Roxanne Amerson, Ph.D., R.N., C.T.N.-A., C.N.E. School of Nursing, Clemson University, Greenville, SC, USA Adam Beaman, M.P.H. School of Nursing, Johns Hopkins University, Baltimore, MD, USA Joyceen S. Boyle, Ph.D., R.N., M.P.H., FAAN College of Nursing, University of Arizona, Tucson, AZ, USA College of Nursing, Augusta State University, Augusta, GA, USA Lynn Clark Callister, R.N., Ph.D., FAAN School of Nursing, Brigham Young University, Provo, UT, USA Giordano Cotichelli, Ph.D., R.N. Faculty of Medicine, University of Ancona, Ancona, Italy Patricia Davidson, Ph.D., Med., R.N., FAAN School of Nursing, Johns Hopkins University, Baltimore, MD, USA Michele DiGiacomo, Ph.D. University of Technology Sydney, Sydney, NSW, Australia Florence Maria Dorwie, D.N.P., R.N.C., A.P.N.-B.C. Sa Leone Health Pride, Inc., North Bergen, NJ, USA New York Presbyterian Columbia University Medical Center, New York, NY, USA Marilyn “Marty” Douglas, Ph.D., R.N., FAAN School of Nursing, University of California, San Francisco, San Francisco, CA, USA Jehad O. Halabi, Ph.D., R.N., T.N.S. College of Nursing, King Saud bin Abdulaziz University of Health Sciences—National Guard, Al Ahsa, Kingdom of Saudi Arabia Carol Sue Holtz, Ph.D., R.N. School of Nursing, Kennesaw State University, Kennesaw, GA, USA Darlene P. Hughes, M.S.N., R.N. College of Nursing, Washington State University, Spokane, WA, USA K Bay Air, Homer, AK, USA

xiii xiv Contributors

Joyce Hyatt, Ph.D., D.N.P., C.N.M. Nurse Midwifery Program, School of Nursing, Rutgers University, Newark, NJ, USA Eun-Ok Im, Ph.D., R.N., FAAN School of Nursing, Duke University, Durham, NC, USA Marianne Jeffreys, Ed.D., R.N. Graduate College and College of Staten Island, The City University of New York (CUNY), New York, NY, USA Lucille A. Joel, Ed.D., R.N., A.P.N., FAAN School of Nursing, Rutgers University, Newark, NJ, USA Leo-Felix M. Jurado, Ph.D., R.N., A.P.N., FAAN Department of Nursing, William Paterson University, Wayne, NJ, USA Janet R. Katz, Ph.D., R.N. College of Nursing, Washington State University, Spokane, WA, USA Sangmi Kim, Ph.D., R.N. School of Nursing, Duke University, Durham, NC, USA Anahid Kulwicki, Ph.D., R.N., FAAN School of Nursing, Byblos Campus, Lebanese American University, Byblos, Lebanon Noriko Kuwano, Ph.D., R.N., M.W., P.H.N. International Nursing Department, Oita University of Nursing and Health Sciences, Oita, Japan Jana Lauderdale, Ph.D., R.N., FAAN School of Nursing, Vanderbilt University, Nashville, TN, USA Manuel Lillo-Crespo, Ph.D., M Anthro., M.S.N., R.N. Facultad Ciencias de la Salud, Department of Nursing, University of Alicante, Alicante, Spain Clinica Vistahermosa Hospital, Alicante, Spain Violeta Lopez, Ph.D., R.N., F.A.C.N., FAAN Nat Yong Loo Lin School of Medicine, Alice Lee Center for Nursing Studies, Clinical Research Center, National University of Singapore, Singapore, Singapore Jody R. Lori, Ph.D., C.N.M., F.A.C.N.M., FAAN PAHO/WHO Collaborating Center, School of Nursing, University of Michigan, Ann Arbor, MI, USA Sandra Lovering, R.N., B.S.N., M.B.S., D.H.Sc. King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia Stephen Marrone, Ed.D., R.N., N.E.A., C.T.N.-A Harriet Rothkoft Heilbrunn School of Nursing, Long Island University of Nursing, Brooklyn, NY, USA Joanna Basuray Maxwell, Ph.D., R.N. Department of Nursing, Multicultural Institute and Faculty Development, Towson University, Towson, MD, USA Victoria Navarro, M.S.N., R.N. Joint Commission International, Oakbrook, IL, USA Contributors xv

Asmah Binti Mohd Noor, M.Sc., R.N., N.I.C.U. Nanyang Polytechnic, Singapore, Singapore Dula Pacquiao, Ed.D., R.N., C.T.N.-A., T.N.S. School of Nursing, Rutgers University, Newark, NJ, USA School of Nursing, University of Hawaii, Hilo, Hilo, HI, USA Larry Purnell, Ph.D., R.N., FAAN School of Nursing, University of Delaware, Newark, DE, USA Florida International University, Miami, FL, USA Excelsior College, Albany, NY, USA Rubab I. Qureshi, M.D., Ph.D. School of Nursing, Rutgers University, Newark, NJ, USA Louise Racine, Ph.D., R.N., FAAN College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada Jorge Riquelme-Galindo, M.S.N., R.N. Department of Nursing, University of Alicante, Alicante, Spain Gennaro Rocco, Ph.D., R.N., FAAN Centre of Excellence for Nursing Scholarship, Ipasvi Rome Nursing Board, Rome, Italy Antoinette Sabapathy, R.N., S.C.M., C.N.M., W.H.N.P. Nursing Maternity Unit, Gleneagles Hospital, Singapore, Singapore Susan W. Salmond, Ed.D., R.N., A.N.E.F., FAAN School of Nursing, Rutgers University, Newark, NJ, USA Donna Shambley-Ebron, Ph.D., R.N., C.T.N.-A. College of Nursing, University of Cincinnati, Cincinnati, OH, USA Alessandro Stievano, Ph.D., M.Sc.N., R.N. University of Rome, Rome, Italy Center for Nursing Excellence, Ipasvi Rome Nursing Board, Rome, Italy Gülbu Tanriverdi, Ph.D. Canakkale School of Health, Terzioglu Campus, Canakkale Onsekiz Mart University, Canakkale, Turkey Rick Zoucha, Ph.D., P.M.H.C.N.S.-B.C., FAAN Joseph A. Lauritis Chair for Teaching and Technology, School of Nursing, Duquesne University, Pittsburgh, PA, USA Conceptual Framework for Culturally Competent Care 1

Dula Pacquiao

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr. (1966)

1.1 Introduction 1.2 Social Determinants of Health Social determinants have been shown to have a greater negative impact on populations who Social determinants of health are the conditions experience cumulative disadvantages in society in which people are born, grow, live, work, and and manifested in poorer health status. Health age (WHO 2015a) as well as the systems put in promotion requires a broad understanding of the place to deal with illness (CDC 2015). These mechanisms by which social disadvantages cre- social circumstances are shaped by a wider set ate health inequities in vulnerable populations. of economic, social, and political forces influ- Vulnerable groups are more likely to experience encing the distribution of money, power, and poverty, social exclusion, and limited access to resources. Social determinants of health are social resources and privileges. Key to improving mostly responsible for health inequities among population health is through culturally compe- populations within a society and across the globe. tent practice to achieve health equity by promot- They determine the extent to which a person or ing a culture of health and healthy communities group possesses the physical, social, and per- (Lavizzo-Mourey 2015), grounded in the prin- sonal resources to identify and achieve personal ciples of social justice, human rights, and benefi- aspirations, satisfy needs, and cope with the envi- cence. Table 1.1 presents the Global Guidelines ronment (Raphael 2004). Social determinants for Culturally Competent Health Care and sam- of health pertain to the quantity and quality of ple applications of each. These guidelines articu- a variety of resources that a society makes avail- late the ethical and moral principles of culturally able to its members, such as, income, food, hous- competent care to achieve health equity for indi- ing, employment, and health and social services. viduals, families, and populations. Both individual- and group-level determinants have been identified (Diez-Roux 2004; Kaufman 2008). At the individual level, factors, such as race and ethnicity, gender, employment, social D. Pacquiao, Ed.D., R.N., C.T.N.-A., T.N.S. class, income, and experience with discrimina- School of Nursing, Rutgers University, tion, are associated with health disparity. At the Newark, NJ, USA group level, social factors such as strength of School of Nursing, University of Hawaii, Hilo, social capital, social cohesion, collective efficacy, Hilo, HI, USA

© Springer International Publishing AG, part of Springer Nature 2018 1 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_1 2 D. Pacquiao

Table 1.1 Guidelines for the practice of culturally competent nursing care Guideline Description Knowledge of cultures Nurses shall gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations they care for, as well as knowledge of the complex variables that affect the achievement of health and well-being Education and training Nurses shall be educationally prepared to provide culturally congruent healthcare. in culturally competent Knowledge and skills necessary for assuring that nursing care is culturally congruent care shall be included in global healthcare agendas that mandate formal education and clinical training, as well as required ongoing, continuing education for all practicing nurses Critical reflection Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage in order to have an awareness of how these qualities and issues can impact culturally congruent nursing care Cross-cultural Nurses shall use culturally competent verbal and nonverbal communication skills to communication identify client’s values, beliefs, practices, perceptions, and unique healthcare needs Culturally competent Nurses shall utilize cross-cultural knowledge and culturally sensitive skills in practice implementing culturally congruent nursing care Cultural competence in Healthcare organizations should provide the structure and resources necessary to healthcare systems and evaluate and meet the cultural and language needs of their diverse clients organizations Patient advocacy and Nurses shall recognize the effect of healthcare policies, delivery systems, and resources empowerment on their patient populations and shall empower and advocate for their patients as indicated. Nurses shall advocate for the inclusion of their patient’s cultural beliefs and practices in all dimensions of their healthcare Multicultural workforce Nurses shall actively engage in the effort to ensure a multicultural workforce in healthcare settings. One measure to achieve a multicultural workforce is through strengthening of recruitment and retention effort in the hospital and academic setting Cross-cultural Nurses shall have the ability to influence individuals, groups, and systems to achieve leadership outcomes of culturally competent care for diverse populations. Nurses shall have the knowledge and skills to work with public and private organizations, professional associations, and communities to establish policies and guidelines for comprehensive implementation and evaluation of culturally competent care Evidence-based practice Nurses shall base their practice on interventions that have been systematically tested and research and shown to be the most effective for the culturally diverse populations that they serve. In areas where there is a lack of evidence of efficacy, nurse researchers shall investigate and test interventions that may be the most effective in reducing the disparities in health outcomes Source: Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J, Milstead, J., Nardi, D., Purnell, L. (2014), Guidelines for Implementing Culturally Competent Nursing Care. Journal of Transcultural Nursing 25 (2):110. Reprinted with permission from Sage Publications, Inc. and diversity of social networks influence quality societal-level variables are intimately linked to of life and health outcomes (Burris et al. 2002). produce health vulnerability. Sampson and Raudenbush (1999) observed that collective efficacy includes such informal mechanisms as behaviors, norms, and actions that 1.2.1 Socioeconomic Status residents of a given community use to achieve public order. Collective efficacy develops when Socioeconomic position is one’s relative posi- members of the community have strong feelings tion as compared to others in society, which is of trust and solidarity for each other. When com- determined by individual characteristics such munity members feel strongly bonded to each as income, level of education, occupation, and other, they cooperate to deter crime and share employment (Babones 2010). Income, education, ownership of their neighborhood. Individual- and and occupation have all been shown to predict 1 Conceptual Framework for Culturally Competent Care 3 morbidity and mortality (Miranda et al. 2012; were among African Americans and American Seith and Kalof 2011; Williams et al. 2012). Indian and Alaskan Natives. Although African Poverty is a socioeconomic position that results Americans represented only 13.3% of the US from a combination of these individual charac- population, they bore a disproportionate burden teristics, with consequent limitation to one’s of poverty with the highest rate between 24% capacity for self-governance and subsequent (rural residents) and 33.8% (metro residents)— dependence on society for survival. Dependence more than double the national average (USDA and lack of autonomy in turn foster marginaliza- 2017). In 2015, children (18 years and younger) tion of the affected group by mainstream society. comprised 33.6% of the people living in pov- Social marginalization excludes or limits access erty with a poverty rate of 19.7%. Nearly 32% to institutional resources and privileges by cer- of Black children and 28.9% of Hispanic chil- tain individuals and groups, creating a cycle of dren were in deep poverty compared to 11.4 for poverty and social dependence. non-Hispanic Whites. Deep poverty is defined Poverty is associated with a number of risk as income less than half the threshold (Institute factors that affect morbidity, disability, and for Research on Poverty 2016). White neighbor- mortality. This association is observed globally, hoods have twice as many social services as in among the poorest and wealthiest countries alike. predominantly African American and Latino The poor face challenges in accessing adequate neighborhoods despite their greater need for general healthcare and prenatal care. Wilkinson such services (Lin and Harris 2009). Hispanics and Pickett (2010) found a strong correlation were more likely than African Americans to enter between the degree of income disparity within poverty between 2009 and 2011 but were more a society and health outcomes. Populations in likely than African Americans to get out of pov- countries with greater socioeconomic inequality erty. African Americans also spent longer periods experience poorer health outcomes than those liv- of time in poverty with an average of 8.5 months ing in societies with greater parity. For example, compared to 6.5 months among Hispanics the proportion of the population reporting mental (Edwards 2014). illness was much lower in Japan (9%), a country with a very small income gap as compared to 20% in countries with a greater degree of income 1.2.2 Environment inequality such as New Zealand, Australia, and the UK (Wilkinson and Pickett 2010). Chronic stress is experienced by residents of In the USA, African Americans, American neighborhoods with concentrated poverty associ- Indians and Alaskan Natives, and Hispanics are ated with high crimes, dilapidated infrastructure, minority groups that are most greatly affected and environmental hazards from toxic pollutants. by poverty. Predominantly African American In the USA, children who are poor and of African communities reside in neighborhoods with a descent have a higher prevalence of asthma poverty level greater than 40% (Iceland 2012). (25%) as compared to poor White (16%) and Neighborhoods with concentrated poverty and Hispanic children (13%) (Seith and Kalof 2011). higher proportions of people of color are more Neighborhoods with concentrated poverty lack likely to exhibit signs of material deprivation and resources such as safe public spaces, transpor- economic disinvestment. Some individuals who tation, affordable and healthy food venues, and are not poor but living in these neighborhoods are quality schools and healthcare services. exposed to the same kind of challenges as poor Wilson (1996) noted that the high rate of job- residents. lessness has concentrated poverty, particularly According to the US Census (2016), the offi- in inner-city neighborhoods in the USA, as jobs cial poverty rate dropped slightly from 14.8% in requiring low education and skills moved to sub- 2014 to 13.5% in 2015; close to 43 million were urban communities along with the flight of White living in poverty. The highest rates of poverty residents from urban areas. More recently there 4 D. Pacquiao has been a steady shift in demand away from tions of calories, sugar, refined grains, salt, and the less skilled toward the more skilled jobs in fat because these are less costly. These energy- advanced economies, creating dramatic inequali- dense foods are processed for longer shelf life ties in wage and income between the more and enhanced palatability but have low nutri- and the less skilled, as well as unemployment tional value and are a factor in causing obesity. among the less skilled (Slaughter and Swagel Healthier foods such as fruits, vegetables, and 1997). These same changes in labor demands lean sources of protein are often inaccessible, have caused widening income gaps in a number easily perishable, and beyond the means of those of developing countries as well as in advanced in poverty. Thus the poor are at risk for malnutri- economies. In countries with relatively flexible tion, food insufficiency, and obesity with its asso- wages set in decentralized labor markets, such as ciated health risks of diabetes, hypertension, and the USA and, increasingly, the UK, the decline cardiovascular diseases. In 2011–2012, 8.4% of in demand for less-skilled labor has translated Americans between 2 and 5 years of age, 17.7% into lower relative wages for these workers. of those between 6 and 11 years, and 20.5% of Trade liberalization in Mexico in the mid-to-late the 12–19-year-old population were considered 1980s led to increased relative wages of high- obese. The prevalence of obesity was highest for skilled workers but has not boosted the demand preschool-aged children between 2 and 4 years of for unskilled labor nor raised unskilled wages. In age in households with incomes at or below the fact, the demand for unskilled labor has declined, federal poverty threshold (CDC 2015). and their wages have fallen in some developing In 2014, nearly 40% of the world’s adult countries (Slaughter and Swagel 1997). population was overweight and 13% were obese. Pervasive joblessness undermines social orga- At least 42 million children under the age of 5 nization and social capital of neighborhoods that were overweight or obese. The rate at which could otherwise buffer the effects of poverty in obesity is increasing among middle- and lower- these communities. According to Wilson (1996), income countries is 30% higher than those of the lack of role models from adults who are gain- higher-income countries (WHO 2015b). Obesity fully employed has contributed to the widespread is steadily becoming a health crisis among the degradation of work ethic in the young and the poor worldwide, more so than starvation. Income belief that education brings economic returns. and gender differences in the rate of overweight African American communities in the north- and obesity are more pronounced among low- east USA that were largely composed by freed income and lower-middle-income countries. For slaves from the south have built strong social example, in low-income countries, the rate of networks and connections that supported each obesity among women is more than three times other. According to Fullilove (2004), the urban higher than that of men (7.3% and 2.2%, respec- gentrification movement dismantled this social tively). In lower-middle-income countries, obe- network causing “root shock” especially among sity among women is twice that of men (10.4% younger generations of African Americans who vs. 5.1%). were separated from a stable network of social Overall, African Americans have a higher rate and emotional integration in racially divided of obesity, nearly 50% compared to the rate of communities. obesity among Whites, Hispanics, and Asians Obesogenic environment refers to features (43%, 33%, and 11%, respectively). In addition, of the living and working spaces that contrib- African Americans have higher rates of high ute to the development of obesity. In the USA, blood pressure than Whites and nearly twice that Drewnowski and Specter (2004) observed an of Mexican Americans (CDC 2014a). Income association between poverty and obesity. As and education are correlated with obesity in income decreases, the rate of obesity increases. women in the USA. Women with higher income Low-income families are more likely to consume and more years of education, particularly with poor-quality diets that include higher concentra- college degrees, are less likely to be obese (CDC 1 Conceptual Framework for Culturally Competent Care 5

2014b). Heart disease and obesity are risk factors The Whitehall studies confirmed that access to for diabetes, another chronic health condition that healthcare services does not guarantee equity of disproportionately affects African Americans. health outcomes, suggesting that health status African Americans are 70% more likely to be is more significantly shaped by life conditions. diagnosed with diabetes compared to Whites and Despite universal access to healthcare services, are two times more likely to die from the disease. differential health status was observed among The prevalence of visual impairment is 20 per 100 thousands of White British civil servants. This adults with diabetes among African Americans suggests that programs and policies providing as compared to 17 per 100 adults with diabetes equal access and opportunity fall short in achiev- among Whites (United States Department of ing equity of outcomes because of failure to con- Health and Human Services-Office of Minority sider the fundamental differences in the needs Health [USDHHS-OMH], 2014). and statuses of population groups.

1.2.3 Social Stratification 1.3 Vulnerable Populations

People do not get sick randomly but in relation Vulnerable populations comprise groups of peo- to their living, social, political, and environmen- ple who have systematically experienced greater tal circumstances (Bambas and Casas 2001). social or economic obstacles to health that are Socioeconomic and political structures create historically linked to discrimination or exclusion. conditions resulting in wealth or poverty, job These factors may be based on their racial or eth- stability or instability, educational advancement nic group, religion, socioeconomic status, age, or exclusion, acceptance or marginalization, and gender, gender identity or sexual orientation, and community progress or deprivation. Leading migration status. Other obstacles are associated causes of death have been primarily attributed with mental health, cognitive, sensory or physical to lifestyle factors. However, lifestyle factors do disability, and geographic location of residence not rest solely on individual choice but rather (USDHHS 2010). As a consequence, vulner- on life conditions and circumstances that con- able populations experience multiple cumulative tribute to unhealthy behaviors (WHO 2015b). adversities in life with consequent predisposition Conventional explanations of poor health, such to higher and multiple health risks (Frohlich and as lack of access to medical care and unhealthy Potvin 2008). A group’s vulnerability is linked lifestyles, only partially explain differences in with a particular society’s social, cultural, and health status (Marmot and Bell 2009). The semi- environmental inequalities that are differentially nal Whitehall I and II studies of British civil ser- manifested in health inequity. Vulnerable popula- vants (Marmot et al. 1978, 1991) found a social tions may include the poor with limited literacy gradient in health among Caucasians who were and education; victims of war, violence, enslave- not poor and had equal access to health services. ment, and sex trafficking; migrant workers and This social gradient existed for heart disease, those without legal status; mentally ill and indi- some cancers, chronic lung disease, gastroin- viduals with cognitive and physical disabilities; testinal disease, depression, suicide, sickness females in male-dominated societies; and victims absence, back pain, and general feelings of ill of stigma and discrimination such as LGBTQ, health. Higher social position was associated HIV/AIDS infected, incarcerated, prostitutes, etc. with better health. A common thread across vulnerable popu- Social gradient is conditioned by the status lations is poverty that can stem from lack of syndrome (Marmot 2006). The lower individu- access to quality education, resources supporting als are in the social hierarchy, the less likely they achievement, and job opportunities. Poverty not are able to meet their needs for autonomy, social only predisposes individuals to social discrimi- integration, and participation (Marmot 2006). nation and exclusion but also prevents access to 6 D. Pacquiao basic services and opportunities that can improve predispose one to the development of obesity, their lives. The consequence of social discrimina- hypertension, immunosuppression, and impaired tion and stigma is disempowerment and chronic coping (McEwen et al. 2015). underachievement, unemployment, and poverty. Krieger (2011) has posited that individuals and The poor experience the added burden of the groups embody their material and social world as “poverty penalty.” According to Mendoza (2011) evident in the differential patterning of disease the five penalties of poverty are poor quality, exposure and susceptibility and ultimately mor- higher prices, nonaccess, non-usage, and cata- tality. Epidemiological data reflect the biological strophic spending burden. Those with the least embodiment of social inequalities of individuals financial means end up paying more in order to within the same family and population groups in participate in the market economy as compared communities across the globe. In other words, the to those with more economic means. Because cumulative impact of social adversities differen- poor neighborhoods have less proximity to goods tially experienced by humans across their life and services, residents have fewer options for course shapes their health and well-being. The competitive pricing of goods and services. When author emphasizes the role of social inequalities priced out of the market, the poor must priori- as the root cause of health inequities that condi- tize their necessities of daily living, often forgo- tion the life chances and health trajectories of ing services, preventive healthcare services, and groups in society. Krieger argues that remedies healthier food. They lack the disposable income should be focused on social change because of to take advantage of lower prices offered when its greater impact on vulnerable individuals and purchasing larger quantities of goods and ser- groups, moving away from the individualistic vices, a situation that is compounded by their paradigm that emphasizes self-responsibility lack of storage space and transportation. Because for one’s health. In other words, accountability of limited access to a variety of healthcare pro- for change rests heavily on society and the gov- viders and services, the poor have less autonomy ernment. According to Krieger, the progress in and choices in healthcare decisions, which in turn decreasing smoking in the USA was largely facil- impact the effectiveness of healthcare, education, itated by public policies mandating labeling of compliance, and outcomes. The poverty penalty tobacco products as carcinogenic by the Surgeon contributes to the downward spiral of vulnerable General, legislation prohibiting targeted market- populations and their health. ing of tobacco to minorities and youth, and legal McEwen and associates (2015) have done measures compelling scientific and economic seminal work distinguishing the effects of accountability of tobacco companies for their chronic, unmitigated stress from acute, episodic product and its health effects. While smoking stress and its link to health. The chronic stress cessation programs focusing on individual-level experienced with poverty, subordination, and change are helpful, social policies have greater discrimination produces allostatic load or “wear- impact on population health because they address and-tear” effects. Primarily mediated by neuro- sociopolitical inequity. endocrine responses in three regions of the brain (hippocampus, amygdala, and prefrontal cortex), allostatic load triggers a cascade of mental, emo- 1.4 Health Inequity tional, and physical effects. These include insom- nia, depression, post-traumatic stress disorders, Health inequity is the disparity due to differences impaired cognitive ability, and engagement in in social, economic, environmental, or health- high-risk behaviors such as tobacco, alcohol, care resources. According to Whitehead (1992) and drug use. These behaviors further aggravate health inequities are differences in health status allostatic load effects. Physical effects are medi- that are unnecessary, avoidable, and considered ated by the hypothalamic-pituitary axis, resulting unfair and unjust. Health inequity implies a need in sustained high levels of stress hormones that for collective moral obligation to correct unfair 1 Conceptual Framework for Culturally Competent Care 7 structure and practices that places an unequal bur- low education as well as the elderly are most dis- den of risks for poorer health among socially disadvantaged (Kronfol 2012b). advantaged groups (Braverman 2014). Although Rural residents in Middle Eastern countries evidence of health inequity exists in all societ- and North Africa such as Sudan are more at risk ies, the gap between the privileged and vulner- of poverty and social exclusion. Geographic able groups is mitigated by decreasing the impact distance and lack of transportation pose barri- of social inequalities that create the pathways to ers to access and utilization of preventive health poor health. services such as vaccination and antenatal ser- Using data from the World Values Survey with vices (Ibnouf et al. 2007). There is also concern over 15,000 respondents from 44 countries rep- about the safety, cost of transportation, and ease resenting developed and developing nations in of boarding public buses. Most people walk or several continents, Babones (2010) found that use private transportation to the clinics. The poor individual indicators of socioeconomic status elderly and functionally impaired individuals are (income, education, and occupation) affect self- greatly disadvantaged. In many Muslim coun- reported health status worldwide, independently tries, a male guardian is needed to arrange for and collectively. People of high income have more transport which further limits access because of than 50% greater odds of reporting good health the need to wait for this person to get off work, than those with low income, even when educa- and many clinics are closed before he gets home tion and occupational class remained the same. from work (Kronfol 2012a). Those with higher levels of education have more In countries like Tunisia, Syria, and Egypt, than 60% greater odds of reporting good health gender significantly influences access and utili- than people with lower educational achievement zation of health services by women. In general, (Babones 2010). Selected examples of health dis- women prefer female physicians for reproduc- parities in some countries are presented. tive health issues (Romdhane and Grenier 2009). Gender congruence and sensitivity of health providers affect service use by women (Kronfol 1.4.1 Africa 2012c). Although women are major healthcare users as well as providers, they are underrepre- 1.4.1.1 North Africa and Middle East sented in healthcare decision-making. Religion Differences in health system size, structure, and has an important influence on specific health financing occur in Middle Eastern countries. practices such as male and female circumcision, Public healthcare programs in the Arab countries the practice of medicine and litigation, the belief provide comprehensive coverage of all levels in fate and destiny, and other social determinants of care, including prevention, ambulatory care, of health. There are legal, religious, medical, and inpatient services either completely free and social factors that serve to support or hinder of charge or at a nominal fee (Kronfol 2012a). women’s access to safe abortion services in the 21 There are gaps in coverage such as nonprescrip- predominantly Muslim countries in the Middle tion drugs, dental care, cosmetic surgery, and East and North Africa, where 1 in 10 pregnan- smoking cessation. Some countries prohibit cies ends in abortion (Hessini 2007; Kronfol fertility treatments and abortion based on reli- 2012a). Gender-related issues include improv- gious and bioethical grounds. Dental services ing women’s access to healthcare, education and are limited even in countries that adopted social literacy for girls and women, employment, and health insurance such as Lebanon. Many dentists social protection for women and female genital practice in the private sector and cities, limiting mutilation (Kishk 2002). access to dental services by rural and poor resi- Ethnic minorities in Arab countries experi- dents. Mental health services are frequently not ence discrimination in healthcare, public places, available in public clinics. People with mental and public transport. Language barriers and dif- retardation, severe mental health problems, and ferences in health beliefs and practices have 8 D. Pacquiao been documented among Bedouins in a Beirut boys. In Angola, the situation has actually wors- Hospital (Kronfol 2012a). Barriers are also ened, from 76 girls per 100 boys in 1999 to 65 in related to nationality in the Gulf countries (e.g., 2012. The country with the greatest inequity in Kuwait and United Arab Emirates) because sepa- primary and lower secondary is Chad. In Guinea rate healthcare facilities are reserved for nation- and Niger, approximately 70% of the poorest als of the country, non-nationals, or expatriates. girls had never attended school compared with Facilities for nationals receive more government less than 20% of the richest boys. Gender dispari- support. This differentiated care setting promotes ties in secondary education have barely changed segregation and unequal treatment of individuals in sub-Saharan Africa since 1999, with approxi- and groups based on nationality (Kronfol 2012a). mately eight girls for every ten boys enrolled. In a few poor countries, such as Rwanda, new gen- 1.4.1.2 Sub-Saharan Africa der gaps at the expense of boys have emerged. According to Benatar (2013), in 2008, 54% of In Lesotho, only 71 boys were enrolled for every South Africans had an income below $3/day. While 100 girls in 2012, a ratio unchanged since 1999 the top 10% earned 58% of annual national personal (UNESCO 2015). income, 70% of the population received a mere Although gender gaps in youth literacy are 16.9%. The Gini coefficient, a measure of income narrowing, the report had predicted that fewer inequality, increased from 0.6 in 1995 to 0.679 in than seven out of every ten young women in 2009. Infant mortality rates (IMR) have remained sub-Saharan Africa were literate in 2015. Two- stable between 1990 and 2005 reflecting White and thirds of adults who lack basic literacy skills are Black disparities—18 per 1000 live births among women, a proportion unchanged since 2000. Half Whites as compared to 74 per 1000 live births of adult women in sub-Saharan Africa cannot read among Black South Africans. IMR differed across or write. Gender-based school disparities that geographical regions with 27/1000 live births in the have been attributed to gender-based violence, Western Cape and 70/1000 live births in the Eastern child marriages, and secondary school dropout Cape. Overall maternal mortality increased from by pregnant girls remain a persistent barrier to 150/100,000 pregnancies in 1998 to 650/100,000 in girls’ education. If existing laws mandating older 2007. Sub-Saharan Africa has endured dispropor- age for females at marriage were enforced, this tionately high prevalence of HIV/AIDs compared to would result in an overall 39% increase in years other countries in the world. South Africa accounts of schooling in sub-Saharan Africa. Pregnancy for almost 17% of the world’s population living has been identified as a key driver of dropout and with HIV/AIDS. The country has the largest anti- exclusion among female secondary school stu- retroviral treatment program in the world, yet only dents in sub-Saharan African countries, including 40% of eligible adults are receiving treatment. The Cameroon and South Africa. The prevalence of prevalence of HIV infection among those older than premarital sex before age 18 years, increased in 19 years ranges from 16.1% in the Western Cape 19 out of 27 countries in the region between 1994 to 38.7% in KwaZulu-Natal (Benatar, Sullivan and and 2004 (UNESCO 2015). Brown 2017). UNESCO’s EFA Global Monitoring Report (2015) noted that not a single country in sub- 1.4.2 Asia Saharan Africa has achieved gender parity in either primary or secondary education, with the 1.4.2.1 China poorest girls as most disadvantaged. In 2012, at As the most populous nation in the world, China’s least 19 countries around the world had fewer population as of January 1, 2017 was approxi- than 90 girls for every 100 boys in school; 15 of mately 1.38 billion people, representing an these countries were in sub-Saharan Africa. In increase of 0.53% (7.3 billion people) from 2016. the Central African Republic and Chad in 2012, China has a population density of 148 people per the number of girls in secondary was half that of square kilometer. In 2016, the number of births 1 Conceptual Framework for Culturally Competent Care 9 exceeded the number of deaths by 7,315,733, and viruses. Heavy metals and polycyclic aromatic but because of external migration, the population hydrocarbons carried by PM2.5 can enter and increased by only 41,254. The sex ratio of the deposit in human alveoli, causing inflammation total population was 1.051 (1051 males per 1000 and lung diseases, as well as enter the circulation females), which is higher than the global sex ratio and affect the normal functioning of the cardiovas- (Countrymeters 2017a). Since the 1950s, the cular system. Exposure to PM2.5 can lead to sig- process of industrialization in China has shifted nificantly increased mortality from cardiovascular, its economy from agriculture to manufacturing, cerebrovascular, and respiratory diseases, as well which has significantly increased its energy con- as greater cancer risks (Pan et al. 2012). sumption and created mass rural to urban migra- Air pollution in China is mainly caused by tion. In 2011, the proportion of the population burning coal in factories and power plants and oil living in urban areas surpassed those living in combustion by vehicles. During winter, homes rural areas for the first time, and an additional are heated through a central heating system 200 million rural-to-urban migrants are antici- powered by coal burning; hence “smog” days pated during the next 10 years (Gong et al. 2012). are more frequent in winter seasons. Rohde and Industrialization has led to serious environmental Muller (2015) have analyzed national reports and ecological problems, both in urban and sur- on hourly air pollution from 1500 sites in China rounding areas, including increased air and water over 4 months including airborne particulate mat- pollution, local climate alteration, and a major ter, sulfur dioxide, nitrogen dioxide, and ozone. reduction in natural vegetation and production Significant widespread air pollution is observed (Fang et al. 2003). A major threat is the absence across Northern and Central China, not limited to of continuous healthcare coverage for rural-to- major cities and geologic basins. Sources of pol- urban migrants who are at risk of dual infectious lution are widespread but are particularly intense disease burden from exposure to pathogens asso- in the northeast corridor from near Shanghai to ciated with rural poverty like parasitic worms in north of Beijing. Rohde and Muller found that the soil and pathogens such as tuberculosis in 92% of the Chinese population experienced more crowded urban environments. Urbanization has than 120 h of unhealthy air (based on US-EPA led to changes in patterns of human activity, diet, standard) and 38% experienced average concen- and social structures with profound implications trations that were unhealthy. The authors con- for noncommunicable diseases, e.g., diabetes, cluded that this level of exposure contributes to cardiovascular disease, cancer, and neuropsychi- 1.6 million deaths/year (0.7–2.2 million deaths/ atric disorders. Urban residents have experienced year at 95% CI), roughly 17% of all deaths in an increase in the levels of cholesterol- related China. diseases (Lee 2004) and an overall decline in Wheat is the third largest crop and an essen- quality of life. tial contributor to food security in China and the According to statistics from China’s Ministry world. Higher levels of air pollution in the North of Environmental Protection, cities in the Yangtze China Plain region during winter and spring, River Delta, Pearl River Delta, and Beijing- which correspond to the early growing phase Tianjin-Hebei region suffer over 100 haze days of winter wheat, significantly reduce sun radia- every year, with particulate matter/PM2.5 con- tion and increase relative humidity, resulting in centration of two to four times above the World decreased photosynthetic rate, higher risks of Health Organization guidelines, which can lead fungal infection, and negative effects on wheat to systemic damage to human health (Pan et al. yields (Liu et al. 2016). Particulate matter such 2012). PM2.5 are small-sized particles in the air as cement dust, magnesium-lime dust, and car- that can reach a large surface area of the respiratory bon soot deposited on vegetation can inhibit system that carry a variety of toxic heavy metals, plants’ respiration and photosynthesis and cause acid oxides, organic pollutants, and other chemi- chlorosis and death of leaf tissues because of the cals, as well as microorganisms such as bacteria thick crust formation and alkaline toxicity from 10 D. Pacquiao wet weather. The dust coating may also affect the also noted high occurrence of cardiovascular normal action of pesticides and other agricultural disease, stroke, and diabetes in middle-aged chemicals. Accumulation of alkaline dusts in the urban women. The higher rates of greater body soil can increase soil pH to levels adverse to crop mass index, waist-to-hip ratio, and cholesterol growth (Last et al. 1985). in urban middle-aged women may be attributed to greater caloric and fat intake and decrease 1.4.2.2 India in comparative physical activity. While some Being the second most populous country in the Hindus are vegetarian, saturated fat is derived world, India’s population as of January 1, 2017 from use of ghee (clarified butter), coconut milk, was estimated at 1.33 billion representing an and cream in the food preparation. Middle-class increase of 1.26% (16.6 million) from 2016. In urban women have the highest cardio-metabolic 2016, the number of births exceeded the num- risks compared to poor urban and rural women ber of deaths by 17,154,513, but due to external (Mohan et al. 2016). migration, the population declined by 541,027. The rate of cardiovascular disease rates The sex ratio of the total population was 1.068 among individuals 30–60 years of age is 405 (1068 males per 1000 females) which is higher per 100,000 in India as compared to in Great than the global sex ratio (Countrymeters 2017b). Britain (180/100,000) and China (280/100,000) Forty-one percent of India’s population is pre- (Chauhan and Aeri 2013). Higher prevalence dicted to live in urban areas by 2030 (United of cardiovascular disease is noted in urban than Nations 2004). India’s rapid urbanization comes rural India. There has been a tenfold increase with opportunities to make cities more livable in the prevalence of coronary artery disease in and transform their economy, but this also comes urban India during the last 40 years, and rates with negative consequences by weakening an have ranged between 1.6 and 7.4% in rural pop- already inadequate social service infrastructure ulations and 1 and 13.2% in urban populations creating lack of basic services and pressure on (Gupta 2012). resources. Cities have a transport crisis, road con- The American College of Cardiology’s gestion, and pollution from noise, air, and waste. Pinnacle India Quality Improvement Program Public health concerns are associated with lack (PIQIP) found that women had fewer patient of quality housing, clean water, and sanitation. medical encounters than men, including visiting In addition to urbanization, gender inequity a physician, hospital, or clinic for evaluation, test- is a significant social determinant of health of ing, or treatment. Although women had a higher Indians. Being female is associated with lack of rate of noncommunicable diseases, they received education, employment, health access, and auton- less medication prescriptions than men (Kalra omy. Studies indicate that Indians in urban areas et al. 2016). Women are more at risk for hyperten- and women in particular have poorer health out- sion, diabetes, and hyperlipidemia but receive less comes than rural Indians and men, respectively. medical care than men. Sengupta and Jena (2009) India has the largest number of people with dia- found rural and urban women suffer from goiter, betes than any other country, and the prevalence 1.93 and 3.62 times more than men, respectively. of diabetes among urban Indians rose from 2.1 to Urban women were observed to suffer more from 12.1% from 1970 to 2003 (Ramachandran et al. asthma than their male counterparts. 2003). The study by Mohan et al. (2016) using a In 2011, the Indian population over 65 years cross-sectional sample of 6853 rural, poor urban, comprised 90 million and is predicted to exceed and middle-class urban women between 35 and 227 million by 2050. Women are considered a 70 years old revealed that urban middle-class disadvantaged group among the aging popula- women have the highest levels of anthropom- tion. Although Indian women live longer than etry, body mass index, cholesterol, waist-to-hip men, they consistently report poorer health, ratio, hypertension, and diabetes as compared to higher disabilities, lower cognitive function, and poor urban and rural Indian women. The study lower utilization of health services (Rao 2014). 1 Conceptual Framework for Culturally Competent Care 11

Kakoli and Chaudhuri (2008) found wide health healthcare, representing 7.5% points above the disparities between elderly men and women even OECD average of 9.3%. Forty-eight percent of after controlling for demographics, medical con- US healthcare is publicly financed, well below ditions, and known risk factors. However control- the average of 72% in OECD countries (OECD ling for economic independence reduced the gaps 2014a). The USA lags behind other developed significantly, suggesting that financial empower- countries and some less developed countries in ment may be the key to improving health out- many health outcomes (OECD 2014b). Health comes of elderly women. coverage for able adults below 65 years of age is The Longitudinal Aging Study conducted generally acquired through employer-sponsored in the southern states of Karnataka and Kerala health insurance. An employer-sponsored sys- and two northern states of Rajasthan and Punjab tem of access to care fosters inequity by favoring found that elderly women have lower cogni- high wage earners with good benefits over low- tive function than elderly men and the disparity income groups whose employers may not have was linked with gender discrimination evident the ability to provide optimal or any coverage for in women having poorer education and less their employees. social engagements, both of which impact their At the end of 2014, more than seven of every health. Higher level of discrimination against ten uninsured individuals in the USA have at women was observed in the two northern states least one full-time worker in their family, and (Population Reference Bureau 2012). an additional 12% have a part-time worker in In India, gender bias is evident in all life stages the family. Yet, for these families, employment of a woman—female infanticide, poor education does not translate to enough income to be able facilities, dowry practices, stereotypical roles to purchase health insurance. While access to of women as homemakers, and discrimination healthcare does not guarantee equity in health against widows. Although dowry practices have outcomes, lack of universal access perpetuates been declared illegal, some families continue social and health inequity. Many gaps in cov- to expect payment by the bride’s family to the erage remain. While Medicare is available for groom’s family before marriage. The burden of adults 65 years and older, procurement of supple- dowry payments has created a strong preference mental benefits depends on the financial capac- for sons and marginalization of females as a bur- ity of the individual or his/her family. Medicaid den to their families. It is exceptionally hard for and the State Children Health Insurance provide elderly women to have good health and quality of healthcare access to eligible indigent families and life. Although there are existing government ini- their children. However, because these costs are tiatives for female children, they do not address shared by each state with the federal government, the current generation of elderly women who funding is not the same across different regions. continue to face discrimination, poverty, poor In addition, some healthcare practitioners do education, and poor health. not accept patients with Medicaid, leaving these patients with even fewer options. The Patient Protection and Affordable Care 1.4.3 North America Act or the Affordable Care Act (ACA) was signed into law by President Obama on March 23, 2010, 1.4.3.1 United States with a goal to provide access to health coverage The USA is the only one among the most eco- to more than 40 million Americans. ACA aims nomically developed member countries of the to expand healthcare coverage to most US citi- Organization for Economic Co-operation and zens and permanent residents by requiring most Development (OECD) that does not provide people to obtain or purchase health insurance universal healthcare access to its citizens. Yet, (USDHHS 2015). To date, ACA has failed to it outspends all other members on healthcare. reach its goal of expanding access to affordable In 2012, the USA spent 16.9% of its GDP on health insurance for many Americans because of 12 D. Pacquiao lack of political will to establish a universal sys- Table 1.2 Racial and ethnic health disparities in the tem of healthcare that offers equity of access to USA quality healthcare for all. Most vulnerable/disadvantaged Racial and ethnic minorities in the USA Health disparity groups Life expectancy from African Americans receive lower quality and intensity of healthcare birth compared with Whites across a wide range of Mortality preventive, diagnostic, and therapeutic services Cancer African Americans and disease states (Washington et al. 2008). The Complications of African Americans adjusted rate of preventable hospitalizations is diabetes higher among African Americans and Hispanics Coronary artery African Americans disease and stroke compared with the rate for non-Hispanic Whites Homicide African Americans (Moy et al. 2011). Among adults aged 65 years Motor vehicular American Indian and Alaskan or more, racial and ethnic differences in influenza deaths Natives (AIANs) vaccination rates persist, with African Americans Suicide AIANs consistently having the lowest each year (Setse Morbidity et al. 2011). Childhood asthma Puerto Ricans and African The Agency for Healthcare Research and Americans Quality/AHRQ (2014) reported continuing evi- Diabetes African Americans, AIANs Human African Americans, AIANs, dence of suboptimal quality of care and access to immunodeficiency males who have sex with men health services among minority and low-income virus (HIV) (MSM) groups despite the ACA. Health disparities and Hypertension and its African Americans access to care have shown no improvement for complications disadvantaged groups. The Centers for Disease Obesity African Americans, Mexican-Americans Control and Prevention (CDC 2011) reported that Infant mortality African Americans despite progress over the past 20 years, racial/ Low birth weight African Americans ethnic, economic, and other social disparities in Extremely preterm African Americans health persist. Racial and ethnic minorities expe- birth rience greater rates of poverty, unemployment, Preterm birth African Americans lack of health insurance, shorter life expectancy, Health behaviors and higher morbidity and mortality rates than Smoking AIANs White Americans, as shown in Table 1.2 (AHRQ Sources: Agency for Healthcare Research and Quality 2014; CDC 2011). Advancing Excellence in Health Care (2014). 2014 National healthcare quality and disparities report. In 2014, individuals below poverty level were Rockville, MD: USDHHS at the highest risk of being uninsured. Over eight Centers for Disease Control and Prevention. (2011). in ten of uninsured individuals were in low- or Health disparities and inequalities report. Atlanta, GA: moderate-income families, with incomes below Author 400% of the poverty line, a requirement to receive subsidies for health insurance. While 45% of the uninsured were non-Hispanic Whites, people of Americans have significantly higher uninsured color are at higher risk of being uninsured than rates (20.9% and 12.7%, respectively) than non-Hispanic Whites. People of color make up Whites (9.1%) (Kaiser Family Foundation 2015). 40% of the overall population but account for Health inequities occur along racial and eth- over half of the total uninsured population. The nic lines. Differences in life expectancy between disparity in insurance coverage is especially African and White American populations high for Hispanics, who account for 19% of the remain although the gap has narrowed. African total population but more than a third (34%) of Americans, on average, have a life expectancy the uninsured population. Hispanics and African of 4 years shorter than Whites (CDC 2014a). 1 Conceptual Framework for Culturally Competent Care 13

African Americans comprise only 25% of the living in food-secure households (Mikkonen and population living in poverty (Iceland 2012), but Raphael 2010). the effect of poverty is worsened by discrimi- Social exclusion is evident among recent nation and marginalization. The mortality rate immigrants and aboriginal populations in Canada. of infants born to Black women is 2.3 times Recent immigrants have higher unemploy- higher than infants born to White women, and ment rates and lower labor force participation the maternal mortality rate for Black women than Canadian-born workers. Compared to non- is 3 times higher than that of White women Aboriginal Canadians, First Nation Aboriginal (USDHHS, HRSA-MCHB 2013). Almost half people earn much less income, have twice the of African American women (46%) are hyper- rate of unemployment, are more likely to live in tensive compared to 30% of White women crowded conditions, and are much less likely to (CDC 2014c). African American women are graduate from high school. Aboriginal Canadians victims of interpersonal violence at a rate of live the shortest lives and have higher rates of 7.8 per 1000 females aged 12 years and older as infant mortality, suicide, major depression, alco- compared to White women and Latinas (6.2 and hol, and childhood sexual abuse than non-Aborig- 4.0, respectively) (National Coalition on Black inal Canadians (Mikkonen and Raphael 2010). Civic Participation 2014). 1.4.3.3 Mexico 1.4.3.2 Canada Mexico is considered most advanced of all the Despite a universal healthcare system in Canada, developing countries in the world. Since 2004, low-income Canadians are less likely to see a Mexico has extended healthcare coverage to 52 specialist when needed, have more difficulty million previously unenrolled Mexicans through getting care on weekends or evenings, and are the Seguro Popular. Although some areas like more likely to wait 5 days or more for an Mexico City has an impressive number of tier one appointment with a physician. Canadians with hospitals with top-notch medical advancements, below-average incomes are three times less many public hospitals are underfunded, lack likely to fill a prescription and 60% less able to medical technology, and offer limited services. get a needed test or treatment due to cost than Access to quality care is reserved for those who above-average income earners (Mikkonen and can pay for private hospital care (Izek 2016). Raphael 2010). According to Guthrie and Fleck (2017), type Men living in the wealthiest neighborhoods 2 diabetes is the leading cause of death and on average live more than 4 years longer than disability in Mexico and has been declared a men in the poorest neighborhoods. In compari- national health emergency. In 2013, the coun- son, women in wealthiest neighborhoods live try has launched the National Strategy for the almost 2 years longer than women in the poorest Prevention and Control of Overweight, Obesity neighborhoods. Those living in the most deprived and Diabetes through public health, medical neighborhoods had higher suicide and death care, and fiscal and regulatory policies. Mexico rates. Adult-onset diabetes and heart attacks are accounts for the most hospitalizations (many of far more common among low-income Canadians. them preventable) related to diabetes, among Food insecurity is common in households led by the 35 OECD countries. Many Mexicans are lone mothers and aboriginal households. Food- diagnosed with diabetes at a relatively early age insufficient households are more likely to report with 3.25% of cases detected between 20 and having diabetes, high blood pressure, and food 39 years, compared to the OECD average of allergies than households with sufficient food. 1.7% (Guthrie and Fleck 2017). Children in food-insecure households are more The rapid increase in obesity, diabetes, hyper- likely to experience a wide range of behavioral, tension, and hypercholesterolemia in Mexico puts emotional, and academic problems than children women of reproductive age at higher risk for pre- 14 D. Pacquiao existing hypertensive disorders and diabetes mel- status. Occupation was a more important deter- litus (WHO 2016). Socioeconomic disparities are minant of SSS among British civil servants com- evident in maternal mortality rates (MMR) from pared to education and income among the US direct causes. MMR from direct maternal deaths subjects. SSS was significantly related to overall has been declining between 2006 and 2013; the health and depression in all groups and to hyper- rate among women residing in the poorest munic- tension in all groups except African American ipalities decreased from 119.1 to 72.7 deaths per males. Socioeconomic factors did not predict 100,000 live births as compared to the decline SSS scores for Black Americans as well as they from 35.2 to 26.9 deaths per 100,000 live births did for the British subjects and White Americans. among women in the wealthiest municipalities. Overall, relationships between SSS and health Between 2008 and 2010 the poorest quintile had were stronger for the British and White US sub- a statistically significant higher MMR from indi- jects than for African Americans, suggesting rect causes than the wealthiest quintile (WHO other factors, such as racial characteristics, influ- 2016). Between 2000 and 2013, the number of ence their health. stillbirths decreased from 9.2 to 7.2 per 1000 as Studies done in a number of countries showed compared to the 2015 worldwide average of 18.4 that health disparities affect racial and ethnic per 1000 births. Approximately 51% of stillbirths minorities more than dominant groups in the occurred intrapartum, with 40% occurring at same society. A longitudinal study of inpatient 28 weeks’ gestation or later, comparable to the psychiatric admissions of adolescents in London global estimate of 33–46% for third-trimester found that young Blacks are nearly six times stillbirths (Murguia-Peniche et al. 2016). more likely than those in the White group to be admitted with psychosis, followed by “Other” (other ethnic groups and those with mixed eth- 1.4.4 European Countries nic background) and Asians. Young people with psychosis in the Black and Other groups were Bask (2011) examined the accumulation of around three times more likely to experience problems among welfare recipients by using formal detention on admission (Corrigall and two waves of data from annual surveys of living Bhugra 2013). In Spain, Romanies (Gypsies), a conditions in Sweden in 1994–1995 and 2002– marginalized group, were found to have greater 2003. The analysis focused on such factors as prevalence of migraines compared to the general chronic unemployment, economic problems, population. Romanies suffering from migraines health problems, experiences of threat or vio- had the worse self-reported health status and lence, crowded housing, lack of a close friend, greater incidence of depression (Jimenez- and sleeping problems. Being single (with or Sanchez et al. 2013). without children) and immigrant was associated with the most clusters of problems. Interestingly, education and economic factors were not signifi- 1.4.5 Latin America and Caribbean cant, which was attributed by the author to the fact that Sweden is a welfare state with an ambi- In Latin and Caribbean countries, the poor tend tious universal social policy agenda involving to use fewer public resources than middle- and redistributive activities and extensive spending upper-income groups. Large patterns of health on public welfare. inequalities between socioeconomic groups, as A study comparing all-White British civil ser- well as between gender and ethnic groups, sug- vants with Whites and Blacks in the USA found gest a link between health outcomes and material that socioeconomic status was related to health and social living conditions. There is a grow- (Adler et al. 2008). Subjective social status ing impact of social determinants reflected by (SSS), that is, the perception of one’s socioeco- inequalities in health and overall well-being of nomic position, was also associated with health the poor populations (Bambas and Casas 2001). 1 Conceptual Framework for Culturally Competent Care 15

Social determinants of C health O M Human rights P Population A Culturally competent care health equity S • Individual level Social justice S •Organizational level I • Community level Culture of health O Beneficence Health Vulnerable N inequity populations

Fig. 1.1 Framework for culturally competent healthcare

Assurance of health and well-being must take 1.5 Framework for Culturally steps to address social determinants of health, Competent Healthcare which are multiple, complex, and interrelated. Human rights protection is critical particularly This section explains the key concepts under- for individuals and groups who are vulnerable girding the framework for culturally competent because of social exclusion, poverty, and other healthcare (see Fig. 1.1). The goal of culturally structural factors hindering their social mobility competent care is the achievement of health and autonomy. Health is intimately linked with equity, particularly for vulnerable populations such life realities as poverty, unemployment, who are most affected by the social determinants educational opportunities, and living environ- that lead to health inequity. In order to achieve ments. Although human beings have universal health equity, culturally competent care must be rights, there is ample evidence that the privileged grounded in the principles of social justice and groups enjoy unfair advantages over the disem- human rights. powered groups. Social justice places the responsibility on society and its institutions to safeguard the health 1.5.1 Social Justice and Human and well-being of the vulnerable while ensuring Rights protection of the basic human rights of everyone. Achieving health equity, however, requires Human rights are founded on the principle that a moral obligation to redistribute resources to all human beings have dignity and equal value. uplift those who do not have enough to live a Article 25 of the Universal Declaration of Human decent life. Rawls (1971) first proposed a theory Rights promulgated by the UN Assembly in 1948 of justice with a set of principles governing the emphasized the right of everyone to a standard of distribution of primary social goods, such as lib- living adequate for the health and well-being for erties, opportunities, income, and wealth. A just oneself and one’s family, including food, cloth- society according to Rawls is one that renders the ing, housing, medical care, and necessary social most vulnerable less vulnerable. services. UDHR also emphasized the right to Powers and Faden (2008) argue that injustice security in the event of unemployment, sickness, does not arise solely from the distribution of mate- disability, widowhood, old age, or other lack of rial goods and services but also in the allocation of livelihood in circumstances beyond his control non-distributive aspects of well-being. Victims of (ICHRP 2012). These human rights are indivis- social subordination, discrimination, and stigma ible and must coexist as a collective in order to experience lack of respect, attachment, and auton- assure protection of an individual’s dignity and omy that impact their well-being. The authors rec- well-being. The right to health is not possible ommend that social justice needs to integrate the without assuring economic, social, and cultural distributive and non-distributive aspects of justice. rights (UN 1948). Indeed, improvement of health and well-being of 16 D. Pacquiao vulnerable groups should address inequity in the 1.5.2.2 Organizational Level allocation of material goods and services as well Organizational practices constitute development as prevent maldistribution of goodwill such as of infrastructure, leadership and management, love, respect, compassion, and advocacy. Both are and care delivery systems that promote culturally essential to becoming a fully participating member competent care. Healthcare organization initia- of society. These nonmaterial variables can make tives may include (a) programs for training and individuals either flourish or diminish their life development of multidisciplinary employees in chances in society (Powers and Faden 2008). culturally competent care; (b)offering services during hours and in locations convenient to patients who are unable to take time off work, 1.5.2 Cultural Competence have no private transportation, and need someone to look after their children when they go for Several definitions and alternate terms exist in the their medical appointments; (c) providing trained literature on cultural competence. The definition interpreters and translators with expertise in com- by Cross et al. (1989) was adopted by the Office mon languages or dialects presented by patients; of Minority Health in developing the National (d) offering menus and pastoral services that Standards for Culturally and Linguistically accommodate ethnic and religious differences of Appropriate Services (CLAS) (USDHHS 2001). patients; and (e) providing adequate social ser- Cultural competence is defined as a set of congru- vices to address needs of patients and families. ent behaviors, attitudes, and policies that come together in a system, agency, or among profession- 1.5.2.3 Community Level als that enable them to work effectively in cross- Community-level cultural competence is an area cultural situations. Cross et al. used competence that needs development. This is a critical approach to indicate different levels of capacity at the indi- to address social determinants of health in vulner- vidual, organizational, and system levels. At the able populations who have limited social capital. system level, the needs of the community and soci- Bourdieu (1977) first defined social capital as the ety are addressed. Cultural competence initiatives aggregate of actual or potential resources that are have achieved some success at the individual care linked to a durable network of institutionalized level, particularly in using linguistically congruent memberships in a group and that provides and services, accommodation of different values and maintains material and symbolic gains for its mem- practices in healthcare, and education of health pro- bers. While poor ethnic enclaves may offer emo- fessionals. However, the evidence of lingering and tional support and acceptance for their members, widening health disparities among diverse groups lack of economic and symbolic capital poses many demonstrate that culturally competent initiatives constraints on their ability to be financially secure have not eliminated population health disparities. and influence the conditions in which they live. By contrast, individuals and communities with higher 1.5.2.1 Individual Level socioeconomic status and who are accepted as part Cultural competence is based on the requisite of the dominant group have access to a social net- knowledge, attitudes, skills/behaviors, and prac- work that can enhance their socioeconomic posi- tices that value and respect differences. At the tion and power. Social and economic stratification individual level, knowledge pertains to a level in society is culturally reproduced, perpetuating of understanding of different cultural values, vulnerability of some groups and privileged posi- beliefs, and practices of individuals and families tions of others. seeking care. Attitudes include respect, openness, Culturally competent professionals and orga- sensitivity, self-awareness, and critical reflection. nizations are actively engaged with vulnerable Skills include cross-cultural communication, cul- communities. By forging multisectoral and mul- tural assessment, cultural conflict management, tidisciplinary social networks in partnerships and accommodation of cultural differences. with the community, they promote broad aware- 1 Conceptual Framework for Culturally Competent Care 17 ness of the community’s problems and compel organizational-level approaches. While individu- power brokers to make changes on their behalf als and organizations may have a plan of action, through policies and programs that can transform without acceptance and engagement by the com- their lives. Social networks may be comprised munity, these approaches will not be sustainable. of scientists, academicians, local politicians, Successful partnerships and collaborations bureaucrats, health professionals, advocates, and are built on a good understanding of the com- members of the community who can foster social munity and its people and prolonged engage- connections built on mutual trust, reciprocity, and ment with them that is built on mutual trust and collective cooperation (Putnam 2000). Mutual reciprocity. Partnership is a close cooperation trust and engagement are based on a common between two or more parties having specified and norm of conduct, shared goals, commitment, joint rights and responsibilities and equal share and understanding (Coleman 1990). The goal of of the risks as well as the rewards. Partners join community-level cultural competence is com- forces in pursuit of a shared goal, commitment, munity empowerment and social change that are rights, and obligations to participate and will be only possible with prolonged engagement and affected equally by the benefits and disadvan- collaboration with the community. Sustainability tages arising from the partnership. Partnerships of initiatives is enhanced by community cham- require mutual trust and respect for each other pions who are trained and mentored to push for in order to create joint teamwork and coalitions change and monitor the implementation and out- and eliminate boundaries among them (Carnwell comes of change. and Carson 2005). As shown in Tables 1.3 and 1.4, community- By contrast, collaboration involves coopera- level strategies are distinct from individual- and tion with less formalized set of responsibilities

Table 1.3 Examples of implementing guidelines for culturally competent nursing care Healthcare organizations Caregivers Leaders/managers Guideline #1: Knowledge of cultures 1. Participate in learning modules on the general 1. Facilitate staff participation in classes on culturally principles of culturally competent care competent care and knowledge of cultural groups served 2. Participate in learning modules on specific 2. Organize cultural awareness activities to promote knowledge of the most common cultural groups cultural competence (such as, Heritage Days with served culturally diverse speakers, media, ethnic food, etc.) 3. Identify the nurse’s healthcare beliefs and values 3. Provide accessible resources for staff to learn about that may be different than those of the patient and specific cultures and common language terms used by family populations served Guideline #2: Education and training 1. Attend required orientation and annual in-service 1. Provide orientation and annual in-service training in classes on cultural diversity cultural competence for all levels of staff, including all 2. Attend continuing education classes or other management, professional, and nonprofessional staff in learning experiences to maintain cross-cultural any department with patient contact skills 2. Provide classes to increase staff’s cultural knowledge 3. Mentor healthcare colleagues in culturally about the ethnically diverse patients who receive health competent care services in the facility 4. Role model lifelong learning of cultural 3. Provide classes to enhance nurses’ skills in cross- competence cultural assessment and communication skills 4. Use a variety of modalities to teach cultural competency, such as workshops, conferences, online training, films, and immersion experiences 5. Partner with transcultural experts to provide staff with continuing education courses, consultation, and practice skills for culturally competent care (continued) 18 D. Pacquiao

Table 1.3 (continued) Healthcare organizations Caregivers Leaders/managers Guideline #3: Critical reflection 1. Reflect on one’s own cultural beliefs, values, and 1. Incorporate critical reflection into performance practices evaluations of staff 2. Analyze patient care problems through the prism 2. Promote critical reflection of staff through team of critical reflection meetings and case study discussions in which staff uses critical reflection 3. Host programs and workshops for staff that encourage critical reflection and self-awareness of cultural values and beliefs Guideline #4: Cross-cultural communication 1. Consider culturally specific variations in 1. Provide budget for translation of materials communication, such as, body language; eye 2. Develop, produce, and/or distribute patient education contact; distance between speakers; voice volume, materials in the languages of populations served tone, intonation, and inflections; and willingness 3. Coordinate a program to effectively use interpreters to share thoughts and feelings within the agency 2. Use pain scales in the preferred language of the 4. Use symbols and pictograms in hospitals, clinics, and patient or use “faces of pain” scale for those who other healthcare organizations whenever possible do not speak language of caregivers 3. Develop skills in using interpreters and translators 4. Provide patients with discharge materials that are translated into their preferred language 5. Distribute educational materials in the patient’s preferred language Guideline #5: Culturally competent practice 1. Establish a trusting relation through open and 1. Develop policies that reflect local cultural beliefs, sensitive communication, active listening, and norms, and practices respect of patient’s cultural beliefs and practices 2. Supervise staff to ensure that effective cross-cultural 2. Conduct a cultural assessment that includes nursing practice is being delivered patient’s preferences on the following: language, 3. Provide staff with adequate resources to deliver designated decision-maker, perception of causes culturally competent practice of health and illness, and culturally defined 4. Evaluate effectiveness of culturally appropriate services treatment modalities 5. Revise policies related to culturally appropriate services 3. Incorporate cultural assessment information into as needed plan of care 4. Demonstrate skill in cultural brokering, bridging, and negotiation in conflict situations 1 Conceptual Framework for Culturally Competent Care 19

Table 1.3 (continued) Healthcare organizations Caregivers Leaders/managers Guideline #6: Culturally competent healthcare systems and organizations 1. Participate on agency committees on cultural 1. Develop systems to promote culturally competent care diversity delivery 2. Participate in agency-sponsored cultural diversity 2. Ensure that mission and organizational policies reflect events respect and values related to diversity and inclusivity 3. Maintain annual cultural competency educational 3. Assign a managerial-level task force to oversee requirements diversity-related issues within the organization (93) 4. Establish an internal budget for the provision of culturally appropriate care, such as for the hiring of interpreters, producing multi-language patient education materials, adding signage in different languages, etc. (94) 5. Include cultural competence requirements in job descriptions, performance measures, and promotion criteria 6. Develop a data collection system to monitor demographic trends for the geographic area served by the agency (95) 7. Obtain patient satisfaction data to determine the appropriateness and effectiveness of services 8. Collaborate with other health agencies to share ideas and resources for meeting the needs of culturally diverse populations 9. Bring healthcare directly to the local ethnic population 10. Enlist community members to participate in the agency’s program planning committees, for example, for smoking cessation or infant care programs Guideline #7: Patient advocacy and empowerment 1. Assist patients and families in accessing resources 1. Implement an impartial mechanism that patients and to resolve cultural differences in preferences for families can use to address cultural preferences for care care 2. Create a forum for nurses to examine respectful 2. Help patients and their families communicate their interactions with their patient populations care preferences to those who provide care Guideline #8: Multicultural workforce 1. Participate in mentoring culturally diverse staff 1. Establish a priority of hiring bilingual/bicultural 2. Volunteer to visit schools to speak with students provider staff about healthcare professions 2. Celebrate cultural differences through institutional special events 3. Establish policies for zero tolerance for discrimination by all care providers 4. Develop a mentoring network for support of culturally diverse staff 5. Send staff to schools with large ethnic student bodies to encourage students to choose healthcare professions Guideline #9: Cross-cultural leadership 1. Participate in community activities and/or 1. Participate in collaborative partnerships to facilitate organizational initiatives to promote delivery of participation and promote effective communication culturally competent care with the community of diverse consumers 2. Participate in professional associations dedicated 2. Contribute to establishing systems for coordinating care to the promotion of culturally competent between all levels of healthcare services, both internally healthcare and with the culturally diverse community at large 3. Provide support for staff participation in collaborative research and integration of best evidence in care specific to diverse patient populations (continued) 20 D. Pacquiao

Table 1.3 (continued) Healthcare organizations Caregivers Leaders/managers Guideline #10: Evidence-based practice and research 1. Participate in journal clubs to review the 1. Provide nursing staff with resources for improving transcultural health literature library search and research critique skills of the staff 2. Participate in committees that monitor satisfaction 2. Establish journal clubs to review current literature of patients from diverse cultural backgrounds and about the most common cultural groups served to assess efficacy of care given ensure evidence based practice 3. Participate in agency committees to investigate a 3. Develop advanced practice nurse (APN) consultants to cross-cultural nursing problem that is unique to facilitate implementation of evidence-based cross- an area of practice cultural practice 4. Implement research-based protocols regarding 4. Consult with local faculty for expertise in research culturally competent care process and study design 5. Collaborate with colleagues to establish a national agenda of priorities for transcultural nursing research 6. Develop interdisciplinary teams of researchers to collaborate on quality improvement projects or research studies and to apply for funding 7. Conduct research through networks with high proportions of patients from diverse populations 8. Collaborate with national and international colleagues to design and implement large scale intervention studies of cultural phenomena 9. Host workshops and conferences to disseminate evidence on effective approaches to culturally congruent nursing practice Source: Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J, Milstead, J., Nardi, D., Purnell, L. (2014), Guidelines for Implementing Culturally Competent Nursing Care. Journal of Transcultural Nursing 25 (2):116–118. Reprinted with permission from Sage Publications, Inc.

Table 1.4 Community societal strategies Perform community assessment • Identify strengths and deficits of the community • Collect demographic, SES (income, education, occupation), and crime statistics • Describe characteristics of vulnerable population group applicable to specific community • Document ethnohistory (racial and ethnic relationships, social hierarchy, internal and external migration) • Graph morbidity and mortality patterns • Ascertain resources for health-related initiatives • Identify gatekeepers, stakeholders, and potential partners (academic, health, religious, politicians) • Appreciate previous experience with community advocacy and activism • Identify existing health resources and collaboratives • Locate potential venues for community initiatives • Recognize the impact of existing policies on health and SES (land use, zoning, sanitation, economic development, housing, funding of social programs) Create partnerships and collaboratives within the community • Seek common goals and objectives • Promote long-term engagement and advocacy by members of collaboratives • Promote immersion of partners in local community • Develop plan of action • Create a demand for safe and better places to live; responsive and equitable healthcare system and elimination of health disparities • Strengthen vulnerable kids and families • Delineate specific responsibilities of partners 1 Conceptual Framework for Culturally Competent Care 21

Table 1.4 (continued) • Seek funding sources • Seek venues for community action • Develop evaluation strategies and outcomes to be achieved • Monitor implementation of planned action • Monitor interconnections of policies and structures with community health Build cognitive and social capital of vulnerable communities • Establish trust and mutual goals with vulnerable groups • Promote respectful communication and collective solidarity • Promote awareness of collective problems, efforts to create change, and outcomes across groups • Emphasize connections between social determinants and poor health • Engage members of community by developing local champions • Use bridging, mentoring, and modeling techniques • Structure incentives for continued engagement and participation of community • Facilitate access of community members to ongoing planning and implementation • Engage community members to collect data and monitor progress of initiatives • Increase awareness and participation of local community in planning, implementation, and evaluation • Establish a system for ongoing feedback and resolution of conflicts • Empower community members in data collection, communicating directly with stakeholders, and making decisions about their health • Publicize impact of initiatives in community and broader society • Give credit to community members and partners for achievements or involvement than a formal partnership. A ent shelters run by the city while the city gains collaborative exists when several people pool additional healthcare manpower and expertise their common interests, assets, and professional to promote health of the homeless. The univer- skills to promote broader interests for the com- sity also collaborated with the local hospital to munity’s benefit. Fundamentally, the relation- refer patients for emergencies and laboratory ship between collaborators is nonhierarchical, tests, police department for security at the shel- and shared power is based on knowledge and ter during clinic hours, and nearby churches to expertise, rather than role or title (Henneman offer parking for students and faculty. et al. 1995). The defining attribute of collabora- Building healthy communities involves tion is the sharing of expertise in a joint ven- empowering communities with the cognitive ture for an agreed purpose. While effective and social capital to transform their own lives collaboration needs some of the same attri- for health. Culturally competent strategies at this butes of partnership such as team work, mutual level must follow a specific process of commu- trust and respect, and a highly connected net- nity assessment before any partnership or col- work, there are, however, lower expectations laboration begins. The process of identifying the of reciprocation and less sharing of risks and problem, setting priorities, and selecting a plan rewards than with a formal partnership. It is of action and outcomes to be monitored must important to create and nurture both types of involve the community. The effectiveness of relationships to strengthen community capac- this process is built on mutual trust among the ity to obtain services, resources, and power for partners/collaborators and the community which health achievement as shown in the following develops from prolonged and committed engage- example. A health science center of a local ment with the community. Health promotion university partnered with the city government for vulnerable communities must be informed to provide health services for the homeless in by an in-depth knowledge of the community’s the city. Multidisciplinary faculty and students strengths, the people (residents, gatekeepers, have exclusive access to the homeless in differ- and stakeholders), shared values, and concerns. 22 D. Pacquiao

Community strategies require collaborations and borhood. The area is considered a food desert as partnerships that cut across disciplines and sec- many households have limited access to large tors of the community. grocery stores offering affordable and quality healthy foods. One of the city’s municipal council members, an African American educator, is 1.5.3 Compassion a resident of this district. Several generations in his family have remained in this same neighbor- The antecedent to cultural competence at the com- hood. His family has a broad social network of munity level is the compassionate understanding influential African Americans who were former of the vulnerable (Pacquiao 2016). Compassion residents of the community but have remained stems from both an empathic understanding and engaged in the community. The council member sympathetic connection with the suffering of the is trusted by the community and emerged as the vulnerable. It evolves from the understanding of district’s champion and advocate in the city coun- the plight of the disadvantaged and feeling their cil. The council convenes monthly town meetings suffering. Compassion motivates one to engage in for residents to share issues and concerns. His collaboratives and partnerships with vulnerable social network of community leaders, educators, populations to advocate for beneficial changes in politicians, scientists, and students are invited to the lives of vulnerable populations. Compassion these meetings. compels one to move from non-maleficent actions The goal of one of the initiatives developed (preventing harm to others) to beneficent ones was to decrease obesity by improving access (making a difference for others) by engaging in to healthy foods and safe places to exercise. multisectoral collaboration and partnerships with Ongoing culturally competent strategies to vulnerable communities to address social deter- improve the lives and well-being of residents minants of poor health. Culturally competent include the following: professionals develop partnerships with local communities and stakeholders to build neighbor- 1.5.4.1 Individual Level hood social capital and collective empowerment • Multidisciplinary healthcare staff and students and efficacy in securing or changing social and in health professions, education, and social economic policies in order to improve their lives. work conduct health promotion activities at Culturally competent professionals understand senior centers, barber shops, schools, home- that the agent accountable to make changes in the less shelters, and local churches. lives of vulnerable populations is beyond the pur- –– Culturally congruent communication is view of the individual but rather on society and practiced emphasizing respect for elders the government. and people of lower SES and the use of low-literacy brochures and instructions. –– African American healthcare practitioners 1.5.4 Application of Levels are recruited to provide services, and com- of Cultural Competence munity members serve as cultural mediators. –– Women and religious leaders are encour- The following example occurred in the poorest aged to bring their partners, husbands, district of a large city in Eastern USA with a large brothers, male friends, and sons to be population of low-income African American resi- screened. African American men tend not dents with high prevalence of obesity, diabetes, to participate in health screening. Close asthma, cancer, and cardiovascular disease. The follow-up is done for men through women district has many abandoned homes, a dilapi- family members. dated infrastructure, and high unemployment and –– Assessment of weight, blood pressure, crime rates. Fast-food venues and bodegas (small blood glucose, and level of physical neighborhood stores) are prevalent in the neigh- activity. 1 Conceptual Framework for Culturally Competent Care 23

–– Counseling on age- and gender-appropriate • Partnership among local schools, police, and BMI levels is done because of the wide- residents to ensure safe access of school chil- spread acceptance of larger body size in the dren to the local park after school. Most par- community. ents keep their children at home because of –– Counseling on healthy food purchasing, high crimes. reading labels, meal planning and prepara- • Local schools open their gyms for students tion, and meal portion sizes emphasizing after school hours in addition to providing low cost and healthier options. Emphasis is tutoring as most students do not have adequate placed on modifying ethnic menus to support at home and many parents are work- reduce salt, fat, and calories as well as ing. The majority of adults have high school increase fiber. Poor urban African American education. diets tend to have low fiber and high • A local medical school obtained a grant to sodium, sugar, and fat content. bring local farmers to sell their produce –– Accessing food pantries in the area and monthly at the school. Farmers requested a referral to Meals on Wheels—a federally safe place to sell, and the medical school funded program that delivers meals to located in the neighborhood was chosen as the homebound individuals such as the elderly venue because it is accessible to buses. and disabled who are unable to purchase or • The local community and county hospitals prepare their own meals. Counseling is sponsor health fairs aimed at decreasing obe- provided on how to obtain a variety of food sity, particularly during the summer months products that are nutritious, low cost, and and traditional festivals celebrated by the local healthy. community. –– Providing age-appropriate exercise classes • Local schools introduce students to fresh such as home exercises and group walks fruits and vegetables and provide demonstra- for clients in unsafe neighborhoods. tion on healthy food preparation. Because of • Multidisciplinary healthcare staff and students in lack of large grocery stores offering fresh and health professions operate the mobile clinic that low-cost fruits and vegetables, young kids goes into different neighborhoods to conduct have limited exposure to them. health assessment, counseling, disease man- • The local community and county hospitals agement, referral, and follow-up. Community enlist community members to participate on members serve as volunteers to recruit, remind, hospital-wide committees that address chronic and bring people to the venues where the van is diseases and nutrition for clients in their catch- located on specific days of the week. ment areas. • Home health nurses, nursing students, and a nurse practitioner conduct home visits for 1.5.4.3 Community Level homebound residents unable to avail of the • Collaboration between the police chief and mobile van service. the council member in addressing safety concerns of residents. To address complaints 1.5.4.2 Organizational Level about delays in police response, residents • Local primary schools partner with a nonprofit were instructed to document the date and time community organization (donates land, vege- they called, date and time of police response, table seeds, and soil) and a local university person called at the police station, and the rea- (performs soil analysis) to involve students in son for the call. Trust in the police is critical to gardening in the school grounds. Soil analysis residents feeling safe in their neighborhood is important as the city is situated in ten super- and motivate them to get out of their homes. fund sites and toxic pollutants are found in • The council created an advisory council com- most areas, making them unsuitable for grow- prised of local business owners to create jobs ing edible foods unless the top soil is replaced. and offer healthy food choices and menus. 24 D. Pacquiao

• The nonprofit community organizationlittle or nothing to change the status quo of their encourages the use of vacant lots by residents social circumstances, culturally competent strate- for community gardens. Residents can rent the gies cannot achieve health equity because social lot for $1 annually for as long as the produce is determinants of their poor health are not being consumed and shared with neighborhood resi- addressed. dents. The organization offers technical assis- Vulnerable populations are generally comprised tance, seeds, and soil to renters. Preliminary of people who are viewed as different by main- observations noted increased interactions and stream society. Cultural competence is at the core connections among community members of advocacy and beneficent acts for the vulnerable offering the potential for building social capi- because it bridges differences and builds coalitions tal of the neighborhood. through mutual respect, reciprocity, and shared • Residents were given an organizational chart goals. To achieve health equity, cultural compe- of the city with appropriate contact details so tence should primarily focus on health and its social they know the person or office to call for spe- determinants. Emphasis on health rather than dis- cific problems. ease moves cultural competence beyond individual • The council conducts periodic walks with disease-based care toward population health pro- local residents in their neighborhood to ease motion that accounts for the social, economic, cul- safety concerns, improve social interactions tural, and political contexts of people’s lives. among residents, and motivate them to get out and walk. • Cameras were installed by the city on local 1.7 Culture of Health streets in high-crime neighborhoods. A culture of health is a cohesive system of values, beliefs, and practices that support health 1.6 Health Equity throughout the life course and across different life contexts. As health is embedded in life con- Elimination of health inequity and advocacy for ditions, culturally competent approaches should vulnerable populations is central to culturally cut across different sectors and disciplines. competent care. Social determinants of health Health is achieved in homes, employment, are socially constructed institutionalized forces schools, and communities. These are places that create one’s “place” in society, with some healthy people inhabit. Building healthy com- more privileged than others (Jenkins 2002). The munities requires four strategies: (a) making social construction and reproduction of “place” is health a shared value; (b) fostering cross-sector embodied in internalized habits of the vulnerable. collaboration to improve well-being; (c) creating Oscar Lewis (1966) has documented a sense of healthier, more equitable communities; and (d) helplessness and fatalism among poor Mexicans strengthening integration of health services and and Puerto Ricans. This finding has been sup- systems (Lavizzo-Mourey 2015). ported by later studies of poor Hispanics (Baer and Bustillo 1993; Poss and Jezewski 2002). Fatalism and helplessness are the antithesis of 1.8 Summary self-empowerment and self-reliance. Yet the same predispositions are found useful among the poor Equity of health outcomes is achieved by address- in coping with life conditions that are beyond their ing the fundamental conditions that predispose control (Leyva et al. 2014). Culturally competent certain groups to poor health more than others. strategies should be directed toward changing the Health promotion should be grounded in under- life circumstances of poor Hispanics to dismantle standing the social pathways to poor health the cycle of socially constructed “place” and hab- that are rooted in the living and working condi- its of helplessness and fatalism. By simply valu- tions of people. Because social determinants of ing their cultural values and beliefs and doing health have different trajectories for populations, 1 Conceptual Framework for Culturally Competent Care 25

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Guideline: Nurses shall gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse families, communities, and populations they care for, as well as knowledge of the complex variables that affect the achievement of health and well-being. Douglas et al. (2014: 110)

2.1 Introduction system, agency, or those professionals to work effectively in cross-cultural situations” (Cross As globalization and immigration increase, it has et al. 1989, para 1). become more important for nurses, other health- Whereas this chapter does not address specific care providers, and organizations to become cul- models and theories of culture care, nurses and turally competent in order to decrease healthcare other healthcare professionals are encouraged disparities of vulnerable populations. Many defi- to seek models that fit their needs. A plethora of nitions of culture and culture care exist. A defi- images of models for culturally competent care nition for individuals and groups is the totality exist. Some are similar but others are more complex of socially transmitted behavior patterns, arts, (Images of Cultural Models n.d.). The most popular beliefs, values, customs, lifeways, and all other theories and models include Campinha-Bacote’s products of human work and thought character- Model The Process of Cultural Competence in istics of a population that guides their world- the Delivery of Healthcare Services (http://trans- view and decision-making. The patterns may be culturalcare.net/the-process-of-cultural-compe- explicit or implicit and are shared by the majority, tence-in-the-delivery-of-healthcare-services/), but not all, of the culture (Purnell 2013). Culture Jeffrey’s Cultural Competence and Confidence is primarily learned in the family followed by (CCC) Model: Transcultural Self-Efficiency schools, churches, and other organizations where (Jeffreys 2010a, b), Leinginger’s Culture Care people gather. A popular definition of culturally Diversity and Universality Theory (McFarland competent care more specific to organizational and Wehbe-Alamah 2015), the Papadopoulos cultural competence is “cultural competence is Model for Developing Culturally Competent and defined as a set of congruent behaviors, attitudes, Compassionate Care for Healthcare Professionals and policies that come together in a system, (Papadopoulos et al. 2016), the Purnell Model agency, or among professionals and enables that for Cultural Competence (Purnell 2014), and Shim’s Dimensional Puzzle Model of Culturally Competent Care (Schim et al. 2005). Some of the L. Purnell, Ph.D., R.N., FAAN theories and models are used for research, some School of Nursing, University of Delaware, Newark, DE, USA are primarily used for education, and some are used for both education and research. Florida International University, Miami, FL, USA Excelsior College, Albany, NY, USA e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 31 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_2 32 L. Purnell

2.2 The Complexity of Culture: Culture and cultural competence are dynamic, Individual, Group, characterized by constant change and require and Organizational Culture healthcare providers to engage in a lifelong learning process (Jeffreys 2010a, b). Cultural attributes Culture is both objective and subjective. Every cul- and values that influence individual and group ture creates a system of shared knowledge if it is to differences are critical in preventing overgener- survive as a group and foster communication among alizing and stereotyping. Much of what applies its members. These shared patterns of information to a patient’s individual and group culture also are both objective and subjective (obvious and hid- applies to organizational culture. Awareness of den). Objective culture, also considered visible ele- culture progresses along four stages: unconscious ments of culture, are things an outsider can see but incompetence, conscious incompetence, con- may not understand “why things are the way they scious competence, and unconscious competence are.” Objective culture includes things that people (Nursing Best Practice Guidelines: Summary of make such as art, music, and styles of clothing and Key Models Related to Cultural Competence dress; objective culture can be shared and appreci- n.d.; Purnell 2013). ated by others. For example, art from an indigenous In unconscious incompetence, the healthcare population may be quite different from Renaissance, provider is not aware of cultural differences, and Cubism, Expressionism, Surrealism, or Abstract the healthcare provider might do something cul- art. However, one can appreciate all objective forms turally wrong or even offensive and not realize it. of culture, especially their differences. For example, a male nurse may extend his hand Subjective culture, on the other hand, is in an attempt to shake hands with a traditional largely unconscious and is a way of perceiving female Muslim or Orthodox Jewish patient. In the social environment which includes behavioral traditional Islam and Orthodox Jewish religion, a norms, social roles, ideas, beliefs, and values male is forbidden to touch a female unless it is an (Triandis 2002), including those related to health emergency situation (Kulwicki and Ballout 2013; and healthcare that can vary within and among Selekman 2013). groups. Furthermore, subjective culture has two In conscious incompetence, the nurse is aware lenses, etic and emic. Etic culture refers to gen- that differences exist but not understand what eral categories that can be found in all cultures they are and might mean. In this case, the nurse that serve as common grounds for comparison. knows he/she is doing something wrong but Emic refers to categories that might only make not know exactly what is wrong. For example, sense in a specific culture and makes a culture a nurse greets a patient by his/her first name, a unique and meaningful to those who belong to it practice that is considered rude and culturally (Olive 2014). As with objective culture, one can unacceptable among some, especially in collec- appreciate and value the subjective cultural val- tivistic cultures. The patient might inform the ues of many diverse groups of people. nurse to use Mr., Mrs., or Miss before the name Moreover, culture as an anthropological and or give some nonverbal reaction that something social construct has three levels. A primary level is unacceptable. When this happens, the nurse that represents the deepest level in which rules needs to ask about the patient’s reaction, apolo- are known by all, observed by all, implicit, and gize, and provide the preferred name of address taken for granted. A secondary level in which in the patient’s medical record. only members know the rules of behavior and In conscious competence, the nurse knows can articulate them. The healthcare provider that differences exist, knows some of the differ- must make a conscious effort to uncover them. ences, and attempts to know more of these dif- A tertiary level that is visible to outsiders, such ferences and how the provider can use and apply as things that can be seen, worn, or otherwise them for culturally congruent care. The nurse observed, also known as the objective culture knows he/she is doing something right but has (Koffman 2006; Purnell 2013). to consciously focus on doing it the correct way. 2 Knowledge of Cultures 33

For example, in a collectivistic culture where it grate cultural and linguistic competence-related is rude or unacceptable to give a “no” answer measures into internal audits, performance to a question, the only acceptable answer is to improvement programs, patient satisfaction respond affirmatively to “save face,” one’s own assessments and surveys, and outcomes-based sense of dignity or prestige in social contexts. evaluations. In addition, it requires collecting The nurse learns to ask questions that cannot and updating information related to consumers’ be answered with a “yes” or “no.” When asking race and ethnicity and spoken, written, and sign about medication adherence, instead of asking if languages. These data help maintain a current the patient takes a medicine as prescribed, ask the demographic, cultural, and epidemiological pro- patient at what time he/she took the medicine that file of the community to plan for and implement day. Another way to ask is how many days did services that respond to its cultural and linguistic you miss taking your medicine this week. characteristics (Office of Minority Health 2001). Unconscious competence is where cultural To provide effective patient education, a req- appropriate behavior becomes automatic. The uisite is to review the language literacy level of nurse knows he/she is doing something cultur- consumers and use culturally respectful images ally congruent without having to think about it. in written and television or video patient educa- However, this can be problematic and even ste- tion materials. In addition, a system must be in reotypic because individual differences can exist place that indicates whether language assistance greatly among individuals in each culture. is needed prior to or at the point of entry into the A culturally competent healthcare organization organization if at all possible. Organizations have shares most of the concepts related to individual values espoused by the leaders and most often and group cultures. Cultural competence in health- are grounded in shared assumptions of how the care has been defined as “a set of congruent behav- organization should be run. While the espoused iors, attitudes, and policies that come together in a values are often prescribed at the highest level in system, agency, or among professionals and enable an organization, each community may have its that system, agency, or those professionals to work own norms, perspectives, and collective under- effectively in cross-cultural situations” (Health standings. Their willingness to share and to seek Resources and Services Administration 2002: 3). knowledge will be influenced by these collective The tenets of organizational cultural competency views. Furthermore, culturally competent human are inclusive of all professional groups as well as resources departments should promote patient- clerical, technical, and unlicensed assistive per- centered care by including patient satisfaction sonnel. The overall responsibility of providing measures in employee performance appraisals. culturally safe and culturally congruent care is the To be effective, written satisfaction surveys responsibility of the organizations’ managers and should be translated into the languages that rep- administrators (Marrone 2013). resent the catchment area for the organization; Organizational cultural competence is a pro- otherwise, the data collection process is incom- cess and is responsible for assuring that culture plete. It may not be possible to translate satisfac- is incorporated at all levels to meet culturally tion surveys into all the languages (some are only unique needs, thereby increasing quality care. verbal) and dialects spoken by consumers, but at Enhanced quality care reduces health disparities least some should be. and improves health outcomes for vulnerable and Andrews (1998) provides a six-step framework underserved populations. for ensuring organizational cultural competency. Culturally competent healthcare organizations provide consumers with effective, understand- 1. Collect demographic and descriptive data of able, and respectful care provided in ways that the prevalent cultural, ethnic, linguistic, and fit with their cultural values and beliefs and in the spiritual groups represented among patients, consumer’s preferred language if at all possible. families, visitors, the community, and the staff To achieve this goal, the organization must inte- in the service area. 34 L. Purnell

2. Describe the effectiveness of current systems such as local newspapers and community news- and processes in meeting diverse needs. letters. It also requires that the availability of lan- 3. Assess the organization’s strengths and limita- guage assistance services include sign language, tions by examining the institution’s ethos the translation of critical documents such as con- toward cultural diversity and the presence or sents and patient education materials, pain scales, absence of a corporate culture that promotes and communication boards/aids for patients who accord among its constituents. are not able to speak or understand the dominant 4. Determine organizational need and readiness language. for change through dialogue with key stakeholders aimed at discovering foci of anticipated support and recognizing areas of 2.3 Essential Knowledge potential resistance. to Provide Evidence-Based, 5. Implement strategic plans, policies, and pro- Culturally Competent cedures that include measurable benchmarks Nursing Care of success and an ongoing process to ensure that change is maintained. Nurses, as well as other healthcare providers, 6. Evaluate actual outcomes against established need essential basics to practice culturally compe- benchmarks utilizing performance improve- tent and congruent care. All healthcare providers ment, quality, and customer satisfaction data. must understand that culture has a strong effect on attitudes, values, traditions, and behavior, and Culturally competent healthcare organizations they vary within the culture according to age, implement strategies to recruit, retain, and pro- generation, nationality, race and ethnicity, color, mote at all levels of the organization a diverse gender, religion, educational status, socioeco- staff and leadership team that are representative nomic status, occupation, military status, politi- of the demographics of the service area. The cal beliefs, urban versus rural residence, enclave goal of recruiting and retaining a diverse work- identity, marital status, parental status, physical force that matches the demographics of the ser- characteristics, sexual orientation, gender issues, vice area is to reduce health disparities among and reason for migration (sojourner, immigrant, vulnerable and underserved populations that or undocumented) (Purnell 2005, 2013; Purnell often results from discordant consumer–provider and Fenkl 2018). relationships. Culture and language discordance Learning health-seeking behaviors of cultur- can lead to decreased access to care, decreased ally diverse individuals, families, communities, quality of care, increased cost of care, decreased and populations is essential for providing cul- patient satisfaction, recidivism, discrimination, turally competent and culturally congruent care. and poor health outcomes (American Association These skills can be learned through formal edu- of Critical Care Nurses 2008; Europa 2010). To cational programs, in-services on specific cultural reduce discordance between consumers and and ethnic groups, and immersion experiences in providers, an organization needs to integrate diverse cultures in the home environment as well diversity into the organization’s mission state- as immersion experiences in the patient’s home ment, strategic plans, and goals. A diverse work- country. In addition, some travel blogs, although force program includes mentoring programs, they may not be peer reviewed or research based, community-based internships, and collaborations provide basic etiquette, and nonverbal informa- with academic partners such as universities, local tion on gesturing in a specific culture can have schools, training programs, and faith-based orga- value. nizations. To expand the recruitment base, orga- Culture and language are closely related; nizations should recruit at minority health and through language, culture is passed onto each recruitment fairs, advertise in multiple languages, generation. Although language is a communica- and list job opportunities in minority publications tion medium that allows individuals to pass ideas 2 Knowledge of Cultures 35 between them, sharing a language does not nec- In addition, nurses need knowledge of the types essarily mean sharing a culture; nor does a cul- of institutional, class, economic, cultural, and lan- ture necessarily share a language. See Chap. 5 for guage barriers that may prevent individuals and a more extensive information on communication. families from accessing healthcare. Knowledge Health policy can affect culturally diverse can also be gained from associated disciplines groups, particularly those who are economically such as anthropology, sociology, and communi- disadvantaged, vulnerable, and/or underserved. cation arts. Nurses can help ensure social justice by identifying personal and familial social support networks, by working with professional community 2.4 Essential Knowledge human resources, and by engaging in political of Cultural advocacy (see Chap. 8) (International Council and Anthropological of Nurses 2011; National Association of Social Concepts Workers 2007). Professional nurses need specific knowledge Culture is based in anthropology; therefore, about the major groups of culturally diverse indi- a working knowledge of the following terms viduals, families, and communities they serve, is essential. These terms and their definitions including but not limited to specific cultural prac- related to cultural competence follow: encultura- tices regarding health and determining beliefs tion, ethnocentrism, acculturation, assimilation, about health and illness, biological and genetic cultural awareness, culture sensitivity, cultural variations, cross-cultural worldviews, and accul- competence, cultural congruence, generalization turation and life experiences such as refugee and versus stereotype, cultural imperialism, cultural immigration status as well as a history of oppres- imposition, cultural relativism, ethnic group, and sion, violence, and trauma suffered (Andrews and subculture. A brief description of each of these Boyle 2016; Douglas et al. 2014; United Nations terms is defined providing a starting point for a 2015). Culturally competent assessment skills broad understanding of culture so the healthcare (see Chap. 19) are essential to facilitate com- provider can be aware of them in practice. munication, to demonstrate respect for cultural An ethnohistory (the history of peoples and diversity, and to ask culturally sensitive ques- cultures) and the social context of the cultural/ tions about beliefs and practices that need to be ethnic group under care are essential. One might considered in the delivery of health and nursing have a good knowledge base of the group but care. The more knowledge a healthcare provider must still take extreme caution and not stereotype has about a specific culture, the more accurate the individual. At a minimum, nursing curricula and complete the cultural assessment will be. need to include the ethnic and cultural popula- For example, if the nurse is not aware that many tions where students take their clinical practice. patients use traditional healers, the nurse might Moreover, because we live in a global society, not ask specific and appropriate questions about upon graduation, students might practice in set- the individual’s use of these traditional practitio- tings where different populations are present. ners and their therapies. Because nurses cannot Thus, the curricula should also include case stud- know the attributes of all cultures, it is essential ies that are not in the program’s catchment area. to use a cultural assessment model or framework The literature reports many definitions of the (see Chap. 19). Thus, nurses should seek spe- terms cultural awareness, cultural sensitivity, cialized knowledge from the body of literature and cultural competence. Sometimes, these defi- in transcultural nursing practice that focuses on nitions are used interchangeably, but each has specific and universal attitudes, knowledge, and a distinct meaning. Cultural awareness has to skills used to assess, plan, implement, and evalu- do with an appreciation of the external signs of ate culturally competent nursing care (McFarland diversity, such as the arts, music, dress, foods, and Wehbe-Alamah 2015; Papadopoulos 2006). and physical characteristics. There are four lev- 36 L. Purnell els of cultural awareness that reflect how people viding culturally competent care. Ethnocentrism grow to perceive cultural differences (Quappe perpetuates an attitude (sometimes uncon- and Cantatore 2007). sciously) in which beliefs that differ greatly from In the first level of cultural awareness, known one’s own are strange, bizarre, or unenlightened as the parochial stage, people are aware of their and, therefore, wrong. The extent to which one’s way of doing things, and their way is the only cultural values are internalized influences the ten- way. I know their way, but my way is better. Thus, dency toward ethnocentrism (Zikargae 2013). In they ignore the impact of cultural differences. the healthcare arena, ethnocentrism can prevent In the second level of cultural awareness, effective therapeutic communication when the known as the ethnocentric state, people are aware healthcare provider and patient are of different of other ways of doing things but still consider cultural or ethnic backgrounds, and each per- their way as the best one. Thus, cultural differ- ceives their own culture to be superior (Douglas ences are perceived as a source of problems and et al. 2014; Singelis 1998). While it may be ignore them or reduce their significance. natural to believe otherwise, all humans are eth- The third level of cultural awareness, known nocentric, at least to some degree. This is not as the synergistic stage, becomes my way and necessarily always a bad thing because a certain their way. People are aware of their own ways amount of love for one’s own culture is necessary of doing things and others’ ways of doing things to hold societies together. However, anything that and chose the best way according to the situa- is positive at a certain level can become negative tion. This stage can lead to benefits, and people and dysfunctional when taken too far (McKeiver are willing to use cultural diversity to create new et al. 2013). However, culturally competent solutions and alternatives. healthcare providers can train themselves not to The fourth and final stage of cultural aware- judge one culture by the standards of another. ness, our way, is also known as participatory third Although generalizing and stereotyping are stage. This stage brings people from different similar, functionally, they are very different. cultural background together for creating a cul- Generalizing, basically a research principle is a ture of shared meanings. People dialogue repeat- starting point, whereas stereotyping is an end- edly with others, creating new meanings and new point. A generalization, reducing numerous char- rules to meet the needs of a particular situation acteristics of an individual or group of people to (Quappe and Cantatore 2007). a general form that renders them indistinguish- Cultural sensitivity has to do with personal able, is almost certain to be an oversimplification. attitudes and not saying things that might be However, generalizations can lead to stereotyp- offensive to someone from a cultural or ethnic ing, an oversimplified conception, opinion, or background different from the healthcare pro- belief about some aspect of an individual or viders. Cultural sensitivity is being aware that group. The healthcare provider must specifically cultural differences and similarities between ask questions to determine values and beliefs people exist without assigning them a value— and avoid stereotypical views of patients (see the positive or negative, better or worse, and right Sect. 2.5 in this chapter). or wrong. It does not mean that the provider can Within all cultures are subcultures and ethnic apply this knowledge and deliver care congru- groups whose values and experiences differ from ent with the patient’s cultural beliefs and prac- those of the dominant culture with which they tices (Campinha-Bacote 2002; Giger et al. 2007; identify. In sociology, anthropology, and cul- Purnell 2016). tural studies, a subculture is defined as a group Ethnocentrism—the universal tendency of of people with a culture that differentiates them human beings to think that their ways of thinking, from the larger culture of which they are a part. acting, and believing are the only right, proper, Subcultures may be distinct or hidden such as and natural ways (which most people practice gay, lesbian, bisexual, and transgendered popu- to some degree)—can be a major barrier to pro- lations in some countries. The subculture can 2 Knowledge of Cultures 37 include members from the European American, ture through socialization. Enculturation is facili- Thai, Chinese, Hispanic, etc. cultures. Alcoholic tated by growing up in a particular culture, and Anonymous is another example of a subculture. it can be through formal education, apprentice- The membership in Alcoholics Anonymous may ships, mentorships, and role modeling (Clarke include African/Americans and Blacks from dif- and Hofsess 1998; Rudmin 2003). Enculturation ferent countries, Asians, Arabs, etc. creating a is the process of teaching an individual the norms subculture. If the subculture is characterized by and values of a culture through unconscious rep- a systematic opposition to the dominant culture, etition. The totality of actions within a culture then it may be described as a counterculture. establishes a context that sets the conditions for Examples of subcultures are Goths, punks, and what is possible within the society. Learning in stoners, although popular lay literature might this context becomes a lifelong process devel- call these groups cultures instead of subcultures. oped through rhetoric in the form of speech, texts, A counterculture would include cults (What is images, gestures, and practices that reaffirm the the difference between culture and subculture? technological, economic, political, social, ideo- 2017). logical, and philosophical bases of the culture. Acculturation occurs when a person gives up This is a critical concept for anyone working in some, but not all of the traits of his or her cul- the areas of rhetoric, culture, and education. The ture of origin as a result of contact with another process of enculturation sets both possibilities culture. Acculturation is not an absolute, and it and limits, so healthcare providers cannot auto- has varying degrees. Traditional people hold onto matically assume the contexts they create are the majority of cultural traits from their culture unproblematically positive (Rudmin 2003). of origin that is frequently seen when people As globalization and immigration increase, live in ethnic enclaves and can get most of their providers must also address very crucial issues needs met without mixing with the outside world. such as cultural imperialism, cultural relativism, Bicultural acculturation occurs when an individ- and cultural imposition. Cultural imperialism is ual is able to function equally in the dominant the practice of extending the policies and prac- culture and in one’s own culture. People who are tices of one group (usually the dominant one) to comfortable working in the dominant culture and disenfranchised, minority, and vulnerable groups. return to their ethnic enclave without taking on An example is the US government’s forced most of the dominant culture’s traits are usually migration of Native American tribes to reserva- bicultural. Marginalized individuals are not com- tions with individual allotments of lands (instead fortable in their new culture or their culture of of group ownership), as well as forced attendance origin, sometimes because the new culture does of their children at boarding schools attended not accept them. by predominantly White people. Proponents of Assimilation is the gradual adoption and incor- cultural imperialism appeal to universal human poration of characteristics of the prevailing cul- rights, values, and standards (Purnell 2011). ture (Portes 2007; Rudmin 2003). Assimilation Cultural relativism is the belief that the behav- is a process in degrees where people gradually iors and practices of people should be judged adapt to the ways of the majority culture and only from the context of their cultural system. giving more value to the cultural aspects of the Proponents of cultural relativism argue that issues majority community in which they live. Full such as abortion, euthanasia, female circumci- assimilation occurs when it becomes hard to tell sion, and physical punishment in child rearing that the person belongs to or is from a minority should be accepted as cultural values without culture. judgment from the outside world. Opponents Enculturation is a natural conscious and argue that cultural relativism may undermine unconscious conditioning process of learning condemnation of human rights violations, and accepted cultural norms, values, and roles in family violence cannot be justified or excused on society and achieving competence in one’s cul- a cultural basis (Ineneche 2010). 38 L. Purnell

Cultural imposition is the intrusive application World War II to avoid discrimination. Race can- of the majority group’s cultural view upon indi- not be changed, but people can and do make viduals and families (Forte 2016; United Nations changes in their appearance to better fit into soci- 2015). Every person, regardless of native culture or ety, including with cosmetic surgery. Whereas local community possesses universal rights simply many researchers argue that there’s no scientific as humans, regardless of differences among cul- basis for race, the term is still used for data col- tures. Anthropology assertions of universal human lection and used in different ways, including rights and imperialism are intimately connected. A exploring the rates of disease and infections in declaration about human rights can come close to vulnerable populations. Skin color cannot usu- advocacy of another country’s ideological imperi- ally be changed on a permanent basis. alism (Forte 2016). Examples of cultural imperial- Age cannot be changed, but many people go ism in health are prescribing special diets without to extensive lengths to make themselves look regard to patients’ cultures and limiting visitors to younger. One’s worldview changes with age. immediate family. In some cultures, older people are looked upon with reverence and increased respect. Age differences, beliefs, and values with the accompanying 2.5 Variant Characteristics worldview are frequently called the generation of Culture gap. More organizations are including the term “diversity and inclusivity” in mission statements Whereas there is value in learning the health beliefs, to include different age groups. practices, and values of the myriad cultures such as Religious affiliation has an impact on people’s American, Amish, Arab, British, Chinese, Filipino, beliefs and practices, including health beliefs Gypsy, German, Guatemalan, Haitian, Irish, and practices according to how devout they are. Japanese, Peruvian, Turkish, etc., great diversity Moreover, people can and do change their religious exists within each of these broad cultural groups. affiliations or self-identify as atheists. However, if Their health beliefs, practices, and values should be someone changes his or her religious affiliation— seen as generalizations to be validated rather than for example, from Judaism to Pentecostal or Baptist stereotyping each individual. The major influences to Islam—a significant stigma may occur within that shape people’s worldviews and the degree to their family or community. Worldwide, people which they identify with their cultural group of have migrated to accommodate their religion that origin are called the “variant characteristics of cul- was discriminated upon in their home country. The ture.” The variant characteristics include but are Amish immigrated to the United States from Europe not limited to age, generation, nationality, race and for religious freedom. Many Jews immigrated to ethnicity, color, gender, religion, educational status, the United States, Argentina, and other countries socioeconomic status, occupation, military sta- because of discrimination in their home country. tus, political beliefs, urban versus rural residence, Religion can also advise or prescribe dietary prac- enclave identity, marital status, parental status, tices such as Seventh-day Adventists who have long physical characteristics, sexual orientation, gender prescribed a vegetarian diet and abstinence from issues, and reason for migration such as sojourner, alcohol and, for many, even coffee. immigrant, asylee, or undocumented (Purnell 2005, Educational status can also have a major 2013; Purnell and Fenkl 2018). Some variant char- impact on an individual’s cultural beliefs and acteristics cannot be changed but others can. practices. As education increases, people’s world- Nationality cannot be changed; however, view changes and increases their knowledge base throughout history, immigrants have changed for decision-making. However, formal education their names to disguise their ethnic origins to does not necessarily increase health literacy but better fit into society or to decrease prejudice or does provide the ability to think critically. For discrimination. For example, many Jews changed example, someone with an advance degree in his- the spelling of their last names during and after tory might not have good health literacy. 2 Knowledge of Cultures 39

Socioeconomic status can change either up or residents are more likely to be exposed to chemi- down and can be a major determinant for access cal runoff into drinking water due to land or to and use of healthcare. Low socioeconomic water pollution from waste dumping, ambient air status may dictate if or where a person can get pollution of chemicals used in farming, and the healthcare as well as the type of procedures they use of fossil fuels. can afford if not covered by health insurance. Enclave identity can be a deterrent to health One’s occupation can change. A common and healthcare access. People who primarily live omission on intake assessments is to ask about and work in an ethnic enclave where they can get a consumer’s occupation but not delve into past their needs met without mixing with the outside occupations. In addition, if the patient said he/she world may be more traditional than people in was retired, no follow-up is done. For example, a their home country and rely almost entirely on patient may currently be a teacher but was previ- complementary and alternative therapies. ously employed in a high-risk job such as in a Marital status: Married people and people coal mine, on a farm, or in a laboratory collecting with partners frequently have a different world- or handling specimens from known or suspected view than those without partners. Their world- pandemic patients (US Department of Labor: view can change. Occupational Safety and Health Administration Parental status: Often, when people become 2009). In addition, someone may have worked parents—having children, adopting, or taking near a superfund site or swamps exposing them responsibility for raising a child—their world- to additional health risks. view changes and they usually become more People who have had military experience may futuristic. be more accustomed to hierarchical decision- Sexual orientation: Sexual orientation is usu- making and rules of authority. As military people ally, but not always, stable over time. Some travel with their government, they can be exposed people are bisexual, while others may undergo to chemical warfare resulting in health condi- transgendered surgery. tions such as agent orange that do not surface for Gender issues: Men and women may have years later and are exposed to all the war traumas different concerns in regard to type of work and resulting in post-traumatic stress syndrome that work hours, pay scales, health inequalities, and are not assessed on intake interviews after their decision-making expectations. It is best to ask the military leave is over. patient who makes which decisions for healthcare Political beliefs of consumers and health pro- and personal care and responsibilities at home. fessionals can also affect the delivery of health- Physical characteristics: One’s physical char- care. One of the major reasons for worldwide acteristics may have an effect on how people see migration is ideological and political beliefs. themselves and how others see them and include However, they can change over time. Issues like such characteristics as dress, height, weight, hair marijuana, medical or recreational, and birth con- color and style, facial hair, skin color, and tattoos. trol and abortion can have an effect on a patient’s Immigration status (sojourner, immigrant, health as well as how health providers choose to asylee, or undocumented status): Immigration proceed with advising patients and their treat- status and length of time away from the country ment options. of origin also affect one’s worldview. People who Urban versus rural residence can affect voluntarily immigrate generally acculturate and patients’ health risks and access to healthcare. In assimilate more easily. Sojourners who immigrate urban environments, people are more likely be with the intention of remaining in their new home- exposed to pathogens and infectious diseases due land for only a short time on work assignments or to overcrowding, air pollution from vehicle and refugees who think they may return to their home industrial emissions, and pollution from waste country may not have the need or desire to accul- and sewage contaminating water sources, vio- turate or assimilate. In addition, undocumented lence, and traffic hazards to name a few. Rural individuals (illegal immigrants) may have a dif- 40 L. Purnell ferent worldview from those who have arrived awareness activities such as community fairs and legally. Many in this group remained hidden in heritage days with culturally diverse speakers, society so they will not be discovered and returned media, ethnic foods, and spirituality. The bud- to their home country. Being undocumented limits get must also be sufficient to provide accessible a person’s ability to get employment and health resources for staff to learn about specific cultures insurance as well as social engagements. and common language terms used by populations Length of time away from the country of ori- served. A cultural calendar can be developed gin: Usually but not always, the longer people that includes diverse patients’ religious holi- are away from their culture of origin, the less days, Emancipation days, Independence days, traditional they become as they acculturate and and other important events celebrated such as assimilate into their new culture. quinceanera, the celebration of a young woman’s 15th birthday marking her passage from girlhood to womanhood. This social event emphasizes the 2.6 Recommendations importance of family and society in the life of a young woman. Recommendations for clinical practice, administration, education, and research follow. 2.6.3 Recommendations for Education 2.6.1 Recommendations for Clinical Practice The education department should provide in- service classes on the basic terminology related All clinical staff must address culture on intake to culture and anthropology as described previ- assessments and add to the assessment on a con- ously in this chapter. During informal in-services tinual basis (see Chap. 6). Pertinent cultural char- and staff meetings, staff at all levels could be acteristics should be included on the patient’s plan encouraged to give specific examples of patients’ of care. Clinical staff must become knowledgeable cultural practices as well as their own cultural about the cultural attributes of diverse patients practices. A “Train the Trainer” program could that include the variant characteristics of culture. be instituted for staff to provide cultural-related Professional staff can use search engines and information on a 24-hour basis. An internal web libraries to help identify culturally congruent prac- site could be developed where staff can access tices of the populations served. A special attempt cultural general and culturally specific informa- must be made to remember that the practices iden- tion. Staff should also be encouraged to attend tified are generalizations to avoid stereotyping. As formal courses and conferences related to culture. staff provides care to specific ethnic and cultural individuals, encourage them to keep a journal log of practices and share them with all staff. 2.6.4 Recommendations for Research

2.6.2 Recommendations As staff identifies gaps in the evidence-based for Administration literature on culturally diverse patients in their practice, they can make recommendations to Organizational cultural competence must be researchers in the facility. If research assistance included in the overall mission and philosophy is needed, educators in the organization can part- and extended into every department and unit. ner with local colleges, universities, and cultur- Administration must facilitate staff participa- ally based communities to help them conduct tion in classes on culturally competent care and research (see Chap. 39). Staff should be encour- knowledge of cultural groups served. A bud- aged to be active participants with researchers get must be provided to help organize cultural conducting the research. 2 Knowledge of Cultures 41

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Janet R. Katz and Darlene P. Hughes

Maria, a community health registered nurse, was Maria learned the grandmother and both parents living in rural Northwestern USA. She was seek- had diabetes, obesity, hypertension, and ing a position in an Indian Health Services (IHS) expressed signs of depression. Maria would often clinic. Maria knew that Native Americans suf- see the three younger children for common cold fered some of the worst health disparities in the viruses, minor injuries, and common health USA, as did most indigenous peoples around the issues that is nothing out of the ordinary for world (Katz et al. 2016), and she wanted to help. growing children. The children were always Maria had met several Native American nurses cheerful when they came to the clinic; however, when she was in school but had never talked to Maria did notice their clothes were often thread- them about their communities. She would later bare. The older son, John, seldom came to the see this as a great missed opportunity. clinic, but when he did, he said he was okay. In her new job, Maria noticed a high rate of Maria was concerned; she knew alcohol and drug diabetes, hypertension, heart disease, depression, misuse was prevalent in this area. Raymond and alcohol misuse similar to other clinics in worked seasonally as a smoke jumper and a which she had worked. But, one family repre- trucker the remainder of the year. Due to his sented a turning point for her. She realized she schedule, he rarely came to appointments. When did not know much about the people, culture, set- he did, Maria noticed he stood quietly in the ting, and community that the clinic served. The background. family included a grandmother (Sadie), Sadie’s On one visit, Sadie came to the clinic alone. daughter (Violet), Sadie’s grandchildren (Kyla, She confided that she was very tired and was feel- age 5 years; Charles, age 6 years; Martha, age ing overwhelmed. Her daughter was traveling 8 years; and John, age 15 years), and the chil- searching for work and was leaving the grand- dren’s father (Raymond). After multiple visits, children with her more often, sometimes for multiple days at a time. She said she might have to take the children into her home permanently if her daughter could not find work locally. Sadie also confided that Kyla was not Violet’s biological child but her cousin’s. Sadie knew her daugh- J. R. Katz, R.N., Ph.D., FAAN (*) ter was trying hard to be a good parent to all of D. P. Hughes, M.S.N., R.N. the children. Raymond was away every 2 weeks College of Nursing, Washington State University, Spokane, WA, USA and so was unable to help much. Sadie stated she e-mail: [email protected]; [email protected] no longer had the energy to care for young

© Springer International Publishing AG, part of Springer Nature 2018 43 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_3 44 J. R. Katz and D. P. Hughes

children. She also voiced concern about John. imposed on American Indian/Alaska Native (AI/ She stated that he was home less often and AN) people have led to much mistrust in institu- appeared to have been drinking. She told Maria tions and non-native people. A community nurse, she had struggled with alcohol misuse several like Maria, needs to learn and understand cultural years ago. specifics to adequately care for the people in her Over the next month, Maria saw the grand- clinic service area. Although native people expe- mother several times for uncontrolled hyperten- rience many health, economic, and social dispari- sion and medication changes. This made her ties, tribal family and community structure often more fatigued. Maria was concerned that Sadie provide advantages for their members’ commu- was at increased risks for stroke or heart attack. nity ties, family bonds that span centuries, and a Maria decided she really needed to talk to Violet. persistence for survival translate to deep resil- At first, Violet was unable to come in. When iency and strength (Kicza and Horn 2016). Violet was able to make it to the clinic, Maria Building trust and relationships with a tribal noted she appeared tired and frustrated. She community and its members is essential. seemed depressed and overwhelmed. She was Understanding the impact of historical and socio- unable to find work, Raymond was often away, political harms on present-day life includes a Sadie was not well, John was partying with his solid understanding of how broken cultural tradi- friends more, and she didn’t have money to buy tions impacts present-day childcare. the children new school clothes. There had been Communication is predicated on trust and several suicides in the community this last win- follows sociocultural norms. When erroneous ter, and Violet was very worried about John. generalizations are made by the nurse or other Maria asked her if she wanted to speak to a men- health-care providers, trusting communication tal health provider. Violet stated, “Oh, I don’t can break down. For tribal communities in the need that; they can’t help me anyway; they don’t northwestern area of the USA, a handshake understand what we go through, how hard it is; may be most often used when greeting people. and they talk all the time, but talk doesn’t find us Remember that many stereotypes or generaliza- jobs.” Maria did not want to breach Sadie’s confi- tions, such as handshaking, may or may not be dentiality, so she tried to ask Violet about care of true for any one individual; taking cues from the children. Violet said, “I am worried about the the person being greeted is important (Mihesuah kids, I know mom is having a hard time.” “I wish 2013). I knew what to do.” Another factor to be cognizant of is the concept of family and the extensive familial relationships within communities. It is not uncommon to 3.1 Cultural Issues be told a person is a cousin, sister, or auntie, when there is no biological connection. This does There are 562 federally recognized tribes in the not diminish the familial bond. Over many hun- USA (Bureau of Indian Affairs 2015). American dreds of years, extensive family networks have Indian or Alaskan Native identity does not imply developed. You may find people with the same a homogeneous but instead is represented by last name who are distant cousins. Although there unique cultures from multiple regions and tribes are close family ties throughout a community, (Champagne 2014). However, there are some privacy and confidentiality are imperative to general cultural principles tied to a common his- build trust (Evans-Campbell 2008; Lonczak et al. tory of colonization, boarding schools, loss of 2013). Greetings and introductions often begin culture, trauma, exploitation by researchers and with establishing what family a person belongs to academics, broken treaties, poverty, and under rather than in European/American society where funded health care (Evans-Campbell 2008). It is the first question is “What do you do?” the ques- important to understand that the exploitation, tions may be “Who are your parents, grandpar- broken agreements, and negative stereotypes ents, great-grandparents.” And “Where you are 3 Case Study: Building Trust Among American Indian/Alaska Native Communities 45 from?” These are important questions for estab- on taking over vast tracts of land in exchange for lishing connections. People often identify them- services such as food and health care (Barbero selves with their name, tribal affiliation, and 2005). Health-care funding was first appropriated family connections. in 1832, specifically for small pox epidemics Elders are given added respect by all members (Shelton 2004). Treaties promised these services of the community (Braun et al. 2014). If Elders “in perpetuity” (Shelton 2004). are present, younger people may defer to them Boarding schools were enforced to ensure rather than talk for themselves. At family and assimilation. Many children were taken from community events, elders are always served first. their homes and sent to distant boarding schools It is not uncommon for a community to regard a where they were forbidden to practice traditional community health nurse over 50 years of age as ways (clothing, prayer, language, food, or median elder. Patients may want to talk to family or cine) and were severely punished when they did even tribal elders before making health-care so (Bigfoot and Schmidt 2010; Charbonneau- decisions. Dahlen et al. 2016). Boarding schools have left a The use of medicinal plants remains a common legacy of emotional, sexual, and physical abuse practice by many tribal people (Wendt and Gone which are regarded today as factors in high sui- 2016). To determine if a patient is using tradi- cide rates, depression, substance misuse, and tional plant medicine, questions must be asked in domestic violence (Heart 2003; Thomas and respectful ways to understand non-Western treat- Austin 2012). Assimilation may have been well- ments. Spirituality and religion also vary greatly intentioned by some, but it leads to a rupture in among tribes and individuals. A community’s culture, disconnection in knowledge of tradi- religion is likely influenced by colonization. The tions, and a profound sadness that is being felt religious order that is dominant in the community today. Many cite boarding schools and general may have been determined by first contact or by assimilation policies as directly related to today’s the practices of original religious leaders. In many social determinants of health disparities. Alaska Native villages, the Russian Christian Assimilation policies were followed by laws Orthodox Church remains a strong influence due that allowed non-native people to buy land on to the humanitarian actions the original priest reservations leading to what is called checker showed the Alaska Native peoples (Oleska 2010). boarding (Deyo et al. 2014). Many communities There are also people and bands (groups that now are working on buying back that land to make make up larger tribes) who practice traditional their reservations whole again. The Indian Health spiritual ways. Service was officially formed in the early 1900s; it had formally been under the War Office (Barbero 2005). In 1975 the Indian Self- 3.2 Social Structural Issues Determination and Education Assistance Act and the Indian Health Care Improvement Act were Tribal sovereignty was present among all North enacted to protect native people’s rights to educa- American tribes long before European contact. It is tion and health care, essentially to fulfill treaty estimated in 1492 there were about 75 million promises made years earlier (Barbero: Indian indigenous people in North and South America, Health Services 2007). representing 15% of the world’s population (Thornton 1997). Yet, with colonization came a policy of conquest and control that lasted to the 3.3 Culturally Competent early 1800s, severely reducing the population. It is Strategies Recommended estimated today AI/AN make up 2% of the US population or about 5.4 million people (U.S. Census Health disparities and historical atrocities greatly 2015). Beginning in the early 1800s, treaty making impact individual and community health out- was predominantly US policy. Treaties were based comes. AI/AN people have made tremendous 46 J. R. Katz and D. P. Hughes strides in healing. They continue to realize more • When appropriate, gently discuss concerns tribal sovereignty through controlling their own about teenage son, recent community losses to health services, acting as their own gatekeepers, suicide, and inquire if parents would like you and educating their children to become commu- or another provider to talk to son such as a nity leaders. teacher or a counselor. • Provide education and resources on job opportunities, parenting classes, alcohol or drug 3.3.1 Individual-/Family-Level misuse programs, adolescent support pro- Interventions grams, childcare services, and CNA services (for elder if needed). • Familiarize yourself with health disparity issues relevant to tribal communities. • Learn about historical and intergenerational 3.3.2 Organizational-Level trauma without making assumptions about Interventions individuals or their families. Just be aware. • Upon meeting your client for the first time, be • Be familiar with current politics that may be patient, don’t appear rushed. Offer your hand impacting the tribe. to shake, don’t force it. If appropriate for cul- • Establish a cultural competency program. Do ture, make eye contact, nod, and welcome not assume your facility has cultural them to your office. Ask general questions understanding for the client base, even if it is about how they are doing. an IHS clinic. • Assess family structure through introduction • Advocate for hiring a community member beginning with yourself. Acknowledge elders to consult on unique tribal culture and with respect asking them if they would like to traditions. sit or need anything. When asking questions in • If some elders still speak the native language, a group, be sure to ask elders first. enlist them to help translate some health • Obtain a detailed assessment of any unique information. cultural needs, i.e., religious and language • Propose to host an elder men or women’s preferences; normal health-care provider; group meeting monthly. childcare options, if applicable; environment • Develop a committee to design and produce (home and community); and occupation education materials inclusive of traditional (training, education, and work opportunities). foods, practices, dress, and activities. Allow client/s the opportunity to decline giving information. • Respect patient’s privacy and potential reluc- 3.3.3 Community Societal-Level tance to share information with a non-native Interventions health-care provider. • Ask most pressing questions relevant to spe- • Determine the strengths of community to cific visit. Don’t try or expect to get all back- include cultural practices and traditions, fam- ground information at first visit. Be patient. ily support and caring, and events to attend. Know you will need to build trust. • Collaborate with elder men or other men’s • Provide a thorough explanation of groups to learn about fathering and steps to confidentiality. assisting fathers in becoming more involved in • When appropriate, provide information about parenting. transportation to a more comprehensive • Don’t be afraid to ask questions about the local health-care facility for testing if elder (Sadie) culture and how the tribal members would like needed. your help. Be humble and respectful. 3 Case Study: Building Trust Among American Indian/Alaska Native Communities 47

Conclusion work for exploring impacts on individuals, families, Working with a Native American tribe as a non- and communities. J Interpers Violence 23(3):316–338 Heart MYHB (2003) The historical trauma response native nurse requires learning a great deal of among natives and its relationship with substance new information about Native American cul- abuse: a Lakota illustration. J Psychoactive Drugs ture. Most importantly, be aware of the comfort 35(1):7–13 level of each individual in the family to speak Indian Health Services (2007) Federal basis for health services. Indian Health Service. https://www.ihs. with you. Don’t push, be patient. Develop a gov/newsroom/factsheets/basisforhealthservices/. trusting relationship. Be comfortable with Accessed 30 June 2017 admitting you do not know everything about Katz JR, Barbosa-Leiker C, Benavides-Vaello S (2016) their culture. Use and accept humor. Measuring the success of a pipeline program to increase nursing workforce diversity. J Prof Nurs 32(1):6–14. https://doi.org/10.1016/j.profnurs.2015.05.003 Kicza JE, Horn R (2016) Resilient cultures: America’s References native peoples confront European colonialization 1500–1800. Routledge Barbero CL (2005) The federal trust responsibility: justifi- Lonczak HS, Thomas LR, Donovan D, Austin L, Sigo cation for Indian-specific heath policy.https://uihi.us/ RL, Lawrence N, Tribe S (2013) Navigating the Shared%20Documents/Health%20Policy/Federal%20 tide together: early collaboration between tribal and Trust.doc. Accessed 30 June 2017 academic partners in a CBPR study. Pimatisiwin Bigfoot DS, Schmidt SR (2010) Honoring children, mend- 11(3):395 ing the circle: cultural adaptation of trauma-focused Mihesuah DA (2013) American Indians: stereotypes & cognitive-behavioral therapy for American Indian and realities. SCB Distributors Alaska Native children. J Clin Psychol 66(8):847–856 Oleska MJ (2010) Alaskan missionary spirituality. Braun KL, Browne CV, Ka‘opua LS, Kim BJ, Mokuau N https://www.amazon.com/Alaskan-Missionary- (2014) Research on indigenous elders: from positivis- Spirituality-Michael-2010-02-01/dp/B01K3OUGVU tic to decolonizing methodologies. The Gerontologist Shelton LB (2004) Legal and historical roots of health 54(1):117–126 care for American Indians and Alaska Natives in the Bureau of Indian Affairs (2015) Indian entities recognized United States. Henry J Kaiser Family Foundation. and eligible to receive services from the United States Pub. #7021 Bureau of Indian Affairs. Federal basis for health Thomas L, Austin L (2012) Recognized American Indian services. Federal Register: Bureau of Indian Affairs. Organizations (RAIOs) Health Priorities Summit. https://www.ihs.gov/aboutihs/eligibility/. Accesses 11 Summary Report, Cradleboard to Career. http:// April 2017 uwashington.uberflip.com/i/106618-from-cradle- Champagne D (2014) The term ‘American Indian’, plus eth- board-to-career-summary-report/3. Accessed 30 June nicity, sovereignty, and identity. Indian Country Today. 2017 June 2014. https://indiancountrymedianetwork.com/ Thornton R (1997) Population: precontact to the pres- history/events/the-term-american-indian-plus-ethnicity- ent. In: Hoxie, Encyclopedia of North American sovereignty-and-identity/#. Accessed 3 July 2017 Indians, 501 Charbonneau-Dahlen BK, Lowe J, Morris SL (2016) U.S. Census (2015) FFF: American Indian and Alaska Giving voice to historical trauma through storytelling: Native Heritage Month: November 2015. https://www. the impact of boarding school experience on American census.gov/newsroom/facts-for-features/2015/cb15- Indians. J Aggress Maltreat Trauma 25(6):598–617 ff22.html/. Accessed 30 June 2017 Deyo N, Bohdan M, Burke R, Kelley A, van der Werff B, Wendt DC, Gone JP (2016) Integrating professional and Blackmer ED et al (2014) Trails on tribal lands in the indigenous therapies: an urban American Indian narra- United States. Landsc Urban Plan 125:130–139 tive clinical case study. Couns Psychol 44(5):695–729 Evans-Campbell T (2008) Historical trauma in American Indian/Native Alaska communities: a multilevel frame- Case Study: An 85-Year-Old Immigrant from the Former Soviet 4 Union

Lynn Clark Callister

Katerina Fyodorova, an 85-year-old Russia physicians because of the stigma associated with immigrant, came to the United States in 1998 major depressive disorders in the USSR. with the wave of immigrants coming from the Speaking in a circular fashion, Katerina may former Soviet Union (FSU) with the collapse of describe her bittersweet memories of life under the Soviet regime. Katerina is commonly referred communism in her homeland and her current to as a babushka or grandmother. She is wid- feelings of social needlessness, loneliness, and owed, her parents are deceased, and she has no isolation. The unmet need for diagnosis and treat- living siblings and has no children. ment of depression among immigrants from the Despite living in the United States for nearly former USSR now living in the United States has 30 years, her primary language is still Russian. been reported in the literature (Landa et al. 2015). She speaks Russian in her home and associates In study participants seen in a primary care clinic, mostly with other immigrants from the FSU. She 26.5% had a probable major depressive disorder. lives alone in a high-rise, low-income housing in It is noted that such depression does not diminish a poor-quality neighborhood in a large metropoli- in those who have lived in the United States for tan area on the east coast of the United States. decades and is often underdiagnosed and This area and surrounding environs have the larg- untreated (Landa et al. 2015: 283). est people from the FSU, although Alaska and cities on the East and West coast also have large populations of such immigrants. Katerina enjoys 4.1 Cultural Issues accessing New York’s daily Novoye Russkoye Slovo newspaper and the cable television chan- Like many of her aging peers, Katerina’s health- nels and radio stations available in Russian in the care can be characterized by a pattern of begat’ New York area. po racham or “running between doctors.” This Katerina is subsisting on a very limited includes a variety of both biomedical and tradi- income. At times she feels depressed and lonely tional therapies. This pattern of healthcare has and doesn’t know where to turn to. She some- led to weaker patient-provider communication times feels a sense of hopelessness about her situ- and lower levels of satisfaction with healthcare. ation. She does not feel comfortable confiding in She does not appear to have any serious medical problems, but has little to do, having much time L. C. Callister, R.N., Ph.D., FAAN on her hands, and is living in social isolation, in School of Nursing, Brigham Young University, addition to not having a basic understanding of Provo, UT, USA the normal aging processes. Such a non- systematic e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 49 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_4 50 L. C. Callister pattern of seeking healthcare among FSU immi- 4.2 Social Structural Issues grants to the United States has been described in the literature (Chudakova 2016). There are 15 Soviet republics, which include the In a recent visit at the clinic, she offered the Slavic states (Russian Federation, Ukraine, and clinic nurse an informal payment in the hopes of Belarus; the Baltic States (Estonia, Latvia, and getting a “higher” level of care and bypassing the Lithuania); the Caucasus states (Armenia, lines at the clinic as well as required paperwork, Azerbaijan and George; the Central Asian repub- not understanding that such practices are not lics (Kazakhstan, Uzbekistan, Turkmenistan, appropriate or expected in healthcare facilities in Kyrgyzstan, and Tajikistan) as well as Moldova. the United States (Gordeev et al. 2014). Such Many of these states have large populations of practice is an important health policy issue for ethnic Russians. Katerina came from an ethni- those caring for immigrants from the FSU. cally and culturally diverse background, with a When Katerina sees a healthcare provider, she population of more than 150 minority nationali- is likely to report only fair or poor health than her ties and 100 different languages besides Russian American counterparts which is also reported in living in Russia (Younger 2016). the literature (Hofmann 2012). In Slavic cultures, Since 1991, many immigrants from the newly “speaking positively about one’s own well-being independent states of the FSU have come to the is thought to bring misfortune” (Hofmann 2012: United States, including those from the Russian 319; Paxson 2005). However, her complaints are Federation. The 2015 estimate of the US popula- very vague and general. tion born in the former USSR is 1,066,944 When Katerina has a conversation with an (American FactFinder 2017a). New York State American healthcare provider, she is often and surrounding areas have the largest percent- uncomfortable. She would prefer that providers age of people from the FSU, although Alaska and should communicate with her in a paternalistic cities on the East and West Coasts of the United manner because this is what she was used to in States also have large populations of such immi- the FSU (Younger 2016). This has also been grants (American FactFinder 2017b). reported in the literature in a study of immigrants Like many immigrants from the FSU, from the FSU living in Germany (Bachmann Katerina is an ethnic Jew who came because et al. 2014). of an American program granting asylum to When possible, Katerina prefers to use com- Soviet Jews because of anti-Semitism in the plementary therapies because they are less expen- USSR (Landa et al. 2015). Katerina is secular- sive, come from nature and thus come from God, ized and religiously non-observant. The major- and are available without prescription. She also ity of former Soviet Jewish immigrants were perceives them as having fewer complications over 55 years of age when they came to the than biomedical therapies which are “too strong, United States, which is much older than other chemical, and not natural” (Van Son and Stasyuk immigrant populations. Like many Jewish 2014: 546). Dietary proscriptions include onions, immigrants from the FSU, Katerina has close garlic, lemons, and beets. Herbs most commonly relatives living in Israel because of the divided used include valerian, kava, Siberian ginseng, destinations of Jews leaving the FSU after the St. John’s Wort, pheasant’s eye, and yarrow fall of the Soviet Union. (Tagintseva 2005). She makes decisions about these therapies by conferring with neighbors and friends who are also from the former FSU (Van 4.3 Culturally Competent Son and Stasyuk 2014). This kind of inappropri- Strategies Recommended ate self-care (samolechenie) is problematic as Katerina seeks to “become her own doctor,” char- The following are recommendations to enable acterized by dismissing potential health concerns the development culturally congruent and effec- by saying fatalistically, “it is as it is” (kakoye est). tive strategies to improve the quality of life in 4 Case Study: An 85-Year-Old Immigrant from the Former Soviet Union 51 immigrants from the FSU living in the United on her strengths and resiliency as a survivor of States such as Katerina. challenging life circumstances.

4.3.1 Individual/Family Level 4.3.2 Organizational Level Interventions Interventions

• In the primary care clinic, a physical and • Provide a certified interpreter during health- psychosocial-cultural assessment should be con- care encounters. ducted with Katerina using a certified interpreter. • Provide staff with current literature on immi- This should include learning about language grants from the FSU living in the United preference, how healthcare decisions are made, States and meet to discuss the implications of preferred communication style with healthcare that literature on their clinical practice. providers, perceptions of the promotion of health • Provide cultural competency education for and causes of illness, knowledge about commu- providers serving populations of immigrants nity resources, and culturally preferred treat- from the FSU such as the interprofessional ments for illness (Bachmann et al. 2014; Douglas education Russian cultural competence course et al. 2014). The more knowledge professional at Washington State University described in nurses have about specific cultural groups, the the literature (Topping 2015). more accurate and complete the cultural assess- • Access, or develop, produce, and disseminate ment will be (Douglas et al. 2014). patient education material translated into • Consult with social services to assist Katerina English. in accessing resources such as English classes, • Collaborate with Russian focused media out- health education (including media presenta- lets to provide health messages on the radio tions that have been translated into Russian), and television stations and in print media. smoking cessation initiatives, and community services for seniors including meals and exercise programs. 4.3.3 Community Level • Provide connection with any community orga- Interventions nizations and other community resources for immigrants from the FSU. • Collect quantitative and qualitative data in • Help Katerina understand the difference mixed methods studies on the challenges and between normal aging and symptoms that needs of immigrants from the FSU to increase may indicate underlying health conditions. understanding and facilitate the development • Help Katerina understand the potential health of appropriate interventions. This may be risks associated with combining biomedical done in collaboration with resources such as and complementary therapies. the Davis Center for Russian and Eurasian • Help her to understand how to communicate Studies at Harvard or utilize local universities. effectively with healthcare providers. This could include an oral history project with • Assess Katerina for a major depressive disor- older immigrants such as Katerina which der using tools translated into Russian. would increase our outstanding of the lives of • The Patient Health Questionnaire-I (PHQ) is a immigrants from the FSU. These immigrants screening tool for depression which is avail- have stories to share that are richly descriptive able in Russia (Kroenke et al. 2001) (www. and potentially helpful in facilitating quality phqscreeners.com). healthcare delivery to them. • Help Katerina access resources to overcome • Collaborate with low-income housing facili- feelings of despair and hopelessness, focusing ties to work toward improving the environment 52 L. C. Callister

in a way that helps Katerina and other FSU in primary care consultations. Dtsch Arztebl Int immigrants feel safe and connected. 111(5):51–52 Chudakova T (2016) Caring for strangers: aging, traditional medicine, and collective self-care in Conclusion post-socialist Russia. Med Anthropol Q 31(1): Cultural issues specific to caring for immigrants 78–96 from the FSU may include poor patient-pro- Douglas MK, Rosenkoetter M, Pacquiao DF, Callister LC, Hattar-Pollara M, Lauderdale J, Milsted J, Nardi vider relationships because of linguistic issues D, Purnell L (2014) Guidelines for implementing and differences in communication styles, help- culturally competent nursing care. J Transcult Nurs seeking patterns of accessing multiple provid- 25(2):109–121 Gordeev VS, Pavloa M, Groot W (2014) Informal pay- ers, the use of complementary rather than ments for health care services in Russia: old issue in biomedical therapies, the potential use of infor- new realities. Health Econ Policy Law 9:25–48 mal payment, a lack of knowing the difference Hofmann ET (2012) The burden of culture? Health out- between natural aging processes and potential comes among immigrants from the Former Soviet Union in the United States. J Immigr Minor Health illness, and the significant potential for major 14:315–322 depressive disorders. Strategies for culturally Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ- competent healthcare delivery at the individual, i: validity of a brief depression severity measure. J Gen organizational, and societal levels should be Intern Med 16:606–613 Landa A, Skristskaya N, Nicasio A, Humensky J, Lewis- designed and implemented to address Katerina Fernandez R (2015) Unmet need for treatment of and other immigrant’s vulnerability due to the depression among immigrants from the former USSR social determinants of health related to the in the US: a primary care study. Int J Psychiatry Med health and well-being of immigrants from the 50(3):271–289 Paxson M (2005) Solovyovo: the story of memory in FSU (Douglas et al. 2014). a Russian village. Woodrow Wilson Center Press, Washington, DC Tagintseva TY (2005) The use of herbal medicine by U.S. immigrants from the Former Soviet Union [Master’s References Thesis]. https://research.wsulibs.wsu.edu/xmlui/ bitstream/handle/2376/381/t_tagintseva_072205. American FactFinder (2017a) Place of birth for the pds?sequence=1. Accessed 30 July 2017 foreign-born population in the United States. http:// Topping D (2015) An inter-professional education factfinder.census.gov/faces/tableservices/jsf/pages/ Russian cultural competence course: implementation productview.xhtml?pid=ACS_1 5_1YR_B05006. and follow-up perspectives. J Interprof Care 29(5): Accessed 16 July 2017 501–503 American FactFinder (2017b) Top 101 cites with the most Van Son CR, Stasyuk O (2014) Older immigrants from the residents born in Russia (populations 500+). http:// former Soviet Union and their use of complementary factfinder.census.gov. Accessed 16 July 2017 and alternative medicine. Geriatr Nurs 35:S45–S48 Bachmann V, Volkner M, Bosnerr S, Doner-Banzhoff N Younger DS (2016) Health care in the Russian Federation. (2014) The experiences of Russian-speaking migrants Neurol Clin 34:1085–1102 Case Study: Caring for Urban, American Indian, Gay, or Lesbian 5 Youth at Risk for Suicide

Jana Lauderdale

Larry, a newly graduated baccalaureate-prepared tal health clinic, he quickly realized he had a poor nurse, has just moved to the Midwest from the understanding of the mental health issues facing upper northern United States (US). Being part urban Indians. Larry’s first family to work with on Lakota Indian, he is interested in working with his own had traveled 30 miles to the tribal clinic. tribes different from his own and knows Oklahoma They were there because they had lost their eldest has the largest American Indian (AI) population son to alcohol and suicide at 19 years of age, and of any state in the United States. His career plan is they were afraid their youngest son, 15-year-old to get as much experience as possible working for Andy, was going to follow the same path. tribal clinics, learning about, and caring for AI Larry first interviewed Andy’s parents while he suicide victims in urban settings. He is aware of waited in the reception area. His mother reported several suicides on his reservation as he was he had no appetite, was doing poorly in school, growing up, but no one talked much about them, and had periods of negative, sad talk when he so neither did he. Larry then plans to go to gradu- talked at all. He spent most of his time in his room ate school to become a psych-mental health nurse on the computer. His dad said he noticed he has practitioner (PMHNP) and return to the Dakotas only one person he likes to talk with, an older to work with his people to help reduce psych- adult called Henry, who lives several miles from mental health disparities. For this reason, he has their house. There are also two younger sisters in just accepted a new position with the Indian the family that his mother says, “Are taking up Health Service (IHS) at the Oklahoma City Tribal more and more of my time after school with their Clinic in Oklahoma City, Oklahoma. This will be activities and with his father at work until 7pm a new experience for Larry, not living on a reser- and I am worried about leaving Andy at home in vation and working in an urban setting. the afternoon for up to 3 hours at a time.” Larry As a new graduate nurse in a new work envi- then excused the parents and spoke with Andy. ronment, Larry has had a lot to learn in a short Once they became comfortable with one another, amount of time. As an AI growing up on a reserva- Andy began to open up about his lack of friends, tion, he was prepared for high rates of diabetes, his disinterest in school, and how he missed talk- cancer, cardiovascular disease, and strokes; how- ing to his grandfather who died 2 years ago. When ever, as he had requested to work in the small men- asked what he missed most about his grandfather he said, “You know just someone to talk to that J. Lauderdale, Ph.D., R.N., FAAN understands. My friend Henry is good to talk to School of Nursing, Vanderbilt University, also, but my parents won’t let me go to his house. Nashville, TN, USA I have to sneak over to see him. But he under- e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 53 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_5 54 J. Lauderdale stands me and can talk to me like my grandfather 10–25 years and is complicated by the fact that did.” He sighed and said, “I am really tired of wor- more AI youth are now living in urban areas, far rying about everything and being afraid. from reservation or tribal communities (Burrage Sometimes I think, wouldn’t it be nice if I could et al. 2016). Almost 70% of AIs live in urban areas; just go to sleep and not wake up.” however, the US Census Bureau (2010) indicates When asked of what he was afraid, Andy there is still conflicting information regarding looked at the floor and said, “That I am different.” urban youth suicide rates. This is evident when More probing resulted in Andy quietly saying, “I comparing reports between reservation suicide don’t want to go on dates with girls; you know I rates, documented via the IHS system, and urban am a ‘Two-Spirit,’ but I haven’t told anyone suicide rates reported by hospitals, many times because I am afraid of what will happen.” Larry using inaccurate identification of race or ethnicity knows that for American Indians, Two-Spirit is on death certificates, which only further confounds the contemporary word used that means gay the information (Middlebrook et al. 2001). (Lang 1998). Larry encouraged him to talk to his Common suicide predictors have been reported parents, but he said, “No I can’t do it; they are not for both white and AI youth, including drug and strong enough.” Larry could see Andy’s case was alcohol misuse, family history of suicide or going to require intensive outpatient therapy, so attempts, physical or sexual abuse, emotional he quickly got to his computer to look up mental issues, and weapon carrying (Ayyash-Abdo 2002; health providers in the family’s community, but King and Merchant 2008; Mackin et al. 2012). there was only one who was IHS affiliated. However, many AIs believe suicide is a commu- However, Andy said he did not want to go there nity problem related to loss of cultural beliefs and because his brother had been a patient there and early colonial oppression rather than an individual said, “And look how it turned out for him. No, I problem (Wexler and Gone 2012), indicating sui- won’t go there.” cide factors for this population may have deeper Larry then spoke with Andy’s parents, con- roots in the social, community, and societal realms firming their fears that Andy had recently thought than from the reported predictive factors. AI youth about suicide and his concern regarding Andy’s factors believed to promote suicide behavior resistance to go to the only IHS mental health include gender (Manzo et al. 2015), living in urban facility in their area. Andy’s father had panic in versus reservation areas (Freedenthal and Stiffman his eyes and whispered, “If dad were alive, he 2004), and the strength of the tribal culture (Novins would be able to help. You know, he always knew et al. 1999). Losing one’s culture can decrease cul- how to explain things in a way the kids under- tural identity which eventually can impact health. stood.” Larry has many concerns on how to han- Historically, alternative gender roles and sexu- dle his new young patient’s situation and has not alities have been accepted by many tribes. yet been able to do anything beyond talking with However, today’s AI people who are lesbian, gay, him briefly confirming that indeed, Andy was bisexual, and transgender (LGBT) or identify as experiencing suicide ideations. He felt rushed as Two-Spirit often still see their communities as he tried to find a clinic that was good for both him non-accepting, encouraging isolation, discrimi- and his family. nation, fear, and invisibility which may increase suicide risk factors. The term “Two-Spirits” was accepted in the 1990s at a Chicago conference as 5.1 Cultural Issues an acceptable term to describe LGBT AI individuals. Lang (1998) noted in his interviews with American Indian Youth suicide has become a “Two-Spirit” AIs that culturally it is believed that national health concern. The Centers for Disease the term means a male in a feminine role and a Control and Prevention (2014) reports that AI female in a masculine role. It is considered to be youth suicide rates are the highest in the country, an all-encompassing term for the LGBT AI popu- 62% above the national average for youth ages lation (Medicine et al. 1997). 5 Case Study: Caring for Urban, American Indian, Gay, or Lesbian Youth at Risk for Suicide 55

Newer program development in the area of • Understand the LGBT or Two Spirit health con- suicide prevention focuses on a holistic approach, cerns for pediatric or adolescents include mental combining Western medicine with traditional health, unprotected health, drug and alcohol mis- Indian medicine to encourage individuals and use, protective factors, illegal hormone injections families to improve their mental, physical, spiri- (transgender), and self-isolation with loneliness tual, and emotional well-being. Thus, establish- and hopelessness that are the most important facing trust and respect is critical when working tors in suicide attempts in LGBT youth. with LGBT and Two Spirit AI youth populations • Ensure protective factors that include family (Burrage et al. 2016). support. • Understand AI perspectives of health and illness. 5.2 Social Structure • Encourage informal support and use the teaching of the Seven Grandfathers as appropriate, With the majority of American Indians living in as a way to exemplify living one’s life accord- urban settings, healthcare providers must become ing to the values of wisdom, love, respect, sensitive to how people respond when living out- bravery, honesty, humility, and truth. side the comfort of their own culture. Support • Ensure your interventions are tailored for the must be provided for cultural values and beliefs, youth and their family, with their tribal com- respect for differences, and culturally congruent munity in mind. strategies when working with LGBT “Two • Always take the history in person—not just Spirit” AI youth who are at risk for suicide. via the intake form. Eighty-nine percent LGBT teens report verbal • Do not assume the adult who brings him/her harassment; 55% report physical harassment. to the clinic is the biological father. AIs have LGBT high school students are two times less extended families, aunts, uncles, and grand- likely to finish high school or pursue a college edu- parents that may be the caregiver. cation. LGBT youth rejected by parents are more • Do not make assumptions about sexual activ- likely to attempt suicide, report depression, use ity or practices. Specifically ask the following: illegal drugs, and have unprotected sex. Twenty to Who are you dating? What are the genders of forty percent of homeless youth are LGBT. your sexual partners? What do you do with them? When you use condoms for anal or vaginal sex, how often do you use them? 5.3 Culturally Competent • Screen for depression, alcohol, smoking, and Strategies Recommended drug use. • Discuss protective factors and specifically ask 5.3.1 Individual/Family Level the following: To whom do you turn when you Interventions feel sad or need someone to talk to? What is school like for you? How did your family • Know the populations you serve. There are react to your coming out? 566+ federally recognized tribes. Be aware of your population’s commonalities and their individual nuances. 5.3.2 Organizational Level • Be aware of the most important factors lead- Interventions ing to LGBT AI youth suicide attempts that include loneliness, isolation, and hopelessness • Consider intervention approach that focus on which lead to lack of social support, social getting support to people rather than people to withdrawal, and victimization, causing social services. isolation, cognitive isolation, emotional isola- • Realize access to traditional healers may be as tion, and concealment of identity. important as access to Western medicine. 56 J. Lauderdale

• Recognize the importance of traditional AI • American Civil Liberties Union (ACLU) for culture to promote the well-being of youth. legal support. Available at https://www.aclu. • Realize the importance for informal support org/ family, mentors, friends, youth leaders in the • The Trevor Project for LGBT-focused suicide community, strong value of “Natives Helping hotline. Available at http://www.thetrevorpro- Natives” vs. formal support (professional ject.org/ services). • APA Lesbian, Gay, Bisexual and Transgender • Make sure your referrals take into account Concerns Office: www.apa.org/pi/lgbt/ travel time and that referrals are made to pro- • Association of Gay and Lesbian Psychiatrists: viders knowledgeable in the ways of AI www.aglp.org/ populations. • Fenway Institute: http://thefenwayinstitute. org/ • Gay and Lesbian Medical Association: www. 5.3.3 Societal Level Interventions glma.org • The National Alliance on Mental Illness • Identify community mentors for youth and LGBT Resources & Fact Sheets: https://www. provide suicide training. nami.org/Find-Support/LGBTQ • Mutual support is important and preferred to help AI youth struggling with suicide and is Conclusion seen as part of AI identity and culture. New AI graduates working for the first time in • Understand that peer support benefits emo- a suicide situation can become overwhelmed. tional youth well-being. The important point is to always gain trust, • Involve as many community members as pos- give respect, maintain a calm demeanor, and sible to help with education on youth suicide be a reassuring presence when working with in AI communities. This will reduce the stigma Two Spirit, AI adolescents. Suicide or even of suicide and build a supportive community. thoughts of suicide can make families feel • Don’t be surprised if the community, family, panicked and helpless. Always be culturally or youth does not want to talk about suicide congruent in your approach and with interven- openly as there is a b.elief that doing so invites tions used. Understand that if prevention is negativity and may bring on harmful states. viewed only as increasing access to clinical services and educating community members about suicide, little room is left for culturally 5.4 Resources for LGBT Youth congruent strategies (Burrage et al. 2016).

• Gay and Lesbian Medical Association (GLMA) for finding a provider. Available at References http://glma.org/ Ayyash-Abdo H (2002) Adolescent suicide: an ecological • Parents and Friends of Lesbians and Gays approach. Psychol Sch 39:459–475 (PFLAG) for support for friends and family. Burrage R, Gone J, Momper S (2016) Urban American Available at https://www.pflag.org/ Indian community perspectives on resources and chal- • Gay, Lesbian, and Straight Education Network lenges for youth suicide prevention. Am J Community Psychol 58:136–149 (GLSEN) for support in schools. Available at Centers for Disease Control and Prevention (2014) Web- https://www.glsen.org/ based injury statistics query and reporting system [Data • Children of Lesbian and Gays Everywhere File]. https://search.cdc.gov/search?query=Web-based (COLAGE) for children in LGBT families. +injury+statistics+query+and+reporting+system+&u tf8=%E2%9C%93&affiliate=cdc-main. Accessed 20 Available at https://www.colage.org/ Sept 2017 • Lambda Legal for legal support. Available at Freedenthal D, Stiffman AR (2004) Suicidal behavior https://www.lambdalegal.org/ in urban American Indian adolescents: a comparison 5 Case Study: Caring for Urban, American Indian, Gay, or Lesbian Youth at Risk for Suicide 57

with reservation youth in a Southwestern state. Suicide context. In: Two-Spirit people. Native American gen- Life Threat Behav 34(2):160–171 der identity, sexuality, and spirituality. University of King CA, Merchant CR (2008) Social and interpersonal Illinois Press, Champaign-Urbana, pp 145–255 factors relating to adolescent suicidality: a review of Middlebrook DL, LeMaster PL, Beals J, Novins DK, the literature. Arch Suicide Res 12:181–196 Manson SM (2001) Suicide prevention in American Lang S (1998) Men as women, women as men: chang- Indian and Alaska Native communities: a criti- ing gender in ‘Native American culture’. University of cal review of programs. Suicide Life Threat Behav Texas Press, Austin 31(Suppl I):132–149 Mackin J, Perkins T, Furrer CJ (2012) The power of pro- Novins DK, Beals J, Roberts RE, Manson S (1999) Factors tection: a population-based comparison of native and associated with suicide ideation among American non-native youth suicide attempters. Am Indian Alsk Indian adolescents: does culture matter? Suicide Life Native Ment Health Res 19:20–54 Threat Behav 29:332–346 Manzo K, Tiesman H, Stewart J, Hobbs GR, Knox S Wexler LE, Gone JP (2012) Culturally responsive suicide (2015) A comparison of risk factors associated with prevention in indigenous communities: unexamined suicide ideation/attempts in American Indian and assumptions and new possibilities. Am J Public Health White youth in Montana. Arch Suicide Res 19:89–102 102:800–806 Medicine B, Jacobs SE, Thomas W, Lang S (eds) (1997) Changing Native American sex roles in an urban Part II Guideline: Education and Training Education and Training in Culturally Competent Care 6

Larry Purnell

Guideline: Nurses shall be educationally prepared to provide culturally congruent health care. Knowledge and skills necessary for assuring that nursing care is culturally congruent shall be included in global health care agendas that mandate formal education and clinical training, as well as required ongoing continuing education for all practicing nurses. Douglas et al. (2014: 110)

6.1 Introduction 6.2 Individualistic and Collectivistic Attributes In addition, to culture being incorporated into as a Framework formal nursing programs, continuing education of nurses in culturally competent and congru- A good starting point for staff at all levels is to ent care is increasingly becoming a requirement gain an understanding of general principles of for accreditation of healthcare organizations by broad cultural groups and an understanding of agencies such as the Joint Commission (The individualistic and collectivistic cultures. All cul- Joint Commission 2010; The Joint Commission tures that vary along a continuum of individual- International 2011). Education for culturally ism and collectivism, subsets of broad competent care encompasses knowledge of the worldviews, are somewhat context dependent. cultural values, beliefs, lifeways, and worldview of population groups as well as individu- Individualism versus collectivism scale Individualism Collectivism als (Papadopoulos 2006). Although Great Britain 1 2 3 4 5 6 7 8 9 10 has encouraged culturally competent education in nursing and other healthcare professions, no official mandate has materialized (George et al. A degree of individualism and collectivism 2015). Whereas Australia and New Zealand has exists in every culture. Moreover, individualism initiatives on cultural competence in education, and collectivism fall along a continuum, and some a mandate for including cultural competence in people from an individualistic culture will, to some nursing education could not be found. The same degree, align themselves toward the collectivistic is true for other countries around the world. end of the scale. Some people from a collectivist culture will, to some degree, hold values along the individualistic end of the scale (see Table 6.1). The degree of acculturation and assimilation and the variant characteristics of culture (see Chap. 2) L. Purnell, Ph.D., R.N., FAAN determine the degree of adherence to traditional School of Nursing, University of Delaware, Newark, DE, USA individualistic and collectivist cultural values, beliefs, and practices (Hofstede and Hofstede 2005; Florida International University, Miami, FL, USA Purnell 2013). They include orientation to self or Excelsior College, Albany, NY, USA group; decision-making; knowledge transmission; e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 61 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_6 62 L. Purnell

Table 6.1 General collectivistic versus individualistic values Collectivistic cultures Individualistic cultures Communication • Implicit indirect communication is most common. • Explicit, direct, straightforward communication is People are more likely to tell the professional what the norm they think the professional wants to hear • More informal greeting frequently use the given • More formal greeting is required by using the name early in an encounter. Professionals should surname with a title. This can be a first step in introduce themselves by the name they preferred to gaining trust. The professional should always ask by be addressed. Ask the individual by what name they what name the person wants to be called want to be addressed • Present temporality is most common, although • Futuristic temporality is the norm. The person balance is sought. The person usually wants to know usually wants to know how the disease/condition how the illness/condition will affect them on a will affect them on a long-term basis short-term basis. Address the individual’s and • Punctuality is valued. People are usually on time or family’s concern before moving on early for formal appointments • Punctuality is not valued except when absolutely • Truth telling is expected at all times. Individuals will necessary such as making transportation usually answer the professional truthfully or evade connections. If punctuality is required, explain the the question completely if they do not want to importance and the repercussions for tardiness such answer it as a not being seen or a charge is made for being late • Questions requiring “yes” or “no” are usually • Truth telling may not be valued in order to “save answered truthfully face” • Direct eye contact is expected and is a sign of truth, • “Yes” may mean I hear you or I understand, not respect, and trust necessarily agreement. Do not ask questions that can • Sharing intimate life details is encouraged, even with easily be answered with “yes” or “no.” The answer is non-intimates, and does not carry a stigma for people invariably “yes.” Instead of asking if the individual or their family takes the medicine as prescribed, ask “what time do • Spatial distancing with non-intimates is 18–24 you take the medicine?” “How many times have you inches. Sexual harassment laws encourage a low missed taking your medicine this week/month?” touch culture. Explain the necessity and ask • Direct eye contact may be avoided with people in permission before touching hierarchical positions as a means of respect, • A diagnosis of depression does not carry a stigma especially among older more traditional people but is and can be shared with individuals and their families maintained with friends and intimates. Do not (if necessary) without a stigma assume that lack of eye contact means that the person is being evasive or not telling the truth • Sharing intimate life details of self or family is discouraged because it may cause a stigma for the person and the family. Ask intimate questions after a modicum of trust has been developed • Spatial distancing with non-intimates may be closer than 18 inches. Do not take offense if the person stands closer to you than what you have been accustomed to • Touch is readily and usually accepted between same-sex individuals but not necessarily between people of the opposite sex. Always ask permission and explain the necessity of touch • A diagnosis of depression is usually not acceptable. Do not use this diagnosis until a modicum of trust has been established 6 Education and Training in Culturally Competent Care 63

Table 6.1 (continued) Collectivistic cultures Individualistic cultures Family roles and organization • Decision-making is a responsibility of the male or • Egalitarian decision-making is the norm, although the most respected family member. The male is there are variations. Ask who is the primary usually the spokesperson for the family, even though decision-maker for health-related concerns he may not be the decision-maker • Individual autonomy is the norm • Individual autonomy is not usually the norm • Younger people are expected to become responsible • Older people’s opinions are sought but not and independent at a young age. Determine necessarily followed responsibilities for children and teenagers. • Young adults and children are not expected to have a • Children are encouraged to express themselves. high degree of dependence until they leave their Allow children to have a voice in decision-making parent’s home • Each person in a group has an equal right to express • Children are not usually encouraged to express an opinion themselves; they are expected to be seen, not heard • No stigma is attached for placing a family member • A stigma may result when a family member is placed in long-term care or substance misuse rehab in long-term care. Home care with the extended • Alternative lifestyles are gaining more acceptance family is the norm than in the past. Ask about same-sex relationships • Alternative lifestyles are not readily accepted and after a modicum of trust has been established may be hidden from the public and even within the • Nuclear family living is the norm. However, the extended family. Do not disclose same-sex professional must still ask who else lives in the relationship to family or outsiders household and what are their responsibilities • Extended family living is common with collective • Beneficence a normative statement to act for others’ input from all members benefit requires the healthcare professional to reveal • Beneficence a normative statement to act for others’ grave diagnoses or outcome directly to the individual benefit may mean that the healthcare professional in order to make informed decisions regarding the should not reveal grave diagnoses or outcome future directly because it may cause them to give up hope. Therefore, the professional should disclose this information to the family who makes the decision to disclose the diagnosis to the individual. An alternative is to tell a story about someone else who has the condition High-risk health behaviors • Accountability is a family affair or some hierarchal • People are accountable for their own actions authority • High-risk health behaviors are revealed to healthcare • High-risk health behaviors are less likely to be professionals. However, it is still best to ask about revealed to healthcare professionals. Do not disclose substance misuse after a modicum of trust has been substance misuse to family members established (continued) 64 L. Purnell

Table 6.1 (continued) Collectivistic cultures Individualistic cultures Healthcare practices • Traditional practices are common as a first line of • Traditional practices are common as a first line of defense for minor illnesses. Specifically ask about defense for minor illnesses. Ask about over-the- traditional practices, including herbs counter medications and herbs • Complementary and alternative therapies are • Complementary and alternative therapies are gaining frequently preferred over allopathic practices. acceptance because they are less invasive. Specifically ask about complementary and Specifically ask the individual about their alternative practices complementary and alternative practices • Preventive practices are stressed • Curative healthcare practices have been the norm, • Rehabilitation is frequently a family responsibility. but preventive practices and healthy living are Great stigma can occur by placing a family member gaining acceptance in a long-term care or rehab facility • Rehabilitation is well-integrated into allopathic care • Self-medication is common and expends to • Liberal pain medication is expected although recent prescription medicines that may be obtained from research is sometimes discouraging this overseas pharmacies and friends. Specifically ask • Mental health issues do not usually carry a stigma what medicines the person is taking for the family. However, ask the person about • Pain may be seen as atonement for past sins. Take disclosure of substance misuse and reveal it only to every opportunity to dispel this myth those who need to know • Mental health issues may be hidden because they • Advance directives that convey how the individual carry a stigma for the family. Disclose mental health wants medical decisions made in the future are and substance misuse only to professionals who compatible with individualism “need to know” • Advance directives that convey how the individual wants medical decisions made in the future may not be acceptable to some because this is a family, not individual, responsibility Healthcare practitioners • Allopathic professionals may be seen as a first • Age of professional healthcare providers is usually resource for major health problems, although not a concern traditional healers may be seen simultaneously. • Same-sex healthcare providers are usually not Professionals should partner with traditional healers required except for traditional Muslims and orthodox • Spiritual leaders frequently serve as alternative Jews. Specifically ask if a same-sex professional is practitioners for emotional concerns and substance required for non-emergent conditions misuse • Age of the professional may be a concern. Ask the individual if they prefer an older professional • Opposite sex healthcare provider may not be acceptable with devout Jewish and Muslim individuals. Ask the individual if a same-sex professional is required for non-life-threatening conditions A degree of individualism and collectivism exists in every culture. Some people from an individualistic culture will, to some degree, align themselves toward the collectivistic end of the scale. Some people from a collectivist culture will, to some degree, hold values along the individualistic end of the scale. Thus, the information in this table should be seen as a guide individual choice and personal responsibility; the ered “eccentrics or local characters” are tolerated concept of progress, competitiveness, shame, and (Purnell 2010; Singelis 1998; Triandis 2001). guilt; help-seeking; expression of identity; and interaction/communication styles (Hofstede 2001; Hofstede and Hofstede 2005; Rothstein-Fisch 6.2.1 Individualism et al. 2001). One should not confuse individualism from individuality. Individuality is the sense that Individualism is a moral, political, or social each person has a separate and equal place in the outlook that stresses independence (Bui and community and where individuals who are consid- Turnbull 2003; Greenfield et al. 2003; Markus 6 Education and Training in Culturally Competent Care 65 and Kitayama 1991; Hofstede and Hofstede 2005; most important person in society is self. A person Purnell 2013; Triandis 2001). Consistent with feels free to change alliances and is not bound by individualism, individualistic cultures encour- any particular group (shared identity). Although age self-expression. Adherents freely express they are part of a group, they are still free to act personal opinions, share many personal issues, independently within the group and less likely to and ask personal questions of others to a degree engage in “groupthink.” that may be seen as offensive to those who come from a collectivistic culture. Direct, straightforward questioning with the expectation that 6.2.2 Collectivism answers will be direct is usually appreciated with individualism. Small talk before getting down to Collectivism is a moral, political, or social out- business is not always appreciated. However, the look that stresses human interdependence—it is healthcare provider should take cues from the important to be part of a collective. The individ- patient before this immediate, direct, and intru- ual is defined in terms of a reference group— sive approach is initiated. Individualistic cultures family, church, work, school, or some other usually tend to be more informal and frequently group. Collectivism can stifle individuality and use first names. Ask the patient by what name diversity leading to a common social identity she/he prefers to be called. Questions that require (Bui and Turnbull 2003; Greenfield et al. 2003; a “yes” or “no” answer are usually answered Hofstede and Hofstede 2005; Markus and truthfully from the patient’s perspective. In indi- Kitayama 1991; Triandis 2001). Some collectiv- vidualistic cultures with values on autonomy istic cultures include American Indian/Alaskan and productivity, one is expected to be a pro- Native and most indigenous populations, Asian ductive member of society (Purnell 2011, 2013; Indian, Chinese, Korean, Pakistani, Filipino, Singelis 1998). Some highly individualistic Japanese, Mexican, Spanish, and Taiwanese countries include Australia, Belgium, the United (Darwish and Huber 2003). States, Great Britain, England, Canada, Finland, Most collectivist cultures are high context Germany, Ireland, Israel, Great Britain, Finland, where implicit communication may be valued Luxembourg, Norway, the Netherlands, postcom- over explicit communication: the meaning is usu- munist Poland, Slovakia, South Africa, Sweden, ally embedded in the information, and the lis- and Switzerland, to name a few (Darwish and tener must “read between the lines” (Keeskes Huber 2003). 2016). Shame and guilt are strong, and the indi- Individualistic cultures expect all to follow the vidual must not do anything to cause shame to rules and hierarchical protocols, and each person self, the family, or the organization. Most believe is expected to do his/her own work and to work in the hierarchal structure, and one should not until the job is completed (Eshun and Hodge stand out in the crowd (Greenfield et al. 2003; 2014). In addition, children are often expected to Hofstede and Hofstede 2005; Markus and become responsible at a young age and have Kitayama 1991; Purnell 2011). To interrupt more independence and self-expression. another in a conversation is considered extremely However, in situations where the group makes rude. Sensitive issues that may cause a stigma to decisions, each member has an equal right to family or others are not revealed. express their opinions, and opinions can differ Time is more relaxed; punctuality is valued greatly, enhancing the chance the decision is bet- only in business and situations where it is essen- ter than what one person’s decision would be. tial such as in making transportation connections. The expectation is that all will follow the deci- Most value formality; therefore, always greet the sions made (Eshun and Hodge 2014). patient and family members formally until told to Individualistic cultures socialize (enculturate) do otherwise. In most traditional cultures, but not their members to view themselves as indepen- all, men have decision-making authority or are dent, separate, distinct individuals, where the the spokesperson for the family, even if they are 66 L. Purnell not the primary decision-maker. Gender roles are care provider and the patient, educational usually less fluid than in individualistic cultures; level, and health literacy can add to commu- however, expectations upon immigration may nication difficulties. Effective communica- cause significant family discord (Purnell and tion is the first and probably the most Pontious 2014). important aspect of obtaining an accurate health assessment (see this chapter). 3. Family Roles and Organization: Includes 6.3 Knowledge of Specific concepts related to the head of the house- Cultures Cared hold, gender roles (a product of biology and for in the Practice Setting culture), family goals and priorities, developmental tasks of children and adolescents, Whereas the individualistic and collectivistic roles of the aged and extended family, indi- framework is a good starting point for under- vidual and family social status in the commu- standing culture and a broad assessment guide, nity, and acceptance of alternative lifestyles providers need to obtain an understanding of the such as single parenting, same-sex partner- specific cultural and subcultural groups seen in ships and marriage, childless marriages, and their practice. Specific content of the groups divorce. should include the overview and heritage of the 4. Workforce Issues: Includes concepts related group, communication practices, family roles to autonomy, acculturation, assimilation, gen- and organization, workforce issues, biocultural der roles, ethnic communication styles, and ecology, high-risk health behaviors, nutrition, healthcare practices of the country of origin. pregnancy and the childbearing family, death rit- 5. Biocultural Ecology: Includes physical, bio- uals, spirituality and religion, healthcare prac- logical, and physiological variations among tices, and healthcare practitioners. A brief ethnic and racial groups such as skin color description of these concepts follows (Purnell (the most evident) and physical differences in 2013; Purnell and Fenkl 2018). body habitus; genetic, hereditary, endemic, and topographical diseases; psychological 1. Overview and Heritage: Includes concepts makeup of individuals; and the physiological related to the country of origin and current differences that affect the way drugs are residence and the effects of the topography metabolized by the body. In general, most dis- of the country of origin and the current resi- eases and illnesses can be divided into three dence on health, economics, politics, rea- categories: lifestyle, environment, and genet- sons for migration, educational status, and ics. Lifestyle causes include cultural practices occupations. and behaviors that can generally be controlled, 2. Communication: Includes concepts related for example, smoking, diet, and stress. to the dominant language, dialects, and the Environment causes refer to the external envi- contextual use of the language; paralanguage ronment (e.g., air and water pollution) and variations such as voice volume, tone, into- situations over which the individual has little nations, inflections, and willingness to share or no control (e.g., the presence of malarial thoughts and feelings; nonverbal communi- mosquitos, exposure to chemicals and pesti- cations such as eye contact, gesturing, facial cides, access to care, and associated diseases expressions, use of touch, body language, and illnesses). Genetic conditions are caused spatial distancing practices, and acceptable by genes. greetings; temporality in terms of past, pres- 6. High-Risk Health Behaviors: Includes sub- ent, and future orientation of worldview; stance use and misuse of tobacco, alcohol, clock versus social time; and the amount of and recreational drugs; lack of physical formality in use of names. Differences activity; increased calorie consumption; between the language spoken by the health- nonuse of safety measures such as seat belts, 6 Education and Training in Culturally Competent Care 67

helmets, and safe driving practices; and not formal education programs. In practice, each taking safety measures to prevent contract- organization can select the model or theory that ing HIV and sexually transmitted infections. they deem fits their needs. 7. Nutrition: Includes the meaning of food, Although some of these simplistic techniques common foods and rituals, nutritional defi- can be used for collecting initial interview data, ciencies and food limitations, and the use of they do not work well with all ethnic and cultural food for health promotion and wellness and groups nor are they comprehensive. Two exam- illness and disease prevention. Multiple dis- ples are acronymic approaches: LEARN and eases and illnesses are a consequence of this BATHE. The LEARN approach includes the fol- major cultural component. lowing guidelines: listen to your patients from 8. Pregnancy and Childbearing Practices: their perspectives; explain your concerns and Includes culturally sanctioned and unsanc- your reasons for asking for personal information; tioned fertility practices, views on preg- acknowledge your patients’ concerns; recom- nancy, and prescriptive, restrictive, and taboo mend a course of action; and negotiate a plan of practices related to pregnancy, birthing, and care that considers cultural norms and personal the postpartum period. lifestyles (Berlin and Fowkes 1983). The BATHE 9. Death Rituals: Includes how the individual acronym stands for background, information, and the society view death and euthanasia, affect [sic] the problem has on the patient, trouble rituals to prepare for death, burial practices, the problem causes for the patient, handling of and bereavement behaviors. Death rituals are the problem by the patient, and empathy con- slow to change. veyed by the healthcare provider (McCullough 10. Spirituality: Includes formal religious beliefs et al. 1998). related to faith and affiliation and the use of The limited space available here does not prayer, behavioral practices that give mean- permit an exhaustive description of the numer- ing to life, and individual sources of strength. ous models and theories centered on culture. A 11. Healthcare Practices: Includes the focus of brief description of the models most commonly healthcare (acute versus preventive); tra- used in practice, education, administration, and ditional, magico-religious, and biomedical research follows. beliefs and practices; individual responsibility The Campinha-Bacote Model is a practice for health; self-medicating practices; views on model focusing on the process of cultural compe- mental illness, chronicity, and rehabilitation; tence in the delivery of healthcare services. This acceptance of blood and blood products; and model, which is currently referred to as a volcano organ donation and transplantation. model, is used primarily in practice and educa- 12. Healthcare Practitioners: Includes the status, tion; it does not have an accompanying organiza- use, and perceptions of traditional, magico- tional framework. According to Transcultural religious, and biomedical healthcare provid- C.A.R.E. Associates (2015), individuals, as well ers and the gender of the healthcare provider. as organizations and institutions, begin the journey to cultural competence by first demonstrating an intrinsic motivation to engage in the process of 6.4 Cultural Theories cultural competence. The five concepts in this and Models for Patient model are cultural awareness, cultural knowledge, Assessment cultural skill, cultural encounter, and cultural desire (Transcultural C.A.R.E. Associates 2015). A number of cultural theories and models for The Giger and Davidhizar Model focuses on patient assessment have been developed. Some assessment and intervention from a transcultural are very extensive, while others are more general nursing perspective. The six areas of human in nature without a specific framework. All of diversity and variation include communication, these theories and models should be included in space, social orientation, time, environmental 68 L. Purnell control, and biological variations (Giger and or families adhere to their traditions. A traditional Davidhizar 2012). person observes his or her cultural traditions more The Papadopoulos, Tilki, and Taylor Model closely. A more acculturated individual’s practice focuses on the process of cultural competence in is less observant of traditional practices (Spector the delivery of healthcare services and is used 2009). in education, practice, and administration. This The cultural safety model includes actions model does not have an assessment guide or which recognize and respect the cultural identi- organizing framework. The four main compo- ties of others and safely meet their needs, expec- nents of this model are cultural awareness that tations, and rights. Strategies that enhance the includes an ethnohistory, cultural knowledge, ability to be culturally safe are (a) reflecting on cultural competence, and cultural sensitivity. one’s own culture, attitudes, and beliefs about The center of the model includes compassion “others”; (b) having clear, value-free, open, and (Papadopoulos 2006). respectful communication; (c) developing trust; Leininger’s Cultural Care: Diversity and (d) recognizing and avoiding stereotypical barri- Universality Theory and Sunrise Model pro- ers; (e) being prepared to engage with others in a mote understanding of both the universally two-way dialogue where knowledge is shared; (f) held and common understandings of care and understanding the influence of culture shock among humans and the culture-specific caring (Cultural Connections for Learning: Cultural beliefs and behaviors that define any particular Safety 2013). caring context or interaction. This theory incor- Cultural humility has three processes: (a) life- porates (a) care (caring); (b) generic, folk, or long commitment to self-evaluation and self-cri- indigenous care knowledge and practices; (c) tique, (b) a desire to fix power imbalances, and professional care knowledge and practices that (c) aspiring to develop partnerships with people vary transculturally; (d) worldview, language, and groups who advocate for others (American philosophy, religion, and spirituality; and (e) Psychological Association 2013). kinship, social, political, legal, educational, The Purnell Model for Cultural Competence economic, technological, ethnohistorical, and has been classified as a holographic and com- environmental contexts of cultures. Within a plexity theory because it includes a model and cultural care diversity and universality frame- organizing framework that can be used by all work, nurses may take any or all of three cul- health disciplines. The purposes of this model are turally congruent action modes: (a) cultural to (a) provide a framework for all healthcare pro- preservation/maintenance, (b) cultural care viders to learn concepts and characteristics of accommodation/negotiation, and (c) cultural culture; (b) define circumstances that affect a per- care repatterning/restructuring (McFarland and son’s cultural worldview in the context of histori- Wehbe-Alamah 2015). cal perspectives; (c) provide a model that links Spector’s HEALTH Traditions Model incorpo- the most central relationships of culture; (d) rates three main theories: Estes and Zitzow’s heri- interrelate characteristics of culture to promote tage consistency theory, the HEALTH Traditions congruence and to facilitate the delivery of con- Model, and Giger and Davidhizar’s theory about sciously sensitive and competent healthcare; (e) the cultural phenomena affecting health. The provide a framework that reflects human charac- HEALTH Traditions Model is based on the con- teristics such as motivation, intentionality, and cept of holistic health and explores what people do meaning and provide a structure for analyzing to maintain, protect, or restore health. This model cultural data; and (f) view the individual, family, emphasizes the interrelationship between physi- or group within their unique ethnocultural envi- cal, mental, and spiritual health with personal ronment (Purnell and Fenkl 2018) (see methods of maintaining, protecting, and restoring Appendices 1 and 2). health. Spector also provides a heritage assessment tool to determine the degree to which people 6 Education and Training in Culturally Competent Care 69

6.5 Interdisciplinary Practice be addressed at the department level as well as each unit within a department. Administrators Cultural competence is a requisite for all profes- and managers, whether in direct or indirect care, sionals who have direct or indirect contact with must role model cultural competence and work patients. Most cultural concepts, knowledge, and with national and community organizations to practice skills are shared by all health disciplines, ensure that patients’ needs are being met. They making cultural competence a requirement for all. should also seek positions and be involved on For example, cross-cultural communication prin- community and national boards. ciples do not change for direct care professionals, Staff should be provided with unit-written auxiliary staff, or administrative personnel. resources and partner with universities for online Workshops and conferences should include multi- resources that all staff can access. In addition, disciplinary professionals where personal cultural administration can support and host workshops stories can be shared. and conferences as effective approaches to culturally congruent nursing practice. Hosting community health fairs with ethnic community 6.6 Recommendations organizations that support vulnerable populations adds value to the organization’s mission. Recommendations for clinical practice, administration, education, and research follow. 6.6.3 Recommendations for Education 6.6.1 Recommendations for Clinical Practice In the academic setting, all the concepts included in Chap. 2, knowledge of cultures, should be Staff at all levels should attend continuing educa- included. The preference is to have a separate tion classes, in-services, conferences, and other course on culture that includes both cultural gen- learning experiences to maintain cross-cultural eral as well as cultural specific information in skills. Upon admission, professional staff need to every course and include the use of complemen- use a comprehensive cultural assessment tool that tary and alternative practices. What might be can be added to as time and circumstances permit complementary and alternative in one culture (see this chapter). The assessment should include may be mainstream health care in other the patient’s cultural and ethnic background as cultures. well as familiar genetic and hereditary health The curriculum must include content on vul- conditions. The assessment needs to include not nerable populations, socioeconomics, and cul- just current work environment but previous work tural general information on the populations in as well. In addition, the work history needs to be clinical areas that also stress the importance of completed for patients who are retired. individual cultural values and beliefs. Culture Environmental living arrangements are included needs to also be integrated throughout all in an assessment. courses such as pathophysiology, pharmacology, and simulation labs and clinical courses. If a specific cultural course is not feasible, main- 6.6.2 Recommendations tain a system that assures cultural content is for Administration included in all courses so that cultural content is not lost. Organizational administration has the prime In the service setting, cultural content needs to responsibility to assure that culturally competent be addressed in orientation with annual in-ser- care is delivered throughout the organization. vice training in cultural competence for all levels The organization’s mission and philosophy must of staff including management, other profession- 70 L. Purnell als, and auxiliary staff in any department with be used in quality improvement projects or to patient contact. Classes to increase staff’s cultural conduct research. knowledge about the ethnically diverse patients who receive health services in the facility should Conclusion be conducted and reinforced in the organization’s Cultural competence has become one of the intranet with population health beliefs and values. most important initiatives worldwide for a Educators should mentor staff for whom the number of reasons. Diversity has increased in dominant language is not the same as the many countries due to wars, political strife, patient’s for sociopragmatic competence specific world socioeconomic conditions, and to the medical setting (Sedgwick and Garner migration. In addition, the last few decades 2017). A variety of modalities to teach cultural have demonstrated that culturally congruent competency can include workshops, conferences, care increases patient satisfaction, improves online training, films, and immersion experiences patient care, and reduces cost. The recognition whether in diverse communities, in the home of the social determinants of health with environment, or in other countries. Faculty vulnerable populations (see Chap. 1) has been should partner with transcultural experts to a focus to help alleviate heath disparities. provide staff with continuing education courses, Therefore, a requisite is to include culturally consultation, and practice skills for culturally competent education in formal health-related competent care. programs and continue the process where the organization includes cultural competence during orientation and yearly thereafter. 6.6.4 Recommendations Cultural competence education and training for Research are for all healthcare providers, including those who encounter diverse patients and Journal clubs can be established to review cur- families even though they may not be direct rent scholarly evidence-based literature on the care providers. populations served by the organization and Formal education must include content on should be instituted and offered at times that the various models and approaches to learn clinical staff can attend. Consultants from local culture and provide a stand-alone course on university and college faculty can be employed culture if possible and then integrate culture to facilitate implementation of evidence-based in every theory and clinical course. If a cross-cultural practice. Staff wanting to separate stand-alone course is not possible, conduct research can partner with local faculty the education organization needs to keep a for expertise in the research process and study tracking system to assure that culture design. is included in every course. Cultural An interdisciplinary team of researchers and competence is required for the organization educators can collaborate on quality and the individual provider. The American improvement projects and to apply for funding. Association of Colleges of Nursing; the Initial research should be on ethnic/cultural Office of Minority Health in the United groups common to the organization. Although it States, Australia, and New Zealand; Royal might not be possible to translate satisfaction College of Nursing; American Medical surveys in all the patients’ languages served by Association; National Medical Association; the organization, at least they should be International Council of Nursing; and the translated into the most common languages of American Nurses Association have all patients; otherwise, only part of the data is recognized the importance of culturally com- collected. The results of satisfaction served can petent education. 6 Education and Training in Culturally Competent Care 71

Appendix 1: Recommended courses. Some essential terms and concepts Content for Beginning Level are collectivism, individualism, and individ- Cultural Competency Education uality; cultural awareness, sensitivity, competence, and congruency; cultural imposition, Beginning level includes vocational or practical relativism, and imperialism; cultural assimi- nursing programs, associate degree and diploma lation and accommodation, ethnocentrism, programs, and continuing education and in-ser- and stereotyping versus generalizing; indi- vice programs. The cultural content can be pro- vidual and organizational cultural compe- vided in a separate course as well as integrated tence; interpretation versus translation; and into existing clinical curriculum. Modules of key ethnicity and subculture. concepts can be developed to provide for the 6. Biocultural variations should be incorpo- greatest flexibility of presentation of this mate- rated into anatomy and physiology and rial. Key concepts that need to be integrated pathophysiology and reinforced in clinical follow. courses. 7. Genetic and hereditary diseases should be included in pathophysiology courses and Overall Program Objectives Related reinforced in all clinical courses. to Culture 8. Common illnesses and diseases in cultural and ethnic groups should be included in Develop cultural assessment skills of self and pathophysiology and reinforced in clinical others (individuals and families): courses. 9. Dietary practices that include prescriptive, 1. Identify cultural similarities and differences restrictive, and taboo practices of specific and potential approaches to differences. cultural and ethnic groups should be included 2. Use culture-related resources available for in all clinical courses. potential problems. 10. Health belief systems and complementary 3. Recognize forms of discrimination in nursing and alternative practices can be incorporated care and take action to prevent or address in pharmacology and/or assessment and them. reinforced in all clinical settings.

Content Related to Culture Appendix 2: Recommended Content for Advanced-Level 1. Effective communication is essential for Cultural Competency Education healthcare practice at all levels. A sample communication exercise is included (see Components of culture should be integrated into Appendix 2 Chap. 14). courses such as health assessment, pharmacology, 2. Culturally congruent care should be inte- anatomy and physiology, and all specialty clinical grated as a component of every clinical courses. Communication strategies beginning course. with assessing the client’s preferred language and 3. Social and material determinants of health health literacy along with spatial distancing, eye should be included in theory courses and contact, greetings, temporality, touch, and name reinforced in clinical courses. format are essential. Interpretation and translation 4. Cultural patterns and values of select cultural that include sign languages are also essential and ethnic or subcultural groups should be components of communication (see Chap. 14). In included in theory courses and reinforced in a pharmacology course, the racial/cultural differ- clinical courses. ence in response to drugs should be included. In 5. Common cultural terms should be included physiology and pathophysiology courses, the bio- in theory courses and reinforced in clinical cultural aspects of diseases should be included as 72 L. Purnell well as the biocultural variations in pain, height, 4. Evaluate the socioeconomic impact of cli- weight, musculoskeletal variations, and physical ent’s cultural needs upon levels of care: pri- appearances in general. mary, secondary, and tertiary The following is a sample stand-alone course 5. Articulate theory, research methods, and recommended for senior healthcare practitioners, advanced multicultural-sensitive nursing nurse practitioners, and masters and doctoral practice concepts level students. Cultural case studies should be 6. Formulate a model of care integrating cultur- included in all courses with content appropriate ally sensitive assessment, planning, interven- for the course. In addition, resources for teaching tion, and evaluation culture are included. 7. Analyze impact of public and organizational policies on health of individuals and populations 8. Develop collaborative engagement with indi- Course Description viduals and groups to mitigate health inequity Components of this course can be used in in- 9. Promote engagement of individuals, groups, service and continuing education classes as and organizations in health promotion for deemed relevant or pertinent by the organiza- disadvantaged populations tion. A comprehensive course should include 10. Develop cross-cultural leadership to promote theories and models focused on culture, social culturally competent care and retention of and material determinants of health, health dis- multicultural workforce parities, selected culturally specific groups commonly found in the catchment area of the school or organization, and common research method- Possible Teaching Strategies ologies used in cultural research. Evidence-based practice must be incorporated in discussions and PowerPoint lectures formal scholarly papers (see Chap. 30). Students Live classroom or online discussions of cul- will critically reflect on their own cultural beliefs tural, ethnic, or subcultural groups and values. Assignments should include group Required and recommended readings deter- discussions on cultural and religious groups with mined by the faculty teaching the course an application to nursing practice. A formal team Recommended Web sites paper with four to six students is recommended because it increases learning knowledge. The team paper should be on a cultural or subcultural Topical Outline group different from anyone on the team. A. Introduction to culture and related concepts 1. Values and culture Suggested Course Objectives 2. Vulnerability as a framework 3. Expanding definitions of cultural groups Upon completion of this course, the student will and underserved populations be able to: 4. Review of common cultural terms: collectivism, individualism and individuality; cul- 1. Articulate the concepts that explain cultural tural awareness, sensitivity, competence and diversity and their relevance for nursing congruency; cultural imposition, relativism, practice and imperialism; cultural assimilation and 2. Examine cultural issues and trends in nurs- accommodation, ethnocentrism, stereotyping practice ing, and generalizing; individual and organi- 3. Analyze selected population group cultural zational cultural competence; interpretation patterns and behavioral manifestations of versus translation; and ethnicity and cultural values subculture. 6 Education and Training in Culturally Competent Care 73

B. Selected theoretical models for nursing • Biocultural ecology practice • High-risk health behaviors 1. Andrews and Boyle Assessment Guide • Nutrition and the meaning of food 2. Campinha-Bacote’s Model The Process of • Pregnancy and the childbearing family Cultural Competence in the Delivery of • Death and dying rituals Healthcare Services • Spirituality and religion 3. Giger and Davidhizar Transcultural • Healthcare practices including comple- Assessment Model mentary and alternative practices 4. Leininger’s Culture Care Diversity and 2. In a team paper, each team should have no Universality Theory more than four to six members. 5. Jeffrey’s Cultural Competence and 3. Most references should come from the last Confidence (CCC) Model: Transcultural 6 years, although classic references are Self-Efficiency acceptable. 6. Papadopoulos, Tilki, and Taylor Model for 4. Most of the references should come from the Developing Culturally Competent and research literature. Internet sources are accept- Compassionate Healthcare able as long as they come from governmental 7. Purnell Model for Cultural Competence organizations, universities, or professional 8. Schim, Dorenbos, Benkert, and Miller associations and organizations. Wikipedia is Dimensional Puzzle Model of Culturally not an acceptable reference because content Competent Care has not been refereed. Blogs and travel sites C. Managing health disparities through cultur- are not acceptable. ally competent research 5. Once the literature review is completed, create 1. Minorities, migrants, and refugees a list of at least four recommendations for 2. Health disparities in the catchment area research based on gaps in the literature. The where students do clinical research questions must be something that a D. Cultural patterns and values of select cultural graduate student can accomplish. For each and ethnic, or subcultural groups: Hispanic/ question, identify if the research is qualitative Latino, Arab/Muslim, Jewish, Haitian, Lesbian or quantitative research, the specific method- Gay Bisexual Transgender, Alcoholics ology (phenomenology, grounded theory, cor- Anonymous, and/or others. Some should come relational, quasi-experimental, etc.), and a from the catchment area where the students brief description of the methods to carry out practice and at least one that is not common this research. among the community to give the course a 6. Identify applications to practice. Be specific, global perspective. not something general that would be the same for any cultural group.

Scholarly Formal Paper on a Specific Cultural, Ethnic, or Subcultural Group Resources for Advanced Courses in Cultural Competency Education

1. Conduct a literature review on four domains • American Association of Colleges of Nursing. of a cultural, ethnic, or subcultural group dif- (2017). Essentials of Baccalaureate and ferent from your own culture. The domains Graduate Education in Nursing. Available at for the literature review can include: http://www.aacnnursing.org/. [Accessed 7 • Heritage overview (as the introduction) December 2017]. • Communication • Andrews, M.M., and Boyle, J.S. (2016). • Family roles and organization Transcultural concepts and nursing care • Workforce issues (7ed.). Philadelphia, Wolters Kluwer. 74 L. Purnell

• Campinha-Bacote, J. Transcultural C.A.R.E. • Transcultural Nursing Society. Available at Associates. Available at http://transcultural- http://www.tcns.org/. [Accessed 7 December care.net/the-process-of-cultural-competence- 2017]. in-the-delivery-of-healthcare-services/. • United Nations Millennium Development [Accessed 7 December 2017]. Goals. (n.d.). Available at http://www.un.org/ • Douglas, M. and Pacquiao, D. (2010). Core millenniumgoals/. [Accessed 7 December, Curriculum for Transcultural Nursing and 2017]. Health Care. Sage Publications. http://www. • U.S. Department of Health and Human tcns.org/TCNCoreCurriculum.html. Services Office of Minority Health, (n.d.). [Accessed 7 December, 2017]. National CLAS Standards. Available at https:// • CIA World Factbook. Available at http://ruby- minorityhealth.hhs.gov/omh/browse. worldfactbook.com/, [Accessed 7 December, aspx?lvl=2&lvlid=53. [Accessed 7 2017]. December 2017]. • Giger, J., and Davidhizar, R. (eds.) (2012). Transcultural nursing: assessment and intervention (3rd. ed.). Philadelphia, PA: References Elsevier. • Jeffreys, M.R. (2010). Teaching cultural com- American Psychological Association (2013) Reflections petence in nursing and health care. NY: on cultural humility. http://www.apa.org/pi/families/ Springer. resources/newsletter/2013/08/cultural-humility.aspx. Accessed 29 July 2017 • European Transcultural Nursing Society. Berlin EA, Fowkes WC (1983) A teaching framework for Available at http://europeantransculturalnurses. cross-cultural health care: application in family prac- eu/. [Accessed 7 December 2017]. tice. West J Med 139(12):93–98 • McFarland, M and Wehbe-Alamah, HB. Bui Y, Turnbull A (2003) East meets west: analysis of person-centered planning in the context of Asian (eds). (2015). Leininger’s culture care American values. Educ Train Ment Retard Dev Disabil diversity and universality: a worldwide 38:18–31 nursing theory, (3e). Burlington, ME: Jones & Cultural Connections for Learning: Cultural Safety Bartlett Learning. (2013) http://www.intstudentsup.org/diversity/cul- tural_safety/. Accessed 29 July 2017 • Papadopoulos, Tilki, and Taylor Model for Darwish AFE, Huber GU (2003) Individualism vs col- Developing Culturally Competent and lectivism in different cultures: a cross-cultural study. Compassionate Healthcare. Available at Intercult Educ 14(1):48–55 http://cultureandcompassion.com/what-is- Douglas M, Rosenketter M, Pacquiao D, Clark Callister L et al (2014) Guidelines for implementing culturally culturally-competent-compassion-2/, competent nursing care. J Transcult Nurs 25(2):109–221 [Accessed 7 December 2017]. Eshun S, Hodge D (2014) Mental health assessment • Purnell, L. (2013). Transcultural health care: among ethnic minorities in the United States. In: a culturally competent approach. Philadelphia: Gurung RAR (ed) Multicultural approaches to health and wellness in America, vol 1. Praeger, Santa Barbara F.A. Davis. George RE, Thornicroft G, Dogra N (2015) Research • Sagar, P. (2014). Transcultural nursing educa- paper: exploration of cultural competency training in tion strategies. NY: Springer Publishing UK healthcare settings: a critical interpretive review Company. of the literature. Divers Equal Health Care 12(3): 104–115 • Schim, Dorenbos, Benkert, & Miller, (2007). Giger J, Davidhizar R (eds) (2012) Transcultural nurs- Dimensional Puzzle Model of Culturally ing: assessment and intervention, 3rd edn. Elsevier, Competent Care Available at http://europepmc. Philadelphia org/articles/PMC3074191. [Accessed 7 Greenfield P, Trunbull E, Rothstein-Fisch C (2003) Bridging cultures. Cult Psychol Bull 37:6–16 December 2017]. 6 Education and Training in Culturally Competent Care 75

Hofstede G (ed) (2001) Culture’s consequences: comparing Purnell L, Pontious S (2014) Collectivist and individual- values, behaviors, institutions, and organizations across istic approaches to cultural health care. In: Gurung R nations, 2nd edn. Sage, Thousand Oaks (ed) Multicultural approaches to health and wellness Hofstede G, Hofstede J (eds) (2005) Cultures and organi- in America, vol 1. ABC-CLIO-LLC, Santa Barbara zations: software of the mind, 2nd edn. McGraw-Hill, Rothstein-Fisch C, Greenfield P, Quiroz B (2001) New York Continuum of individualistic and collectivistic values. Keeskes I (2016) Can intercultural pragmatics bring some National Center on Secondary Education. http://www. new insight into pragmatic theories? In: Capone A, ncset.org/publications/essentialtools/diversity/partIII. Mey JL (eds) Interdisciplinary studies in pragmatics, asp. Accessed 29 July 2017 culture and society. Springer, New York Sagar P (2014) Transcultural concepts in adult health Markus HR, Kitayama S (1991) Culture and the self: courses. In: Sagar P (ed) Transcultural nursing edu- implications for cognition, emotion, and motivation. cation strategies. Springer Publishing Co. LLC., Psychol Rev 98:224–253 Philadelphia McCullough J, Ramesar S, Peterson H (1998) Sedgwick C, Garner M (2017) How appropriate are the Psychotherapy in primary care: the BATHE technique. English language test requirements for non-UK- Am Fam Physician 57(9):2131–2134. http://www. trained nurses? A qualitative study of spoken commu- aafp.org/afp/980501ap/mcculloc.html. Accessed 29 nication in UK hospitals. Int J Nurs Stud 71:50–59. July 2017 https://doi.org/10.1016/j.ijnurstu.2017.03.002 McFarland M, Wehbe-Alamah HB (eds) (2015) Singelis TM (1998) Teaching about culture, ethnicity, and Leininger’s culture care diversity and universality: a diversity. Sage Publications, Thousand Oakes worldwide nursing theory, 3rd edn. Jones & Bartlett Spector R (2009) Cultural diversity in health and ill- Learning, Burlington ness, 7th edn. Pearson Prentice Hall, Upper Saddle Papadopoulos I (2006) Transcultural health and social River care: development of culturally competent practitio- The Joint Commission (2010) Advancing effective com- ners. Churchill Livingstone, London munication, cultural competence, and patient- and Purnell L (2010) Cultural rituals in health and nursing family-centered care: a roadmap for hospitals. The care. In: Esterhuizen P, Kuchert A (eds) Diversiteit Joint Commission, Oakbrook Terrace. https://www. in de verpleeg-kunde [Diversity in nursing]. The jointcommission.org/topics/health_equity.aspx. Netherlands, Springer Utigeverij Accessed 9 Sept 2017 Purnell L (2011) Application of transcultural theory to The Joint Commission International (2011) Patients mental health-substance use in an international con- beyond Borders. http://www.patientsbeyondborders. text. In: Cooper D (ed) Intervention in mental health- com/about/accreditation-agency/joint-commission- substance use. CRC Press, Boca Raton international. Accessed 29 July 2017 Purnell L (ed) (2013) Transcultural health care: a cultur- Transcultural C.A.R.E. Associates (2015) http://www. ally competent approach. F.A. Davis, Philadelphia transculturalcare.net. Accessed 29 July 2017 Purnell L, Fenkl E (eds) (2018) Guide to culturally com- Triandis H (2001) Individualism-collectivism and person- petent health care. F.A. Davis, Philadelphia ality. J Pers 69(6):907–924 Case Study: Traditional Health Beliefs of Arabic Culture During 7 Pregnancy

Jehad O. Halabi

Muna is 37 years old. She is 5 months pregnant Huda: “Why did you become pregnant? You and has insulin-dependent diabetes mellitus, have diabetes, hypertension, and anemia. Your hypertension, and anemia. She has four children; last baby is about 7 months old, and you can two were born by cesarean section. The house- hardly afford your family’s expenses.” hold income is equivalent to US $150 per month, Muna: “My husband refuses to let me use any and she lives in a rural area with her in-laws. family planning method. He wants a large family. Muna completed her education until sixth grade He thought that the children might support him and then left school because it was far from her when he gets older. Do you want my husband to home. She married at the age of 16 to Ali who is marry another woman?” 50 years old and employed in a cement factory. Huda: “What about Ali’s diabetes and hyper- He also has insulin-dependent diabetes mellitus tension? We discussed these conditions in our and hypertension, and he is a heavy smoker. class today. Is he still smoking heavily?” Muna is his second wife. Muna’s cousin, Huda, is Muna: “His sugar level and blood pressure are a nursing student. One day, Huda visited Muna always high.” and had the following discussion. Huda: “How about your sugar and blood Huda: (Knocks on the door.) pressure?” Muna: “Whose there?” Muna: “They are high too.” Huda: “This is your cousin Huda.” Huda: “Aren’t you following the treatments as Muna: (Kissing her) “Welcome, I haven’t seen you should?” you for a long time. I miss you. Come in for Muna: “Sometimes I do. You know it is hard coffee.” to afford insulin. It is expensive. We borrow some Huda: “Oh, are you pregnant again?” medicine from our neighbors. They told us that it Muna: (Laughing and saying) “Yeah. I’m works well. We tried different kinds of herbs. My 5 months pregnant because my husband likes mother gave me this blue stone to put around my children.” neck to prevent others’ envy to affect my health.” Huda: “Oh Muna, this is nonsense. Yesterday I called my mother to ask about your health. I was surprised that she doesn’t know that you J. O. Halabi, Ph.D., R.N., T.N.S. have diabetes and high blood pressure. You said College of Nursing, King Saud bin Abdulaziz that even your husband doesn’t know?” University of Health Sciences—National Guard, Muna: Shouting at Huda. “Did you tell her Al Ahsa, Kingdom of Saudi Arabia e-mail: [email protected], [email protected] that we both have diabetes?”

© Springer International Publishing AG, part of Springer Nature 2018 77 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_7 78 J. O. Halabi

Huda: “Why are you angry? Is it a shame that diet and exercise. Did you follow my anybody knows this?” suggestions?” Muna: “Yes. I have a daughter, who is 14, and Huda: “I think she doesn’t follow any of your she is at the age of getting married. I am afraid suggestions.” that nobody will ask to marry her. You know peo- Muna: “How do you expect me to follow ple think diabetes is a hereditary disease. You for- your suggestions with this hard life? How can I get this, but you belong to our culture.” cook special food for myself while I have large Huda: “But you believe in Allah. You told me family, and they can see what I eat? I also can’t before that having pain, sickness, and illness is a afford it. You want me to exercise and walk means of guaranteeing physical and psychologi- around in the street where people can observe cal peace. You said it removes your sins and helps me! How can I do that? What will they say about you go to paradise. Oh God! How do I solve this me?” conflict! Am I a bad nursing student?” Nurse: “I don’t understand what you mean. I Muna: “I agree with you. I try to do what you assume that everybody can do that if they want told me, but you should ask me first if I want any- to. Do you follow the 2500 calorie diet that I gave body to know that I have diabetes. Do you want you? I noted at the clinic that your weight is to drink tea?” increasing.” (They continue their conversation while drink- Muna: “Yes I follow exactly the 2500 g you ing tea.) told me about.” Huda: “Where do you think you will deliver Nurse: “Can you show me how you follow it the baby?” and do the calculations?” Muna: “Maybe at home.” Muna: “Here is the scale I bought from the Huda: “I forgot to tell you that a nurse will grocery shop. I put the food on the scale up to come to visit you. I saw her at the clinic. She was 2500 g, and then I eat it. I do that all the time asking people for directions to your house.” since you told me.” (The nurse knocks on the door.) Nurse: “My God, you don’t understand. I said Nurse: “Good morning Muna.” 2500 calories not grams. You are...” Muna: “Good morning Nurse. The tea is still Muna: “Nurse, I don’t understand. You are warm. Come in. This is my cousin Huda. She is a shouting at me, and at the clinic the doctor asked nursing student.” me why I continue to look like a cow. What is Nurse: “How are you Muna? How do you feel this? I don’t want your help; leave me alone.” today?” Huda: “You know. She also borrows medica- Muna: “Well, I’m ok. Don’t worry about me. I tions from her neighbors.” can take care of myself. But how did you find my Nurse: “You borrow medication? Why?” home?” Muna: “Well, all medications are the same. Nurse: “Muna, I asked the neighbors and peo- We all share medications with one another. At the ple in the street about the diabetic woman who end, God controls everything, and it is in His lives here. It wasn’t easy to find you; it seems that hands. Why bother? Take it easy and forget it. I they don’t know you have diabetes.” have been doing that for a long time. You never Muna: “My God! Why you tell everybody? asked me about that.” Both of you put me in trouble. What should I do? Nurse: “I don’t want to force you to do things. This is a disaster. My husband doesn’t know I You know God’s order to take care of ourselves. have diabetes. What if he found out? What if he We will talk about it later. Can we just talk about left me? What if nobody marries my daughters?” the plan for this visit?” Crying… Muna: “Can you tell me why you came here Nurse: “I came here to follow up on your for this visit. What brought you here? After all, treatment plan. Why did you miss your last clinic you exposed my secret to everybody. What do appointment? I told you about the importance of you want?” 7 Case Study: Traditional Health Beliefs of Arabic Culture During Pregnancy 79

Nurse: “I want to talk to you about your health. abdomen to let her uterus return to its normal Do you have any concerns?” position. She should also eat lots of meat and Muna: “I suffer from heartburn, and some- chicken every day. She should eat enough for two body told me that it is due to the hair of the baby. people, not just one.” I was told not to drink cinnamon because it initi- Nurse: “Really! What about her baby Muna? ates contractions and not to sleep with my hus- Did you tell her anything special?” band because it affects the baby’s development. Muna: “I told her many things! Like, she They also told me not to take a warm bath because should put kuhl/kohl around his eyes to make it affects the baby’s movement. I heard that I them look bigger. And wrap him tightly with a should eat whatever I desire so that the baby will sheet to let him grow taller and to help him sleep not have any birthmarks on his body. I have to better. She should put salt and oil on his body and avoid drinking too much water to minimize going leave it on for 10 hours in order to make his skin to the bathroom often.” softer. She should also put some Arabic coffee or Nurse: “You have misinformation (misunder- kohl on his umbilicus to promote healing.” standing) about certain issues, especially changes Nurse: “Oh Muna, how can you tell her these related to pregnancy. This pamphlet will give you things? These practices are crazy and unhealthy. more information. I will visit you next Monday at Here is a pamphlet with suggestions from health 10 am.” professionals. I should tell your doctor what you Huda: “So this is how difficult patients will be are doing so he can arrange to have an open dis- when I graduate from nursing. I am leaving now.” cussion with you about these things next week.” (The nurse and Muna continue to talk.) Muna: “Nurse, you think that I can read these Muna: “Ok nurse, please don’t go now. I have things! You always give me papers to read. But I things to say but I couldn’t say them in Huda’s can arrange with my neighbors to attend this dis- presence.” cussion with me. They can help me understand.” Nurse: “We can talk about it next time.” Nurse: “Oh, yes. Good, you women in the Muna: “Let’s visit my neighbor Sawsan. She countryside understand each other very well. had her first baby boy.” How about if you all come to the health center (Muna and the nurse knocked on Sawsan’s and have this open discussion there with other door.) women like yourself?” Muna: “Hello Sawsan, I have the nurse with Muna: “We will meet there if we can. We will me (shakes her hand). I want her to see how good have to ask our husbands’ permission and then let I am. Do you follow what I told you to do after you know.” the delivery?” Nurse: “Why ask your husband? You should Sawsan: “Oh, I did everything you told me to make more decisions independently. Don’t be do.” ‘weak’ women. I don’t understand you. You can’t Nurse: “What have you told her to do?” even make a small decision like this. I’m leaving Muna: “She should stay in bed for 40 days and now.” should avoid getting close to her husband till the Muna and Sawsan: “Are we small children? I end of 40 days, not taking a shower, not drinking thought we are grown up women. We are nothing lemon, and not letting anybody enter her room as you see.” while she has her menses because this will affect Nurse: “Bye, Salam-Alaikum.” her milk. Wait until after the third day of delivery to start breastfeeding because it isn’t healthy for the baby. Don’t use any family planning method 7.1 Cultural Issues because that could lead to becoming barren. Don’t let anybody see her baby until she puts the The patient is a middle-aged rural pregnant blue stone around his neck (to ward off envy). I woman with limited formal education and has also told her she should wrap a belt around her diabetes mellitus, hypertension, and anemia. Her 80 J. O. Halabi illnesses were unknown to her husband, relatives, not explored the subculture and worldview of and neighbors. These diseases are disorders char- this rural patient. The nurse and the nursing stu- acterized by chronicity and predispose the person dent were not effective in understanding the to an increased risk of complications. They have patient’s concerns. The patient tried to express an impact on the mother and baby, resulting in a her thoughts and beliefs to the nurse, assuming high-risk pregnancy. The risks are higher due to that they would understand her. They were not nonadherence with medication. effective. This patient is unable to afford the medica- Communication with the patient was limited tions due to her low socioeconomic status. She to providing her with written instructions in the shares and borrows medications. Like many rural form of a pamphlet. The assumption was that the women, she uses traditional herbs. This can lead patient would be able to figure out, on her own, to psychosocial problems or complications with the misconceptions and questionable practices. prescriptive medications (Cleveland Clinic The nurse assumed that the patient could read 2017). and understand the pamphlets. She failed to The patient has cultural beliefs and percep- assess the educational and background level of tions about health and practices that could put her the patient to make sure she could read and ben- at risk. She hides diabetes from others because efit from such material. she believes that it is shameful. It could cause The nurse criticized the patient and accused negative perceptions by her neighbors and lead to her of being crazy because she was following unacceptance. The client fears marriage insecu- potentially unhealthy practices for the mother rity and failure. She had multiple pregnancies and the baby. She labeled the client by stating and avoided family planning to stay secure. In “rural women understand each other.” addition, she used traditional treatments and The nurse accused the patient of being a weak amulets for protection and ward off envy. These woman who could not make a small decision on perceptions need to be carefully assessed and her own. The patient felt belittled and that she considered in planning health care for this client. was being treated like “a small child.” The patient The patient has misinformation about preg- recognized that the nurse was talking to them in a nancy and postpartum care. She follows several condescending way (inferiorly). cultural practices that are based on traditional beliefs and perceptions. Women exchange these ideas through their social interactions with oth- 7.2 Culturally Competent ers, including their neighbors. Strategies Recommended The patient indicated the necessity of asking her husband about attending the clinic and Pregnant women are at an increased risk for expressed that any such activities are needed to health problems. Rural women from Arabic cul- be discussed with the spouse ahead of time. She tures are particularly at risk of health problems is not allowed to make a decision on her own. due to multiple pregnancies and increased inci- The nurse, a role model, and the nursing stu- dence of chronic health problems such as diabe- dent have their assumptions about this client. tes, hypertension, and anemia. Their health Insufficient assessment and awareness of the cli- beliefs and practices might be of special concern ent’s beliefs were judgmental and lacked respect. to nurses because they are disrespected or The nurse followed the medical model ideas and unrecognized. assumed that her scientifically based advice Health is highly individual and influenced would be followed. She bombarded the patient by everything with whom clients interact, with information learned in college without including their internal and external environ- incorporating the patient’s personal and cultural ment (WHO 2006). Values are transmitted from values and beliefs. Even though they both are and influenced by their sociocultural traditions from the same cultural background, they have and environment (Berman et al. 2016). Patients’ 7 Case Study: Traditional Health Beliefs of Arabic Culture During Pregnancy 81 cultural beliefs and values are reflected in their • Provide opportunities for nursing students to behaviors and practices. These cannot be judged come in contact with patients from a variety of as right or wrong by nurses who have differing cultural and ethnic groups where possible. values from that of their clients. Rather, values • Encourage participation of nurses and nursing and beliefs need to be examined and clarified students in various activities that aim to using a caring process of values clarification. increase their cultural skills such as seminars, workshops, conferences, online material, and exchange opportunities if available (Gebru 7.2.1 Individual and Family Level and Willman 2010; Mager and Grossman Recommendations 2013) and global learning experiences (Jones et al. 2010). • Remain objective without conveying approval • Provide certified programs or certified cultural or disapproval to avoid biases and misconcep- classes/courses through known cultural soci- tions that may lead to cultural imposition and eties and/or experts from different cultures. force personal values and beliefs on other cul- • Incorporate cultural assessment tools (Purnell tures and subcultures (Miller-Keane 2003). 2014; Purnell and Finkl 2017) as part of health • Promote behavioral changes through educa- records and care plans for patients. tion and practice. • Conduct research studies to assess students • Respect patients’ different values and beliefs. and nurses’ cultural competence in order to Learn about clients’ values, beliefs, norms, plan action plans and programs. customs, and practices to develop culturally congruent practice. • Search for information about the culture of 7.2.3 Community Societal Level patients. Recommendations • Be committed to respecting the principal values of any culture and avoid voicing disagree- • Collect information about cultural and ment with values that can create conflicting sociodemographic data of patients from dif- situations. ferent cultures (such as Arab and rural com- • Accept differing nonharmful values, beliefs, munities) as well as the health beliefs and and perceptions among different cultures as norms related to health, illness, and care. well as within cultures (Ludwick and Silva • Understand that health decisions are not nec- 2000). essarily made by one individual. In some cul- • Assess beliefs within a cultural context. tures, patients have to include their families, relatives, community, and even society in simple decisions. 7.2.2 Organizational Level • Explore how to incorporate cultural sensitivity Interventions into nursing care. Do not assume that a non- Western (e.g., Arab) patient can have full con- • Incorporate cultural care and related concepts in trol over health decisions as in Western the curriculum and provide learning experi- culture. These decisions are usually made by ences for nursing students at all levels. somebody else, such as the head of the family Incorporate role-playing and drama using real or the elder person and, therefore, should be case scenarios and situations from different respected as part of their traditions (Berman cultures. et al. 2012). • Establish continuing education programs and • Recognize that even when people are from the in-service training activities for nurses to same culture, there are diversity and variation update their cultural knowledge and compe- within the group (e.g., rural vs. urban). For tence with different cultural groups. example, the Arab regions extend across 23 82 J. O. Halabi

countries who share similar language and tra- marriage and concern for children’s future. ditions; however, each region has its own spe- The fear of stigmatization limits patients’ cific practices (Berman et al. 2012; Muliira interactions with people and the ability to dis- and Muliira 2013; Nies and McEwan 2007). close health situation to others such as close • Provide culturally sensitive care and avoid ste- family and husband. reotyping clients and focus on differences as Furthermore, financial limitations as well well as similarities (Leininger 1991, 2002). as knowledge deficits hinder the patient’s • Recognize that the cognitive aspects of spe- compliance with treatment standards and cific cultural groups can lead to stereotyping evidence-based practice. An inability to instead of identifying the unique needs of the make an autonomous decision is evident due patient (Williamsona and Harrison 2010). to family’s cultural interaction system. The • Cultural preservation and maintenance entail nurse lacked cultural competence for assess- the use of cultural practices for health and use ing and planning culturally congruent inter- of herbs, as well as the cultural accommoda- ventions for the patient, even though she tion of clients’ opinions and negotiation, help- came from a similar cultural background. In ing create a linkage between the nurse’s addition, she was not a role model for the scientific framework and the cultural perspec- nursing student in her interaction. Cultural tives of patients (Berman et al. 2016; Leininger assumptions and impositions must be 2002). avoided in providing care to patients from • Collaborate with key community leaders and diverse cultures. A recommendation is to use plan culturally congruent health campaigns the Guidelines for Implementing Culturally aimed at health awareness and health promo- Competent Nursing Care (Douglas et al. tion for pregnant as well as other women. 2014). Different strategies and interventions • Establish partnerships with local communities are needed at different levels for the patient in order to disseminate information and health and her family, the organization, and as well education programs related to women’s health, as the wider community to enhance the best especially at-risk women. evidence-based cultural care for pregnant • Establish support groups and common-interest women from a disadvantaged environment. groups for women from disadvantaged areas such as rural women. • Encourage women leaders to come forward References and help other women from the same cultural background. Berman A, Erb GL, Snyder S, Abdalrahim MS, Abu- Moghli F et al (eds) (2012) Fundamentals of nursing • Prepare health education material in a simple concepts, process and practice. Arab World Edition. format consistent with the educational level of Pearson International, New Jersey recipients. Berman A, Snyder SJ, Fransden G (eds) (2016) Kozier • Train traditional midwives who work with and Erb’s fundamentals of nursing concepts, process and practice, 10th edn. Pearson International, New pregnant women to provide safe and cultural Jersey competent care to women and their children. Cleveland Clinic (2017) Herbal supplements, helpful of harmful. https://my.clevelandclinic.org/health/articles/herbal-supplements-heart-health. Accessed 28 Conclusion Apr 2017 Clients might have several misunderstandings Douglas MK, Rosenkoetter M, Pacquiao D, Callister LC and health beliefs adopted from their commu- et al (2014) Guidelines for implementing culturally nities. Their educational background might competent nursing care. J Transcult Nurs 25(2):109– limit their ability to seek and obtain informa- 121. https://doi.org/10.1177/1043659614520998 Gebru K, Willman A (2010) Education to promote cul- tion about their health as well as their preg- turally competent nursing care—a content analysis nancy and neonatal care. This case study is of student responses. Nurse Educ Today 30:54–60. further complicated by the fears related to https://doi.org/10.1016/j.nedt.2009.06.005 7 Case Study: Traditional Health Beliefs of Arabic Culture During Pregnancy 83

Jones ED, Ivanov LL, Wallace D, VonCannon L (2010) Saunders, an imprint of Elsevier, Inc. http://medical- Global service learning project influences culturally sen- dictionary.thefreedictionary.com/cultural+imposition. sitive care. Home Health Care Manag Pract 22(7):464– Accessed 29 Apr 2017 469. https://doi.org/10.1177/1084822310368657 Muliira JK, Muliira RS (2013) Teaching culturally appro- Leininger M (1991) Culture care diversity and universal- priate therapeutic touch to nursing students in the ity: a theory of nursing. National League for Nursing Sultanate of Oman. Holist Nurs Pract 27(1):45–48. Press, New York https://doi.org/10.1097/HNP.0b013e318276fccf Leininger MM (2002) Culture care theory: a major contri- Nies MA, McEwan M (eds) (2007) Community/Public bution to advance transcultural nursing knowledge and health nursing: promoting the health of population, practices. J Transcult Nurs 13(1):189–192 4th edn. Saunders Elsevier, St. Louis Ludwick R, Silva MC (2000) Ethics: nursing around the world: Purnell L (ed) (2014) Transcultural healthcare: a culturally cultural values and ethical conflicts. Online J Issues Nurs competent approach, 4th edn. F.A. Davis, Philadelphia 5(3). www.nursingworld.org/MainMenuCategories/ Purnell L, Finkl E (eds) (2017) Guide to culturally compe- ANAMarketplace/ANAPeriodicals/OJIN/Columns/ tent health care. F.A. Davis, Philadelphia Ethics/CulturalValuesandEthicalConflicts.aspx. WHO (2006) Constitution of the World Health Accessed 29 Apr 2017 Organization. World Health Organization, Geneva. Mager DR, Grossman S (2013) Promoting nursing stu- http://www.who.int/governance/eb/who_constitution_ dents’ understanding and reflection on cultural aware- en.pdf. Accessed 26 May 2017 ness with older adults in home care. Home Healthc Williamsona M, Harrison L (2010) Providing cultur- Nurse 31(10):582–588 ally appropriate care: a literature review. https://doi. Miller-Keane (2003) Miller-Keane encyclopedia and dic- org/10.1016/j.ijnurstu.2009.12.012. Accessed 26 May tionary of medicine, nursing, and allied health, 7th edn. 2017 Case Study: Perceived Cultural Discord and Possible 8 Discrimination Involving a Moroccan Truck Driver in Italy

Alessandro Stievano, Gennaro Rocco, and Giordano Cotichelli

Ahmed is a 40-year-old Moroccan truck driver opportunities to develop strong ties with the local who has been working in Italy for the last 13 years. Moroccan immigrant community in his town of Ahmed has a basic level of education and a suffi- residence in the Northern Italy. His connection to cient conversational skill in the Italian language. the community was through sporadic contacts Ahmed lives alone, and although is married with with the local imam (religious clerk). two children, his wife and children were left A few months ago, Ahmed started to experience behind in Morocco. He is also financially account- and complained of severe acute back pain. Over able for his visually disabled younger brother who time his pain became more frequent and more lives in Morocco. Ahmed, being the sole bread- intense. One night he was obliged to rush to the winner, relies on his truck driving job to support accident and emergency room where he was visited himself, his immediate family, and his brother’s by an orthopedic surgeon who advised him to have family (Pfau-Effinger 2004). a series of examinations to rule out spondyloarthro- Ahmed travels back to Morocco a couple of sis. He prescribed a therapy with nonsteroidal anti- times year where he is often greeted with joy and inflammatory drugs and suggested that he take gratitude for the financial support he offers. time off work to rest and heal. The physician also Ahmed wishes that one day, once he is financially advised him to modify his work duties and refrain capable, he could return to Morocco; however, as from continuing as a truck driver. an added security option, he is also pursuing steps to acquire Italian citizenship. Given his truck driving occupation, Ahmed did not have 8.1 Cultural Issues

As was recommended by the treating physician, Ahmed took 2 weeks off work to rest and to A. Stievano, Ph.D., M.Sc.N., R.N. (*) receive anti-inflammatory injection to relieve his University of Tor Vergata, Rome, Italy pain. However, he refrained from seeking further Center for Nursing Excellence, Ipasvi Rome Nursing diagnostic testing as ordered by the accident and Board, Rome, Italy emergency room physician. The truck company G. Rocco, Ph.D., R.N., FAAN proprietor was very sympathetic with his condi- Centre of Excellence for Nursing Scholarship, Ipasvi Rome Nursing Board, Rome, Italy tion and allowed Ahmed to modify his work duties by offering him an office position as an G. Cotichelli, Ph.D., R.N. Faculty of Medicine, University of Ancona, accountant. While Ahmed appreciated his boss’s Ancona, Italy accommodation, he nonetheless was worried that

© Springer International Publishing AG, part of Springer Nature 2018 85 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_8 86 A. Stievano et al. his income would be impacted. His very reason mindedness against people who were coming for being in Italy and away from his family is that from the Maghreb region in Morocco. However, they depended on his ability to generate income some nurses working in the clinic had concerns to sustain himself and his family. and doubted that Ahmed was “another of those While receiving injection therapy in a nursing- North Africans” who did not feel like having a run outpatient clinic, Ahmed resisted the nurse’s burdensome and onerous job and that he longed effort to help him adhere to the treating physi- for having the nonsteroidal anti-inflammatory cian’s order for further diagnostic tests. He did drugs just to receive some more time off work. not engage in the nurse’s therapeutic care plan, and at some point during the course of treatment, he became belligerent and argumentative. He 8.2 Cultural Issues shifted blame for not getting better on the dysfunctional bureaucratic system. To study the global movements of people is a Efforts toward establishing and building a health priority in the globalized world (Tschudin therapeutic relationship with Ahmed came to a and Davis 2008). The mass inflow of immigrants halt when his demeanor became verbally aggres- and refugees to Italy is very complicated and sive with the nursing staff. The result of this harsh goes beyond traditional migration theories of conversation was a further worsening of an push-and-pull factors (Prescott and Nichter already degraded relationship with the nursing 2014). In fact, the interconnections of political staff. Ahmed, at a certain point to avoid possible and economic reasons that are at the ground of debates with the healthcare team, declared that he the migratory processes to Italy ought to be ana- would be better off if he received the injections lyzed through the lens of the ever-changing from a fellow countryman who had studied medi- global trajectories (Stievano et al. 2017). Despite cine in Morocco. He also was against having an the 2008 economic recession, Italy is a country orthopedic consultation and possible diagnostic that hosts a high number of immigrants: 5,200,000 workup for fear that a potential orthopedic diag- (Idos Migrantes 2016). Italy is Europe’s main nosis may declare him unfit, potentially losing gateway for asylum-seekers from Africa. his truck driving job. He was also scared of losing Although most of those asylum-seekers are res- the right to ask for Italian citizenship. cued during the journey from the North African Ahmed’s physical health worsened due to his coasts to the Southern Italy shores, a large per- excessive use of steroidal anti-inflammatory centage of these refugees end up being homeless drugs—drugs for which Ahmed experienced gas- in Italy and in other European nations due to the tric discomfort—although he was verbally lack of supportive systems. Italy is home to informed about possible gastric complications by immigrant from North African and Eastern the orthopedic surgeon in the accident and emer- European countries. Romanian immigrants form gency room. Despite the fact that Ahmed had an the largest group (1,131,839, 22.9%), followed adequate command of the Italian language, dur- by Moroccans (510,450, 13%), Albanians ing one of his visits to the outpatient department, (490,483, 9.3%), Chinese (265,820, 5.4%), and he was not able to make himself fully understood Ukrainians (226,060, 4.6%). Other immigrants and explain the pain he felt in direct relation to are from the Philippines 3.3%, India 3.0%, gastric symptomatology. Moldova 2.8%, Bangladesh 2.4%, and Egypt The attending nurse also ignored his com- 2.2% (Idos Migrantes 2016). Hence, Moroccans plaints because she was convinced that it was just are the second largest immigrant community in another excuse to keep him on the anti- Italy and represent one of the most important inflammatory injection therapy. Ahmed perceived countries in the Maghreb area. Nowadays, the the nurse’s lack of attention to his complaints migration from Morocco to Italy is one of the based on prejudice and racism. He was justifying longest and largest migrations in Europe, and his attitude on his overall perception of narrow- Moroccans who are present in Italy in 2016 were 8 Case Study: Perceived Cultural Discord and Possible Discrimination Involving a Moroccan Truck Driver 87

510,450 which is equal to 13% of the non- only knowledge and skills of the client culture European residents in Italy (Ministry of Work and the societal stigma associated with the cli- and Social Welfare 2016). ent’s background but, as in this situation, require There is no doubt that the continuous influx of the reflective unpacking and evaluation of the cli- immigrants is taxing the Italian systems, espe- ent’s personnel trials and tribulation and his or cially the housing and the healthcare system. The her real or perceived threats of discrimination Italian society is reeling the brunt of immigrant due to racism. As a strategy, healthcare providers groups who do not know or adhere to the local must consider multidimensional assessment and norms or abide the laws. Current security concerns intervention approaches. in Italy and worldwide may heighten stereotypes and may have an impact on the nature of care that is offered or perceived. Adding to the already held 8.3.1 Individual-/Family-Level negative attitude that Moroccans tend to avoid Interventions hard work, the potential for non-culturally responsive healthcare encounters is very high. • Assessment must include external forces After having delineated the cultural setting impacting the person and the available coping where this case had taken place, some consider- resources. ations must to be highlighted. Ahmed’s impetus for • Assessment and intervention strategies of the coming to Italy is similar to those of his compatri- contextual variables impacting the cross- ots—the search for economic opportunities with cultural health encounter include the organi- higher pay and better working conditions (Correia zational and socio-structural levels of et al. 2015). Ahmed came seeking work in Italy in interventions to meet the healthcare needs of order to provide not only for his own immediate persons similar to Ahmed’s. family but also for his extended family. In the eyes • Consideration of the geopolitical forces and of his family, he is the beacon of hope and the their impact on the host society and on the anchor for their survival and potential progress. individual immigrant is increasingly impor- This conceptual mindset is possibly the source of tant in ensuring fair treatment. anxiety and uncertainty for Ahmed because, as his • Offering interprofessional case studies and health is worsened, he is likely to fail in meeting educational lectures/seminars to enhance the financial obligation toward his family. healthcare providers’ understanding of inter- Ahmed’s possible avoidance of seeking fur- secting cross cultural variables that can poten- ther orthopedic consultation may be based on his tially affect the healthcare outcomes of fear of being labeled inept or disabled and as persons similar to Ahmed’s. such limit his chances to continue with his truck • Attention should be paid to repairing and driving job. Ahmed is also frightened to seek help rebuilding the therapeutic relationship from his fellow citizens and from the spiritual between Ahmed and the nursing staff through guide of his community, the Imam, because he intentional and focused communication and fears he could be seen as a fragile man. He is also problem-solving among the healthcare worried that his dignity and reputation as a strong providers and through a culturally responsive man who is looked up to may be tarnished. care plan (Bergum and Dossetor 2005).

8.3 Culturally Competent 8.3.2 Organizational-Level Strategies Recommended Interventions

In healthcare settings with cross-cultural encoun- • Establish specific policies and procedures ters such as the case of Ahmed, the knowledge focused on the care of vulnerable and under- and skills of the healthcare provider demand not served immigrant populations with a special 88 A. Stievano et al.

emphasis on social determinant variables such vider. Offering quality, cost-effective, and as gender, age, ethnic and religious back- culturally responsive healthcare outcomes grounds, and cultural beliefs and values. requires knowledge and skills on the part of • Supportive health organization’s resources are healthcare providers, supportive resources on required to assist healthcare providers in the part of the healthcare organizations, and delivering culturally responsive healthcare. culturally responsive community resources. • Offer ongoing training and education toward culturally responsive and congruent care and Acknowledgments The authors of this case study would language and cultural interpretive services. like to acknowledge the assistance of Marianne Hattar- Pollara, PhD, RN, FAAN in editing this case study. Dr. Hattar-Pollara is the Chair of the Department of Nursing at California State University, Northridge. Her email is 8.3.3 Community-/Societal-Level [email protected]. Interventions

• An enhanced evaluation of the influxes of References immigrants is the first step to carry out a personalized cultural congruent plan of care Bergum V, Dossetor J (2005) Relational ethics: the full meaning of respect. University Publishing Group, (Douglas et al. 2014). Hagerstown • Know the diverse habits of the main ethnic Correia T, Dussault G, Pontes C (2015) The impact of the groups and provide information that health- financial crisis on human resources for health poli- care providers should consider in order to cies in three southern-Europe countries. Health Policy 119:1600–1605 have a stronger connection with the North Douglas MK, Rosenkoetter M, Pacquiao DF, Callister African community. LC, Hattar-Pollara M, Lauderdale J, Purnell L (2014) • Involve social care networks to provide a bet- Guidelines for implementing culturally competent ter link with the North African community to nursing care. J Transcult Nurs 25(2):109–121. https:// doi.org/10.1177/1043659614520998 assist in improving the understanding of Idos Migrantes (2016) Statistic immigration report 2016. Ahmed’s social and economic concerns by Imprinting Publishing, Rome healthcare providers. Ministry of Work and Social Welfare (2016) The • Social work professionals should strategically Moroccan community in Italy. Annual report on the presence of migrants. Anpal Servizi, Rome connect Ahmed with his community and with Pfau-Effinger B (2004) Socio-historical paths of the male a religious guide to provide advice, support, breadwinner model—an explanation of cross-national and resources. differences. Br J Sociol 55(3):377–399 Prescott M, Nichter M (2014) Transnational nurse migration: future directions for medical anthropological Conclusion research. Soc Sci Med 107:113–123 Ahmed’s clinical case represents a common Stievano A, Olsen D, Tolentino Diaz Y, Sabatino L, Rocco health situation in Italy where the culture, G (2017) Indian nurses in Italy: a qualitative study organizations, and professionals intersect to of their professional and social integration. J Clin Nurs 26(23–24):4234–4245. https://doi.org/10.1111/ produce unwarranted negative health encoun- jocn.13746 ters for both the patient and the healthcare pro- Tschudin V, Davis AJ (2008) The globalisation of nursing. Radcliffe Publishing, Abingdon Case Study: A Multiracial Man Seeks Care in the Emergency 9 Department

Marianne R. Jeffreys

Franklin is a 58-year-old multiethnic, multiracial able to quit smoking, she strongly insisted that man of African-American, Cherokee, and her grandchildren would never become smokers Scottish background who views all aspects of his and advocated a diet of fresh vegetables, poultry, heritage as important. He also considers being and fish, outdoor exercise, and post-secondary multiracial as a unique cultural experience. He trade school or college education. The family’s grew up in a multi-generation household consist- diet consisted of many fresh vegetables grown in ing of his paternal grandmother (Cherokee), their backyard, fish and crabs caught in the adja- mother (third-generation Scottish-American), cent river, and eggs and chickens from a nearby father (African-American and Cherokee), and his farm. three brothers and two sisters. Unable to marry in The factory has long been closed, with the their home state due to miscegenation laws, dilapidated property now declared a superfund Franklin’s parents married in a US state that per- site that is yet to be cleaned and proclaimed envi- mitted interracial marriages where they then set- ronmentally safe. The nearby farm, frequently tled to start a new life and family together. The sprayed with pesticides during the 1960s and opening of a factory with employee housing pro- 1970s, had been recently transformed from a vided steady employment that led to a factory- remediated superfund site to a crowded low- sponsored mortgage to purchase a family home income housing complex. Signs along the river- in a new housing development bordering the fac- bank display warnings against eating more than tory. Although federal laws purported “equal one fish or crab per month, noting extra cautions opportunities” in employment, education, and for pregnant women and young children. housing, the reality was that overt and covert dis- Franklin’s grandmother, a lifelong smoker, died 2 crimination existed, so factory work and com- decades ago from a stroke, but his parents still pany housing were greatly welcomed. reside in the family homestead, fondly reminisc- With both high school-educated parents working about times gone past, still in love and unable ing many overtime shifts, Franklin and his sib- to imagine living anywhere else but “home.” lings were raised by his grandmother who shared Since completing college on a baseball scholar- many Cherokee traditions through storytelling, ship and graduate school at age 25, Franklin has cooking, and everyday activities. Although never been working as a high school teacher and baseball coach in a suburban town where he currently M. R. Jeffreys, Ed.D., R.N. lives with his Argentinian-born wife (also a high Graduate College and College of Staten Island, The school teacher) and their two children. On the City University of New York (CUNY), way to his weekly visit to assist his elderly New York, NY, USA

© Springer International Publishing AG, part of Springer Nature 2018 89 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_9 90 M. R. Jeffreys

parents, Franklin stops at the one remaining local Many multiple heritage individuals acknowledge store (deli-liquor-drugstore) to pick up their pre- being multiracial or multiethnic as a separate and scriptions and unknowingly startles two armed unique culture” (Root 1992, 1997; Jeffreys and men in the midst of a robbery. When Franklin Zoucha 2001, 2017a, b, c: 81). Individuals within flings himself in front of a pregnant teenager to multiracial families may also self-identify with protect her, he suffers a gunshot wound to the groups different than their siblings or other fam- right side of the abdomen yet manages to divert ily members (Root 1993; Tutwiler 2016). other gunshots by forcefully pitching several Despite multidisciplinary literature document- cans of prominently displayed spam that knock ing disparities in past and present-day life experi- out one robber and disarm and injure the other. ences of multiracial individuals (Remedios and A work-up at the emergency room reveals that Chasteen 2013; Tran et al. 2016), they lack visi- Franklin’s general health is excellent; however, bility in the nursing and healthcare literature the doctor tells him that the abdominal scan (Jeffreys and Zoucha 2017a, b). Additionally, shows a right colon mass. During emergency anti-discrimination policies are frequently abdominal surgery, the surgeon removes the bul- directed at individuals who identify with a single let and mass and suspects that the biopsy will race (minority group), keeping multiracial indi- confirm colon cancer. While lying semi-awake in viduals “invisible” and marginalized. In an effort the recovery room, Franklin overhears someone to make this invisible group “visible,” Tutwiler say “You would think that a black man who sur- (2016) introduced the term “fifth minority.” vived this long would know better than to still be While also noting that much diversity and var- involved in gangs and crime in that horrible ied experiences exist for mixed-race individuals neighborhood. They must have been after drugs within families, schools, communities, and soci- or drug money. We better make sure he doesn’t ety, mixed-race individuals more frequently have get too much narcotics. We taxpayers will end up their heritage and identity questioned, chal- paying for his cancer treatment one way or the lenged, ignored, and/or pressured to select one other through Medicaid or the prison system. It choice over others (Tutwiler 2016). Forced- just isn’t fair.” choice dilemmas such as presenting a demo- Franklin feels angry, hurt, invisible, misla- graphic form stating “select one” restrict identity beled, profiled, alone, sad, anxious, mistreated, autonomy and contribute to psychological stress and vulnerable. Vital signs on his monitor show (Sanchez 2010). Furthermore, forced-choice an immediate jump of 30 beats/min and BP dilemmas may foster beliefs that multiracial jumps from 124/76 to 152/92. More alert now identity is unacceptable, stigmatized, undesir- and fighting anesthesia drowsiness, Franklin able, and devalued by society. Sanchez’s (2010) feels severe pain but hesitates to request medi- study suggests that multiracial people with black cine. Fatigued from his immediate response to heritage encounter the most forced-choice dilem- discrimination-related stress, post-traumatic mas. Such experiences can result in cultural pain stress (crime victim), and postoperative stress, he and adversely affect quality of everyday life and falls into an exhausted sleep. Later, excruciating health (Jeffreys and Zoucha 2017a, b, c). pain jolts him awake.

9.2 Social Structural Factors 9.1 Cultural Issues Almost every time the US Census has been “Multiple heritage identity can include simulta- administered, it has contained different catego- neous membership with two or more distinct ries, and it continues to change. It was not until groups, membership within one select group, 1960 that Americans could choose their own synthesis of cultures, and/or fluid identities that race. Forty years later, Americans were permitted change with time, circumstances, and setting. to select more than one option. In 2010, 9 Case Study: A Multiracial Man Seeks Care in the Emergency Department 91

approximately nine million Americans selected conduct an in-depth assessment of the per- more than one race, with Latino-white being the son’s cultural background, self-identity, val- highest combination (Davenport 2016; Pew ues, beliefs, and healthcare practices. Commission 2015). By 2050, it is predicted that • Proactively initiate culturally congruent edu- one in five Americans will claim multiracial heri- cation and screening based on the person’s tage (Farley 2001; Jackson and Samuels 2011). background (genetics), family history, life- At one time or another until 1967, miscegena- style, and environmental risk factors. tion laws in 41 US states or colonies prevented • Be aware of past and current ethnohistorical, marriages, relationships, sexual intercourse, or political, social, economic, and environmental unions between whites and 1 or more of the fol- factors that influence the lifestyle, health, and lowing groups: African-Americans, American opportunities of multiracial, multiethnic Indians, Chinese, Filipinos, Hindus, Japanese, individuals. Koreans, Malays, and Mongolians. Of the 227 • Respect that multiracial people have the right court of appeals cases concerning miscegenation to self-identify with one or more cultural iden- (1850 to 1970), 95 were recorded as criminal tities, change self-identification over time or (Pascoe 1996; Jeffreys and Zoucha 2001, 2017b). circumstance, embrace all identities in vary- Children born of such unions often suffered ing degrees, consider being multiracial as a social and economic disadvantages of illegiti- unique identity, and change any of the above macy, were stigmatized, and were assigned the without explanation (Root 1993). racial status low on the hierarchy with “white” • Proactively assess and manage pain. being highest in a society of white versus non- • Provide culturally congruent pain manage- white and the hypodescent rule (one drop rule) ment education. putting blacks in the lowest status. Such disad- • Apologize for cultural mistakes and make vantages impacted opportunities for education, concerted efforts to prevent future cultural jobs, housing, environment, food security, and mistakes. access to quality healthcare and services. In con- • Provide education on colon cancer treatment, temporary society, both conscious and uncon- prognosis, and holistic care that incorporates scious biases toward minorities and multiracial culturally congruent approaches and family children and families contribute to disparities heritage (risk factors) without emphasizing (DeJesus et al. 2016). disparities (Landrine and Corral 2015; May et al. 2015; Rice et al. 2015). • Recognize the potential cognitive, affective, 9.3 Culturally Competent and behavioral responses to environmental Strategies Recommended stigma that may be associated with living in or near areas of pollution, high crime rates, Many past and present social structural factors dilapidated buildings, or other undesirable have impacted Franklin’s health and illness expe- qualities (Zhuang et al. 2016). rience. In addition to actions specific to assist Franklin, education for all staff members is required, and reaching out to community is 9.3.2 Organizational-Level essential. Interventions

• Conduct a staff meeting to address the cultural 9.3.1 Individual-/Family-Level bias, pain, discrimination, and disparities Interventions Franklin experienced. • Using a cultural competence education frame- • On admission (after explaining rationale for work, design, implement, and evaluate cultural background and identity questions), organization-wide cultural competence 92 M. R. Jeffreys

education for all employees concerning multi- • Create collaborative partnerships between racial, multiple heritage individuals as con- new and old community residents for elder- sumers and co-workers (Jeffreys 2005, 2016). care support, prescription and food delivery, • Revise hospital demographic forms to include teen pregnancy prevention, and childcare. “multiracial” and permit selection of more • Establish community neighborhood watch than one option. and auxiliary police force to combat crime and • Publicize/post the Bill of Rights for People of foster a sense of community connectedness Mixed Heritage (Root 1993), incorporating in and safety. all organizational cultural competence litera- • Collect demographic, socioeconomic, and sta- ture with photos of multiple heritage families. tistical data including morbidity and mortality • Train peers from the community as patient rates disaggregated by ethnic and racial cate- navigators for proactive cancer screening, gories that encourage identification of multi- incorporating culturally congruent strategies ple races and ethnicities and trend data and coordinating with available transporta- accordingly. tion, mobile units, and organizational culture • Develop a community-based participatory (Sly et al. 2012). approach to risk reduction in at-risk commu- • Encourage proactive cancer screening among nities through interprofessional collaboration, vulnerable populations, such as low test advisory boards, and ad hoc resident advisory copayments, low-cost and convenient follow- partnerships (Derrick et al. 2008). up, and incentives (Pignone et al. 2014). • Collaborate with community members, gov- • Educate healthcare providers concerning pain ernment organizations, academic institutions, management, noting ethnic and racial dispari- other organizations, and key stakeholders to ties, pharmacogenetics, and current literature address environmental and health-related recommendations (Shah et al. 2015). issues proactively through screening, treatment, education, and follow-up (United States Environmental Protection Agency 2016). 9.3.3 Community-/Societal-Level Interventions Conclusion Past and present policies, politics, myths, ste- • Lobby governmental officials and agencies reotypes, and societal attitudes influence the concerning environmental cleanup. lived experience of multiracial individuals, • Coordinate community-based and culturally often resulting in marginalization, disparities, congruent health teaching for the promotion invisibility, cultural pain, and/or unmet needs of healthy lifestyles and neighborhoods. (Jeffreys and Zoucha 2017a). Acknowledging • Network with farmers and others to bring the uniqueness of multiple heritage individuals responsibly grown, healthy foods and respon- without attaching pity, stigmatization, alien- sibly raised or hunted animals and fish to the ation, marginalization, forced-choice pres- local community in conjunction with a coop- sures, or lowered social status is an important erative business alliance with the local store. first step in making this “culture” truly visible • Negotiate strategies with storeowners to and fully appreciated (Jeffreys and Zoucha prominently display economical healthy food 2001, 2017b). choices and offer incentives for their selection Creating a culturally safe environment vis- over less healthy choices. ibly inclusive of multiracial/multiple heritage • Reach out to current and past community individuals is an ethical, legal, and interpro- members for screening past and current expo- fessional expectation. Without it, social jus- sure to toxins and/or incidence of cancer and tice, environmental justice, and quality other diseases associated with environmental healthcare cannot be achieved. The Bill of hazards. Rights for People of Mixed Heritage (Root 9 Case Study: A Multiracial Man Seeks Care in the Emergency Department 93

1993) succinctly captures the cultural, lived to report lack of provider recommendation for colon experience of mixed-heritage people, provid- cancer screening. Am J Gastroenterol 110:1388–1394 Pascoe P (1996) Miscegenation law, court cases, and ide- ing a valuable guide for everyday contempla- ologies of “race” in twentieth-century America. J Am tion, advocacy, and action. Hist 83(1):44–69 Pew Commission (2015) http://www.pewsocialtrends. org/2015/06/11/chapter-1-race-and-multiracial-americans-in-the-u-s-census/. Accessed 18 Sept 2017 References Pignone MP, Crutchfield TM, Brown PM, Hawkey S, Laping JL, Lewis CL, Lich KH, Richardson LC, Davenport LD (2016) The role of gender, class, and reli- Tangka FKL, Wheeler SB (2014) Using a discrete gion in biracial Americans’ racial labeling decisions. choice experiment to inform the design of programs Am Sociol Rev 81(1):57–84 to promote colon cancer screening for vulnerable DeJesus A, Hogan J, Martinez R, Adams J, Lacy TH populations in North Carolina. BMC Health Serv Res (2016) Putting racism on the table: the implementa- 14:611. https://doi.org/10.1186/s12913-014-0611-4 tion and evaluation of a novel racial equity and cul- Remedios JD, Chasteen AL (2013) Finally, someone who tural competency training/consultation model in “gets” me! Multiracial people value others’ accuracy New York City. J Ethn Cult Divers Soc Work 25(4): about their race. Cult Divers Ethn Minor Psychol 300–319 19(4):453–460 Derrick CG, Miller JSA, Andrews JM (2008) A fish con- Rice LJ, Brandt HM, Hardin JW, Annang Ingram L et al sumption study of anglers in an at-risk community: (2015) Exploring perceptions of cancer risk, neigh- a community-based participatory approach to risk borhood environmental risks and health behaviors of reduction. Public Health Nurs 25(4):312–318 blacks. J Community Health 40:419–430. https://doi. Farley R (2001) Identifying with multiple races. Report org/10.1007/s10900-014-9952-5 01-491. University of Michigan, Population Studies Root MPP (1992) Racially mixed people in America. Center, Ann Arbor. As cited in Shih M, Sanchez DT Sage, Newbury Park (2009) When race becomes even more complex: Root MPP (1993) Bill of rights for people of mixed toward understanding the landscape of multiracial heritage. Online. http://www.drmariaroot.com/doc/ identity and experiences. J Soc Issues 65(1):2 BillOfRights.pdf Jackson KF, Samuels GM (2011) Multiracial compe- Root MPP (1997) Multiracial Asians: models of ethnic tence in social work: recommendations for cultur- identity. Amerasia J 23(1):29–41 ally attuned work with multiracial people. Soc Work Sanchez DT (2010) How do forced-choice dilemmas 56(3):235–245 affect multiracial people? The role of identity auton- Jeffreys MR (2005) Clinical nurse specialists as cultural omy and public regard in depressive symptoms. J Appl brokers, change agents, and partners in meeting the Soc Psychol 40(7):1657–1677 needs of culturally diverse populations. J Multicult Shah AA, Zogg CK, Zafar SN, Schneider EB, Cooper Nurs Health 11(2):41–48 LA et al (2015) Analgesic access for acute abdominal Jeffreys MR (2016) Teaching cultural competence in pain in the emergency department among racial/eth- nursing and health care: inquiry, action, and innova- nic minority patients: a nationwide examination. Med tion, 3rd edn. Springer, New York Care 53(12):1000–1009 Jeffreys MR, Zoucha R (2001) The invisible culture of Sly JR, Jandorf L, Dhulkifl R, Hall D et al (2012) the multiracial, multiethnic individual: a transcultural Challenges to replicating evidence-based research in imperative. J Cult Divers 8(3):79–83 real-world settings: training African-American peers Jeffreys MR, Zoucha R (2017a) Revisiting “the invisible as patient navigators for colon cancer screening. J culture of the multiracial, multicultural individual: a Cancer Educ 27:680–686 transcultural imperative”. J Cult Divers 24(1):3–5 Tran AGTT, Miyake ER, Csizmadia A, Martinez-Morales Jeffreys MR, Zoucha R (2017b) The invisible culture of V (2016) “What are you?” multiracial individuals’ the multiracial, multicultural individual: a transcul- responses to racial identification inquiries. Cult Divers tural imperative: a reprint from 2001. J Cult Divers Ethn Minor Psychol 22(1):26–37 24(1):6–10 Tutwiler SW (2016) Mixed-race youth and schooling: the Jeffreys MR, Zoucha R (2017c) Book review: mixed-race fifth minority. Routledge, New York youth and schooling: the fifth minority. J Cult Divers United States Environmental Protection Agency (2016) EJ 24(1):11–12 2020 action agenda: the US EPA’s environmental jus- Landrine H, Corral I (2015) Targeting cancer information tice strategic plan for 2016-2020. Author, Washington, to African Americans: the trouble with talking about DC disparities. J Health Commun 20:196–203 Zhuang GJ, Cox J, Cruz S, Dearing JW et al (2016) May FP, Almiro C, Ponce N, Brennen MR, Spiegel BMR Environmental stigma: resident responses to living in a (2015) Racial minorities are more likely than whites contaminated area. Am Behav Sci 60(11):1322–1341 Part III Guideline: Critical Reflection Critical Reflection 10 Larry Purnell

Guideline: Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage in order to have an awareness of how these qualities and issues can impact culturally congruent care. Douglas et al. (2014: 110)

10.1 Introduction Dewey, critical reflection is an active, persistent, and careful consideration of any belief or sup- An understanding of one’s own cultural values posed form of knowledge in light of the grounds and beliefs as well as the culture of others is that support it. Moreover, it includes a conscious essential if healthcare providers are to deliver and voluntary effort to establish a belief upon a culturally congruent care to patients, families, the firm basis of evidence and rationality (Dewey community, and organizations where healthcare 1933). is delivered. Personal cultural reflectivity can According to Mezirow (1990), critical reflec- help assure that the healthcare provider does not tion is a process: testing the justification of validity engage in cultural imposition or cultural imperi- of premises that have been taken for granted. One alism and make a concerted attempt at cultural consistency on definition of critical reflection is relativism (see Chap. 2). Moreover, in critical that it is a process of questioning one’s beliefs, val- reflection, the healthcare provider analyzes his or ues, and behaviors to justify things we do in con- her personal cultural beliefs, values, and world- trast with others’ beliefs, values, and behaviors. view, therefore, challenging personal beliefs and Regardless of the different definitions on critical assumptions to improve professional practice reflection, four criteria include the following: (a) (Timmins 2006). Reflective thinking includes reflection moves the learner from one experience actions, analysis, and evaluation which can fur- into the next with deeper understanding of rela- ther increase personal cultural awareness tionships and connections with other experiences (Canadian Nurses Association 2010). Critical and ideas; (b) reflection is a systematic, rigorous, reflection is more than just “thinking about” or and disciplined way of thinking with its roots in “thoughtful” practice. It is a way of “critiquing” scientific inquiry; (c) reflection needs to occur in our practice in a systematic and rigorous way. the community and in interaction with others; and Although there is no one agreed-upon defini- (d) reflection requires attitudes that value personal tion of critical reflection, a few have been consis- and intellectual growth of oneself and of others. tently been recognized over time. Adapted from Accordingly, critical reflection is a process of reconstructing and reorganizing experiences that L. Purnell, Ph.D., R.N., FAAN adds meaning to the experience (Rogers 2002). School of Nursing, University of Delaware, A variety of methods exist that healthcare pro- Newark, DE, USA viders, educators, and administrators can use to Florida International University, Miami, FL, USA teach and learn how to reflect critically: journal Excelsior College, Albany, NY, USA writing, case studies, action research, practical e-mail: [email protected] experience (especially with diverse groups),

© Springer International Publishing AG, part of Springer Nature 2018 97 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_10 98 L. Purnell autobiographical stories, action learning groups, 10.2.1 Models of Critical Thinking and immersion in diverse cultures. Each of these activities involves recognizing assumptions that A number of models exist that healthcare provid- underlie one’s beliefs and behaviors and helps ers can use in their personal critical cultural avoid egocentrism and seeing things from reflection. The following describes a few of the different perspectives. more popular models. A number of tools exist to help practitioners assess their views and values related to bias. Three 10.2.1.1 Ways of Knowing tools are included in the following appendices: Carper’s (1978) seminal work in the ways of knowing identified four fundamental patterns of • Appendix 1—Promoting Cultural and knowing to form a conceptual structure of nursing Linguistic Competency: Self-Assessment knowledge: personal, empirical, ethical, and Checklist for Personnel Providing Primary aesthetic knowing. Since that time, her work has Healthcare Services been expanded by others. • Appendix 2—Promoting Cultural and Personal knowing is what we have seen and Linguistic Competency: Self-Assessment experienced and comes through a process of Checklist for Personnel Providing Services observation, reflection, and self-actualization. and Supports in Early Intervention and Early Knowledge of self establishes professional, Childhood Settings therapeutic relationships and propels the learner • Appendix 3—Personal Self-Assessment of toward wholeness and integrity (Chinn 2018; Antibias Behavior Chinn and Kramer 2015). Placing oneself in situations to be challenged and taught by teachers and mentors is helpful in gaining a personal way 10.2 Personal Responsibility: of knowing and critically reflecting (Sullivan- Critical Reflection Marx 2013). Carper’s (1978) sense of personal knowing is engagement with others and using Critical cultural reflection is not a casual but knowledge of self to commit, encounter, and risk rather a personal responsibility and a standard to commitment (Sullivan-Marx 2013). Personal which all healthcare practitioners should strive. It knowing is introspective and consciously begins with the novice student and continues dissecting our own thoughts and beliefs, including throughout one’s professional life. Respect for all personal beliefs about social justice and cultures is fundamental (ICN Code of Ethics for vulnerable populations. One needs to critically Nurses 2012). To critically reflect and become reflect on how and why assumptions are made. culturally competent, one must do a number of Ask yourself “What can I do to better the things: situation?” Empirical knowing comes from research and 1. Recognize that your own culture is a product objectivity and is systematically organized into of your environment whose basis is socially general laws and theories. This knowledge is constructed beginning with child-rearing applied through applying evidence-based practice practices. (see Chap. 39) and is referred to as the science of 2. Appreciate your own multiple identities. nursing (Chinn 2018; Chinn and Kramer 2015). 3. Acknowledge assumptions, biases, and Empirics require constantly attending to self prejudices. through evidence-based learning (Sullivan-Marx 4. Accept responsibility and tolerate ambiguity. 2013). 5. Recognize the limits of your competence. Ethical knowing is developed through the 6. Have the capacity for introspection. healthcare provider’s moral code: a sense of 7. Work to eliminate native prejudicial tendencies. knowing what is right and what is wrong. 8. Know your attitudes toward disabilities, age- Personal ethics is based on an obligation to ism, sexism, classism, racism, and protect and respect human life, being true to self, heterosexism. and doing what ought to be done. Empirics 10 Critical Reflection 99 require constantly attending to self through to recognize them in others, and to make inter- evidence-based learning (Sullivan-Marx 2013), ventions such as calming or redirecting them in especially when it comes to social justice and useful ways (Goleman 2005). A pivotal char- vulnerable populations. The Code of Ethics for acteristic of affective feelings is that they are Nurses (American Nurses Association 2015) informative enhancing the process and impact guides professionals in developing and refining of critical reflection on learning, leading one to their moral code. At a minimum, question your deeper and richer understanding of values and beliefs, values, and behaviors to justify what beliefs. Critical reflection undertaken by some- needs to be done to create social justice. Maintain one who has a high-level emotional literacy will open-mindedness. have greater consciousness or awareness of their The fourth way of knowing is aesthetic know- emotions, other peoples’ emotions, and the inter- ing and is commonly known as the art of nursing. action and impact of each (Goleman 2005; Akers Aesthetic knowing is an “aha” moment when and Grover 2017). something new is uncovered providing the pro- The following is an example of how one can vider with new perspectives (Chinn 2018; Chinn learn from emotions, emotional literacy, and and Kramer 2015). Aesthetics also highlights emotional intelligence. A nurse examined a 5-year- empathy as essential to understanding others old Vietnamese child and found multiple scratch (Sullivan-Marx 2013). marks on his back. Shocked at the marks, she The practice of nursing is a holistic, human became angry and loudly asked the parents “with discipline. The ways of knowing allow us to what did they hit the child?” She was accusing understand ourselves and nursing practice at a them of abusing the child. Out of fear, the parents much deeper level, to appreciate nursing as both yelled “no, no” and started to take the child home. an art and a science. Consider how the ways of Hearing loud voices from the examining room, knowing can assist you in being a better person, a another nurse entered the patient’s room, examined better student, and a better nurse (Johns 1995). the child, and recognized the marks as cao gio In addition to Carper’s ways of knowing, eight (coining), a recognized and common dermabrasion additional ways of knowing have been added to procedure used by the Vietnamese (and other the literature: emotion, faith, imagination, groups) for fever, cough, and colds. The nurse in intuition, language, memory, reason, and sense this instance was unable to control her emotions in perception. These require balancing and blocking a professional manner. As a result, the nurse was out unreliable knowledge and remaining receptive directed to learn about emotional intelligence that toward knowledge that provides genuine insight. could lead to the ability to control her emotions. Using all the ways of knowing will increase the Faith is arguably one of the more disputed healthcare provider’s ability to engage in critical ways of knowing and depends on its interpreta- cultural reflection (Ways of Knowing: Theory of tion by the knower. It may or not may have Knowledge.net 2017). religious connotations. One’s faith is highly Emotion can act as a catalyst for reflection, dependent on culture and the knowledge of the be it a source of reflection or a by-product. community in which one belongs. Faith refers Goleman (2005) identifies self-awareness, self- to the notions of trust, commitment, and the management, social awareness, and relationship acceptance of assumptions; it may fulfill a psy- skills as emotional literacy. Emotional literacy chological need (Ways of Knowing: Faith is a self-conscious awareness: an awareness of 2017). Providers who have faith in their prac- the assumptions, reasoning, evidence, and justi- tice are in a better position to critically reflect fication that underpin one’s values and beliefs. on their cultural abilities. Faith as a way of Emotional intelligence is defined by a person’s knowing is a belief without empirical evidence, ability to recognize emotions and emotional a foundational truth upon which other knowl- states and to name them (Akers and Grover edge claims are based or derived. This founda- 2017; Goleman 2005). It also includes the ability tional truth can be metaphysical in nature such to control emotions “appropriately” (a manner as a belief in a supreme being or moral in that is suitable or proper in the circumstances), nature such as a belief in goodness (Faith as a 100 L. Purnell

Way of Knowing 2017) as in seeking social the time reasoning is instinctive, depends on justice for vulnerable populations. previous experiences, and is a requisite in critical A fundamental faith concept is “is there life cultural reflection and self-awareness. after death.” Whereas no scientific evidence Sense perception, such as sight, smell, hear- exists to support this belief, many people believe ing, taste, and touch, is an external stimulus that this is true and encourages them to go on. In this is used by healthcare providers in providing belief, faith is mainly derived through prayer and care. It also includes internal perception such by no other means in life. It can offer deep as a feeling, an awareness or sensitivity to atti- contemplation to self-evaluate actions (Faith as a tudes or a situation, and the meaning of a word Way of Knowing 2017). or expression or the way in which a word or Imagination, forming new ideas or concepts, expression can be interpreted. Although sensing includes the ability to be creative or resourceful. is a valid way of knowing, to what extent can It is a way of developing knowledge without the we trust our senses (Theory of Knowledge.net help of our senses and allows an extra scope in 2014)? understanding concepts, ideas, or phenomena. The ability to make a leap of understanding 10.2.1.2 Dewey’s Model of Reflective without necessarily knowing how and why is Learning included. Healthcare providers who work in Dewey’s model of reflective learning (Miettinen resource-poor environments frequently use their 2000; Rogers 2002) has four criteria. The process imagination in providing care. of reflection moves the learner from one experi- Intuition is the ability to understand some- ence to another, leading to a deeper understand- thing instinctively without the need for conscious ing, and ensures an individual’s progress and reasoning. Intuition is associated with innate ultimately society. Reflection is systematic and knowledge and is linked to ethics and knowing disciplined and has its roots in scientific inquiry instinctively the “right” and the “wrong” way and (Schon 2014). Reflection occurs within the indi- is a combination of memory, emotion, and sense vidual, in the community, and in interactions, in perception (Cholle 2011). this incidence with vulnerable population leading Language is a system of verbal and nonverbal to culturally competent and congruent care. It also communication (see Chap. 2) used by each com- requires attitudes that value diversity and social munity or country. Idioms and colloquialisms justice among individuals and groups, requisites that might be understood in one community may for culturally congruent care. Given Dewey’s four not be understood by outsiders; therefore, the criteria, the healthcare provider who applies these healthcare provider must take caution and not use criteria is in a better cognitive situation to provide colloquialisms and idioms with patients. Patients culturally competent and congruent care with vul- also use colloquialisms and idioms; the onus is nerable populations and have a better understand- on the provider to get clarification of their ing of the social determinants of health (see Chap. meaning. 1). Interactive experiences between oneself and Memory is not a primary way of knowing. the world change healthcare providers’ world- However, it provides us with initial knowledge and view (How We Think: John Dewey on the Art of only afterward employs memory to modify and Reflection and Fruitful Curiosity in an Age of enhance that knowledge. Cultural knowledge Instant Opinions and Information Overload n.d.) increases as one works with diverse staff and vul- and assist them in delivering culturally competent nerable groups. Because memory is notoriously assessment and culturally competent care (Rogers unreliable, it must be treated with care if one is to 2002). build upon objective cultural knowledge. Reason, the way in which we try to make 10.2.1.3 Habermas’s Model of Critical sense of the world, uses logic, rationality, Reflection comparison, judgment, and experience; all of The critical theory of Habermas differentiates three these are requisites for critical reflection. Most of generic cognitive areas in which to generate 10 Critical Reflection 101 knowledge: work knowledge, practical knowledge, they can be examined and integrated with and emancipatory knowledge; they are grounded in new, more refined ideas. different aspects of social existence—work, 3. Learning requires resolving conflicts between interaction, and power (The Critical Theory of opposed adaptations to the world, again in this Jurgen Habermas n.d.). Work knowledge is the way case opposing cultures between the patient we control and manipulate the environment where and the healthcare provider. knowledge is based upon empirical investigation 4. Learning is a holistic process of adapting to and governed by technical rules. Effective control the world and involves integrated functioning of reality directs appropriate actions. Much of what of the whole person—thinking, feeling, we consider “scientific” research such as physics, perceiving, and behaving. chemistry, and biology (shall we include nursing 5. Learning results from synergetic transaction and medicine) belong to the work domain. between the person and the environment Practical knowledge, human social interac- through processes assimilating new experi- tion, is governed by consensual norms and expec- ences into existing concepts and accommo- tations of behavior between individuals. The dating these concepts to new experiences. validity of social norms is grounded in the inter- 6. Learning creates knowledge where social subjectivity of the mutual understanding of inten- knowledge is recreated in the personal tions and determines what appropriate actions knowledge of the learner. are. Descriptive social science, history, aesthetics, legal, and ethnographic literary belong to the 10.2.2.1 Feminist Theory domain of the practical domain. Feminist theory seeks justice for women and the Emancipatory knowledge identifies self- end of sexism in all forms and is driven by the knowledge or self-reflection and is the way one quest for social justice and includes vulnerable sees oneself, one’s roles, and social expectations. populations. Currently, feminist theory has Emancipation limits our options and rational expanded to address a wide range of perspectives control over our lives but has been taken for on social, cultural, and political phenomena and granted as beyond human control. Insights gained includes class and work, disability, the family, through critical self-awareness are emancipatory globalization, human rights, race and racism, in the sense that at least one can recognize and discrimination of all types, reproduction, and probe for underlying circumstances that shape sexuality. Feminist theory does not require a inequality and injustice. Self-emancipation particular methodology but rather addresses topics through reflection leading to a transformed of concern for social justice. Feminist theory has consciousness includes such sciences as feminist been divided into liberal and radical feminism. theory, psychoanalysis, and the critique of Liberal feminism, although considered passé ideology (Chinn 2018; The Critical Theory of by some, is most aligned with the National Jurgen Habermas n.d.). Organization for Women (NOW). However, many disagree that liberal feminism, although considered passé because the 1967 Women’s Bill 10.2.2 Kolb’s Model of Experiential of Rights that have yet to be fully implemented, Learning in less developed and in more developed countries (Tong 2018). Kolb’s model of experiential learning has six Radical feminists claim that women’s funda- components (Kolb and Kolb 2005): mental strength rests in their differences from men. They do not think it is in women’s best 1. Learning is conceived as a process with con- interests to be part of a system that devalues tinuing reconstruction of an experience. caregiving practices and occupations. Women 2. All learning is relearning and is best facili- should reject this system because its values of tated by drawing out a person’s beliefs and power, dominance, hierarchy, and competition ideas about a topic (in this case culture), so breed injustice. 102 L. Purnell

10.2.2.2 Summary Ways of Knowing 10.2.3 Recommendations Nursing and other healthcare professionals have explored and struggled with critical reflection, Recommendations for clinical practice, educa- thinking, and reasoning. No consensus has been tion, and research follow. agreed upon as to what is the best approach. Some ways of knowing have scientific rigor, 10.2.3.1 Recommendations whereas others have no scientific basis and prob- for Clinical Practice ably never will. However, there is some agree- Nurses, and all healthcare professionals, must ment that the nonscientific-based ways of develop an awareness of their own existence, sen- knowing still have merit for many. Health profes- sations, thoughts, and environment without letting sionals should use more than one way of know- then have an undue influence on those from other ing and expand their critical thinking and backgrounds. One must strive to learn the health reasoning skills and engage in self-reflection and beliefs, values, and cultural care practices of awareness when caring for patients from differ- patients to whom care is provided. Inherent in ent cultures. learning patients cultures the provider must accept Chinn (2018) summarized emancipatory ways and respect cultural differences in a manner that of knowing and critical reflection theories based facilitates the patient’s and the family’s abilities to on the American Association of Colleges of make decisions to meet their needs and beliefs. Nursing’s document Essentials of Doctoral One must accept and recognize that the health- Education in Advanced Practice Nursing (2006). care provider’s beliefs and values may not be the In their entirety, these essentials address compe- same as the patient’s being open to new cultural tencies for advanced practice nursing for social encounters and must resist judgmental attitudes justice and advocacy for vulnerable populations. such as “different is not as good.” Moreover, rec- These essentials are: ognize that the variant cultural characteristics determine the degree to which patients adhere to • Scientific underpinnings for practice and how the beliefs, values, and practices of their domi- they account for social and political contexts nant culture (see Chap. 3). To learn cultural attri- for whom care is provided butes of diverse populations, make contact with • Organizational and systems leadership for and have experiences with the communities from quality improvement and systems thinking which patients come. with a global, social, and political systems As professionals, nurses must accept responsi- approach bility for their own education in cultural compe- • Clinical scholarship and analytical methods tence by attending conferences, reading cultural for evidence-based practice by asking ques- literature, and observing cultural practices. In tions such as who will be disadvantaged or addition, they must develop an attitude of open- stereotyped mindedness, respect for individuals, and discour- • Information systems/technology and patient age racial and ethnic slurs among coworkers. care technology for the improvement and Participating in cultural events provides knowl- transformations of healthcare for disadvan- edge about the primary characteristics of culture taged and vulnerable populations for that population and helps develop respect • Healthcare policy for advocacy in healthcare from for them. for the disadvantaged as well as all members Additional activities can incorporate a journal of the community to record thoughts, experiences, and observations • Interprofessional collaboration for improving with culturally diverse encounters. Learning a patient and population health outcomes second or third language helps increase tolerance • Clinical prevention and population health for for ambiguity and helps develop rapport with improving a nation’s health by looking at what patients. Taking a self-administered tool helps is creating patterns of injustice, disadvantage, determine one’s biases and prejudices (see and discrimination Appendices 1–3). 10 Critical Reflection 103

10.2.3.2 Recommendations In college settings, faculty can engage stu- for Administration dents in cultural immersion and exchange pro- Administration must integrate diversity and inclu- grams, especially with populations seen in the sivity statements in the organization’s mission and catchment area of the facility. Cultural immer- philosophy along with creating policies that address sions can also occur in foreign countries and in bias, discrimination, and racial and ethnic slurs. other parts of a country, especially in such These policies should be incorporated into perfor- large countries as the United States, China, and mance evaluations of all staff, mangers, and admin- India as examples. istrators. Administration must also provide a budget for staff and managers to attend cultural compe- 10.2.3.4 Recommendations tence courses and conferences. for Research Developing patient satisfaction surveys in lan- Establish journal clubs to review current litera- guages spoken by the organization’s patient pop- ture on critical reflection and self-awareness of ulation and specifically asking questions on bias, staff’s beliefs and values related to practice. discrimination, and ethnic and racial slurs will Evidence-based publications are a requisite, help assure language-diverse populations being although the gray literature can be used if no able to complete them. More complete data research publication can be found on the specific assists with questioning routines that do not meet patient population. Obtaining experienced the need of multicultural staff and patients. researchers can assist staff and managers to con- Actively participating providers in community duct research and quality improvement projects activities and organizations enhances visibility on cultural competence and critical reflection. and trust in the community. Engaging city policymakers and planners in discussions on vulnerable Conclusion population can help alleviate health disparities of Although the literature provides numerous vulnerable populations. Other activities are part- definitions of cultural self-awareness and cul- nering with community churches and social ser- tural critical reflection, research integrating the vice agencies to address the social and structural concept of self-awareness with multicultural determinants of health in the community. competence is minimal. Many theorists and diversity trainers imply that self-examination 10.2.3.3 Recommendations for or awareness of personal prejudices and biases Education and Training is an important step in the cognitive process of Educational leaders can organize cultural developing cultural competence (Andrews and awareness activities and promote critical reflec- Boyle 2016; Calvillo et al. 2009; Hickson tion through team meetings by discussing pub- 2011). Given that all healthcare providers have lished case studies as well as encouraging staff conscious and unconscious biases, concerted to talk about cases in which they have provided effort must be taken to recognize them and not care. Classes that address bias, discrimination, let them affect care (Cuellar 2017). Conscious and racial and ethnic slurs should be included; and unconscious biases can include race, eth- some staff are not aware that they make racial nicity, color, socioeconomic class, gender, slurs or use terminology/words that are seen as alternative life styles, religion, and a host of offensive to others. This will help assist staff to other “differences (Ghoshal et al. 2013). recognize biases and stereotyping and devise a Introspective critical reflection requires con- plan to overcome them. stantly reviewing one’s own thoughts, feelings, The education department can host programs and beliefs concerning social justice and vul- and workshops for staff that encourage critical nerable populations. Academic literature on reflection and self-awareness of cultural values emotional feelings elicited by this cognitive and beliefs and offer them to other area organiza- awareness is somewhat limited regarding the tions that might have a different patient potential impact of emotions and conscious population. feelings on behavioral outcomes. Management 104 L. Purnell

and administration must make a concerted B = Things I do occasionally, or statement applies effort to assist staff to recognize their con- to me to a moderate degree scious and unconscious bias. C = Things I do rarely or never, or statement Cultural critical reflection is a deliberate applies to me to minimal degree or not at all and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional Physical Environment, Materials, knowledge standards, your ethics, and the and Resources impact of these factors on the various roles you play when interacting with individuals differ- _____ 1. I display pictures, posters, artworks, and ent from yourself (Purnell and Salmond 2013). other decors that reflect the cultures and Critically analyzing our own values and beliefs ethnic backgrounds of clients served by in terms of how we see differences enables us my program or agency. to be less fearful of others whose values and _____ 2. I ensure that magazines, brochures, and beliefs are different from our own (Calvillo other printed materials in reception et al. 2009; Hickson 2011). The ability to areas are of interest to and reflect the understand oneself sets the stage for integrat- different cultures and languages of indi- ing new knowledge related to cultural differ- viduals and families served by my pro- ences into the healthcare provider’s knowledge gram or agency. base, perceptions of health, interventions, and _____ 3. When using videos, films, or other media the impact these factors have on the various resources for health education, treatment, roles of professionals when interacting with or other interventions, I ensure that they multicultural patients. Critical reflection is a reflect the culture and ethnic backgrounds key activity in creating caring cultures because of individuals and families served by my it can enable individuals to develop greater program or agency. self-awareness by helping them to develop _____ 4. I ensure that printed information dis- new understanding that informs actions. seminated by my agency or program Every patient and caregiver has the right to takes into consideration accuracy and be treated without prejudice; people should without bias. not be discriminated against because of religion, ethnicity, race, socioeconomic status, or physical or mental disability. Feminist theory Communication Styles emphasizes social and ethical issues, as well as political and personal perspectives. _____ 5. When interacting with individuals and families who have limited English proficiency, I always keep in mind that: Appendix 1: Promoting Cultural * Limitations in English proficiency and Linguistic Competency are in no way a reflection of their level of intellectual functioning. Self-Assessment Checklist * Their limited ability to speak the for Personnel Providing Primary language of the dominant culture Healthcare Services has no bearing on their ability to communicate effectively in their Please select A, B, or C for each item listed language of origin. below. * They may neither be literate in their language of origin nor in English. A = Things I do frequently, or statement applies ______6. I use bilingual/bicultural or multilingual/ to me to a great degree multicultural staff and/or personnel and 10 Critical Reflection 105

volunteers who are skilled or certified in cultures or ethnic groups other than the provision of medical interpretation my own. services during treatment, interventions, _____ 15. I screen books, movies, and other meetings, or other events for individu- media resources for negative cultural, als and families who need or prefer this ethnic, or racial stereotypes before level of assistance. sharing them with individuals and ______7. For individuals and families who speak families served by my program or languages or dialects other than agency. English, I attempt to learn and use key _____ 16. I intervene in an appropriate manner words so that I am better able to com- when I observe other staff or clients municate with them during assessment, within my program or agency engag- treatment, or other interventions. ing in behaviors that show cultural ______8. I attempt to determine any familial col- insensitivity, racial biases, and loquialisms used by individuals or prejudice. families that may impact on assess- _____ 17. I recognize and accept that individuals ment, treatment, health promotion and from culturally diverse backgrounds education, or other interventions. may desire varying degrees of accul- ______9. For those who request or need this turation into the dominant culture. service, I ensure that all notices and _____ 18. I understand and accept that family is communiqués to individuals and defined differently by different cul- families are written in their language tures (e.g., extended family members, of origin. fictive kin, godparents). _____ 10. I understand that it may be necessary _____ 19. I accept and respect that male-female to use alternatives to written commu- roles may vary significantly among nications for some individuals and different cultures (e.g., who makes families, as word of mouth may be a major decisions for the family). preferred method of receiving _____ 20. I understand that age and life cycle information. factors must be considered in interac- _____ 11. I understand the principles and prac- tions with individuals and families tices of linguistic competency and: (e.g., high value placed on the deci- * Apply them within my program or sion of elders, the role of eldest male agency or female in families, or roles and * Advocate for them within my pro- expectation of children within the gram or agency family). _____ 12. I understand the implications of health _____ 21. Even though my professional or moral literacy within the context of my roles viewpoints may differ, I accept indi- and responsibilities. viduals and families as the ultimate _____ 13. I use alternative formats and varied decision-makers for services and sup- approaches to communicate and share ports impacting their lives. information with individuals and/or _____ 22. I recognize that the meaning or value of their family members who experience medical treatment and health education disability. may vary greatly among cultures. _____ 23. I accept that religion and other beliefs may influence how individuals and Values and Attitudes families respond to illnesses, disease, and death. _____ 14. I avoid imposing values that may con- _____ 24. I understand that the perception of flict or be inconsistent with those of health, wellness, and preventive health 106 L. Purnell

services has different meanings to dif- tribute to health and mental health dis- ferent cultural groups. parities or other major health problems _____ 25. I recognize and understand that beliefs of culturally and linguistically diverse and concepts of emotional well-being populations served by my program or vary significantly from culture to agency. culture. _____ 35. I am well versed in the most current _____ 26. I understand that beliefs about mental and proven practices, treatments, and illness and emotional disability are interventions for the delivery of health culturally based. I accept that and mental healthcare to specific responses to these conditions and racial, ethnic, cultural, and linguistic related treatments/interventions are groups within the geographic locale heavily influenced by culture. served by my agency or program. _____ 27. I recognize and accept that folk and reli- _____ 36. I avail myself to professional develop- gious beliefs may influence an individ- ment and training to enhance my ual’s or family’s reaction and approach knowledge and skills in the provision to a child born with a disability or later of services and supports to culturally diagnosed with a disability, genetic dis- and linguistically diverse groups. order, or special healthcare needs. _____ 37. I advocate for the review of my pro- _____ 28. I understand that grief and bereave- gram’s or agency’s mission statement, ment are influenced by culture. goals, policies, and procedures to _____ 29. I accept and respect that customs and ensure that they incorporate principles beliefs about food, its value, prepara- and practices that promote cultural tion, and use are different from culture and linguistic competence. to culture. _____ 30. I seek information from individuals, Reprinted with Permission: Tawara D. Goode families, or other key community • National Center for Cultural Competence informants that will assist in service • Georgetown University Center for Child & Human adaptation to respond to the needs and Development • University Center for Excellence preferences of culturally and ethni- in Developmental Disabilities, Education, cally diverse groups served by my pro- Research & Service • Adapted Promoting Cultural gram or agency. Competence and Cultural Diversity for Personnel _____ 31. Before visiting or providing services Providing Services and Supports to Children with in the home setting, I seek information Special Health Care Needs and their Families on acceptable behaviors, courtesies, • June 1989 (Revised 2009). customs, and expectations that are SCORING: This checklist is intended to unique to the culturally diverse groups heighten the awareness and sensitivity of person- served by my program or agency. nel to the importance of cultural and linguistic _____ 32. I keep abreast of the major health and cultural competence in health, mental health, and mental health concerns and issues for human service settings. It provides concrete ethnically and racially diverse client examples of the kinds of beliefs, attitudes, values, populations residing in the geographic and practices which foster cultural and linguistic locale served by my program or agency. competence at the individual or practitioner level. _____ 33. I am aware of specific health and men- There is no answer key with correct responses. tal health disparities and their preva- However, if you frequently responded “C,” you lence within the communities served may not necessarily demonstrate beliefs, atti- by my program or agency. tudes, values, and practices that promote cultural _____ 34. I am aware of the socioeconomic and and linguistic competence within health and environmental risk factors that con- mental healthcare delivery programs. 10 Critical Reflection 107

Appendix 2: Promoting Cultural and their families to create their own and Linguistic Competency books and include them among the resources and materials in my early Self-Assessment Checklist childhood program or setting. for Personnel Providing Services ______7. I adapt the above referenced and Supports in Early Intervention approaches when providing services, and Early Childhood Settings supports, and other interventions in the home setting. Directions: Please select A, B, or C for each item ______8. I encourage and provide opportunities listed below. for children and their families to share experiences through storytelling, pup- A = Things I do frequently, or statement applies pets, marionettes, or other props to to me to a great degree support the “oral tradition” common B = Things I do occasionally, or statement applies among many cultures. to me to a moderate degree ______9. I plan trips and community outings to C = Things I do rarely or never, or statement places where children and their fami- applies to me to minimal degree or not at all lies can learn about their own cultural or ethnic history as well as the history of others. Physical Environment, Materials, _____ 10. I select videos, films, or other media and Resources resources reflective of diverse cultures to share with children and families ______1. I display pictures, posters, and other served in my early childhood program materials that reflect the cultures and or setting. ethnic backgrounds of children and _____ 11. I play a variety of music and introduce families served in my early childhood musical instruments from many program or setting. cultures. ______2. I select props for the dramatic play/ _____ 12. I ensure that meals provided include housekeeping area that are culturally foods that are unique to the cultural diverse (e.g., dolls, clothing, cooking and ethnic backgrounds of children utensils, household articles, furniture). and families served in my early child- ______3. I ensure that the book/literacy area has hood program or setting. pictures and storybooks that reflect the _____ 13. I provide opportunities for children different cultures of children and fami- to cook or sample a variety of foods lies served in my early childhood pro- typically served by different cul- gram or setting. tural and ethnic groups other than ______4. I ensure that tabletop toys and other their own. play accessories (that depict people) _____ 14. If my early childhood program or set- are representative of the various cul- ting consists entirely of children and tural and ethnic groups both within my families from the same cultural or eth- community and the society in general. nic group, I feel it is important to plan ______5. I read a variety of books exposing chil- an environment and implement activi- dren in my early childhood program or ties that reflect the cultural diversity setting to various life experiences of within the society at large. cultures and ethnic groups other than _____ 15. I am cognizant of and ensure that cur- their own. ricula I use include traditional holi- ______6. When such books are not available, days celebrated by the majority I provide opportunities for children culture, as well as those holidays that 108 L. Purnell

are unique to the culturally diverse (b) Advocate for them within my pro- children and families served in my gram or agency early childhood program or setting. _____ 23. I use bilingual or multilingual staff and/or trained/certified foreign language interpreters for meetings, con- Communication Styles ferences, or other events for parents and family members who may require _____ 16. For children who speak languages or this level of assistance. dialects other than English, I attempt _____ 24. I encourage and invite parents and to learn and use key words in their lan- family members to volunteer and guage so that I am better able to com- assist with activities regardless of their municate with them. ability to speak English. _____ 17. I attempt to determine any familial col- _____ 25. I use alternative formats and varied loquialisms used by children and fam- approaches to communicate with chil- ilies that will assist and/or enhance the dren and/or their family members who delivery of services and supports. experience disability. _____ 18. I use visual aids, gestures, and physi- _____ 26. I arrange accommodations for parents cal prompts in my interactions with and family members who may require children who have limited English communication assistance to ensure proficiency. their full participation in all aspects of _____ 19. When interacting with parents and the early childhood program (e.g., other family members who have lim- hearing impaired, physical disability, ited English proficiency, I always keep visually impaired, not literate or low in mind that: literacy, etc.). ____ (a) Limitation in English profi- _____ 27. I accept and recognize that there are ciency is in no way a reflec- often differences between language tion of their level of used in early childhood/early interven- intellectual functioning. tion settings, or at “school,” and in the ____ (b) Their limited ability to speak home setting. the language of the dominant culture has no bearing on their ability to communicate Values and Attitudes effectively in their language of origin. _____ 28. I avoid imposing values that may con- ____ (c) They may neither be literate flict or be inconsistent with those of in their language of original cultures or ethnic groups other than English. my own. _____ 20. I ensure that all notices and communi- _____ 29. I discourage children from using racial qués to parents are written in their lan- and ethnic slurs by helping them guage of origin. understand that certain words can hurt _____ 21. I understand that it may be necessary others. to use alternatives to written commu- _____ 30. I screen books, movies, and other nications for some families, as word of media resources for negative cultural, mouth may be a preferred method of ethnic, racial, or religious stereotypes receiving information. before sharing them with children and _____ 22. I understand the principles and prac- their families served in my early child- tices of linguistic competency and: hood program or setting. (a) Apply them within my early child- _____ 31. I provide activities to help children hood program or setting learn about and accept the differences 10 Critical Reflection 109

and similarities in all people as an _____ 41. I understand that beliefs about mental ongoing component of program illness and emotional disability are curricula. culturally based. I accept that _____ 32. I intervene in an appropriate manner responses to these conditions and when I observe other staff or parents related treatments/interventions are within my program or agency engag- heavily influenced by culture. ing in behaviors that show cultural _____ 42. I understand that the healthcare prac- insensitivity, bias, or prejudice. tices of families served in my early _____ 33. I recognize and accept that individuals childhood program or setting may be from culturally diverse backgrounds rooted in cultural traditions. may desire varying degrees of accul- _____ 43. I recognize that the meaning or value turation into the dominant culture. of early childhood education or early _____ 34. I understand and accept that family is intervention may vary greatly among defined differently by different cul- cultures. tures (e.g., extended family members, _____ 44. I understand that traditional approaches fictive kin, godparents). to disciplining children are influenced _____ 35. I accept and respect that male-female by culture. roles in families may vary significantly _____ 45. I understand that families from differ- among different cultures (e.g., who ent cultures will have different expec- makes major decisions for the family, tations of their children for acquiring play and social interactions expected toileting, dressing, feeding, and other of male and female children). self-help skills. _____ 36. I understand that age and life cycle _____ 46. I accept and respect that customs and factors must be considered in interac- beliefs about food, its value, preparations with families (e.g., high value tion, and use are different from culture placed on the decisions or child-rear- to culture. ing practices of elders or the role of _____ 47. Before visiting or providing services the eldest female in the family). in the home setting, I seek information _____ 37. Even though my professional or moral on acceptable behaviors, courtesies, viewpoints may differ, I accept the customs, and expectations that are family/parents as the ultimate deci- unique to families of specific cultural sion-makers for services and supports groups served in my early childhood for their children. program or setting. _____ 38. I accept that religion, spirituality, and _____ 48. I advocate for the review of my pro- other beliefs may influence how fami- gram’s or agency’s mission statement, lies respond to illness, disease, and goals, policies, and procedures to death. ensure that they incorporate principles _____ 39. I recognize and understand that beliefs and practices that promote cultural and concepts of mental health or emo- diversity, cultural competence, and tional well-being, particularly for linguistic competence. infants and young children, vary sig- _____ 49. I seek information from family mem- nificantly from culture to culture. bers or other key community infor- _____ 40. I recognize and accept that familial mants that will assist me to respond folklore, religious, or spiritual beliefs effectively to the needs and prefer- may influence a family’s reaction and ences of culturally and linguistically approach to a child born with a dis- diverse children and families served ability or later diagnosed with a dis- in my early childhood program or ability or special healthcare needs. setting. 110 L. Purnell

Reprinted with Permission: Tawara D. Goode 3. I look at my own attitudes and behaviors as • National Center for Cultural Competence an adult to determine the ways they may be • Georgetown University Center for Child & contributing to or combating prejudice in Human Development • University Center for society. Excellence in Developmental Disabilities, Edu Never ______Always cation, Research & Service • Adapted Promoting 4. I evaluate my use of language to avoid terms Cultural Competence and Cultural Diversity for or phrases that may be degrading or hurtful Personnel Providing Services and Supports to to other groups. Children with Special Health Care Needs and their Never ______Always Families • June 1989 (Revised 2009). 5. I avoid stereotyping and generalizing other SCORING: This checklist is intended to people based on their group identity. heighten the awareness and sensitivity of per- Never ______Always sonnel to the importance of cultural diversity, 6. I value cultural differences and avoid state- cultural competence, and linguistic compe- ments such as “I never think of you tence in early childhood settings. It provides as______,” which discredits concrete examples of the kinds of practices differences. that foster such an environment. There is no Never ______Always answer key with correct responses. However, 7. I am comfortable discussing issues of rac- if you frequently responded “C,” you may not ism, anti-Semitism and other forms of preju- necessarily demonstrate practices that pro- dice with others. mote a culturally diverse and culturally com- Never ______Always petent learning environment for children and 8. I am open to other people’s feedback about families within your classroom, program, or ways in which my behavior may be cultur- agency. ally insensitive or offensive to others. Never ______Always 9. I give equal attention to other people regard- Appendix 3: Personal Self- less of race, religion, gender, socioeconomic Assessment of Antibias Behavior class or other difference. Never ______Always Directions: Using the rating scale of NEVER to 10. I am comfortable giving constructive feed- ALWAYS, assess yourself for each item by plac- back to someone of another race, gender, age ing an “X” on the appropriate place along each or physical ability. continuum. When you have completed the check- Never ______Always list, review your responses to identify areas in 11. The value of diversity is reflected in my need of improvement. Create specific goals to work, which includes a wide range of racial, address the areas in which you would like to religious, ethnic and socioeconomic groups, improve. even when these groups are not personally represented in my community. 1. I educate myself about the culture and expe- Never ______Always riences of other racial, religious, ethnic and 12. I work intentionally to develop inclusive socioeconomic groups by reading and practices, such as considering how the time, attending classes, workshops, cultural location and cost of scheduled meetings and events, etc. programs might inadvertently exclude cer- Never ______Always tain groups. 2. I spend time reflecting on my own upbring- Never ______Always ing and childhood to better understand my 13. I work to increase my awareness of biased own biases and the ways I may have internal- content in television programs, newspapers ized the prejudicial messages I received. and advertising. Never ______Always Never ______Always 10 Critical Reflection 111

14. I take time to notice the environment of my Canadian Nurses Association (2010) Position statement: home, office, house of worship and children’s promoting cultural competence in nursing. https:// www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ school, to ensure that visual media represent ps114_cultural_competence_2010_e.pdf?la=en. diverse groups, and I advocate for the addi- Accessed 2 June 2017 tion of such materials if they are lacking. Carper BA (1978) Fundamental patterns of knowing in Never ______Always nursing. Adv Nurs Sci 1(1):13–23 Chinn P (2018) Critical theory and emancipatory knowing. 15. When other people use biased language and In: Butts JB, Rich KL (eds) Philosophies and theories behavior, I feel comfortable speaking up, ask- for advanced nursing practice. Jones & Bartlett Learning ing them to refrain and stating my reasons. Chinn PL, Kramer MK (2015) Knowledge development in Never ______Always nursing theory and process, 9th edn. Elsevier, St. Louis Cholle FP (2011) What is intuition, and how do we use it? 16. I contribute to my organization’s achieve- https://www.psychologytoday.com/blog/the-intuitive- ment of its diversity goals through program- compass/201108/what-is-intuition-and-how-do-we- ming and by advocating for hiring practices use-it. Accessed 2 June 2017 that contribute to a diverse workforce. Cuellar N (2017) Unconscious bias. What is yours? J Transcult Nurs 28(4):333 Never ______Always Dewey J (1933) How we think: a restatement on the rela- 17. I demonstrate my commitment to social jus- tion of reflective thinking to the educative process. tice in my personal life by engaging in activi- D.C. Health, New York ties to achieve equity. Douglas M, Rosenketter M, Pacquiao D, Clark Callister L et al (2014) Guidelines for implementing cul- Never ______Always turally competent nursing care. J Transcult Nurs 25(2):109–221 This activity was adapted from “Commitment to Faith as a Way of Knowing. http://www.agakhanacad- emies.org/sites/default/files/AKA%20Faith%20 Combat Racism” by Dr. Beverly Tatum & Andrea Booklet%20for%20IB%20TOK.pdf. Accessed 3 June Ayvazian in White Awareness: Handbook for Anti- 2017 Racism Training by Judy H. Katz. ©1978 by the Ghoshal RA, Lippard C, Ribas V, Muir K (2013) Beyond University of Oklahoma Press, Norman. Reprinted bigotry: teaching about unconscious prejudice. Teach Sociol 41(2):130–143. http://vlib.excelsior. by permission of the publisher. All rights reserved. edu/login?url=http://search.ebscohost.com/login.asp Permission was also granted from the Anti- x?direct=true&db=sih&AN=86187613&site=eds- Defamation League, Education Division, A live&scope=site. Accessed 11 July 2017 WORLD OF DIFFERENCE® Institute © 2007 Goleman D (2005) Emotional intelligence: why it can matter more than IQ. Bloomsbury Publishing, London Anti-Defamation League: www.adl.org/educa- Hickson H (2011) Critical reflection: reflecting on learn- tion; email: [email protected]. ing to be reflective. Reflect Pract Interprof Multidiscip Perspect 12(6):829–839 How We Think: John Dewey on the Art of Reflection References and Fruitful Curiosity in an Age of Instant Opinions and Information Overload (n.d.) https://www.brain- Akers M, Grover P (2017) What is emotional intelli- pickings.org/2014/08/18/how-we-think-john-dewey/. gence? Psych Central. https://psychcentral.com/lib/ Accessed 2 June 2017 what-is-emotional-intelligence-eq/. Accessed 2 June ICN Code of Ethics for Nurses (2012) http://www.icn. 2017 ch/who-we-are/code-of-ethics-for-nurses/. Accessed American Association of Colleges of Nursing (2006) 2 June 2017 Essentials of doctoral education in advanced practice Johns C (1995) Framing learning through reflection nursing. http://www.aacn.nche.edu/publications/posi- within Carper’s fundamental ways of knowing in nurs- tion/DNPEssentials.pdf. Accessed 5 June 2017 ing. J Adv Nurs 22:226–234 American Nurses Association (2015) Code of ethics for Kolb AY, Kolb DA (2005) Kolb learning style inventory. nurses with interpretive statements. Author, Silver Experience Based Learning Systems, Inc. https://search. Spring yahoo.com/yhs/search;_ylt=A0LEViOkBIFYzec Andrews MM, Boyle JS (eds) (2016) Transcultural con- ABzonnIlQ;_ylu=X3oDMTEwcTc4aWkwBGN cepts and nursing care, 7th edn. Wolters Kluwer, vbG8DYmYxBHBvcwMxBHZ0aWQDBHNlYwNxc3 Philadelphia MtcXJ3?ei=UTF-8&hspart=mozilla&hsimp=yhs- Calvillo E, Clark L, Purnell L, Pacquiao D, Ballantyne 002&fr=yhs-mozilla-002&p=Kolb%2C+%26+Kolb%2 J, Villaruel S (2009) Cultural competencies in health C+D.A.+%282005%29.+Kolb+Learning+Style+Invento care: emerging changes in baccalaureate nursing edu- ry.+Experience+Based+Learning+Systems%2C+Inc. cation. J Transcult Nurs 20(2):137–145 &fr2=12642. Accessed 2 June 2017 112 L. Purnell

Mezirow J (1990) Fostering critical reflection in adult- Sullivan-Marx EM (2013) The bear and the canyon: hood. Jossey-Bass, San Francisco toward an understanding of personal leadership. Nurs Miettinen R (2000) The concept of experiential learning Sci Q 26(4):373–375 and John Dewey’s theory of reflective thought and The Critical Theory of Jurgen Habermas (n.d.) http:// action. Int J Lifelong Educ 19(1):54–72. https://doi. physicsed.buffalostate.edu/danowner/habcritthy.html. org/10.1080/026013700293458. Accessed 7 June 2017 Accessed 4 June 2017 Purnell L, Salmond S (2013) Individual cultural com- Theory of Nursing Knowldege. http://www.theoryofknowl- petence and evidence-based practice. In: Purnell L edge.net/. Accessed March 10, 2018 (ed) Transcultural health care: a culturally competent Timmins F (2006) Critical practice in nursing care: analy- approach, 4th edn. F.A. Davis, Philadelphia sis, action and reflexivity. Nurs Stand 20:49–54 Rogers C (2002) Dewey’s model of reflective learning. Tong R (2018) Feminist ethics: some applicable thought Teach Coll Rec 104(4):842–866. file:///D:/dewey.pdf. for advance practice nurses. In: Butts JB, Rich KL Accessed 2 June 2017 (eds) Philosophies and theories for advanced nursing Schon DA (2014) The theory of inquiry: Dewey’s legacy practice. Jones & Bartlett Learning to education. Curric Inq 22(2):119–139. http://www. Ways of Knowing: Faith (2017) http://sohowdoweknow. tandfonline.com/doi/abs/10.1080/03626784.1992.110 weebly.com/faith.html. Accessed 3 June 2017 76093?src=recsys. Accessed 2 June 2017 Ways of Knowing: Theory of Knowledge.net (2017) http://www.theoryofknowledge.net/ways-of-knowing/. Accessed 2 June 2017 Case Study: Human Trafficking in Guatemala 11

Joyceen S. Boyle

Maria Luisa, a 16-year-old young woman from logical father as she was abandoned by him at a Escuintla, Guatemala, fled to the United States very young age. Maria Luisa’s family is very and is currently living in Connecticut. She fled poor. She managed to attend school although she Guatemala by herself and after a very arduous often did not have sufficient money to ride the and dangerous journey through Mexico entered bus or to purchase clothes or school supplies. She the United States at Brownsville, Texas. She vol- met an older boy named Geraldo at school who untarily turned herself into US immigration noticed that she often walked to school and fre- authorities and asked for asylum, telling them quently did not do the school assignment as she that she feared for her life if she were returned to did not have money to purchase supplies for the Guatemala. Maria Luisa was very nearly a victim project. Maria Luisa’s mother expected Maria of trafficking for sexual exploitation in Luisa to care for the three younger children; Guatemala. According to the analysis of the those responsibilities also interfered with her International Commission against Impunity in school activities. Geraldo talked to Maria Luisa Guatemala (CICIG) and the United Nations about how good his mother was to him and Children’s Fund (UNICEF), there are an esti- invited her to his home to meet his mother, mated 48,500 direct victims of trafficking for the Regina. Regina would cook for Maria Luisa who purpose of sexual exploitation in Guatemala. The often went hungry and promised that if Maria illegal profits produced by this offense amount to Luisa moved in with her, she would take care of 12.3 billion quetzals (1.75 billion US dollars), her; she would never have to go without anything equivalent to 2.7% of the gross domestic product again. Since the situation at home was not good (GDP), more than the total budget that Guatemala and it seemed to Maria Luisa to be getting worse, spends to educate children and adolescents she moved in with Regina and Geraldo. (CICIG and UNICEF 2016, p. 7). The first day in her new home, Regina took In Guatemala, Maria Luisa lived with her her to buy much-needed new clothes. She then mother, her stepfather, her siblings, and her told Maria Luisa that she needed to go to work maternal grandmother. She never met her bio- with her in a bar at night to help her out. When Regina took Maria Luisa’s phone away from J. S. Boyle, Ph.D., R.N., M.P.H., FAAN her, she suspected something was wrong, but College of Nursing, University of Arizona, she was afraid to ask. While Maria Luisa was at Tucson, AZ, USA the bar wiping up a table, a man approached College of Nursing, Augusta State University, and whispered to her. He asked if she was Augusta, GA, USA related to Regina and Maria Luisa answered no. e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 113 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_11 114 J. S. Boyle

He then told her that Regina (with Geraldo’s 2016, p. 73). Gender-related violence in help) was going to force her into prostitution Guatemala is consistent with a culture of patriar- with male clients at the bar. He urged her to call chy as well as machismo and other widespread her mother and he slipped her his cell phone. dominant expressions of masculinity that struc- Maria Luisa called her mother and begged her ture and reinforce the notion that men “own” to come and get her. The next day, Regina women and that women should be controlled by locked Maria Luisa in the house and would not them. At the present time, gender-based violet her out. Her mother came looking for her, lence, including rape, sexual abuse, beatings, but Regina refused to let Maria Luisa return to and killings, are often inflicted by a woman’s her mother’s home saying that “Maria Luisa family members, a friend, an acquaintance, a wanted to live with her and Geraldo.” Maria partner, a spouse, or a former spouse. Family Luisa’s mother managed to file a complaint members often reinforce behavior related to with the local police who insisted that Regina machismo by telling the abused woman that gen- let Maria Luisa return to her mother. der subordination is “normal” or that the woman For several months after this incident, Geraldo did something to encourage or deserve the vio- kept looking for Maria Luisa, stalking and harass- lence she has suffered. ing her. He threatened to take her back to his The most common type of exploitation may mother. Maria Luisa obtained a restraining order be perpetrated by close relatives of the victim— against Geraldo, but he said that his uncle was a the trafficker may be the brother, the father, an police officer and he (Geraldo) did not need to uncle, or a teacher. Many times mothers allow the pay attention to the restraining order. Maria Luisa abuse to continue in order not to lose income was very frightened; she transferred to a new from their spouse or because they themselves are school, but Geraldo found her there. Geraldo victims of domestic violence. In such a context, would drive by her house with other boys on sexual abuse and gender violence are reproduced motorcycles, stopping to tell her that one day he generationally, always against the weakest and would find her alone and force her back to most vulnerable. UNICEF (2014, p. 20) has Regina’s house. For 10 months, Maria Luisa noted that girls who have experienced physical, lived in fear and finally decided to leave. Even sexual, or psychological violence often have now that she is living in the United States, her mothers who were also victims of abuse. These former classmates in Guatemala tell her that mothers have difficulty managing situations of Geraldo texts them asking about Maria Luisa’s sexual violence; they end up ignoring it and whereabouts. Maria Luisa is afraid that if she is accepting what happened as normal. returned to Guatemala, Regina and Geraldo will kidnap her, perhaps even kill her or force her into prostitution. 11.2 Social Structure Factors

Because of its geographical location, Guatemala 11.1 Cultural Issues is particularly vulnerable to human trafficking. Intensified migration flows have turned it into a CICIG and UNICEF (2016, p. 72) report that the country of origin, transit, and destination of patriarchal culture is the most important factor transnational trafficking. Hondurans and for the existence of trafficking in Guatemala. Salvadorans must cross Guatemala to reach Sexual violence is a constant occurrence in many Mexico and then the United States. Guatemala Guatemalan homes, where the father, the stepfa- has become an important sexual destination; ther, or other close relatives rape boys and girls tourism packages promote these activities, par- at an early age. Forty-five percent of the victims ticularly around the larger cities. However, traf- of sexual or gender violence in Guatemala are ficking does not stand alone as organized crimes under 14 years of age (CICIG and UNICEF involving drug cartels, gang violence, and par- 11 Case Study: Human Trafficking in Guatemala 115 ticularly human trafficking are criminal activi- 11.3 Culturally Competent ties that can only take place with the active or Strategies Recommended passive participation of state authorities. The Policia Nacional Civil (PNC), the security force Many healthcare professionals in the United responsible for civilian safety, has a long history States will come into contact with persons who of ignoring human rights abuses, including have been sexually exploited in Guatemala or human trafficking for sexual exploitation. In other Central America countries. “In fiscal 2016, addition, a weak judiciary system that fails to the Border Patrol apprehended 58,819 unaccom- investigate, judge, and punish perpetuators of panied children and 73,888 family units along the criminal activities only promotes strong criminal southwest border. Most were from El Salvador, structures. A justice system that exhibits sexist Honduras, and Guatemala” (Sherman 2017). and discriminatory behaviors that reinforce the While some of these migrants are in immigration social ideology that a victim causes or is guilty detention centers, others have been given immi- of initiating the crime (provocative dress or gration court dates and are living with relatives behaviors) excuses the behavior of the throughout the country. Some migrants who have aggressor. applied for asylum are eligible for Medicaid and Victims of exploitation and trafficking have CHIP (Children’s Health Insurance Program). reported that municipal officials and employees There are also many free-standing clinics and are users of sexual services of girls and adoles- urgent care centers that serve migrants in border cents. According to CICIG and UNICEF (2016, regions and elsewhere. Many churches and non- p. 82), the most frequent customers are drug traf- governmental agencies sponsor health clinics in fickers who pay large sums of money for sexual the Central America countries, so it is possible services. As customers, drug traffickers are that North American health professionals will be extremely violent and demanding; they unmerci- in contact with persons who have experienced fully abuse the victims who are treated as mer- sexual exploitation. chandise and may be given over to bodyguards In view of the complexity involved in human or to other drug traffickers. The patriarchal cul- trafficking in Guatemala, any response must be ture also results in fewer opportunities for aimed at three priority areas: to eradicate traffick- women. Education for boys is valued more than ing for the purposes of sexual exploitation, to education for girls. Fewer girls have opportuni- provide assistance to victims, and to impart jus- ties to break the cycle of poverty through school, tice to prevent offenses from remaining unpun- and they are always in a position of social vul- ished (CICIG and UNICEF p. 7). Such a massive nerability that is often used to exploit them for undertaking involves the countries of the work and sex. Girls are often bullied or pres- Northern Triangle (El Salvador, Honduras, and sured by teachers to have sex in exchange for a Guatemala), Mexico, and the United States. better grade. Even girls or women who escape However, in this case study, we focus only on situations of abuse including trafficking face for- Guatemala. midable obstacles to a better life. A considerable number of Guatemalan and Central American women who are migrating through Mexico are 11.3.1 Individual/Family-Level trapped by trafficking networks and are forced Interventions again into a life of sexual exploitation. In addition, it has been estimated that eight out of ten • A victim of sexual trafficking suffers harm to migrant women from Central America traveling their physical, psychological, social, and through Mexico suffer some kind of sexual abuse financial health. Conduct an in-depth assess- in Mexico. They start the journey aware that they ment for sexually transmitted diseases, includ- may be raped once, twice, three times, or per- ing HIV/AIDS, and injuries to the reproductive haps more. system such as syphilis, gonorrhea, and 116 J. S. Boyle

chlamydia that can cause serious long-term America and drug trafficking in the United damage such as sterility, infertility, and pelvic States. inflammatory disease. • Trafficking is a serious human rights viola- • Assess for drug and alcohol dependency as tion, and the international magnitude of this victims are forced from an early age to con- offense has been recognized since the adop- sume alcohol and drugs. tion of the Convention on the Abolition of • Assess symptoms of emotional crises, low Slavery that dates back to 1926 and ratified by self-esteem, depression, and eating and sleep- the Guatemala State in 1983 (CICIG and ing disorders. UNICEF 2016, p. 15). Support anti-slavery or • Threats, beatings, and other forms of punish- anti-trafficking organizations in your ment take a tremendous toll on victims’ psy- community. chological health and should be reported to • Publicize the US National Human Trafficking local authorities. Research Center Hotline 1-888-373-7888. • Refer to psychiatric care or counseling if available. Conclusion Guatemala is a country of origin, transit, and destination of persons who are trafficked for 11.3.2 Organizational-Level purposes of sexual exploitation. Highly struc- Interventions tured networks exist in Honduras and El Salvador that recruit and transfer victims to • Support activists in Guatemalan women’s Guatemala where they are exploited. As a organizations who are speaking out and country of origin, thousands of families and attempting to protect young women from children as well as unaccompanied minors exploitation. have fled drug and gang violence in Guatemala • Collaborate with community organizations and have made their way to the United States. and churches to establish educational pro- Along the way through Mexico, sexual exploi- grams that explain trafficking and sexual tation frequently occurs. exploitation to young persons as well as how Maria Luisa was fortunate in many ways. to avoid being trafficked. While her home life was not ideal, her mother • Contact your congressional representatives to did rescue her from sexual exploitation. express your concern and urge them to sup- However, Geraldo continued to stalk and port legislation that addresses poverty, educa- harass her, and there was little she could do tion, and employment opportunities in legally to stop him. Guatemala as opposed to focusing only on A culture of patriarchy pervades Guatemala, military solutions to gang violence and drug influencing attitudes of ordinary Guatemalans, trafficking. the police, and the judicial officials. Patriarchy condones the abuse and degradation of women. Maria Luisa knew that eventually 11.3.3 Community Societal-Level Geraldo would find her and that there would Interventions be little she could do to resist sexual exploitation. She continually lived in fear of Geraldo • Criminal activities involve the participation of who threatened and intimidated her; he state authorities as well as police and munici- actively participated, along with his mother, to pal authorities. Trafficking and sexual exploi- lure Maria Luisa into a dangerous situation for tation in Guatemala must focus on criminal purposes of trafficking her for sexual networks in Mexico and Central and Latin exploitation. 11 Case Study: Human Trafficking in Guatemala 117

Maria finally fled to the United States to References escape his harassment and unwanted attention. She applied for asylum in the United Comisión Internacional contra la Impunidad en Guatemala States but was terrified of the current political (CICIG), United Nations Children Educational Fund (UNICEF) (2016) Human trafficking for sexual exploi- climate in the United States that denigrates tation purposes in Guatemala. Guatemala de la Asunción migrants. While focusing on her needs sec- Sherman C (2017) Mexico won’t take 3rd-country deport- ondary to her immigration status and fear of ees from US, official says. Associated Press, The sexual exploitation, culturally competent care Arizona Daily Star. Accessed 25 Feb 2017 United Nations Children Fund (UNICEF) (2014) Update: should promote her mental and physical health national diagnostic on the situation of unaccompanied and a potential for participating as a produc- boys, girls and adolescents in the migration process. tive citizen. Antigua, Guatemala, 2014 Case Study: A Young African American Woman with Lupus 12

Donna Shambley-Ebron

Nia Monroe is a 20-year-old African American health center and was referred to a rheumatolo- woman who lives in a mid-sized city in the gist, whom she has seen only once. The rheuma- Midwestern United States. She, her mother, and tologist prescribed numerous medications that her 3 younger siblings live in a large public hous- she is unable to afford. ing community consisting of 700 individual Nia was able to begin her classes at the univer- units. Despite many obstacles, Nia graduated in sity; however, numerous lupus flares during her the top of her class in high school and was a stu- first year led her to withdraw from school, having dent athlete. She was awarded a full scholarship fallen behind in all of her classes. Back at home to the public university in her city where she with her family and being unemployed led to planned to study nursing, as the first person in her social isolation, frequent exacerbations, increas- family to attend college. ing debilitation, and major depression. During her senior year in high school, Nia started experiencing joint and muscle pain, which she attributed to soreness or injury from her last 12.1 Cultural Issues athletic event. When symptoms did not subside and she began experiencing fever, she went to her The Monroe family resides in a mid-sized neighborhood health center, where she was Midwestern US city with a population of 300,000. finally diagnosed with systemic lupus erythema- It is estimated that about 44% of the city residents tosus (SLE). SLE, more commonly known as are African American. Nia and her family live in a lupus, is an autoimmune disorder that dispropor- public housing community for low-income resi- tionately affects Black women. Lupus affects dents operated by the Metropolitan Housing numerous organs, including the skin, brain, heart, Authority. The public housing project in which Nia and kidneys, and can lead to a significant lifelong and her family reside is home to 3800 residents, disability. The disease may have periods of remis- 98% of whom are African American. Eighty-seven sions and exacerbations, and Black women have percent of the residents are women and their chil- an earlier onset and also greater severity of dis- dren under the age of 18. County residents have a ease. Nia was given a pamphlet about lupus at the median income of $50,000, which is similar to the state’s median income; however within the city, the median income is $35,000. To qualify for public D. Shambley-Ebron, Ph.D., R.N., C.T.N.-A. housing, residents must live below the federal pov- College of Nursing, University of Cincinnati, erty level, which for Nia’s family of four is $24,600 Cincinnati, OH, USA (Office of the Federal Register 2017). Resources in e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 119 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_12 120 D. Shambley-Ebron the community include a large recreation center change adverse life circumstances, study of sacred with a swimming pool, two churches, a social ser- scriptures, and often includes a spiritual community vice agency, a federally qualified healthcare center, or family with whom believers congregate to wor- and a K-8 elementary school. Crime is high in the ship, pray, and fellowship. Oftentimes, the spiritual community, often perpetrated by people who come leader provides counsel and advice to members. in from outside of the community, with gun vio- Spiritual beliefs often influence life decisions and lence as a frequent occurrence. choices, and the spiritual family serves as a source Nia’s mother works as a STNA (state-tested of support during illness, death, and other life nurse aide) in a long-term care facility and takes difficulties. evening classes to earn her LPN. Two of Nia’s According to the Pew Research Center on brothers attend the community school, and the Religion and Public Life (2009), African oldest attends high school outside of the commu- Americans, when compared with other groups in nity. Nia’s mother has an old, unreliable vehicle the United States, are considered more religious, to drive to work, which leaves Nia at home with- based on affiliation, attendance at church, fre- out transportation. quency of prayer, and the importance of religion. Because Nia is over the age of 19, she is no lon- The majority of African Americans practice ger eligible for Medicaid but cannot afford insur- Christianity; however, they are represented in ance under the Affordable Care Act and therefore other religious groups such as Islam, Buddhism, remains uninsured. Nia and her family attend and Judaism. Others report no religious group Sunday services at the community church in the affiliation (Pew Research Center 2009). neighborhood and rely on their spiritual family for Although spirituality and religious beliefs can emotional and social support. Also, Nia’s aunts and serve as a source of strength for African cousins who live on the other side of town visit on Americans, it may also lead to a failure to seek weekends and provide some social support, professional healthcare. This may be especially although they do not understand her illness. true for certain mental health conditions such as There is a small “corner store” in the neighbor- depression, which can be seen as evidence of hood which is a “hangout” for young people in the spiritual weakness. community that sells snacks, soda, and beer; however, the closest full-service grocery store is 3 miles away, qualifying the community as a “food 12.3 Mistrust of the Healthcare desert” or low-access community (USDA 2011). System Because Nia is uninsured, she has avoided going to see her rheumatologist. She is also unable African Americans have had a long history of to pay for the expensive medications and does not discrimination and maltreatment in the health- feel as if her provider genuinely cares about her care system (Washington 2006). Numerous his- condition. Even though she was able to secure a torical offenses have been documented and also bus pass from the community social service have been passed down by word of mouth, lead- agency for her first visit, to get to the rheumatolo- ing to mistrust of providers and the overall gist required a long bus ride with several transfers healthcare system by African Americans. This that end up taking an entire day for a short visit. mistrust can lead African Americans to be reluctant in seeking healthcare and adhering to prescribed treatment plans. 12.2 Cultural Issues: Spirituality

For many African Americans, spirituality is a deeply 12.3.1 Stigma held value that is manifested by the recognition of a spiritual world that has influence on one’s everyday Among African Americans, stigma still exists as existence in the tangible world. Spirituality is often it relates to mental illness. Acknowledging men- accompanied by a belief in the power of prayer to tal illness, particularly depression, is often 12 Case Study: A Young African American Woman with Lupus 121 frowned upon and seen as a weakness. Treatment neighborhoods, no doubt, is a contributor to may not be sought or is discouraged by others, poorer health and life expectancy, evidenced by including family members. Moreover, African the health inequities found between African American women have had a history of being Americans and White Americans in many areas, required to be “strong” in the face of adversity. e.g., cardiovascular disease including hyperten- This history of being strong has been passed sion, diabetes, SLE, high infant mortality rates, down from generations since the time of their and many types of cancer. The chronic stress enslavement and has influenced African American brought on by living in such conditions over an women’s responses to adverse life circumstances extended period of time leads to a diminished (Shambley-Ebron and Boyle 2006). This tradi- ability to resist illness and also a shortened lifes- tion of “being strong” is related to living and rais- pan (Williams et al. 2015). Moreover, even with ing families independently, coping with illness, the Affordable Care Act and Medicaid expansion, and caregiving for family members, among other it is estimated that 12.2% of African Americans situations. Although this perception may be use- remain uninsured (Kaiser Family Foundation ful for helping African American women to be 2016). resilient, it may also prevent them from seeking SLE is one such illness that represents a sub- appropriate help and practicing needed self-care. stantial health disparity that negatively impacts the lives of African American women (Minority Women’s Health 2010). Not only are African 12.3.2 Extended Family Networks American women three times more likely to and Fictive Kin develop SLE than Caucasians, but they also have greater severity and earlier onset. Lupus can lead African American families build networks of to significant disability and impairment, includ- extended family for everyday subsistence. Often ing neurologic, cardiovascular, and end-stage extended family members may share living renal disease. In addition, women with lupus may arrangements and child-care responsibilities. In have skin discoloration and hair loss, leading to addition, non-blood-related relationships (fictive low self-esteem and physical image issues kin) are often considered family members and (Beckerman et al. 2011). Although the reasons are called “auntie,” “uncle,” or “cousin” (Taylor for this difference in incidence and severity of et al. 2013). lupus among African American women are unknown, environment and stress, including discrimination, have been posited as risk factors in 12.4 Social Structural Factors exacerbations and severity of the disease (Williams et al. 2015; Chae et al. 2015). In spite of gains in education, 27% of all African Another important societal factor that greatly American people live beneath the poverty line influences African Americans and leads to compared to only 11% of Whites (Black chronic stress is the systemic racism and discrim- Demographics 2014). According to the report on ination that daily impact their lives in the form of race and inequality produced by The Century both micro and macro aggression and structural Foundation, African Americans are more likely inequalities (Hollingsworth et al. 2017). Racism to live in concentrated poverty, that is, segregated and discrimination have a direct impact on how high-poverty neighborhoods and census tracts healthcare is delivered and how it is accessed. that place them in a type of “double jeopardy” Implicit bias has been studied among healthcare from both individual and collective poverty providers, particularly physicians. It has been (Jargowsky 2015). These high-poverty neighbor- found in studies of physicians’ attitudes that hoods are often isolated and located a distance many White physicians view their Caucasian from resources needed to sustain health, such as patients more favorably and communicate with affordable healthy foods, green space, safe walk- them differently than they do with their African ing spaces, and recreational areas. Living in such American patients (Cooper et al. 2012). It has 122 D. Shambley-Ebron also been found that African Americans are less • Investigate patient’s comfort level with involv- likely to receive aggressive treatments for many ing clergy in providing counsel. health conditions and under certain circumstances are less likely to receive needed pain medication (Oliver et al. 2014). 12.5.2 Organizational Level The neighborhood in which Nia and her family live is an example of an urban community of eco- • Ensure all providers have adequate training in nomic segregation and concentrated poverty in the promotion of culturally competent care. which the environmental stressors contribute to Provide ongoing and continuing education. overall poor health and vulnerability. In spite of • Actively engage providers in community Nia’s opportunity to leave her community, poor activities and organizations to enhance visibil- health has forced her back into the environment ity and trust in the community. that has possibly contributed to her condition. • Develop a local media campaign about lupus to increase community awareness. • Provide literature on lupus and other condi- 12.5 Culturally Competent tions that disproportionately impact African Strategies Recommended Americans in health centers and in the community. In order to address the complex health concerns • Identify community members with lupus and faced by Nia, the following recommendations are establish a support group that meets in the made to provide culturally appropriate care on the health center. individual, organizational, and societal levels.

12.5.3 Community/Societal Level 12.5.1 Individual-/Family-Level Interventions • Establish community-empowerment groups for members to address concerns such as food • Encourage monthly appointments with access and safety in the community. advanced practice nurse at the Federally • Partner with local public safety to establish a Qualified Health Center (FQHC) for physical, plan to address neighborhood concerns such mental health, and socioeconomic assessments. as high crime. • Educate patient about her condition and asso- • Develop academic-community partnerships to ciated symptoms and comorbidities. address Lupus and other community health • Validate patient’s feelings and emotions issues through community-based participa- regarding her illness. tory research methods. • Develop self-care plan using complementary • Engage city policy makers and planners in a therapies as needed. discussion around alleviating the burden of • Refer to social services for assistance with highly concentrated poverty neighborhoods. needed resources regarding medication costs, • Collaborate with community churches and assistance with applying for Medicaid under social service agencies to address the social Medicaid expansion, and assistance with and structural determinants of health in the returning to school, part-time. community. • Refer to free mental health services clinic for depression. Conclusion • Locate lupus support group and help enroll Systemic lupus erythematosus (SLE) is a patient. chronic and sometimes acute autoimmune dis- • Include family in education and planning with ease that destroys connective tissue and organs patient’s permission. in the body. African American women carry a 12 Case Study: A Young African American Woman with Lupus 123

great burden of SLE, being impacted at three Cooper LA, Roter DL, Carson KA, Beach MC et al times the rate of Caucasian women. In addi- (2012) The associations of clinician’s implicit attitudes about race with medical visit communication tion, African American women have a much and patient ratings of interpersonal care. Am J Public earlier onset and have a greater severity and Health 102(5):979–987. https://doi.org/10.2105/ higher mortality rate from the disease. The ajph.2011.300558 disease is characterized by remissions and Federal Register: The Daily Journal of the United States exacerbations that can be brought on by Government (2017) Annual update of the HHS poverty guidelines. https://www.federalregister.gov/ numerous factors including stress. documents/2017/01/21/2017-02076/annual-update- Nia Monroe has developed the disease in of-the-hhs-poverty-guidelines. Accessed 3 July 2017 young adulthood, and it has dampened her Hollingsworth DW, Cole AB, O’Keefe VM, Tucker RP et al (2017) Experiencing racial microaggres- dreams of becoming the first college attendee sions influences suicide ideation through perceived in her family. Having had to drop out of school burdensomeness in African Americans. J Couns in her first year, she has returned to a low- Psychol 64(1):104–111. https://doi.org/10.1037/ resource community with concentrated pov- cou0000177 Jargowsky P (2015) Architecture of segregation: civil erty, a public housing project with her family. unrest, the concentration of poverty, and public pol- She is unable to adequately access the cultur- icy. The Century Foundation. https://tcf.org/content/ ally competent healthcare and resources of report/architecture-of-segregation/. Accessed 3 July which she is in need. She has become isolated 2017 and depressed because of her health status and Kaiser Family Foundation (2016) Key facts about the uninsured population. http://kff.org/uninsured/fact- living conditions. Nia’s condition places her at sheet/key-facts-about-the-uninsured-population/. increased vulnerability to frequent exacerba- Accessed 3 July 2017 tions, the development of comorbidities, and Minority Women’s Health (2010) Lupus. https://www. overall diminishing physical and mental health. womenshealth.gov/minority-health/african-americans/lupus.html. Accessed 3 July 2017 Interventions should focus on three levels Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB et al of strategies that address not only the physical (2014) Do physicians’ implicit views of African conditions that Nia is faced with but also the Americans affect clinical decision-making? J sociocultural and structural issues that influ- Am Board Fam Med 27(2):177–188. https://doi. org/10.3122/jabfm.2014.02.120314 ence her health and the health of her commu- Pew Research Center: Religion and Public Life (2009) A nity. Only by addressing the root causes of religious portrait of African Americans. www.pewfo- poorer health in high-poverty communities rum.ort/2009/01/30/a-religious-portrait-of-african- can strides be made to reduce the health dis- americans/. Accessed 3 July 2017 parities that negatively impact African Shambley-Ebron D, Boyle JS (2006) In our grandmother’s footsteps: perceptions of being strong in African Americans and affect the health of our entire American women. Adv Nurs Sci 29(3):195–206 society. Taylor RJ, Chatters LM, Woodward AT, Brown E (2013) Racial and ethnic differences in extended family, friendship, fictive kin, and congregational informal support networks. Fam Relat 62(4):609–624. https:// References doi.org/10.1111/fare.12030 United States Department of Agriculture, Food and Beckerman NL, Auerbach C, Blanco I (2011) Psychosocial Nutrition Locator (2011) https://www.fns.usda.gov/ dimensions of SLE: implications for the health care tags/food-desert-locator. Accessed 3 July 2017 team. J Multidisc Healthcare 4:63–72. https://doi. Washington HA (2006) Medical apartheid: the dark his- org/10.2147/JMDH.A19303 tory of medical experimentation on Black Americans Black Demographics.com (2014) Poverty in Black from colonial times to the present. Doubleday, America. http://blackdemographics.com/households/ New York poverty/. Accessed 3 July 2017 Williams EM, Zhang J, Anderson J, Bruner L, Tumiel- Chae DH, Drenkard CM, Lewis TT, Lim SS (2015) Berhalter L (2015) Social support and self-reported Discrimination and cumulative disease damage among stress levels in a predominantly African American African American women with SLE. Am J Public sample of women with systemic lupus erythema- Health 105(10):2099–2107. https://doi.org/10.2105/ tosus. Autoimmune Dis 2015:401620. https://doi. AJPH org/10.1155/2015/4016 Case Study: Intimate Partner Violence in Peru 13

Roxanne Amerson

Sarah Moxley recently graduated from a bacca- Sarah has become a close friend of a young laureate nursing program in the United States. Quechua mother, Silvia Puma Quispe, who lives During nursing school, she participated in a next door. Silvia is 18 years old, has two small 1-month immersion program in Guatemala to children, and lives with an older man, Jorge, educate indigenous people about health issues. whom she plans to marry in the future. It is com- Recognizing her desire to continue working in a mon for Peruvians to cohabit for several years Latin American country, after graduation she before getting married. Silvia’s family arranged accepted a volunteer position with a nongovern- her relationship with Jorge when she was 15 mental organization (NGO) to educate low- years old. While the legal age of marriage in Peru income women in a small community in the has increased to 18 years, the age of sexual con- southeastern region of Peru. The mission of this sent remains at 14 years. Prior to this recent leg- organization is to empower women through edu- islative change, the age of consent for marriage cation and to promote economic development for was 16 years. The common practice of early mar- women and their children in the remote villages riage is a major contributing factor to young girls of the nearby Andes Mountains. dropping out of school early to assume the duties Sarah lives with a host family in a small town of wife and mother, rather than completing an near the site of the NGO. Living and working in education. the small community allows Sarah to become In the last week, Sarah has been hearing shout- friends with many of the local people within the ing and sounds of fighting coming from Silvia’s town. The home where she lives shares adjacent house during the late hours of the night. This walls with the neighbors’ homes. The proximity morning, Silvia arrived in the market with a swol- of homes is representative of the collectivistic len right cheek and a black eye. When Sarah culture of Peru and allows for little privacy. It is asked Silvia, “What happened last night?,” Silvia quite common to hear the family activities of the replied that Jorge sometimes has too much to neighbors. drink and gets angry with her. If she argues with him, he will hit her or push her to the ground. Silvia starts to cry but tells Sarah it is her duty as Jorge’s future wife to make her husband happy and not anger him. He is the father of her chil- R. Amerson, Ph.D., R.N., C.T.N.-A., C.N.E. dren, and it is important for her to stay with him. School of Nursing, Clemson University, Greenville, SC, USA Because Silvia quit school early, she has a very e-mail: [email protected] limited education and no way to support her

© Springer International Publishing AG, part of Springer Nature 2018 125 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_13 126 R. Amerson

children financially. Silvia’s mother and father Family values play an important role in the are poor and have too many mouths to feed to decision for women to remain in abusive relation- take her back into their home. ships. The collectivistic nature of Peruvian cul- Sarah is angry and frustrated by what she ture supports the concept of familismo (the hears from Silvia. Sarah has been brought up in a importance of putting the needs of the family culture where women are expected to be edu- before the needs of the individual) (Bernal and cated, have an equal voice in the marital relation- Rodriquez 2009). Women commonly will choose ship, and should not be hit by a man. She cannot to remain in a relationship to ensure the needs of understand why Silvia would choose to stay with their children are met, even when the woman a man who beats her. Nor does she understand faces tremendous physical or emotional abuse. why Silvia believes it is her duty to remain in a Only when her children’s health or safety is at relationship for the sake of her children when she risk, then a woman may choose to leave the abu- is being hurt and abused. sive relationship (Kelly 2009). Economic status plays a major role in the decision to remain with an abusive partner. The 13.1 Cultural Issues illiteracy rate is approximately 20% with an average 6 years of school for women in rural Intimate partner violence (IPV) represents a communities (Pan American Health Organization major public health problem in Peru. In 2009, 2012). Indigenous women of Quechua descent over 45% of Peruvian women experienced physi- are more likely to be less educated and live in cal, sexual, and emotional abuse (Cripe et al. poverty in rural areas of Peru. A lack of educa- 2015). Women who reside in rural areas of Peru tion leads to fewer opportunities for work out- experience even higher rates of IPV with esti- side of the home. Poverty rates in rural areas mates as high as 69% (Gelaye et al. 2010). Girls exceed 50% with extreme poverty being present are taught the concept of marianismo (to model in more than 20% of the Quechua populations in their behavior after the Virgin Mary) that encour- Peru. Early marriage or cohabitation leads to ages females to be submissive and to accept the greater risk of dropping out of school and fewer burdens of life without complaint. Furthermore, opportunity to engage in the workforce (Malé boys are instilled with values of machismo (dom- and Wodon 2016). Women with limited educa- inance and strength) which precipitates the power tion and a lack of financial resources are much issues that often arise in a marriage or relation- more likely to remain under the control of an ship. Men are expected to have control over the abusive partner. Both low socioeconomic status women in their lives. and poverty are commonly linked with violence Even the state of Peru has perpetuated vio- (Holtz 2017). lence against women in the past. Indigenous Quechua women underwent forced sterilization from 1996 to 2000 and were the frequent victims 13.2 Cultural Competent of sexual violence during the 20-year reign of the Strategies Recommended Sendero Luminoso (Shining Path), a communist terrorist group that operated in Peru starting in Nurses must engage in critical reflection to exam- the 1970s. According to the World Health ine their own cultural beliefs and values and how Organization Multi-Country Study on Domestic these values influence the provision of culturally Violence Against Women, violence often begins competent care (Douglas et al. 2014). Reflection early with one in five female children experienc- is the process of “inner awareness of thoughts, ing sexual abuse in urban Lima, Peru (Devries feelings, beliefs, judgments, and perceptions” et al. 2011). While Peruvian legislation is now in (Smith et al. 2015, p. 28). Critical reflection place to reduce violence against women, the laws allows one to analyze personal perceptions to are poorly enforced. improve future care, especially in situations 13 Case Study: Intimate Partner Violence in Peru 127 where the nurse’s values conflict with the values • Provide information in a nonjudgmental man- of the patient or family. ner about the childhood effects of witnessing Sarah engages in critical reflection when she violence in the home (Amerson et al. 2014). asks herself the following questions: • Respect Silvia’s autonomy to decide whether to stay or leave (Cripe et al. 2015). 1. How do my own cultural values of relationships between men and women affect my response to Silvia’s experience with 13.2.2 Organizational-Level IPV? Interventions 2. How do my values of individualism influence my expectation that Silvia will leave her abu- • Encourage the NGO where Sarah volunteers sive partner? to start a primary IPV prevention program to 3. If I were Silvia and based on her worldview in help break the cycle of violence (Gelaye et al. rural Peru, what options would I see available 2010). to me to leave an abusive situation? • Design an intervention program to teach self- 4. How can I provide culturally competent rec- help behaviors for abused women (Gelaye ommendations for IPV to Silvia based on the et al. 2010). resources available in her situation? • Maintain a database of available microcredit programs or other financial program to help women become more self-sufficient. 13.2.1 Individual- or Family-Level Interventions 13.2.3 Community- or Societal-Level • Examine one’s own personal values, beliefs, Interventions perceptions, and biases related to IPV. • Encourage Silvia to discuss her previous • Begin gender equality education in primary experiences with violence, including any his- school to break the cycle of violence. tory of sexual violence. • Recognize “gate-keepers” such as forensic • Help Silvia to recognize that abuse is not doctors, police, and nurses who can affect the acceptable (Cripe et al. 2015). outcome of IPV cases that go to trial; there- • Assess Silvia for signs of depression, suicidal fore, training for service providers is crucial to behaviors, anxiety, or alcohol dependency, prevent further victimizing of women who which are common in women who have expe- come forward to report IPV (Cripe et al. rienced IPV (Gelaye et al. 2010). 2015). • Determine if Silvia engages in violent self- • Start a support group for women who are vic- defense behaviors with Jorge during periods tims of IPV where they can find and maintain of conflict. Women who are severely abused supportive relationships (Cripe et al. 2015). are more likely to respond in a violent manner • Work with community and government lead- to defend themselves, therefore, increasing ers to establish professional counseling ser- the amount of violence witnessed by children vices and legal services to assist battered in the home (Gelaye et al. 2010). women (Cripe et al. 2015), while recognizing • Encourage Silvia to participate in a secondary that resources will be minimal in more rural, IPV prevention program available through the isolated areas. local NGO to learn about help-seeking behaviors, rather than remaining a victim. Conclusion • Assist Silvia to enroll in a microcredit (small Sarah now realizes that her initial reaction to loan to promote self-employment) program Silvia’s situation and the expectation that available through the local NGO if available. Silvia should leave her partner are based on 128 R. Amerson

Sarah’s own cultural values; therefore this Devries K, Watts C, Yoshihama M, Kiss L et al (2011) may not be the best solution for Silvia and her Violence against women is strongly associated with suicide attempts: evidence from the WHO multi- children. The combination of economic, cul- country study on women’s health and domestic vio- tural, and educational factors has a crucial lence against women. Soc Sci Med 73(1):79–86 impact on a woman’s decision to leave an abu- Douglas M, Rosenkoetter M, Pacquiao D, Callister L et al sive situation. Simply telling a woman to leave (2014) Guidelines for implementing cultural competent nursing care. J Transcult Nurs 25(2):109–121 may actually create new problems when a Gelaye B, Lam N, Cripe S, Sanchez S et al (2010) community does not have resources in place Correlates of violent response among Peruvian women to protect or provide shelter to a woman and abused by an intimate partner. J Interpers Violence her children. Few rural communities in rural 25(1):136–151 Holtz C (2017) Global health care: issues and politics, 3rd Peru will have battered women shelters, and edn. Jones & Bartlett Learning, Burlington many members of the community will simply Kelly U (2009) I’m a mother first: the influence of mother- see IPV as a “burden the woman must bear.” ing in the decision-making process of battered immigrant Latino women. Res Nurs Health 32:286–297 Teaching self-help behaviors, providing Malé C, Wodon Q (2016) Basic profile of child marriage in psychological counseling, and establishing Peru. Knowledge brief: health, nutrition and population support groups may be the best choice for help- global practice. World Bank Group. http://documents. ing women cope with abusive relationships worldbank.org/curated/en/765701467991927389/ pdf/106417-BRI-ADD-SERIES-PUBLIC-HNP- when there is simply no place to go in the short Brief-Peru-Profile-CM.pdf. Accessed 3 July 2017 term. Helping the woman to become more Pan American Health Organization (2012) Health financially independent may be a good long- in the Americas, 2012 edition: country volume. term solution to helping escape the abuse. Each http://www.paho.org/salud-en-las-americas-2012/ index.php?option=com_docman&task=doc_ woman has a unique situation where one size view&gid=143&Itemid=. Accessed 3 July 2017 does not fit all. Finding the right solution Smith M, Carpenter R, Fitzpatrick J (2015) Encyclopedia involves weighing the risks and benefits to have of nursing education. Springer, New York an optimal outcome while maintaining a safe environment for the woman and her children. Useful Websites

Summary Report: Violence Against Women in Latin References America and the Caribbean: a comparative analysis of population-based data from 12 countries (2013) Amerson R, Whittington R, Duggan L (2014) Intimate PAHO, Washington. http://www.endvawnow.org/ partner violence affecting Latina women and their uploads/browser/files/paho-vaw-exec-summ-eng.pdf. children. J Emerg Nurs 40(6):531–536 Accessed 3 July 2017 Bernal G, Rodriguez M (2009) Advances in Latino family Understanding and addressing violence against women research: cultural adaptations of evidence-based inter- (2012) World Health Organization. http://www.end- ventions. Fam Process 48(2):169–178 vawnow.org/uploads/browser/files/paho-vaw-exec- Cripe SM, Espinoza D, Rondon MB, Jimenez ML et al summ-eng.pdf. Accessed 3 July 2017 (2015) Preferences for intervention among Peruvian Country Reports: Peru Facts and Culture (2017) http:// women in intimate partner violence relationships. www.countryreports.org/country/Peru.htm. Accessed Hisp Health Care Int 13(1):27–37 3 July 2017 Part IV Guideline: Cross Cultural Communication Cross Cultural Communication: Verbal and Non-Verbal 14 Communication, Interpretation and Translation

Larry Purnell

Guideline: Nurses shall use culturally competent verbal and nonverbal communication skills to identify clients’ values, beliefs, practices, perceptions, and unique healthcare needs. Douglas et al. (2014: 112)

14.1 Introduction pology, cultural studies, psychology, and communication theory. The goal of cross-cultural Despite decades of attention and awareness, communication is to understand how people from healthcare disparities persist across the United different cultures communicate among insiders States and other countries throughout the world. such as family and friends and with outsiders. Racial and ethnic minorities, people with limited Healthcare providers are considered outsiders. English proficiency (LEP) and low health liter- Effective cross-cultural communication can acy, sexual and gender minorities, and people be challenging because it provides people with with disabilities experience worse health out- ways of thinking and interpreting the world. comes, decreased access to healthcare services, Cross-cultural communication includes verbal and lower-quality care than the general popula- and nonverbal components as well as the health tion (Building an Organizational Response to literacy of patients. Health Disparities 2016). Vast demographic changes are occurring around the world; inherent in these demographics are cross-cultural commu- 14.2 Verbal Communication nication issues between patients and healthcare providers. Communication is culture bound: The components of verbal communication consist what works in one culture may not work in of a number of elements: a dominant language and another culture. Thus, the onus on effective cul- its dialects; contextual use of the language; tural communication is on healthcare providers. paralanguage variations, such as voice volume, Cross-cultural communication combines anthro- tone, and intonations; the willingness to share thoughts and feelings; degree of formality; and L. Purnell, Ph.D., R.N., FAAN name format (Galanti 1991; Papadopoulos 2006; School of Nursing, University of Delaware, Purnell 2013). In addition, the healthcare provider Newark, DE, USA needs to pay attention to the nonverbal communi- Florida International University, Miami, FL, USA cation such as a grimace or lack of eye contact dur- Excelsior College, Albany, NY, USA ing verbal communication. Dialects, regional e-mail: [email protected] variations of a language, can be troublesome

© Springer International Publishing AG, part of Springer Nature 2018 131 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_14 132 L. Purnell because specific words may have a different mean- colloquialisms are “go bananas” for going insane ing or the provider has difficulty understanding an or angry, “feel blue” for feeling sad, and “y’all” accent as is the case in some parts of Appalachia in (yawl) for you all. Health providers must make a the United States where Elizabethan English is concerted effort and avoid slang and colloquial- still spoken. In addition, sometimes the word does isms. When the patient uses colloquialisms or not exist in another language. In Mexico, while slang, ask the patient to explain the terms. Spanish is the most widely spoken language, the In some cultures, people disclose very personal government also recognizes 68 Mexican indige- information about themselves, such as information nous languages as official national languages about sex, recreational drug use, sexual orientation, (Mexican Languages 2017). India has 18 major and family problems to friends (and even casual languages and over 1600 regional dialects. Even acquaintances) and healthcare providers. However, though Hindi is the official language, many people in other cultures, it is taboo to disclose this infor- in India do not speak it at all. Hindi is spoken by mation to others, even among healthcare providers. about half the population, mostly in North India Even though some cultures willingly share their (How many Languages do Indian People Speak? thoughts and feelings among family members and 2017). The current estimate of languages spoken close friends, they may not easily share them with in Nigeria is 521 with English being the official “outsiders” until they get to know them. Outsiders language, although only 75% of the people speak may include healthcare providers. By engaging in it. Yoruba, Hausa, Igbo, Fulfulde, Kanuri, and small talk and inquiring about family before Ibibio are also popular (Languages of Nigeria addressing the patient’s health concerns, healthcare n.d.). When a patient speaks a dialect for which providers can help establish trust and, in turn, there is no interpreter, use an interpreter using the encourage more open communication and sharing language of popular radio stations because most important health information (see Chap. 2 for more people will understand this language. on collectivistic and individualistic cultures). The same words can mean different things to In some cultures, having well-developed ver- people from different cultures, even when they bal skills is seen as important, whereas in other speak the same language. The use of idioms, slang, cultures, such as among some Appalachians, the colloquialisms, and technical jargon should be person who has very highly developed verbal avoided because they may not be understood by skills is seen as having suspicious intentions everyone, even by those who have good language (Huttlinger 2013). In addition, health literacy and proficiency. In addition, they do not translate well limited language proficiency can compromise into other languages. Even though a patient might cross-cultural communication and lead to incom- be somewhat bilingual, it can be difficult to fully plete or inaccurate diagnoses. Such miscommu- understand the nuances of a language, especially nication can affect the ability to follow healthcare with words that sound alike but spelled differently recommendations and prescriptions, even when (homonyms) and must be viewed in context. For the patient is in agreement with them (Andrews example, a “case” can be something that contains and Boyle 2016; Helman 2000; Purnell 2011; papers or other paraphernalia, a “case” as in a law- Sagar 2014). suit, or as an adjective as in a “case” study. Another Paralanguage is an area that combines verbal example is “glass,” something to hold liquid for and nonverbal communication using nuances drinking, or “glass” as in a window. “Iron” could such voice volume, tone, and posturing as means be an element or something used to iron clothing. of expressing thoughts and feelings. People nor- Slang and colloquial expressions can be particu- mally use paralanguage multiple times per day larly difficult and cause communication concerns. and are sometimes not even aware they are doing Some slang expression are the buck (versus as male so; this can include healthcare providers during deer) stops here and sweet to describe a person assessments and at other times communicating (versus the sweet taste in a drink). Colloquialisms, with patients. The ability to interpret this kind of using informal words or phrases, can be trouble- human communication correctly is considered an some, especially for whom the host language is not important competency in both personal and pro- the patient’s primary language. Some examples of fessional settings. Good communicators also 14 Cross Cultural Communication 133 have the ability to gauge how their own paralan- a patient if he/she took a medicine today, ask guage affects others and to alter it so as to gain what time did you take your medicine today? patients’ trust and to project confidence. For the healthcare provider, deciding to whom In collectivistic cultures, such as Amish, to direct the conversation can also be compli- Chinese, Filipino, Indigenous Indian, Vietnamese, cated. In some cultures, decision-making is a Korean, and Panamanian cultures to name a few, responsibility of the male or most respected fam- implicit indirect communication is common. ily member. And in some cases, the male may be People are more likely to tell the healthcare pro- the spokesperson for the family, even though he viders what they think they want to hear (Bui and may not be the decision-maker. Turnbull 2003). In individualistic cultures, such as those of In collectivistic cultures a formal greeting is Western Europe, European American, and usually required by using the surname of the Canadian to name a few, explicit, direct, straight patient or family member with a title. This can be forward communication is the expected norm a first step in gaining trust. Names are important (Rothstein-Fisch et al. 2001). More informal to people, and name formats differ among cul- greetings using the given name early in an tures. The most common Western system is to encounter are common, especially among the have a first or given name, a middle name, and younger generation. Healthcare providers should then the family surname. The person would usu- introduce themselves by the name they preferred ally write the name in that order. In formal situa- to be addressed. Again, asking the individual by tions, the person would be addressed with a title what name they wish to be addressed is the better of Mr., Mrs., Ms., or Miss and the last name. plan of action. Friends and acquaintances would call the person In individualistic cultures individuals will by the first name or perhaps a nickname. Married usually respond to the healthcare provider with women may take their husband’s last name, keep straightforward answers or evade the question their maiden name, or use both their maiden and completely if they do not want to answer it. married names. However, in some cultures, such Questions requiring “yes” or “no” are answered as many in Asia, the family or surname name frankly. Sharing intimate life details is encour- comes first, followed by the given name and then aged, even with non-intimates, and does not carry the middle name. The person would usually write a stigma for patients or their families. Egalitarian and introduce himself or herself in that order. decision-making is the norm, that is, patients/cli- Married women usually, but not always, keep ents are empowered to make health-related deci- their maiden name. Diversity in naming formats sions for themselves, although there are can create a challenge for healthcare workers variations. When in doubt, ask who the primary keeping a medical record; it is important to ask decision-maker is for health-related concerns. for the family name and then for their given names. The healthcare provider should always ask what is the legal name for medical record 14.3 Nonverbal Communication keeping and by which name the patient wishes to be addressed. Nonverbal communication includes touch; eye In some cultures, the concept of “saving face” contact; facial expressions; body language; tem- is highly valued and is reflected in communica- porality in terms of past, present, and future ori- tion patterns (Baron 2003). Sharing intimate life entation; clock versus social time; and dress and details of self or family is discouraged because it adornment. Touch has substantial variations in could stigmatize the person and the family. “Yes” meaning among cultures. For the most part, indi- may mean I hear you or I understand. “Yes” does vidualistic cultures (see Chap. 2 for individualistic not necessarily mean agreement with what is and collectivistic cultural values) are low-touch being asked or being explained but rather I hear cultures, which have been reinforced by sexual you. Therefore healthcare providers need to exer- harassment guidelines and policies in the United cise caution in framing questions and interpreting States and many other countries. For many, even responses to Yes/No questions. Instead of asking casual touching may be seen as a sexual overture 134 L. Purnell or taboo and should be avoided whenever possi- sants tend to place at least 18 in. of space ble as is the case with traditional Muslims and between themselves and the person with whom Orthodox Jews as examples. In many cultures, they are talking. Most collectivist cultures people of the same sex (especially men) or oppo- require less personal space when talking with site sex do not generally touch each other unless each other (Hall 1990a). They are quite comfort- they are close friends (Purnell 2013; Purnell and able standing closer to each other than are peo- Finkl 2018). However, among most collectivist ple from individualistic cultures; in fact, they cultures, two people of the same sex can touch interpret physical proximity as a valued sign of each other without it having a sexual connotation, emotional closeness (Hall 1990a). However, although modesty remains important (Black- patients who stand very close and stare during a Lattanzi and Purnell 2006; Hall 1990a). Being conversation may offend some healthcare pro- aware of individual practices regarding touch is viders. Thus, an understanding of personal space essential for effective health assessments. Always and distancing characteristics can enhance the explain the necessity and ask permission before quality of communication among individuals touching a patient. (Gardenswartz and Rowe 1998; Hall 1990b; Under Islamic law, it is haram (forbidden) for Ritter and Hoffman 2010). a man to expose himself to any woman other than Regardless of the class or social standing of his wife. Likewise, for a woman to expose herself the conversants, people from individualistic cul- to a man who is not her husband is also forbid- tures are expected to maintain direct eye contact den. Therefore, except for an emergency, a full without staring. A person who does not maintain physical examination generally must be carried eye contact may be perceived as not listening, not out by a healthcare professional of the same sex being trustworthy, not caring, or being less than as the patient unless it is an emergency situation truthful (Hall 1990b). Among some traditional or (Kulwicki and Ballout 2014), and even then the collectivist cultures, sustained eye contact can be patient may be reluctant or refuse touching. seen as offensive. Furthermore, a person of lower When a same-sex healthcare professional is not social class or status is expected to avoid eye con- available, some patients may give permission to tact with superiors or those with a higher educa- touch using gloves, having the healthcare pro- tional status (Purnell 2010). Thus, eye contact vider’s hand over the patient’s hand for palpation must be interpreted within its cultural context to or through a layer of clothing. When examining optimize relationships and improve health assess- women, especially young unmarried girls, a ments and recommendations. female chaperone must be present. The chaper- Although many people in individualistic cul- one could be a member of the family, allowing tures consider it impolite or offensive to point the patient to feel more at ease. Married women with one’s finger, many do so and do not see it as may wish their husbands to be present. Moreover, impolite. In other cultures, beckoning is done by the patient should also be examined in an area waving the fingers with the palm down, whereas where the sudden intrusion of other people is not extending the thumb, like thumbs-up, is consid- possible. ered a vulgar sign. Among some cultures, signal- In general, the physical health assessment pro- ing for someone to come by using an upturned gresses from head to toe, touching less intimidate finger is a provocation, usually done to a dog areas of the body first such as the head, arms, and (Purnell 2013). hands. However, traditional Vietnamese never Temporal relationships—people’s worldview touch another’s head because it is deemed disre- in terms of past, present, and future orientation— spectful, especially that of a child, and is some- vary among individuals and among cultural thing that only an elder may do (Mattson 2013). groups. Highly individualistic cultures are pri- Personal space needs to be respected when marily future-oriented, and people are encour- working with multicultural patients and staff. aged to sacrifice for today and work to save and Among more individualistic cultures, conver- invest in the future. The future is important in that 14 Cross Cultural Communication 135 people can influence it (Gudykunst and more fluid. Expectations for punctuality can Matsumoto 1996). cause conflicts between healthcare providers and In terms of healthcare, more future-oriented patients, even if one is cognizant of these differ- cultures are more likely to have at least yearly ences. These details must be carefully explained preventive health checkups and prenatal visits, to individuals when such situations occur. Being adhere to immunizations, take advantage of flu late for appointments should not be misconstrued vaccines, engage in healthy physical activities, as a sign of irresponsibility or not valuing one’s and strive to consume a healthy diet. Present- health (Hall 1990d; Purnell and Pontious 2014). oriented patients may have difficulty incorporating the future into long-term plans. For example, present-oriented patients might not take their 14.4 Sign Language antihypertensive medications if they are asymp- tomatic, although this occurs among some from Sign language is a combination of verbal and individualistic cultures as well. Patients with dia- nonverbal communication. Although signing is betes might be reluctant to perform glucose mon- primarily nonverbal, it also includes multiple itoring unless they are symptomatic. Stress, facial expressions and may have guttural sounds poverty, and other social issues may exacerbate to accompany the signed words. It is important to present-oriented beliefs on healthcare. note that signing is not a direct word-for-word In past-oriented cultures, laying a proper interpretation, but rather the interpreter must foundation by providing historical background extract the meaning from a message and then information can enhance communication. Past- convey that meaning. No one form of sign lan- oriented societies are concerned with traditional guage is universal. Different sign languages are values and ways of doing things. They tend to be used in different countries or regions. For exam- conservative in healthcare management and slow ple, British Sign Language (BSL) is a different to change those things that are tied to the past. from American Sign Language (ASL), and Past-oriented patients strive to maintain harmony Americans who know ASL may not understand with nature and look to the land to provide treat- BSL (Lingua translations 2016). Belgium and ment for disease and illness. Herbal remedies are India have more than one sign language. More important and patients usually prefer traditional diversity in sign languages can be found with approaches to healing rather than accepting each Japanese Sign Language (or Nihon Shuwa, JSL), new procedure, treatment, or medication that Spanish Sign Language (Lengua de signos o comes out. However, for people in many societ- señas española, or LSE), and Turkish Sign ies, temporality is balanced among past, present, Language (or Türk İşaret Dili, TID) (World and future in the sense of respecting the past, Federation of the Deaf 2016). In addition, there valuing and enjoying the present, and saving for are numerous country-/language-specific sign the future (Hall 1990a, c). languages such as Filipino and Hebrew (Abdel- Most people from individualistic cultures see Fattah 2004). time as a highly valued resource and do not like Only recently has sign language in the Arab to be delayed because it “wastes time” (Hall world been recognized and documented. Many 1990d). When visiting friends or meeting for efforts have been made to establish the sign lan- strictly social engagements, punctuality is less guages used in individual countries, including important, but one is still expected to appear Jordan, Egypt, Libya, and the Gulf States by within a “reasonable” time frame. In the health- trying to standardize the language. Such efforts care setting, if an appointment is made for produced many sign languages, almost as many 1300 hour (1:00 PM), the person is expected to as Arabic-speaking countries. Levantine Arabic be there 15 min early to be ready for the appoint- Sign Language, also known as Syro-Palestinian ment and not delay the healthcare provider. For Sign Language, is the deaf sign language of collectivistic cultures, the concept of time may be Jordan, Palestine, Syria, and Lebanon (Abdel- 136 L. Purnell

Fattah 2004). Some hospitals in the United patients with adequate literacy skills, resulting in States and Great Britain have used Skype to higher costs to the healthcare system, unneces- connect with Arab countries in order to com- sary visits to healthcare providers, and increased municate with deaf and hearing impaired hospital stays (National Academy on an Aging patients. Society 1999). Seeking medical care, taking medications correctly, and following prescribed treatments require that people understand how to 14.5 Communicating access and apply health information (US with Communities Department of Health and Human Services 2015). People with limited literacy are less likely Communicating with community populations to (a) ask questions during the medical encounter, can be critical for culturally competent care to (b) seek health information from print resources, better understand issues that affect the lives of the and (c) understand medical terminology and jar- vulnerable and to assist them to make informed gon (National Association of the Deaf (n.d.), US decisions for themselves and their community Department of Health and Human Services (Public Health Assessment Guidance Manual 2015). (2005: Update) 2011). At all times, the message Many health-related documents are written at should be in the language(s)/dialect(s) of the a college level and contain a large amount of populations served. text in small print and complex terminology Strategies to communicate with the commu- (Neilsen-Bohlman et al. 2004). However, the nity include announcements on public radio and recommendation is that patient education mate- television stations, local newspapers and media rials should be written at the sixth grade reading outlets, partnering with community organiza- level, although this level varies somewhat by the tions and associations, newsletters, neighbor- language (Cotunga et al. 2005). Those with lim- hood grocery stores, local libraries, town hall ited language proficiency have difficulty under- meetings, focus group discussions, and distrib- standing written information, including uting brochures at public venues such as the medication dosage instructions and warning Post Office, utility companies, restaurants, labels, discharge instructions, consent forms for houses of worship, barber shops and beauty treatment, participation in research studies, and salons, and on public transportation systems if basic health information about diseases, nutri- available. Even partnering with local gangs and tion, prevention, and health services. The inabil- cults can help gather and disseminate ity to read and comprehend such materials also information. impacts patients’ ability to understand medical advice, engage in self-care behaviors, and make informed decisions about their healthcare (US 14.6 Health Literacy Department of Health and Human Services 2015). Health literacy is the degree to which individuals One of the recommendations found in the lit- have the capacity to obtain, process, and under- erature for patients taking medicines is to instruct stand basic health information and healthcare them to take the “green,” “blue,” “yellow,” etc. services required to make health decisions and pill. This practice is not recommended for a follow treatment recommendations (Egbert and number of reasons. Some patients may not be Nanna 2009). Studies have shown that people able to distinguish colors, or the color of a pill from all ages, races, income, and educational lev- may change given the numerous generic medica- els are challenged by this problem. Individuals tions. Moreover, the word for green and blue are with limited health literacy incur medical the same in some languages (World Heritage expenses that are up to four times greater than Encyclopedia 2017). 14 Cross Cultural Communication 137

14.7 Interpretation Versus ily dynamics, but sensitive information may Translation not be transmitted. However, the healthcare provider must also be aware that in some cul- The key difference between interpretation and tures, family or other people in the commu- translation is the choice of communication chan- nity might be preferred as an interpreter nels. Translation deals with written communica- because they are more trusted then tion, while interpretation deals with the spoken outsiders. word (Bureau of Labor Statistics, Department of 3. Avoid the use of relatives if possible because Labor; Occupational Outlook Handbook 2006; they may distort information or not be Lionbridge 2012). Both channels require linguis- objective. tic and cultural knowledge of the working lan- 4. If possible, give the interpreter and patient guages. While translators usually provide time alone to get acquainted. word-for-word translation, interpreters must 5. Use dialect-specific interpreters whenever know both the original speech and the target lan- possible. guage and transpose one language into another in 6. Use a same-sex interpreter as the patient if real-time situations. They also act as facilitators desired. between the speakers and listeners (Translation 7. Maintain eye contact with both the patient Central n.d.). Although, in the past, interpretation and the interpreter. occurred in real time and only face-to-face, the 8. Direct your question to the patient, not the advent of technology has changed this dramati- interpreter. cally. Systems can accommodate (a) headphones 9. Some patients may want an interpreter who used by the patient, healthcare provider, and is older. Ask the patients if they have an age interpreter, (b) Skyping, (c) television/video ser- preference of the interpreter and accommo- vice, and (d) other distance methodologies date this preference if possible. 24 hours a day. Interpreters must capture the 10. Social class differences between the inter- tone, inflection, voice quality, and other intangi- preter and the patient may affect ble elements of the spoken word and convey the interpretation. meaning of the words. Interpretation, unlike 11. Some patients may desire an interpreter of translation, is not word-for-word but a paraphras- the same religion. ing of the words (American Translators Association 2015; Federation of Interpreters and Translators 2015; National Council on Healthcare 14.9 Recommendations Interpreting n.d.). Recommendations for clinical practice, administration, education, and research follow. 14.8 Recommendations for Using Medical Interpreters 14.9.1 Recommendations for Clinical 1. Use certified interpreters whenever possible. Practice Certified interpreters are trained to be ethical and nonjudgmental. Noncertified interpret- Ascertain the possibility that cultural differences ers might not report information that he/she may cause communication problems; pay atten- perceives as superstitious or not important. tion to nonverbal as well as verbal communica- Certified interpreters take an oath of tion. Clinical staff must consider factors that confidentiality. govern diversity within a culture that can affect 2. Normally, children should never be used as cross-cultural communication such as age, interpreters for their family members. Not generation, nationality, race, color, sex, gender only does it have a negative bearing on fam- roles, religion, military status, political beliefs, 138 L. Purnell

educational status, occupation, socioeconomic not show their amount of pain in facial expres- status, sexual orientation, urban versus rural resi- sions. Using numerical pain scales might be more dence, limited language proficiency, health liter- helpful. acy, physical characteristics of patients and When providing instructions for medications, providers, and reasons for immigration/migration the provider should explain them in the correct including documentation status. Refugees and sequence and one step at a time. For example, (a) asylees may have considerable difficulty trusting at 9:00 every morning, get the medicine bottle, healthcare providers based on discrimination in (b) take two tablets out of the bottle, (c) get your their home country (Purnell and Finkl 2018). hot water, and (d) swallow the pills with the Effective communication is a key to providing water. Do not use complex and compound sen- culturally competent and congruent care in clini- tences or use contractions when giving instruc- cal practice. Therefore, healthcare providers need tions. Many languages do not use contractions, to understand their own cultural communication and they can cause confusion for some patients. practices as well as being knowledgeable of the The patient should always demonstrate proce- communication practices of their patients. dures and how medications are prescribed; sim- Concerted efforts must be made for translating ply repeating the instructions does not educational materials according to the patient’s demonstrate understanding. Upon discharge, health literacy level and language proficiency. educational materials should be in the patient’s Every attempt should be made to obtain certified preferred language and at a level that meets the interpreters when needed. Recognize that it is not needs of patients with low health literacy and always possible to have an interpreter for every limited language proficiency (Purnell 2008; language and dialect. Family members and sig- Purnell and Finkl 2018). nificant others should only be used as a last resort and for nonconfidential information such as dietary and medication instructions. Moreover, if 14.9.2 Recommendations possible, it is best to refrain from using interpret- for Administration ers known to the patient or family. Because it is not always possible to know the Administration has a prime responsibility for cultural characteristics and attributes of all obtaining resources to ensure that culturally com- diverse patients, using a collectivistic and indi- petent clinical practice can occur. Resources vidualistic communication framework and guide include finances as well as recruiting adequate can be helpful when you are not familiar with the staff from the population the organization serves. culture of the patient (see Chap. 2). The caregiver In addition, financial resources are needed for should always address the patient formally until interpretation and translation services which are told to do otherwise and ask how he/she wishes to a federal requirement in the United States and be identified, along with their legal name for highly recommended in many other countries. medical record keeping. Likewise, the care pro- Symbols and pictograms should be included viders should introduce themselves by their titles in hospitals, clinics, and other healthcare organi- and positions. Patients have a right to know who zations whenever possible. These symbols and is providing care to them. pictograms need to be validated with members of For the hearing impaired, determine whether the specific ethnic community to assure that they the patient uses American Sign Language, Signed are accurate and not culturally offensive. Intranet English, or other specific sign languages. A writ- websites should be developed and in different ing system for communication when a signer is languages for diverse patient populations. not available should be provided. General health information on illnesses, infec- Develop pain scales in the patient’s preferred tions, diseases, and injury protection in languages language as well as “Faces of Pain” specific to of the patient population can be developed and ethnicities. Recognize that some people might distributed in areas where patients, families, and 14 Cross Cultural Communication 139 significant others shop, congregate, and use pub- the organizations’ library as well as having them lic transportation. Patients and families should be in printed format for staff to take home. informed about their existence upon admission. Disease-oriented practice guidelines for cultur- 14.9.2.2 Recommendations ally diverse populations served in the organiza- for Research tion can be developed and shared with all staff. Research needs to continue on population- When feasible, consider short video clips in lan- specific health beliefs and values to assure cultur- guages spoken by the patient population. ally competent clinical practice. Resource-poor Administration has the responsibility of keep- organizations may not have the human and mate- ing abreast of assistive technology used with the rial resources to conduct research, but with newer hearing and visually impaired and perhaps col- technologies and the Internet, partnering with laborating with communities to develop training educational organizations is a viable alternative. for interpreters if certified interpreters are not At a minimum, staff, educators, and administra- feasible. In addition, satisfaction surveys should tors and managers can identify gaps in the litera- be translated into the languages of the popula- ture of patients cared for in the organization, tions served; otherwise only part of the informa- conduct research on those topics, and conduct tion is gathered. Direct care providers and others quality improvement projects. A culture of nurs- who work with patients, families, and significant ing research can be accomplished by initiating a others from diverse cultures should be surveyed journal club devoted to evidence-based practice on their most pressing issues. Develop disease- and research studies. Advanced practice nurses oriented practice guidelines for culturally diverse with a background in research and evidence- populations served in the organization. based practice can help staff obtain literature and assist them with quality improvement projects. 14.9.2.1 Recommendations for Education and Training Conclusion Culturally competent clinical practice begins The importance of effective verbal and non- with formal classes in educational programs of verbal cross-cultural communication cannot all healthcare professionals. Individual health- be overemphasized as it is the basis of estab- care professionals must continue their education lishing trust and obtaining accurate health on cultural values, beliefs, and skills because cul- assessments and providing instructions. Both tures change over time. In addition, culturally interpretation and translation have some inher- congruent care should be included in orientation ent troublesome concerns. Due to the com- programs for all staff. Cultural assessment tools plexity of languages and multiple dialects of a need to be included on admission forms. Classes language, specific words may not exist in the with common foreign phrases could be included, host language and require an explanation of specific to areas of clinical practice for when the word or phrase; the exact meaning may interpreters are not available. still be lost (Van Ness et al. 2010). For exam- Ongoing continuing education classes and ple, having knowledge of the cultures to whom seminars on the cultures and religions of the care is provided, the variant cultural character- patient population served should be conducted on istics, and the complexities of interpretation a yearly and on an as-needed basis. Train-the- and translation is a requisite for decreasing/ trainer programs can help assure staff have access eliminating health and healthcare disparities to information on a 24/7 basis. Evidence-based (International Medical Interpreters Association printed and electronic resources specific to the 2017). A healthcare provider cannot possibly diversity of patients and staff in the organization know all worldwide cultures; however, an could be in the organization’s Intranet so staff can understanding of the differences between col- access it on a 24/7 basis. Intranet with articles, lectivistic and individualistic cultures is a book chapters, and books could be included with starting point and can be used as a framework 140 L. Purnell

for assessing cross-cultural communication Once this exercise is completed, it should be styles and improving health assessments shared with others for a discussion. This exercise (Keeskes 2016). Intercultural pragmatics, can be used in academic classes, continuing edu- dealing with things sensibly and realistically, cation classes, and in-services. can bring some new insight into theories. • Identify your cultural ancestry. If you have more than one cultural ancestry, choose one Appendix 1: Communication for the sake of this exercise. Exercise • Explore the willingness of individuals in your culture to share thoughts, feelings, and ideas. Effective communication is essential in the deliv- Can you identify any area of discussion that ery of culturally congruent health and nursing would be considered taboo? care. For cultural communication to be effective, • Explore the practice and meaning of touch in the healthcare providers need to understand their your culture. Include information regarding own communication practices. The following touch between family members, friends, exercise will assist providers to understand their members of the opposite sex, and healthcare own communication practices. providers. • Identify personal spatial and distancing strate- Instructions gies used when communicating with others in 1. Identify your own cultural identity and per- your culture. Discuss differences between sonal communication practices and how they friends and families versus strangers. differ with family, friends, and strangers, • Discuss your culture’s use of eye contact. including patients. Include information regarding practices 2. Investigate the scholarly literature on your between family members, friends, strangers, culture after you have completed the and persons of different age groups. exercises. • Explore the meaning of gestures and facial 3. Identify how your communication patterns expressions in your culture. Do specific differ from what was in the scholarly gestures or facial expressions have special literature. meanings? How are emotions displayed? 4. Posit why these personal practices differ. • Are there acceptable ways of standing and greeting people in your culture? Note: Variant characteristics within a culture • Discuss the prevailing temporal relation of can be used as a guide to addressing the state- your culture. Is the culture’s worldview past, ments below. These variant cultural characteris- present, or future oriented? tics include: • Discuss the impact of your culture on your Nationality Age Skin color nursing and/or healthcare. Be specific, that is, Race SES Physical not something that is very general. characteristics Ethnicity Occupation Parental status Gender Marital status Political beliefs Appendix 2: Reflective Exercises Sexual Educational Religious orientation status affiliation The following reflective exercises can be used in Gender issues Health literacy Military experience formal courses at any level and discipline or Enclave identity Urban vs. rural interdisciplinary. They can also be used in staff residence development. Length of time away from country of origin Reason for migration: sojourner, immigrant, 1. What changes in ethnic and cultural diversity undocumented status have you seen in your community over the 14 Cross Cultural Communication 141

last 5 years? Over the last 10 years? Have 19. In what languages are healthcare instructions you had the opportunity to interact with provided in your organization? newer groups? 20. Does your organization offer both interpreter 2. What health disparities have you observed in and translation services? your community? To what do you attribute 21. Given the heritage and diversity of the popu- these disparities? What can you do as a pro- lation in your community, what cultural, fessional to help decrease these disparities? social, and material issues do you consider 3. Who in your family had the most influence important? in teaching you cultural values and practices? Mother, father, or grandparent? 4. How do you want to be addressed? First References name or last name with a title? 5. How do you address older people in your Abdel-Fattah MA (2004) Arabic sign language: a perspec- culture? First name or last name with a title? tive. J Deaf Stud Deaf Educ 10(2):212–221 American Translators Association (ATA) (2015) www. 6. What activities have you done to increase atanet.org. Accessed 29 July 2017 your cultural competence? Andrews MM, Boyle JS (eds) (2016) Transcultural concepts 7. Given that everyone is ethnocentric to some in nursing care, 7th edn. Wolters Kluwer, Philadelphia degree, what do you do to become less Baron, M (2003) Beyond intractability. http://www. beyondintractability.org/essay/cross-cultural-commu- ethnocentric? nication. Accessed 29 July 2017 8. How do you distinguish a stereotype from a Black-Lattanzi J, Purnell L (eds) (2006) Exploring com- generalization? munication in a cultural context. In: Developing 9. How have your variant characteristics of cul- cultural competence in physical therapy practice. F.A. Davis Co., Philadelphia ture changed over time? Bui YN, Turnbull A (2003) East meets west: analysis 10. What ethnic and racial groups do you of person-centered planning in the context of Asian encounter on a regular basis? Do you see any American values. Educ Train Ment Retard Dev Disabil racism or discrimination among these 38(1):18–31 Building an Organizational Response to Health Disparities groups? (2016) A practical guide to a practical guide to imple- 11. What does your organization do to increase menting the national CLAS standards: for racial, diversity and cultural competence? ethnic and linguistic minorities, people with disabilities, and sexual and gender minorities. https://www. 12. What barriers do you see to culturally com- cms.gov/About-CMS/Agency-Information/OMH/ petent care in your organization? School, Downloads/CLAS-Toolkit-12-7-16.pdf. Accessed 15 work, etc. Oct 2017 13. How many languages are spoken in your Bureau of Labor Statistics: Department of Labor, Occupational Outlook Handbook (2006) Interpreters community? and translators. http://www.bls.gov/oco/ocos175.htm. 14. Do different languages pose barriers to Accessed 29 July 2017 healthcare, including health literacy? What Cotunga N, Vickery CE, Carpenter-Haefele KM (2005) affordability concerns for healthcare do you Evaluation of literacy level of patient education pages in health-related journals. J Community Health see in your community? 30(3):213–219 15. What complementary/alternative healthcare Douglas M, Rosenketter M, Pacquiao D, Callister C et al practices do you use? (2014) Guidelines for implementing culturally com- 16. What complementary/alternative healthcare petent nursing care. J Transcult Nurs 25(2):109–221 Egbert N, Nanna K (2009). Health literacy: challenges and practices are available in your community? strategies. Online J Issues Nurs 14, 3, Manuscript 1. 17. Is public transportation readily available to http://www.nursingworld.org/MainMenuCategories/ healthcare services in your community? ANAMarketplace/ANAPeriodicals/OJIN/ What might be done to improve them? TableofContents/Vol142009/No3Sept09/Health- Literacy-Challenges.html. Accessed 29 July 2017 18. What do you do when you cannot under- Federation of Interpreters and Translators. (2015) www. stand the language of your patient? ift-fit.org. Accessed 29 July 2017 142 L. Purnell

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Sangmi Kim and Eun-Ok Im

Jina, a 57-year-old Korean immigrant woman Three years ago, she was diagnosed with a with a high school education, has been a house- Grade III infiltrating ductal carcinoma in her wife since getting married to her husband who right breast with an enlarged lymph node in the ran a small business until they immigrated to the axilla. She underwent chemotherapy followed by United States (USA). Jina and her husband immi- a mastectomy and postoperative radiation ther- grated to the USA in 2000 with their two daugh- apy. Since then, she has experienced chronic pain ters after her husband’s company faced extreme in her chest and underarm as if a wire was wrap- financial difficulties in the middle of the eco- ping around these body parts. The pain becomes nomic crisis that hit South Korea in the late worse at night. After the surgery, she tried over- 1990s. There were no families, relatives, or the-counter and prescribed painkillers and physi- friends living in the USA, but they settled in a cal therapy, but none of them helped relieve the suburban neighborhood within a Korean commu- pain. She once talked about her constant pain to nity on the East coast. They have run a dry clean- her physician, but was told, “Some pain will go ing business since their arrival in the USA. Their away with time, but it does not get too much bet- adult daughters currently work in other states ter. You just need to learn to live with it.” after completing their college education. They After the conversation with her physician, she regularly visit their parents during holidays and did not bring up her pain-related issues again dur- for special occasions. ing her physician’s visits because it was difficult Although Jina has lived in the USA for an to verbally describe the characteristics/patterns extended period of time, she still finds it chal- of pain and her pain experiences in English. She lenging to communicate with others in English. was also hesitant to ask the physician because she She predominantly speaks Korean and socializes did not want to challenge him by questioning his only with Korean friends who she met at her attitudes toward her pain as well as the care plans Korean church. Mostly, she cooks Korean cuisine and their effectiveness to relieve it. at home, watches Korean TV shows, and listens Jina tries not to tell her family that she is in to Korean songs. pain since she does not want them to worry about her condition. She thinks that her family already shoulders the financial burden caused by her sur- S. Kim, Ph.D., R.N. (*) gery and cancer treatment, and she does not want E.-O. Im, Ph.D., R.N., FAAN (*) to add even an emotional burden on her husband School of Nursing, Duke University, Durham, NC, USA and daughters. The couple has experienced finan- e-mail: [email protected]; [email protected] cial strain to some degree since her diagnosis

© Springer International Publishing AG, part of Springer Nature 2018 143 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_15 144 S. Kim and E.-O. Im with breast cancer. Even though the health insur- complaining about pain merely signals weakness ance covers her cancer treatment, she is respon- (Im et al. 2008). Thus, opting out of aggressive sible for paying some of the medical bills with treatment through Western medicine, Korean out-of-pocket money. The limited range of women try to maintain normal lives and use natu- motion of her right arm and pain discouraged her ral modalities for pain management such as mas- from continuing to work in the dry cleaner. sage, meditation, and Qigong (Im et al. 2009). Instead, she stays at home and takes care of Other reasons that Korean women with cancer household chores, while her husband works lon- pain reduce the magnitude of the problem are due ger hours on weekdays and often during week- to the negative meanings attached to breast cancer ends to keep their business running. She tries to and cancer in general as well as the patriarchal act normal by handling all the household chores Korean culture. Specifically, a victim-blaming because she wants to be a strong mother to her tendency is observed among Korean women with daughters. Nevertheless, she is often frustrated cancer (Im et al. 2002). They believe that pain is and stressed by a lack of instrumental and emo- a consequence of bad karma or punishment of tional support from her family and friends. She sins committed in the past (Im et al. 2009). In feels like no one understands what she is going addition, traditional Korean medicine posits that through. one’s misconduct or negative attitudes bring Jina does not depend on pain medications about cancer such that cancer patients need to because they are ineffective and because they are change their reactions to or perspectives toward costly. She is worried about becoming addicted situations rather than modifying the situations to them. Instead, she manages her pain with an themselves. Some feel that one should not think intermittent use of acupuncture and yoga. As a too much about cancer because that would ulti- religious Christian, she goes to church every mately make the person sick (Tam Ashing et al. morning and prays to God to help her overcome 2003). Thus, positive thinking and strong mental- this physical and emotional suffering. After the ity are values to deal with cancer pain. prayer, she feels stronger and less fearful. She A belief that the mind has control over the thinks that she can stand her pain if her suffering physical body seems to contribute to passive pain is part of God’s plan for her, although she cannot management among Korean women cancer sur- understand it right now. vivors by relying not only on mental therapies such as yoga, deep breathing, and reading other cancer patients’ stories but also a religion (Im 15.1 Cultural Issues et al. 2008). Indeed, spirituality plays an essential role in a journey of recovery from cancer among Korean women tend to minimize pain due to their Korean women. Reportedly, Korean Americans cultural beliefs toward pain. Korean culture is are prone to perceive less control over illness and under the influence of Confucianism and Taoism treatment than some other groups (Tam Ashing that highly value stoicism. Specifically,et al. 2003). They believe that God wills a diag- Confucianism teaches people to live in harmoni- nosis of breast cancer or the outcome of the dis- ous social relations and subsequently deters peo- ease is in God’s hands (Tam Ashing et al. 2003). ple from expressing potentially disruptive and Through religious activities (e.g., prayer), Korean unpleasant emotions, including pain (Im et al. women find comfort and strength to undergo 2008, 2009). Moreover, Korean women have a their life crisis, such as cancer (Im et al. 2008). tendency to consider pain as a natural human The Korean patriarchal culture emphasizes experience. If the pain is unavoidable, people family as an essential social unit with women’s should be brave and strong to face and embrace it low status in traditional family systems. The cul- so that they can be role models for others in the ture expects women to sacrifice themselves for same situation. A cultural belief among Koreans their families (Im et al. 2002). Even, the family is that pain helps to build one’s strong character; expects women to function the same as before the 15 Case Study: Korean Woman with Mastectomy Pain 145 breast cancer surgery, providing little or no help unfamiliarity with healthcare systems contribute with household tasks (Im et al. 2002; Tam Ashing to the lack of active pain management among et al. 2003). Women place their family as a prior- Korean women, especially among those who are ity ahead of their personal needs such as health, less acculturated and newly immigrated (Tam resulting in delaying treatment and medical ser- Ashing et al. 2003). Even those with higher edu- vices (Tam Ashing et al. 2003). Women’s health cation and those who are bilingual may find it problems tend to be regarded as trivial even by difficult to navigate healthcare systems and feel women themselves and by their family members uncomfortable with asking questions about their (Im et al. 2000). This applies especially to those health conditions (Tam Ashing et al. 2003). of lower socioeconomic status (SES) and those Korean women often do not seek second opin- who are uninsured; they are more concerned with ions and tend not to ask their physicians’ advice. supporting their families than seeking early care This is derived from their cultural respect for (Tam Ashing et al. 2003). As a result, Korean medical physician’s status as an authority figure women tolerate cancer pain so as not to become a and their cultural belief that physicians know financial or emotional burden on the family and what they are doing and will provide the best care make them worry (Im et al. 2008; Tam Ashing (Im et al. 2002; Tam Ashing et al. 2003). Korean et al. 2003). Also, the most common concern as women desire to be perceived as good patients by barriers to pain control among Korean cancer their healthcare providers (Im et al. 2008). survivors pertains to analgesic use, such as developing tolerance to pain medication; taking pain medication on an around-the-clock versus as on a 15.2 Social Structural Factors needed basis; and developing addiction (Edrington et al. 2009). Racial/ethnic minorities and socioeconomically Cancer pain experience is gendered. Relative disadvantaged groups disproportionately face to men, women may be disadvantaged in cancer system-level barriers to pain management that pain management. For example, people may take include inequalities in high costs of pain medica- men’s cancer pain more seriously and pay more tion, insufficient/lack of health insurance reim- attention to their pain experience than women’s bursement for pain services and medications, and (Im et al. 2009). Women are also more likely to the availability of analgesics in pharmacies (Stein tolerate pain than men not only due to biological et al. 2016; Sun et al. 2007). For example, they differences but also normative gender roles in the are more likely than their non-minority or privi- household. Specifically, women experience pain leged counterparts to be underinsured/uninsured throughout their lives caused by menstruation and have fewer resources for out-of-pocket and childbirth (Im et al. 2009). Household tasks expenses (Anderson et al. 2009; Stein et al. and child rearing have been considered as wom- 2016). The inadequate health insurance coverage en’s responsibilities. Women think that they among racial/ethnic minorities limits the avail- should be stronger to endure pain from cancer ability and affordability of analgesic medications treatment and survive for their children who for pain relief (Anderson et al. 2009; Stein et al. depend on them (Im et al. 2009). 2016). Furthermore, many Korean cancer survivors When minority patients receive a prescription lack information about their diagnosis, treat- for pain medication, they may face limited avail- ments, and cancer-related terminology. This may ability of opioids in their hospital or neighborhood be attributed to healthcare providers’ failure to pharmacy (Anderson et al. 2009; Stein et al. 2016). adequately educate them, language barriers, and Morrison et al. (2000) documented that only 25% of survivors’ belief that they should leave most of New York City pharmacies in predominantly non- the treatment decisions to their physicians (Im White neighborhoods (i.e., those in which less than et al. 2002; Tam Ashing et al. 2003). Lack of flu- 40% of residents were White) had adequate opioids, ency and discomfort in speaking English and while 72% of pharmacies in predominantly White 146 S. Kim and E.-O. Im neighborhoods stocked sufficient opioids. More • Provide Jina and her husband with informa- specifically, in predominantly Korean neighbor- tion about her pain and pain management hoods, the proportion of pharmacies with sufficient options and resources. opioid stocks was 25% as compared with 54% in • Prescribe long- vs. short-acting opioid analge- predominantly non-Korean neighborhoods. sics and an aggressive bowel regimen to prevent opioid-related constipation.

15.3 Social Stratification 15.4.2 Organizational-Level Negative attitudes toward racial/ethnic minorities Interventions or prejudicial racial stereotyping by healthcare providers can also contribute to ineffective pain • Train healthcare providers in communication care among racial/ethnic minorities (Lasch 2000; skills, use of interpreters, and cultural Mossey 2011; Stein et al. 2016). For example, competence. some healthcare providers are inclined to under- • Educate healthcare providers on the central estimate pain severity among racial/ethnic minor- concepts relevant to pain care (e.g., addiction ities and prescribe less effective analgesics to and tolerance), pain assessment, and manage- them (Anderson et al. 2009; Mossey 2011). ment techniques. NSAIDs rather than opioid analgesics or opioids • Develop or implement recommended pain at lower doses are more likely to be prescribed to treatment guidelines and protocols based on Blacks, Hispanics, and Asians than to Whites, research evaluating the efficacy of the pain even though pain severity is comparable among treatments for minority patients with cancer, the groups (Mossey 2011). and regularly monitor if the healthcare providers execute the guidelines and protocols during the care. 15.4 Culturally Competent • Provide certified interpreters for better com- Strategies Recommended munication between healthcare providers and patients with limited language fluency. 15.4.1 Individual-/Family-Level • Implement educational campaigns in Korean Interventions communities for improved pain control among cancer survivors in concert with local Korean • Assess Jina’s linguistic preferences, SES, cul- churches and organizations. tural beliefs about and attitudes toward her • Establish a referral system to supportive pain, coping strategies, and perceived barriers care/social services that can address to pain control. socioeconomic concerns of cancer patients • Examine healthcare providers’ cultural beliefs and families. and implicit negative stereotypical perceptions toward Korean women. • Appreciate the importance to Jina of her 15.4.3 Community Societal-Level beliefs about pain, even though they may not Interventions be scientifically grounded or conflict with the healthcare provider’s beliefs. • Build community-based partnerships and ini- • Dispel misconceptions about opioid tiatives to increase the availability of opioids analgesics. medications in minority neighborhood • Be open, authentic, sensitive, and caring when pharmacies. communicating with Jina and her husband. • Evaluate regulations that may act as disincen- • Coach Jina on how to report her pain and tives for pharmacists to stock controlled empower her to do it accurately. substances. 15 Case Study: Korean Woman with Mastectomy Pain 147

Conclusion health policies that affect cancer patients’ pain Inaccurate assessment and undertreatment of care options. Jina’s cancer pain is a manifestation of the deeply rooted social and racial/ethnic disparities in opportunities and resources to maintain References an optimal health/functional status. Jina’s cancer pain is less appreciated because she is a Anderson KO, Green CR, Payne R (2009) Racial and woman and racial/ethnic minority; her health- ethnic disparities in pain: causes and consequences of unequal care. J Pain 10(12):1187–1204. https://doi. care providers are ignorant about her cultural org/10.1016/j.jpain.2009.10.002 beliefs and attitudes toward pain, and her Edrington J, Sun A, Wong C, Dodd M, Padill G, Paul S, English is not fluent enough to communicate Miaskowski C (2009) Barriers to pain management in her pain experience with healthcare providers. a community sample of Chinese American patients with cancer. J Pain Symptom Manag 37(4):665–675. Jina receives an insufficient treatment due to https://doi.org/10.1016/j.jpainsymman.2008.04.014 healthcare providers’ racial bias toward pain Im EO, Hautman MA, Keddy B (2000) A feminist critique of minority patients and her limited afford- of breast cancer research among Korean women. West ability and availability of opioid pain medica- J Nurs Res 22(5):551–570. https://doi-org.proxy.lib. duke.edu/10.1177/01939450022044593 tions. High cost of opioid pain medications is Im EO, Lee EO, Park YS (2002) Korean women’s breast financially burdensome for Jina and her hus- cancer experience. West J Nurs Res 24(7):751–765. band considering their financial instability https://doi.org/10.1177/019394502762476960 resulting from her cancer treatment and lim- Im EO, Liu Y, Kim YH, Chee W (2008) Asian American cancer patients’ pain experience. Cancer ited health insurance coverage. Even though Nurs 31(3):E17–E23. https://doi.org/10.1097/01. she can afford the medication, having access ncc.0000305730.95839.83 to them is another hurdle when pharmacies in Im EO, Lee SH, Liu Y, Lim HJ, Guevara E, Chee W the segregated neighborhood do not have suf- (2009) A national online forum on ethnic differences in cancer pain experience. Nurs Res 58(2):86–94 ficient opioid stock. Lasch KE (2000) Culture, pain, and culturally sensi- Concerted efforts at multiple levels (i.e., tive pain care. Pain Manag Nurs 1(3, Supplement individual, organization, and community) are 1):16–22. https://doi.org/10.1053/jpmn.2000.9761. called for to address undertreatment of cancer Accessed 4 July 2017 Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang pain that many Korean breast cancer survivors LL (2000) “We don’t carry that”—failure of pharma- like Jina experience. Such individual-level cies in predominantly nonwhite neighborhoods to efforts as cultivating healthcare providers’ cul- stock opioid analgesics. N Engl J Med 342(14):1023– tural sensitivity and empowering Korean breast 1026. https://doi.org/10.1056/nejm200004063421406 Mossey JM (2011) Defining racial and ethnic dis- cancer survivors and their families to engage in parities in pain management. Clin Orthop Relat their pain management plans may not sustain Res 469(7):1859–1870. https://doi.org/10.1007/ without organizational support through s11999-011-1770-9 increasing awareness of the issue and provid- Stein KD, Alcaraz KI, Kamson C, Fallon EA, Smith TG (2016) Sociodemographic inequalities in barriers to ing resources, monitoring, and regulating. cancer pain management: a report from the American Upstream risk factors for pain care for Korean Cancer Society’s study of cancer survivors-II breast cancer survivors (e.g., not affordable or (SCS-II). Psychooncology 25(10):1212–1221. https:// available pain medications) can be addressed doi.org/10.1002/pon.4218 Sun V, Borneman T, Ferrell B, Piper B, Koczywas M, Choi by community involvement through partner- K (2007) Overcoming barriers to cancer pain manage- ships with social service organizations and ment: an institutional change model. J Pain Symptom local pharmacies. Finally, healthcare providers Manag 34(4):359–369. https://doi.org/10.1016/j. and Korean breast cancer survivors can form a jpainsymman.2006.12.011 Tam Ashing K, Padilla G, Tejero J, Kagawa-Singer M united front to advocate the unequal pain care (2003) Understanding the breast cancer experience of as a significant public health issue. Persuade or Asian American women. Psychooncology 12(1):38– negotiate with policymakers to change laws or 58. https://doi.org/10.1002/pon.632 Case Study: An 85-Year-Old Saudi Muslim Woman with Multiple 16 Health Problems

Sandra Lovering

In a hospital in Saudi Arabia, an 85-year-old During the admission assessment, the daugh- Saudi woman, Umm Khalid, was admitted with ter shared that Umm Khalid took Shamar, end-stage heart failure, diabetes mellitus, and Foeniculum vulgare (fennel) and Trigonella infected diabetic foot ulcers. She is a widow with foenum-graecum L (fenugreek), in a hot drink for one son, two daughters, and many grandchildren. her “sugar” (diabetes) and treated the diabetic She lives with her eldest son, Khalid, and his ulcer with honey and myrrh. Cupping marks family in a remote rural community. Her older (Hejama) were noted on her back during the skin daughter and eldest granddaughter take turns assessment. staying with her as a “sitter” throughout the day During visiting hours, the room was over- and night while in the hospital. crowded with visitors including children. The primary consultant reviewed her results Concerned at the overcrowding, the nurses and advised the family that due to her age and requested visitors to leave, which was refused, so general condition the plan was for palliative care. the nurses called security to handle the situation. The adult children discussed the care of their The son was angry that the hospital security made mother, and the son requested the nurses and visitors leave and made the decision to take his physicians not to tell their mother her diagnosis mother home against medical advice so she could as they felt she would lose hope. spend her final days with the family. A few days later, the daughter told the nurse that they had called for a sheik, a religious healer, to visit the patient because a relative suggested 16.1 Cultural Issues that heart failure was caused by the evil eye. The daughter said the sheik would read from the Arab is a cultural and linguistic term referring to Qu’ran, say ruqyah, special verses, and encour- those who speak Arabic as a first language and age her to drink water from a special well called are united by culture and history. Twenty-two Zamzam in Mecca. After the visit of the sheik, Arab countries stretching across the Middle East the family appeared more accepting of their and North Africa have a rich diversity of ethnic, mother’s condition. linguistic, and religious communities including Christians and Jews. Most Arabs are Muslims, but most Muslims are not Arabs. Large social inequalities and health inequities S. Lovering, R.N., B.S.N., M.B.S., D.H.Sc. exist among Arab countries related to social and King Faisal Specialist Hospital and Research Center, economic factors such as access to drinking Jeddah, Saudi Arabia e-mail: [email protected] water, sanitation, and healthcare as well as

© Springer International Publishing AG, part of Springer Nature 2018 149 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_16 150 S. Lovering degree of urbanization. Twenty percent (20%) of Islam are derived from the Holy Qur’an and the Arab countries with low economic development Sunnah (a path of virtue). Muslims believe in such as Yemen and Sudan have high maternal divine predestination and in life after death and child mortality and the burden of communi- when Allah judges people on the Day of cable diseases. In contrast, the top 3% of Arab Judgment for how they have lived their life on countries such as Qatar, Bahrain, and the United earth. A practicing Muslim lives in a way that Arab Emirates with high urbanization have high reflects unity of mind and body with Allah with life expectancy, good access to education and no separation of physical and spiritual health healthcare, and low levels of maternal and infant (Al-Shahri and Al-Khenaizan 2005; Lovering mortality. However, these are offset by the bur- 2012). den of noncommunicable diseases such as obe- Health is defined as complete physical, psy- sity, diabetes mellitus, and injuries from road chological, social, and spiritual well-being with traffic accidents. The remaining 77% of the Arab spiritual health an essential component of the countries such as Saudi Arabia, Oman, and Muslim health belief model. God is the source Jordan have shifted from a desert nomad to a of health, illness, and treatment. Health is a gift modern, urbanized society within the past two or reward from God, while illness, suffering, generations. Significant economic and social and dying are part of life and a test of faith or progress has led to improved life expectancy, atonement for sins. While accepting medical reduced maternal and infant mortality, and a treatment, spiritual healing practices are widely shift from communicable diseases to high rates used including curing disease caused by the of obesity, diabetes mellitus, heart disease, and evil eye or jinn (spirits). Spiritual healing prac- mortality due to road traffic accidents (Boutayeb tices, also called prophetic medicine, include and Serghini 2006). reading from the Holy Qur’an, use of prayer, Saudi Arabia’s population is 31.5 million, of religious supplications, eating honey, black which 19.9 million (63.21 %) are Saudi citizens, cumin seeds (nigella), myrrh, and drinking while 11.5 million (36.78%) are foreign resi- Zamzam water, holy water from Makkah dents. The population profile is similar to other (Al-Shahri and Al-Khenaizan 2005). Traditional countries in the Eastern Mediterranean region medicine and folk remedies such as the use of with over 29.12% of the population under the age wet cupping, cautery, and herbal medications of 15. The population is expected to double by are used alongside Western medicine and spiri- 2030. Only 2.93% of the population is over the tual healing, particularly by the elderly and age of 65 with total life expectancy of 74.3 years rural populations (Alrowais and Alyousefi (Ministry of Health KSA Statistics 2015). 2017). Chronic diseases such as diabetes mellitus, hypertension, heart diseases, cancer, genetic blood disorders, and childhood obesity have 16.2 Family and Decision-Making emerged with the change from communicable to noncommunicable disease patterns in the past Family is the core institution in Arab Muslim generation (Almalki et al. 2011). Free and avail- populations and includes husband, wife, chil- able health services are provided by the govern- dren, and parents and close relatives and relations ment; however, Saudis tend to seek healthcare across all generations. The family is the basis of after developing disease symptoms or reaching an individual’s identity. Marriage is the only an advanced stage of illness despite organized institution that connects family members; sex screening programs and protocols (El Bcheraoui outside of marriage is not permitted. et al. 2015). The roles within the family are based on The Arab Muslim worldview is derived from Islamic tradition and Arab culture. The father is the religion of Islam. Islam means total submis- usually the leader, breadwinner, provider, protec- sion and obedience to the will of Allah and is a tor, and spokesperson of the family. The mother complete way of life. The teachings and laws of is the homemaker and main nurturer of the 16 Case Study: An 85-Year-Old Saudi Muslim Woman with Multiple Health Problems 151

children. Grandparents have significant level of 16.3 Modesty decision-making authority on family matters; parents are regarded with high respect and Modesty is an important religious and cultural children encouraged to obey parents (Al Mutair value. The need to protect modesty and dignity in et al. 2014). Loyalty to family and respect for the the healthcare encounter is from the religious value elderly are the most important social obligations to promote chastity and purity. The wearing of hijab (Ezenkwele and Roodsari 2013). (head scarf and/or face veil) is to protect the mod- Traditionally, the elderly live with the oldest esty of females, including during the healthcare son. The son or daughter will accompany the encounter. Unnecessary touch, including shaking parent during the hospital stay and mediate the hands between unrelated adults of the opposite sex, communication between their parent and the is not acceptable within traditional Islam. health professional. Care giving is a responsibil- A woman must cover all the parts of her body ity shared by all family members (Al Mutair except the hands and face, while a male will wish et al. 2014). It is culturally unacceptable and to cover parts of the body from the navel to the shameful for elderly family members to be insti- knee. Modesty is maintained by covering during tutionalized, such as in a nursing home, because procedures and examinations and avoidance of caring for parents is a cultural and religious skin to skin contact between the sexes. Depending obligation. For this reason, nursing homes are on the degree of conservatism, some patients may not available in most Middle East countries; request sex concordant caring such as in mater- however, some chronic care facilities are devel- nity or gynecology settings (Al-Shahri and oping for patient requiring chronic medical Al-Khenaizan 2005; Lovering 2012). care. It is the role of the family to protect and care for the patient and to relieve the patient of the 16.4 Communication burden of significant treatment decisions while ill. A cultural expectation is that the family Arabs value interpersonal relationships. Indirect decision-maker, usually the older male, will take communication with meaning embedded in socio- responsibility for decisions concerning the cultural context and nonverbal messages and patient after consultation with other family avoidance of direct conflict are important. members. This consultation may or may not Establishing a trusting relationship with the patient include the patient, depending on the patient’s and family is important through the use of formal wishes and the cultural norms. It is important for greetings, such as Asalaam alaikum (peace be the health professional to work through the fam- upon you), and nonverbal communication convey- ily in providing care and building trust. In this ing a calm and respectful approach. Use of Arabic dynamic pattern, the health professional treats words, such as saying Bism’allah (in the name of the patient and family as the unit after confirm- God) before doing a procedure and Insh’allah (if ing with the patient who is their delegated God wills) when discussing the future, is a mean- decision-maker. ingful way to connect and establish trust with the Visiting is a religious and cultural requirement patient and family, even when used by a non-Arab on family members (Al Mutair et al. 2014), and it non-Muslim person (Lovering 2012). is considered shameful not to visit ill relatives. Cultural rules need to be understood when inter- Support for the extended visitation is important preting eye contact and use of body language in the to the well-being of the patient and to the family, healthcare encounter. To show respect, touch and with the family “in charge” of the visiting pro- direct eye contact between male health workers cess. The family may need support from the nurse and female Arab Muslim patients should be to ensure a balance of psychological support avoided unless necessary. Listening skills are through visiting and the need for rest. Dismissal important with interpretation of other body lan- of visitors by healthcare providers is culturally guage signals, particularly when a female is wear- unacceptable (Al-Shahri 2002). ing a face veil, which may be challenging for 152 S. Lovering non-Muslims. When communicating with the diabetes mellitus, or be substituted by the elderly, it is disrespectful to call an older person by patient and family for allopathic medicine. their own name (Al Mutair et al. 2014). For exam- • Conduct skin assessment to identify the use of ple, in Saudi Arabia the elderly will be called father cupping or cautery healing practices for skin (Baba) or mother (Mama), or by the name of the integrity issues and need for wound care. eldest son, Abu Khalid, meaning father of Khalid • Use “medical honey” dressings to replace use or Umm Khalid, meaning mother of Khalid. of raw honey for wound care. • Accommodate family requests for a religious healer for treating the evil eye, jinn, or for 16.5 Culturally Competent reading special religious supplications. Strategies Recommended

Culturally competent strategies for Umm Khalid, 16.5.3 Support for Religious Caring mother of Khalid, need to address cultural and Practices spiritual caring needs, communication strategies, and working within the sociocultural context of • Support use of prayer by providing prayer patient- and family-centered care within the Arab mats and support for patient doing ablutions, Muslim context. (washing ritual prior to performing prayers), providing a basin with water, and turning the bed to face Makkah (Mecca) for prayers if 16.5.1 Individual/Family requested by patient or family. Interventions • Modify the care routine to accommodate prayer prior to procedures. • Assess the role of the patient within the family • Do not interrupt the patient or family mem- and family support systems. bers during the prayer ritual. • Determine the structure of the family (multi- • Accommodate listening to/reading of the Holy generational), main family decision-maker, Qur’an as a religious healing practice. family roles related to the care of the patient, • Accommodate requests for using Zamzam and the impact of illness and hospitalization water, holy water, to wash the patient, for tak- on the patient’s role within the family. ing Zamzam water with medications, and for • Assess the patient’s relationships with other flushing a nasogastric tube. family members and family support systems • Do not place objects on the Holy Qur’an as it for the patient. is a holy book and ask permission to touch or • Elicit family members in assessing and inter- move the holy book if the provider is a preting the patient’s psychosocial needs, level non-Muslim. of anxiety and stress, as well as coping mechanisms. • Assess the family’s need for emotional sup- 16.5.4 Decisions About Care port because they may bear the burden of coping with bad news rather than the patient. • Ask the patient or the family the preferred way of addressing the patient, i.e., what “name” to use. 16.5.2 Assessment of Health Beliefs • Use Arabic words such as Asalaam alaikum and Use of Traditional Healing (peace be upon you) as a greeting and Methods Bism’allah before performing a procedure as part of establishing a trusting relationship • Assess the use of traditional healing methods with patient and family. such as herbs, traditional medicines, oil, and • Seek permission before touching the patient, honey because some traditional methods may in particular if male/female touching is be harmful to the patient condition, such as required for a procedure. 16 Case Study: An 85-Year-Old Saudi Muslim Woman with Multiple Health Problems 153

• If a female patient wears a hijab (head and/or about harmful traditional practices such as face cover), ensure that the hijab, or similar cautery. such as an operating room cap or a towel, • Engage with the religious community to pro- remains in place under all circumstances when mote healthy living as a religious obligation to a male is present. prevent obesity and diabetes mellitus. • Use an interpreter for communication with patients as family members may not fully dis- Conclusion close information due to the need to protect Working within the Arab Muslim sociocul- the patient from distress. tural context is the key to caring for Umm • Ask the family decision-maker to be respon- Khalid. Umm Khalid is an elderly woman sible for the control of visitors in respect for who has seen a massive transformation from their family member and in respect for the her early life as a desert nomad to experienc- hospital rules. ing modern medicine. Her family is her world, who she expects to completely protect her and care for her to the end of her life. She believes 16.5.5 Organizational-Level that her health and illness are from Allah and Interventions that she must bear suffering as a test of her faith while depending on prophetic medicine • Provide support to the family to care for the and spiritual healing. The modern healthcare patient and for the family members to stay team must place the Western medicine model within the patient room at all times. alongside the traditional practices while work- • Adjust ward routines for supporting prayer by ing with the family to prevent harm. providing prayer mats. The family is the key to planning the care of • Support extended visiting hours, in particular Umm Khalid with the son as the family if end-of-life care is instituted. decision-maker and the daughters most knowl- • Support the use of religious healers/sheiks. edgeable of the patient’s spiritual and cultural • Encourage the use of family conferences by needs. Healthcare organizations in Arab the healthcare team for decision-making about Muslim societies need to refocus care models the care of Arab Muslim patients. on the patient-family unit as the center of care • Modify organization policies to accommodate to be consistent with the sociocultural beliefs. a process for patients to elect a family member At a community level, the religious community as decision-maker on behalf of a competent support for health promotion strategies is the patient. key to tackling the “new” diseases of obesity, • Teach non-Arab Muslim staff about cultural diabetes mellitus, and cardiovascular disease. values and beliefs of Arab Muslim patients.

References 16.5.6 Societal Level Al Mutair Abbas S, Plummer V, O’Brien A, Clerehan R (2014) Providing culturally congruent care for • Develop home health services to support fam- Saudi patients and their families. Contemp Nurse ilies in caring for loved ones at end-of-life 46(2):254–258 care, consistent with the need for family car- Almalki M, Fitzgerald G, Clark M (2011) Health care ing practices. system in Saudi Arabia: an overview. East Mediterr Health J 17:784–793 • Collect data on the use of complimentary Alrowais N, Alyousefi N (2017) The prevalence extent of alternative medicine (traditional and folk) complementary and alternative medicine (CAM) use within the community. among Saudis. Saudi Pharm J 25:306–318 • Target health education strategies on harmful Al-Shahri M (2002) Culturally sensitive caring for Saudi patients. J Transcult Nurs 13(2):133–138 practices within the community. Engage with Al-Shahri M, Al-Khenaizan A (2005) Palliative care for religious community leaders on teaching Muslim patients. J Support Oncol 3:432–436 154 S. Lovering

Boutayeb A, Serghini M (2006) Health Indicators and Ezenkwele U, Roodsari G (2013) Cultural competen- human development in the Arab region. J Health cies in emergency medicine: caring for Muslim- Geogr 5:61. https://ij-healthgeographics.biomedcen- American patients from the Middle East. J Emerg Med tral.com/articles/10.1186/1476-072X-5-61. Accessed 45(2):168–174 4 July 2017 Lovering S (2012) The crescent of care: a nursing model El Bcheraoui C, Marwa T, Farah D, Kravitz H, to guide the care of Arab Muslim patients. Divers Almazroa M, Al Saeedi M, Memish Z, Basulaiman Equality Health Care 9:171–178 M, Al Rabeeah A, Mokdad A (2015) Access and Ministry of Health KSA Statistics (2015) http://www. barriers to healthcare in the Kingdom of Saudi moh.gov.sa/en/Ministry/Statistics/book/Documents/ Arabia: findings from a national multistage sur- StatisticalBook-1436.pdf. Accessed 25 May 2017 vey. BMJ Open 5:e007801. https://doi.org/10.1136/ bmjopen-2015-007801 Case Study: Communication, Language, and Care with a Person 17 of Mexican Heritage with Type 2 Diabetes

Rick Zoucha

Mr. Jose Garcia is a 57-year-old man who identi- Mr. Garcia was born and raised in a State in fies culturally as Mexican American or a person central Mexico, in the capital city of that State in of Mexican heritage. He recently presented at the central Mexico. The city is located in the center behest of his wife to his primary care physician of the country in a mountainous region. The cli- (PCP) with symptoms of type 2 diabetes such as mate is dry with warm days and cool evenings. frequent urination, increased thirst, blurry vision, There is no need for in-house heating and air- and tingling in his hands (American Diabetes conditioning. The population of the city is esti- Association 2017). His blood glucose was 210 mated to be around 70,800 but varies historically and his A1C was 9.5. Mr. Garcia was diagnosed (Consejo Nacional de Población, México 2015). with type 2 diabetes and was provided with edu- For Mr. Garcia’s family, life was difficult with cational information in English and a prescrip- few jobs, crowded housing, and little opportu- tion for metformin 500 mg two times per day. Mr. nity economically, socially, and personally. Mr. Garcia went to his PCP appointment alone since Garcia’s uncle and his family immigrated to the his wife was not able to get off work. After leav- USA in search of a better life. They found a bet- ing the office, Mr. Garcia felt confused and not ter life in the USA and shared that news fre- sure how to proceed with his prescription and quently with family members and friends still suggestions for managing his new diagnosis of living in Mexico. In the late 1970s and early type 2 diabetes. He did not understand much of 1980s, there was an increase in foreign-born the discussion and instructions with the nurse and immigration (14.1 million) to the USA including physician regarding his diagnosis. The interac- people from Mexico. The numbers of immi- tions were in English, and Mr. Garcia did not feel grants continued to grow and by 2009 Mexican- confident in both comprehension and speaking born immigrants accounted for over 29% of the English. Mr. Garcia has certain beliefs about dia- foreign-born residents of the USA (Batalova and betes and was not sure if those beliefs were con- Terrazas 2010). sistent with what he heard and understood during Mr. Garcia, his parents, grandparents, and sib- his visit with the nurse and physician. lings spoke frequently about leaving Mexico for the USA. It was a difficult discussion because the family would leave a large extended family for an unknown country. In addition, no one in the fam- R. Zoucha, PhD, PMHCNS-BC, FAAN Professor and Joseph A. Lauritis Chair for Teaching ily spoke English, which was of concern to the and Technology, School of Nursing, Duquesne family. However, Mr. Garcia’s uncle assured the University, Pittsburgh, PA, USA family that he did not speak much English and e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 155 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_17 156 R. Zoucha that he was doing well and supporting his to work sites and offers suggestions and advice family. but no longer performs roofing. Each male mem- Mr. Garcia immigrated to the southwest region ber of the four generation provides different skills of the USA from Mexico with his parents, his to keep the small business profitable. While at five siblings (four brothers and one sister), and work, the primary language spoken is Spanish. his maternal set of grandparents when he was 17 years old. He completed the equivalency of high school in Mexico prior to coming to the USA. In 17.1 Cultural Issues Mexico, the educational system children complete school until ninth grade. While in ninth There are several cultural issues to consider when grade, students and families make the decision to caring for Mexican Americans through preven- stop their education and go directly into the tion and/or treatment of type 2 diabetes. These workforce or study for the entrance exams for issues include prevalence and beliefs about dia- preparatoria (preparatory) or commonly called betes, family roles, and communication and will prepa. Successful entrance exams allow students be discussed. to be admitted to a 3-year college preparatory Mexican Americans experience an 87% program. This program prepares student to then higher risk for diabetes relative to non-Hispanic be able to apply to a college or university in Whites (CDC 2011). This significant fact is Mexico. Unlike many of his friends and family, important to consider when working with Senior Garcia decided to stop and graduate from Mexican Americans regarding diabetes care. In the ninth grade and work. This was a joint deci- addition, considering Mexican Americans per- sion between him and his parents due to the ceptions and beliefs about diabetes is imperative financial needs of the family. in promoting culturally congruent care. Since Mr. Garcia immigrated with his family, According to Coronado et al. (2004), Mexican he has lived in a multigenerational household: Americans believe that diabetes is caused by eat- first with his siblings, parents, and grandparents ing a high-fat or high-sugar diet, family history and now with his wife and his parents, one daugh- of diabetes, and little to no exercise. Included in ter, son-in-law, and one grandchild. Mr. Garcia this belief is a precipitating event that is thought has one son in addition to his daughter who lives to cause diabetes called sustos. This precipitat- in the same city near the Garcia family. His son is ing event is viewed and experienced as strong married with three children. In total Mr. Garcia emotions and described as fright or soul loss. has four grandchildren living either with him or Some Mexican Americans believe that diabetes near his family. Spanish is the primary language is in the body through heredity and sustos acti- spoken in the home and work. Both of Mr. vates the disease. It is believed that some life Garcia’s adult children and all the grandchildren events have caused the person to be frightened speak both Spanish and English. However, the such as witnessing an accident or a traumatic entire family speaks mainly Spanish with Mr. event of a child and essentially the soul is fright- Garcia. Mr. Garcia lives in a large metropolitan ened out of the body (Caballero 2011). Many city in the southwestern part of the country in a believe that sustos is the eventual cause of diabe- predominately Mexican American neighborhood. tes (Lemley and Spies 2015). It is important for Spanish is the primary language spoken in the nurses and healthcare professionals to under- neighborhood including the stores, restaurants, stand the cultural belief and perception to focus and businesses. care in a culturally congruent manner. Mr. Garcia, along with his father, cousin, son, It is critical to understand the role of family and grandson, runs a small roofing business in the when promoting culturally congruent care in city. There are four generations working together Mexican Americans. There is a saying in the cul- to provide for the family and extended family. ture that God is first, family is second, and the Mr. Garcia’s father continues to join the roofers individual is third. During times of health and ill- 17 Case Study: Communication, Language, and Care with a Person of Mexican Heritage 157 ness, understanding the role of family is ulation (U.S. Census Bureau 2015a, b, 2016). imperative. Illness affects not only the individual The median income of Hispanic households is but the entire family. The idea of presence and $45,150, and the poverty rate among Hispanics attending to family members in which care is is 21.4% in the USA. The percentage either directed or self-directed is important to of Hispanics who lacked health insurance understand (Zoucha 1998). In some traditional was 16.2%, and the 66% of Hispanics age 25 Mexican American families, the female members and older hold at least a high school (wife, daughter, mother, grandmother, aunt) of education. the family may assume the role of caregiver and The census data do not report specifically on health promoter (Caballero 2011; Hatcher and Mexican American voting trends, but it is impor- Whittemore 2007). It would be prudent to include tant to note that in the Hispanic community there women in the care of male members of the family have been increases in voting within this com- if indicated. This practice may be changing over munity. In 1996, 4.7% of all voters were Hispanic time but should be considered with some with an increase in 2012 to 8.4% for presidential families. elections. In 2014, 7.3% of voters were Hispanic There are specific communication patterns for congressional election. This upward trend that are present in many people of Mexican may suggest increased influence on policy and heritage. It is estimated that over 41 million politics in the USA. people speak Spanish in the USA (U.S. Census The changing political climate in the USA Bureau 2015a, b). Many people living in the has produced much anxiety regarding immigra- USA speak both Spanish and English in and tion and residency issues for Mexican Americans outside of the home. Some, depending on their and non-Mexican Americans alike. Recent pres- age, may feel less confident speaking English idential executive order related to the DACA outside of the home and with healthcare profes- (Deferred Action for Childhood Arrivals) is pro- sionals. Whether the individual prefers speak- moting perceived uncertainty regarding health- ing Spanish or English or both, it is important care and healthcare issues for many in the to approach communication with a sense of Mexican American community. Regardless of personalismo and respect (Zoucha and actual immigration, residency, and US citizen- Zamarripa 2013). The first meeting may be ship, people of Mexican heritage have common more formal and respectful when introduced; concerns about the perceptions of the govern- however, the remaining interactions may be ment and some citizens regarding their place in less formal. Personalismo is the process or US society (C. Zamarripa, personal communi- interaction in which the person (healthcare pro- cation, August 17, 2017). This most certainly fessional) behaves like a friend and is less for- will and can impact heath, health status, and mal when communicating. It is common to healthcare access for people of Mexican heri- engage in conversations that may include ques- tage in the USA. tions and conversations on both sides related to family or friends. When using personalismo it can build confianza, confidence, in the relation- 17.3 Culturally Competent ship between the healthcare provider and peo- Strategies ple of Mexican heritage (Zoucha 2017). Past and current social structures have affected Mr. Garcia’s health, illness, and well-being expe- 17.2 Social Structure Factors riences and reality. The following presents ideas and suggestions about individual-, organiza- The total Hispanic population in the USA is tional-, and societal-level strategies to promote 56.6 million, and Mexican Americans repre- care that is competent and congruent with Mr. sent approximately 63.4% of the Hispanic pop- Garcia’s cultural context. 158 R. Zoucha

17.3.1 Individual-/Family-Level that includes concepts important to understand- Interventions ing the cultural care needs of the people they serve, including people of Mexican heritage. • Since Mr. Garcia has some difficulty with the English language, the individual provider and those in the office can provide interpreters 17.3.3 Societal-Level Interventions through a variety of services on site or mobile/ phone or computer-assisted services. • Encourage people of Mexican heritage to vote • If Mr. Garcia comes to his appointments for candidates that promote healthcare access alone, healthcare providers can make aftercare for all people and more specifically to include calls to his wife and/or other family members people of Mexican heritage. to assure that Mr. Garcia has understood any • Healthcare professionals can influence policy medical or nursing interventions. through their professional organizations and • If Mr. Garcia comes to his appointment with elected officials. any family members, it is imperative that they • Encourage health policy that includes social are included in the discussion about the reason justice application for people of Mexican heri- and intervention for the visit. tage for universal access to healthcare. • Healthcare providers should provide educa- • Influence and promote policy that is culturally tional and instructional materials in Spanish congruent with provisions for not only cul- for Mr. Garcia and his family. tural care needs but in language of choice (verbal and written materials) for people of Mexican heritage. 17.3.2 Organizational-Level Interventions Conclusion The USA demographically will continue to • Healthcare systems that include hospitals, evolve and change well into the future. It is pre- PCP offices, clinics, and community centers dicted that the Hispanic population will grow to should adopt policies that are consistent 119 million or 28.6% of the total population in throughout the health system. the USA by 2060 (US Census Bureau 2014). • Consistent policy and implementation of pro- With the continued growth and prediction by cedures regarding family inclusion, interpret- the US Census Bureau of the increases in the ers, and educational materials in Spanish will Hispanic population and more specifically the promote best practices and potentially positive Mexican American population, the quest to health outcomes. promote culturally congruent care will con- • Large and small healthcare institutions should tinue. Nurses and other healthcare profession- partner with businesses, institutions, and lead- als must continue to be vigilant as advocates for ers in the community to plan and provide care people of Mexican heritage as suggested in the that is consistent with people in the commu- levels of interventions outlined earlier. In order nity in their cultural context. to promote health outcomes for people of • Professional schools such as nursing, health Mexican heritage, it remains imperative that sciences, pharmacy, social work, and medi- nurses and healthcare professionals always cine can form a multidisciplinary effort to pro- consider their unique cultural care needs. mote communication and interventions that are consistent with the cultural care needs of people of Mexican heritage. References • Professional schools such as nursing, health sciences, social work, pharmacy, and medicine American Diabetes Association (2017) www.diabetes. can utilize a common approach to education org. Accessed 10 Aug 2017 17 Case Study: Communication, Language, and Care with a Person of Mexican Heritage 159

Batalova J, Terrazas A (2010) Frequently requested sta- the United States. https://factfinder.census.gov/faces/ tistics on immigration and immigration in the United tableservices/jsf/pages/productview.xhtml?src=bkmk. States. Migration Policy Institute. http://www.migra- Accessed 11 Sept 2017 tionpolicy.org/article/frequently-requested-statis- U.S. Census Bureau (2015b) American community sur- tics-immigrants-and-immigration-united-states-1. vey 1-year estimates, Hispanic or Latino origin by Accessed 20 May 2017 specific origin. https://factfinder.census.gov/faces/ Caballero AE (2011) Understanding the Hispanic/Latino tableservices/jsf/pages/productview.xhtml?src=bkmk. patient. Am J Med 124(10 Suppl 5):511–515 Accessed 11 Sept 2017 Centers for Disease Control and Prevention (CDC) (2011) U.S. Census Bureau Population Division (2016) Annual National diabetes fact sheet: national estimates and estimates of the resident population by sex, age, race, general information on diabetes and prediabetes in and Hispanic origin for the United States and States: the United States, 2011. U.S. Department of Health April 1, 2010 to July 1, 2015. Source: U.S. Census and Human Services, Center for Disease Control and Bureau, Population Division. https://factfinder.cen- Prevention, Atlanta sus.gov/faces/tableservices/jsf/pages/productview. Consejo Nacional de Población, [National Population xhtml?src=bkmk. Accessed 11 Sept 2017 Council] México (2015) https://www.citypopulation. U.S. Census Bureau Population Projections (2014) 2014 de/Mexico-Guanajuato.html. Accessed 20 May 2017 National population projections datasets. https://www. Coronado GD, Thompson B, Tejeda S, Godina R (2004) census.gov/data/datasets/2014/demo/popproj/2014- Attitudes and beliefs among Mexican Americans popproj.html. Accessed 11 Sept 2017 about type 2 diabetes. J Health Care Poor Underserved Zoucha RD (1998) The experiences of Mexican Americans 15(4):576–588 receiving professional nursing care. J Transcult Nurs Hatcher E, Whittemore R (2007) Hispanic adults’ beliefs 9(2):34–44 about type 2 diabetes: clinical implications. J Am Zoucha R (2017) Understanding the meaning of Acad Nurse Pract 19:536–545 Confianza (confidence) in the context of health for Lemley M, Spies LA (2015) Traditional beliefs and prac- Mexicans in an urban community: a focused ethnogra- tices among Mexican American immigrants with phy. Unpublished raw data. type II diabetes: a case study. J Am Assoc Nurs Pract Zoucha R, Zamarripa C (2013) People of Mexican heri- 27:185–189 tage. In: Purnell LD (ed) Transcultural health care: a U.S. Census Bureau (2015a) American community sur- culturally competent approach, 4th edn. F. A. Davis, vey 1-year estimates, selected social characteristics in Philadelphia, pp 374–390 Case Study: Stigmatization of a HIV+ Haitian Male 18

Larry Purnell, Dula Pacquiao, and Marilyn “Marty” Douglas

Ronald is a 27-year-old homosexual man with a parents in the United States to receive better high school education who recently emigrated healthcare for his HIV+ condition than was pos- from Haiti to a large urban area in the United sible in Haiti. He was concerned, however, about States. His parents and two siblings emigrated 8 his poor English language proficiency. His par- years earlier because of the country’s political ents successfully applied for Ronald to immi- unrest. At that time, Ronald remained with rela- grate under the Cuban Haitian Entrant Program tives because he did not want to leave his friends. (US Citizenship and Immigration Services 2015). While working in Haiti, Ronald was hospitalized Currently Ronald and his family live in a pre- for pneumonia, at which time he was diagnosed dominantly Haitian community in southeastern with HIV. He did not reveal his HIV status for United States that has a median household fear of discrimination. Even though homosexual- income of $38,525, which is below the state ity in Haiti is legal, it remains a taboo. Ronald median household income of >$47,000 (US joined the local voodoo community because of its Census Bureau 2015). His father works as a bank acceptance of homosexuals. Ronald joined his clerk despite being an accountant back in Haiti. His mother, trained as a teacher in Haiti, now works as a teacher’s aide in the United States. L. Purnell, Ph.D., R.N., FAAN (*) The neighborhood lacks adequate bus service School of Nursing, University of Delaware, and is a long distance from the nearest hospital. Newark, DE, USA Occasionally a mobile health clinic will be avail- Florida International University, Miami, FL, USA able, but the visits are unpredictable. The high Excelsior College, Albany, NY, USA crime rate in the neighborhood has driven out e-mail: [email protected] large-scale grocery stores that would provide D. Pacquiao, Ed.D., R.N., C.T.N.-A. healthy, fresh food, leading to a “food desert” Center for Multicultural Education, Research and environment. The crime rate also is a personal Practice, School of Nursing, Rutgers University, Newark, NJ, USA safety issue, preventing walking to maintain a healthy lifestyle. School of Nursing, University of Hawaii, Hilo, Hilo, HI, USA His family is well-respected in the community e-mail: [email protected] for their strong Catholic faith and display of posi- M. Douglas, Ph.D., R.N., FAAN tive moral values. Ronald is reluctant to attend School of Nursing, University of California, church because he perceives a lack of acceptance San Francisco, San Francisco, CA, USA due to both the community’s and the Church’s e-mail: [email protected]; view of homosexuality. For similar reasons, [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 161 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_18 162 L. Purnell et al.

Ronald has not disclosed either his sexual orien- eted because of this stigma and the fear of dis- tation or HIV status to his parents. He tried crimination. If a family member discloses that he unsuccessfully to find a voodoo community. or she is gay, everyone is silent; there is total Three months after his arrival in the United denial. Within the Catholic Haitian community, States, Ronald was hospitalized for pneumonia there is a strong stigma associated with both and is diagnosed with AIDS. He disclosed his being gay and being infected with HIV (Colin sexual orientation to the doctor but still feels he and Paperwalla 2013). cannot tell his parents for fear of bringing shame The literature cites some cases in which to the family. He was offered the services of an Haitians’ communication patterns include loud, interpreter because of his lack of language profi- animated speech and touching in the form of hand- ciency, but he refused for fear that the interpreter shakes and taps on the shoulder to define or recon- would discuss his condition with members in the firm social and emotional relationships, including community and word would ultimately reach his with healthcare providers. Haitians with lower lev- parents (Colin and Paperwalla 2013). els of education generally hide their lack of knowl- Since Ronald is unemployed, he does not have edge to non-Haitians by keeping to themselves, health insurance and feels that he cannot ask his avoiding conflict, and, sometimes, projecting a family for financial assistance to purchase the timid air or attitude. They may smile frequently expensive drugs. In addition, he has difficulty and may respond in this manner when they do not understanding the directions and information understand what is being said. Traditional Haitians about his medication prescriptions. Ronald generally do not maintain eye contact because it is agreed to a visit from a social worker, who considered rude and insolent, especially when informed him of the Haitian Community speaking to persons of authority. Due to the stigma Coalition, which provides health education, associated with certain sensitive cases, such as English language classes, and certified interpret- HIV/AIDS, some Haitians may prefer to use pro- ers. They have taken an oath of confidentiality fessional interpreters who they will likely never and could help him understand his medications. see again (Colin and Paperwalla 2013). In addition, the social worker assisted Ronald Even though most Haitians are deeply reli- in contacting the Ryan White AIDS Drug gious, spiritual beliefs of many are combined Assistance Program, a program that provides with voodoo (voodooism), a complex religion HIV drugs to low-income people (US Department with its roots in Africa (Religious Tolerance: of Health and Human Services n.d.). Ronald was Religions of the World 2010). Voodoo involves also referred to an organization named Dignity, a communication by trance between the believer community of homosexual Catholics, their fami- and ancestors, saints, or animistic deities. Voodoo lies, and their friends who could help him dis- believers may attribute some of their ailments or close to his parents about his HIV/AIDS status medical problems to the actions of evil spirits and (Dignity USA 2015). therefore not readily seek Western medical care for these problems. For many Haitian patients, the belief in the power of the supernatural can 18.1 Cultural Issues have a great influence on the psychological and medical concerns of the patients (Colin and In the Haitian culture, any action taken by one Paperwalla 2013). family member has repercussions for the entire family; consequently, all members share prestige and shame. The prestige of a family is very 18.2 Social Structural Factors important and is based on attributes such as honesty, pride, trust, social class, and history. Haiti is habitually ranked as the poorest country Homosexuality is taboo in the Haitian culture, so in the Western Hemisphere (Slatten and Egset gay and lesbian individuals usually remain clos- 2004). In 2012, 58.5% of the Haitian population 18 Case Study: Stigmatization of a HIV+ Haitian Male 163 was at or below the poverty level (World Bank factors impinging on their lives, they face huge 2016). As an indicator of their poor health and challenges to maintain health for themselves and healthcare system, Haitians have a life expec- their families without the assistance and support tancy of only 57 years, as compared to an average of the broader society. of 69 years for all Latin Americans. Only about 25% of children are vaccinated, and safe water is accessible to only a quarter of the population 18.3 Culturally Competent (World Bank 2016). Coming from a lifetime of Strategies Recommended these conditions places a huge allostatic load on Ronald and his family, as well as the Haitian Haitian refugees are one of the most at-risk popu- community in the United States. The chronic lations living in the United States. Besides those stress affects the autoimmune system, among actions already employed to assist Ronald, the others, and makes recipients less resilient in the following are recommendations to enable the face of illnesses and disease threat (Global Health development of strategies that are culturally Policy 2015). appropriate, adequate, and effective (Colin and In Haiti, HIV/AIDS is a significant health Paperwalla 2013). problem, with approximately 141,300 Haitians living with the infection (US Central Intelligence Agency 2015). As in the case of Ronald, migrants 18.3.1 Individual-/Family-Level bring their health problems with them to their Interventions new country. In the United States, the HIV/AIDS prevalence rate among Haitian-born residents is • On admission, conduct an in-depth assess- 1.3% or 12,789 (Marc et al. 2010). ment of the person’s cultural self-identity, lin- Haitian immigration to the United States has guistic preferences, and environmental, continued for many years, with most living in occupational, socioeconomic, and educational seven states along the eastern coast (Fact Sheet status. on Haitian Immigrants in the United States 2010). • Be aware of the stigma that HIV+ has with the A majority of those who emigrated before 1920 patient’s family and the community. were members of the upper class. In 1920, the • Respect patient’s privacy regarding his reluc- United States occupied Haiti, and the first wave tant to share his diagnosis of HIV/AIDS. of poverty-stricken Haitian migration to North • Provide a thorough explanation of the role and America soon followed (Colin and Paperwalla confidentiality of certified interpreters and 2013). Today, many Haitians are in low-paying resources available. jobs that do not provide health insurance, and • Ascertain upon admission if the patient wishes they cannot afford to purchase it themselves. a visit from pastoral care. A referral to chap- Thus, economics acts as a barrier to health pro- laincy services might help Ronald with dis- motion. In addition, for those who do not speak cussions of his family situation and HIV/AIDs English well, it is difficult for them to access the status. healthcare system, fully explain their needs, or • Secure a psychiatric liaison professional to understand prescriptions and treatments. assist Ronald with his fear of discrimination The Haitian neighborhood in which Ronald and assistance with informing his family about and his family live exemplifies the environmental his lifestyle. and socioeconomic issues that contribute to the • Secure a referral to social services early in vulnerability of this population. The lack of Ronald’s admission to help him apply for health services, unhealthy food choices, high health insurance and other social programs for crime rate, and personal safety issues influence which he would qualify, such as English how the inhabitants are able to address their classes, job training, and housing, food, and health problems. With so many social structural transportation support. 164 L. Purnell et al.

• Provide education on sexually transmitted Conclusion infections and HIV prior to discharge and in Several social structural factors have enor- the preferred language of the patient. These mous impact on Ronald’s health and illness documents are available in Haitian Creole experience. Ronald has high school education from the Centers for Disease Control and and limited English proficiency that limit his Prevention (CDC). ability to seek better-paying jobs. He is currently unemployed, and his capacity for employment will be further compromised by 18.3.2 Organizational-Level his HIV condition. The stigma associated with Interventions homosexuality and HIV compounded by the fact that he is Haitian descent can potentially • Establish organization-wide committees to isolate Ronald from his family which is his address the promotion of culturally competent main financial support, as well as the Haitian care delivery to all patients. community. This stigma will ultimately shape • Allocate financial resources to fund certified the quality of his interaction with others interpreters in the major languages of the pop- including healthcare providers. All these fac- ulations served. tors create cumulative risks and vulnerability • Provide a certified interpreter when the patient as well as Ronald’s dependence on others. has limited language proficiency in the lan- In order to promote his health, strategies guage that is different from the healthcare should not be limited to the disease alone but providers. rather on the multiple problems that impact the • Provide signage and printed materials on mul- outcomes of his condition. Therefore, cultur- tiple conditions in the major languages of the ally competent strategies should focus not only population served. on him and his family in managing his disease • Partner with local Haitian community centers but to seek organizational and societal resources and coalitions, churches, and businesses to promote his integration in the community including bars, nightclubs, and radio and tele- and potential participation as a citizen in soci- vision stations to provide information on HIV ety. While focusing on his needs secondary to and sexually transmitted infections in English, the disease, culturally competent care should French, and Haitian Creole. promote the socioeconomic, cultural, and environmental supports that can make a difference in the way he lives and enhance his potential for 18.3.3 Community Societal-Level an autonomous and productive life. Interventions

• Collect demographic, socioeconomic, and References health data, including morbidity and mortality, of the Haitian community. Colin J, Paperwalla G (2013) People of Haitian heritage. • Establish a partnership with the Haitian In: Purnell L (ed) Transcultural health care: a cultur- Community Coalition to assist with health ally competent approach, 4th edn. F. A. Davis Co., Philadelphia, pp 269–287 education. Dignity USA (2015) https://www.dignityusa.org/. • Collaborate with the Haitian community to Accessed 14 Sept 2017 organize health fairs to address HIV and other Fact Sheet on Haitian Immigrants in the United States infections common among their population. (2010) http://www.cis.org/HaitianImmigrantFactSheet. Accessed 14 Sept 2017 • Collaborate with the Haitian community in Global Health Policy (2015) The global HIV/AIDs epi- working toward an environment that fosters demic. http://kff.org/global-health-policy/fact-sheet/ healthy lifestyles. the-global-hivaids-epidemic/. Accessed 14 Sept 2017 18 Case Study: Stigmatization of a HIV+ Haitian Male 165

Marc LG, Patel-Larson A, Hall HI, Hughes D, Alegria the-world-factbook/geos/ha.html. Accessed 15 Sept M, Jeanty G, Eveilland YS, Jean-Louis E (2010) HIV 2017 among Haitian-born persons in the United States, U.S. Citizenship and Immigration Services (2015) Cuban 1985–2007. AIDS 24(13):2089–2097 Haitian Entrant Program. http://www.uscis.gov/ Religious Tolerance: Religions of the World (2010) humanitarian/humanitarian-parole/cuban-haitian- Vodun, Voodoo, Vodoun, Vodou. http://www.reli- entrant-program-chep. Accessed 14 Sept 2017 gioustolerance.org/voodoo.htm. Accessed 14 Sept U.S. Department of Health and Human Services (n.d.) 2017 Health Resources and Services Administration: Ryan Slatten P, Egset W (2004) Poverty in Haiti. Fafo White HIV/AIDS Program Guarantee. http://www. U.S. Census Bureau (2015) New York Quick Facts. hrsa.gov/opa/eligibilityandregistration/ryanwhite/ http://quickfacts.census.gov/qfd/states/36000.html. index.html. Accessed 14 Sept 2017 Accessed 14 Sept 2017 World Bank (2016) World development indicators. http:// U.S. Central Intelligence Agency (2015) The World Fact data.worldbank.org/country/haiti#cp_wdi. Accessed book, 2015. https://www.cia.gov/library/publications/ 14 Sept 2017 Part V Guideline: Culturally Congruent Practice Integrating Culturally Competent Strategies into Health Care 19 Practice

Marilyn “Marty” Douglas

Guideline: Nurses shall use cross cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care. Douglas et al. (2014)

19.1 Introduction and adapted to be mutually acceptable and meaningful so that the desired outcomes are achieved Integrating the principles of cultural competence by both. into our health-care practice is the ultimate definition of individualized patient care. Providing such care requires an understanding first of how 19.2 Cultural Definitions the individual and family define health and ill- of Health and Illness ness and then the measures they take to cure illnesses and maintain wellness. These beliefs In the preamble to its constitution, the World about health are constructed by cultural groups Health Organization (WHO) defines health as “...a within a society. The foundation of these beliefs state of complete physical, mental and social well- is laid down in infancy but is later modified by being and not merely the absence of disease or education and life experiences. In order for infirmity” (WHO 1946). This definition remains health-care providers to deliver quality care that today, although it is controversial because it is too is meaningful to the individual, that care must be broad, unmeasurable, and difficult to operational- integrated within the health belief framework of ize in policies and health strategies. One reason for the individual. If not, then there is a risk that the these difficulties is because health is culturally expected outcomes will not be realized because defined and practiced. “In all human societies, the prescription of the provider cannot be incor- beliefs and practices related to ill health are a cen- porated into the individual’s belief system. This tral feature of the culture” (Helman 2007). These asynchrony between the values of the mainstream beliefs about the causes of illness and how to cure health-care providers and individuals of socio- and prevent them are linked to how they view the cultural and economically diverse populations world around them and the social structure in may be one reason for the disparity in health out- which they live. comes. Therefore, it is incumbent upon the In some societies, ill health can be blamed on health-care provider to partner with the individ- the intervention by a supernatural being (a deity), ual to explore ways in which care can be blended an evil spirit, a witch, or another person wishing harm, such as in the “evil eye” (Anderson 2010). M. Douglas, Ph.D., R.N., FAAN Others, notably some persons in Latin America, School of Nursing, University of California, San the Middle East, and Asia, may also ascribe to a Francisco, San Francisco, CA, USA naturalistic framework that originated in China e-mail: [email protected]; marilyn.douglas@ and India and was elaborated upon by nursing.ucsf.edu

© Springer International Publishing AG, part of Springer Nature 2018 169 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_19 170 M. Douglas

Hippocrates. Named the humoral theory, the health concerns and an optimal treatment pro- cause of illness is an imbalance of the four body gram. Obviously not all persons within a cultural humors. In this system, the four humors are char- group believe the same, act the same, or use the acterized as follows: (1) blood (hot and moist), same therapies for specific conditions. But if the (2) phlegm (cold and moist), (3) black bile (cold health-care professional is equipped with the and dry), and (4) yellow bile (hot and dry). More knowledge of cultural beliefs and practices that recently, this system has been distilled into the are different from those of the dominant culture, “hot” and “cold” theory whereby foods and ther- then questions can be framed in such a way as to apies are ascribed “hot” or “cold” attributes, validate which beliefs and practices the individ- unrelated to their actual temperature. Achieving a ual patient adheres to. To avoid stereotyping, it is healthy state then requires the individual to main- absolutely essential to evaluate each patient inde- tain an equilibrium of the body humors by treat- pendently as to which health-care beliefs and ing “hot” illnesses with “cold” therapies and vice practices they ascribe. The following discussion versa (Helman 2007). presents some examples of these alternative Both the Indian Ayurvedic system and tradi- belief systems. tional Chinese medicine, for example, equate health with balance. Within these Eastern worldview systems are the cosmic concepts of yin and 19.3.1 Maternity Care yang. Yin is defined as negative, cold, moist, dark, soft, and female, whereas yang is positive, Cultural variations in the beliefs and practices hot, dry, light, hard, and male (Macdonald 1984). surrounding childbirth have been studied exten- The individual is expected to maintain a balance sively in the past decades (Fishman et al. 1988; or harmony of these positive and negative forces Jordan 1980; Rice and Manderson 1996; Morse in all aspects of life. Balancing these opposing 1989; Manderson 1981). Traditional practices for forces is necessary in order to achieve optimal pregnancy and childbirth center on food choices, health. herbal prescriptions, massage, rest and exercise A religious and spiritual worldview rooted in restrictions, bathing, and postpartum confine- a strong belief in God can also have a health ment periods (Small et al. 1999), many of which dimension. Adherents may believe that faith in are based on the humoral medical theory of “hot” God and prayer will assure health. Their faith in and “cold.” However, there is great variation God helps them deal with illness and disabilities, within countries and even regions within coun- and they may believe that God allows diseases in tries. Many cultures adhering to the humoral order to test their faith. Health-care practitioners theory consider pregnancy a “hot” condition or need to be aware that this strong belief in God’s one that depletes the body of heat and causes the will may explain some of a person’s resistance to woman to be vulnerable to cold. But some con- some forms of prolonged intensive treatments. sider the mother and fetus to be “cold” during some portion of the pregnancy (Manderson 1981). Similarly, cultural prescriptions vary 19.3 Culturally Based Health widely for the herbs used during pregnancy and Beliefs and Practices during the postpartum period and the prescriptions for foods, bathing, and exercise during the It is particularly important to begin this discus- postpartum confinement period. sion with a cautionary note. Certain healthcare These differences are illustrated in reports of practices and beliefs may be common among studies investigating maternity care of cultural specific cultural groups. However, health-care groups around the world. Shewamene et al. professionals should be aware that these are just (2017) performed a systematic review of 20 stud- a framework, a baseline from which to begin a ies conducted in 12 African counties representing discussion with a patient regarding the patient’s 11,858 women, which found that the use of 19 Integrating Culturally Competent Strategies into Health Care Practice 171

various complementary and alternative medi- as female genital cutting or female genital muti- cines (CAM) or traditional medicine was as high lation (FGM), which is a term used in the medical as 80%. Boerleider et al. (2014) describe the literature but not preferred by the women them- maternity care experiences of non-Western immi- selves. The World Health Organization (2017) grants in the Netherlands, whereas Shahawy reports that at least 200 million girls and women et al. (2015) describe the health-care practices of currently alive have undergone some form of Muslim mothers. Wandel et al. (2016) performed FGC. Although this procedure is performed in-depth qualitative interviews with Somali mainly in Africa, it is also practiced in some parts mothers living in Norway, while Chen et al. of the Middle East and Asia. With migration from (2013) explored the differences between mater- these countries currently increasing, health-care nal behaviors and infant care of South Asian practitioners in Western countries are increas- immigrants and Taiwanese women in Taiwan. ingly caring for these women who have had FGC. Naser et al. (2012) compared the birthing prac- Female genital circumcision has been a tradi- tices of Chinese, Malay, and Indian women in tion dating back thousands of years. Hearst and Singapore. And finally, Hadwiger and Hadwiger Molnar (2013) provide illustrations of the geo- (2012) described some of the health beliefs graphical distribution of its prevalence as well as Filipina mothers have about health. But in all detailed photos of the four major types of FGC, these studies, there remained a wide range of which range from partial to full excision of the adherents to specific beliefs and practices. clitoris to infibulation or the stitching or narrow- Therefore, it is problematic to classify the treating of the vaginal opening. These illustrations ment of pregnancy and childbirth according to can be seen at http://www.mayoclinicproceed- one’s culture. For that reason, it is imperative that ings.org/article/S0025-6196(13)00264-4/ the health-care practitioner ask the mother broad fulltext#appsec1. The proponents cite a number questions about the general areas of cultural of traditional, cultural, and religious reasons for diversity in maternal care, such as: this procedure. They believe that this procedure will promote cleanliness, preserve femininity, • What types of foods do you prefer during and ensure marriage. They also believe that this pregnancy or after childbirth? will prevent stillbirths in primigravidae, increase • Do you use any particular herbs or spices, fertility, prevent promiscuity, and enhance male such as ginger, during pregnancy/after birth? sexual performance because of the smaller vagi- • What types of drinks do you prefer during this nal opening (El-Shawarby and Rymer 2008). period (hot or cold)? Health-care professional may see young girls or • Do you have any restrictions on bathing after women who have been circumcised for a number childbirth? of both early and late complications. Early • Do you have any restrictions on exercise complications include bleeding that may have before and after childbirth? occurred due to laceration of the pudendal or • Do you observe a period of “confinement” clitoral artery. Local infection due to unsterile after childbirth? If so, for how long? instruments can be severe enough to lead to tetanus or sepsis. Urinary retention is also seen in some Discussion of the mother’s practices not only cases due to injury to the urinary meatus, vagina, provides the health-care provider with ways in perineum, or bladder. Higher rates of these early which care can be adjusted to the benefit of the immediate complications are seen with those types new mother but also identifies potential risks, of FGC that involve more tissue excision and more such as thrombophlebitis due to prolonged inac- extensive infibulation (Hearst and Molnar 2013). tivity both before and after childbirth. Common long-term complications of this One area of maternity care that requires a procedure are most frequently urinary in nature. great deal of cultural sensitivity is that of female These include urinary strictures and stenosis, genital circumcision (FGC), or sometimes known frequent urinary tract infections due to retention, 172 M. Douglas urinary crystal formation in stagnant urine in the • What help would you like for any of these vestibule created by closed labia, poor urinary flow problems? below the infibulated scar, and occasionally urinary incontinence. Scarring as a result of this procedure The health-care provider cannot be expected can cause fibroids, keloid fusion of the labia, and to know everything about every culture. However, clitoral neuromas, all of which cause severe pain every person who seeks health care is entitled to and may require surgical intervention. Other respect and the willingness on the part of the types of pain commonly encountered in women health-care practitioner to listen to their con- with FGC are painful intercourse, lower cerns. In a study of 318 Vietnamese, Turkish, and abdominal pain, and dysmenorrhea (Momoh Filipino immigrants seeking maternity care in et al. 2001). Complications related to infections Australia, Small et al. (1999) found that the include an increased incidence of yeast infections, women were less concerned that the health-care bacterial vaginosis, and herpes simplex virus. It providers were knowledgeable about their cul- is yet to be determined whether there is a clear tural beliefs. On the other hand, they were more association between FGC and sexually concerned that these Western caregivers were transmitted diseases and HIV (Olaniran 2013). unkind, rushed, and unsupportive. Although lan- Psychological disorders are also sequelae of guage difference could explain some of this inter- FGC, such as anxiety, depression, and sexual pretation, there still remains a considerable dysfunction. portion of these feelings that can be attributed to Providing care for a woman with FGC requires the attitude of the caregiver. a culturally sensitive approach that is kind, empa- thetic, and nonjudgmental. Using the term “circumcision” is more readily understood by the 19.3.2 Pain Assessment: Does patients and their interpreters than female genital Culture Play a Role? mutilation, since they don’t view this procedure as mutilation. Women who have undergone FGC Pain is a symptom reported by patients to their should not be treated as “specimens” wherein the health-care professionals in all specialties and all presence of this condition is more interesting to settings. The experience of pain is a synthesis of the health-care providers than the woman’s pres- physiological, psychological, and sociocultural ent condition. A level of trust must be established factors, only one of which is ethnicity. But as a before the woman will be forthcoming and share subjective experience, pain can have very wide the information that is critical to her care. Some interindividual and group variability in expres- broad questions follow that a health-care profession. Complicating the picture is that ethnicity sional can use to begin the discussion with a and pain are both fluid and multidimensional in woman who has undergone FGC who is seeking nature. Yet, for more than half a century, numer- care. ous investigators have been trying to determine the exact relationship between the two. • Can you share/tell me about your experience Leininger (1979) states that how one reacts to with being circumcised? At what age were illness—pain, for example—is linked to cultural you circumcised? By whom? Where was it values and experiences. Culture defines not only done? health beliefs and practices but also what is • What do you think is good about being expected and how to behave, including how to circumcised? react to painful stimuli. Embedded within the • Does your religion recommend circumcision? cultural context are the perception, expression, • Does your culture recommend it? and management of pain. In a landmark and clas- • Do you have any pain/discomfort/problems sic study that stimulated subsequent studies on because of your circumcision? the relationship between pain and culture, • Other problems? Zborowski (1952) studied four cultural groups in 19 Integrating Culturally Competent Strategies into Health Care Practice 173 the United States: “Old Americans” (Anglo- ethnic groups, there was a wide range of effect Saxon), Irish, Italian, and Jewish hospitalized sizes for both pain tolerance and pain threshold. patients. He concluded that pain behaviors are In a more recent systematic review performed influenced by culture and social conditioning and by Kim et al. (2017), 41 studies investigated the that these patterns of attitudes toward pain may use of the same types of experimental stimula- have different functions in various cultures. He tion, i.e., cold, pressure, electrical, ischemic, and described the Anglo-American response as stoic, thermal, with populations of AA, Hispanics, restrained, avoiding any outward expressions of Asians, and NHW. Meta-analysis showed that pain and withdrawing in the event of severe pain. AA, Asians, and Hispanics had higher pain rat- Unfortunately, the hospital staff were inclined to ings and lower pain tolerance as compared with use the Anglo-American response as the “accept- NHW, but no differences in pain threshold. The able” model and to judge all others as either com- type of painful stimuli and demographic vari- plaining, overacting, or emotional. ables did not contribute to these variations. Numerous subsequent studies attempted to Faculty members of schools of dentistry also further explore this relationship between cul- studied cultural differences in pain sensitivity, ture and the response to pain. These investiga- using only mechanical and electrical stimulation. tions can be categorized into either a study of Al-Harthy et al. (2016) used a case control experimental pain or clinical pain. Although method to study 122 women from three cultures, studies of experimental pain are greatly limited Italians, Swedes, and Saudis, all living in their by solely measuring pain tolerance and pain country of origin. The Italian females reported threshold in essentially healthy participants, statistically significant scores that were lower in they can act as proxies for clinical pain when both pain threshold and tolerance than the Swedes trying to evaluate the basic mechanism of pain, and Saudis. The Swedes reported the highest lev- and they can control for ethnicity through sub- els of pain tolerance. ject selection. These experimental pain studies only address In one large-scale review of 26 studies of eth- a fraction of the pain experience. In the clinical nic differences in experimental pain, Rahim- setting, there is also the psychological aspect of Williams et al. (2012) examined the effect of cold fear and anxiety if pain signals a worsening con- stimuli, ischemic stimuli, mechanical or pressure dition, fear of disability, interference in life activ- stimuli, and electrical stimuli via acupuncture on ities, impact on employment, potential burden on the report of pain tolerance (the highest intensity family, and anticipation for treatment or nontreat- of painful stimulation an individual is able to tol- ment. Therefore, clinical pain studies are needed erate) and pain threshold (the lowest level of to provide the human perspective to this stimulation at which a stimulus can be perceived experience. as painful). The majority of the studies compared Lavin and Park (2014) performed a systematic non-Hispanic Whites (NHW) with African- review of 27 articles addressing pain in racially Americans (AA), but other comparison groups and ethnically diverse older adults. Race and eth- studied included Hispanics, South and East nicity was a statistically significant factor in 17 of Asians, British, Danish and Belgian Whites, these 27 studies. As compared with NHW, minor- Eskimos, and Nepalese, among others. Many of ity older adults reported a greater prevalence of these studies did report ethnic differences in the pain, higher pain intensity ratings, were less response to these painful stimuli, but their expla- likely to receive prescription pharmacologic nations of these differences varied. Of the 26 agents and surgery and were more likely to use studies reviewed, 15 compared AA with NHW; complementary and alternative medicines to treat analysis revealed that there were moderate to their pain. Almost 15 years ago, Green et al. large effect sizes for pain tolerance, with AA (2003) unveiled racial and ethnic disparities in demonstrating lower pain tolerance than NHW. In pain treatment of minorities in a large-scale those investigations comparing NHW with other review of 118 clinical pain research studies 174 M. Douglas

investigating pain treatment across a range of cine (TM), folk medicine, ethnomedicine, and clinical conditions: acute postoperative pain, can- native healing, among others. The earliest cer pain, occupational orthopedic injuries, sickle humans used the plant, animal, and mineral sub- cell disease, pain treatment in emergency depart- stances in their immediate environment to keep ments, and in geriatric patients both hospitalized healthy and deal with diseases that threatened and in hospice care. their survival. As people spread across the globe In addition to the undertreatment of pain, and into new environments, each culture found racial and ethnic minorities carried a larger bur- new sources to help them survive in their current den of the pain, particularly with more disability environment. Hence, traditional medicine is as and depression. The mechanisms for this dispar- wide-ranging and diverse as the regions and cul- ity remain unclear and therefore mandate for fur- tures of the world. As such, traditional medicine ther research in this area if culturally competent is the oldest form of health-care system and one care is to be provided to these populations. More that persists in the present day and is increasing information is needed about the influence of the in demand. In almost every culture, from those in social context on the painful condition. In the developing nations to the most industrialized, meantime, culturally competent health-care pro- some form of complementary therapy is used to fessionals need to be aware of not only the inter- maintain health, whether it be massages, hot min- cultural differences in perception and verbal eral baths, sweat lodges, acupuncture, Indian expression of pain but also the disparities of care Ayurveda, herbal teas, Arabic unani medicine, or that exist. many others. The challenge for the health-care When caring for diverse populations, more practitioner is to be aware that almost every focused attention needs to be paid to pain assess- patient uses some form of these therapies and to ment, especially pain severity and the meaning provide a therapeutic milieu in which the patient and impact of the painful condition on the life feels safe in sharing what other therapies he or situation and social context of the person. A non- she is using. judgmental communication style that engenders The World Health Organization (2013) defines patience and trust can encourage the individual to traditional medicine as “…sum total of the more willingly share their experiences and ways knowledge, skill, and practices based on the theo- of treating their pain, even though they may be ries, beliefs, and experiences indigenous to different from those of the health-care profes- different cultures, whether explicable or not, used sional. When there is a lack of racial and lan- in the maintenance of health as well as in the pre- guage concordance between patient and vention, diagnosis, improvement or treatment of health-care provider, more effort and time is physical and mental illness” (WHO 2013, p. 15). required to accomplish these goals of culturally WHO acknowledges that in some countries, the competent health care. With an increase in refu- terms traditional medicine and complementary gee populations migrating throughout the world, medicine are used synonymously but adds that health-care professionals in all parts of the globe CAM also refers to health-care practices that are will be caring for racially and ethnically diverse not fully integrated into the dominant health-care populations and thus require culturally compe- system. In Traditional Medicine Strategy 2014– tent skills (Schiltenwolf and Pogatzki-Zahn 2023 (WHO 2013), the global health organiza- 2015). tion outlines its aims to develop a TM knowledge base, evaluate the safety and efficacy of TM/ CAM therapies, design policies and regulations 19.3.3 Traditional and for their use, and promote the integration of ther- Complementary Medicine apies into national health-care systems. The result of this work will hopefully be a valuable Complementary and alternative medicine (CAM) tool of health-care practitioners and planners has many synonyms, namely, traditional medi- around the world as they implement TM and 19 Integrating Culturally Competent Strategies into Health Care Practice 175

CAM into their systems to the ultimate benefit of of the lack of quality control and standardization those who seek their care. of the product on the open market and small sam- To provide culturally competent care, the ple sizes of some of the research studies. health-care practitioner must be knowledgeable Another source for information on drug inter- about those TM and CAM therapies most com- actions with herbal medicines is provided by monly seen within their specialty areas of prac- Meng and Liu (2014). These authors outline the tice and used by populations they serve. Abdullahi pharmacokinetic interactions of seven widely (2011) provides a review of 12 herbs and spices used herbal remedies: Ginkgo biloba, ginseng, that are commonly used in 15 African countries, garlic, black cohosh, Echinacea, milk thistle, and as well as the barriers and challenges to integrat- St. John’s wort. And in the area of oncology, ing TM in Africa. Kumar et al. (2017) summarize Haefeli and Carls (2014) estimate that 30–70% the key principles of Ayurvedic medicine and the of cancer patients use CAM, with herbal reme- indications, side effects, and rationale for many dies particularly frequent. They reviewed the common herbs and plants used in Indian tradi- pharmacokinetic drug reactions of those herbs tional medicine. Their reference list will be valu- most commonly used by patients with cancer: able to clinicians in many specialties who care garlic, Ginkgo, ginseng, Echinacea, and St. for Indian populations. Investigations in a num- John’s wort. Of this group of herbs studied, two ber of cultures have documented the extensive have the most notable clinical relevance. Because prevalence of the use of CAM in a wide variety of of ginseng’s effect on the clearance of vitamin K conditions: in racial and ethnic groups in the antagonists, close monitoring is warranted when United States (Upchurch and Rainisch 2012), co-administered with warfarin. St. John’s wort Iran (Ghaedi et al. 2017; Mahjoub et al. 2017; had the greatest impact on drug metabolism, with Shokoohi et al. 2017), and Caribbean immigrants the potential for decreasing the efficacy of some in Canada (Braithwaite and Lemonde 2017). drugs by as much as 70%. Finally, using a sys- One area of significant importance to clini- tematic review of the literature, Kooti et al. cians is the pharmacokinetic drug interaction (2017) compiled brief descriptions of actions and between TM herbal extracts and the synthetic effectiveness of 36 Iranian plants used in cancer medicines used in many Western and dominant treatment in Iran. The studies cited above should health-care systems. Co-administration of herbal provide the health-care practitioner with a begin- drugs with conventional drugs can modulate the ning knowledge of herbal-drug interactions. uptake and elimination pathways when they are CAM, particularly herbal supplements, are metabolized. One example is Ginkgo biloba, a most commonly used for chronic illnesses. With popular herbal extract used mainly in Asian the rising incidence of chronic illnesses around countries but also in Europe and the United States the world, the demand for and use of herbal rem- for conditions as varied as cognitive impairment, edies is also increasing. Some of the barriers to diabetes, vertigo, hypertension, rheumatism, communication with the health-care practitioner peripheral vascular disease, and GERD. In an about TM and CAM were a lack of trust and a extensive investigation of Ginkgo biloba, Unger perception of superiority (van der Watt et al. (2013) reviewed more than 150 studies con- 2017). Culturally competent health-care practi- ducted both in vitro and in vivo. He found evi- tioners need to project cultural humility and a dence that the extracts of Ginkgo can be both sense of respect for the persons seeking care who inhibitors and inducers of drug-metabolizing use TM and CAM in order for those persons to enzymes, but usually the effects were weak in divulge the therapies they use. Only then can the each direction. He concluded that the risk for culturally competent practitioner begin to jointly drug interactions is minimal but only if the rec- develop a plan of care that safely integrates both ommended low dose of 120–240 mg/day is the person’s cultural meaning of their illness and ingested and other comorbidities are controlled. their ways of treating it with the treatment plan of However, much more research is needed because the dominant health-care system provider. With 176 M. Douglas the safety and efficacy of many CAM therapies • Are there any traditional practices or cultural still unknown and with the lack of quality control aspects of your care that we need to be aware of these agents, this integration remains a of? challenge. There are a number of cultural assessment tools available that health-care practitioners can use to 19.4 Cultural Competence Skills select the questions and discussion points appropriate to the clinical situation and cultural populations 19.4.1 Cultural Assessment being served. One that can be used in many different situations is the Purnell Cultural Assessment A thorough health assessment is a composite of Tool (Purnell 2014) provided below in the physical, psychological, social, and cultural fac- Appendix. The practitioner can use questions from tors that contribute to the person’s current state of this tool to design a tool specific to the desired clin- wellness or illness. Particularly in the case of a ical situation and population. In addition, Andrews mismatch between the cultures of the caregiver and Boyle (2016) provide detailed cultural assess- and the recipient of that care, a thorough cultural ment guides that can be used with specific types of assessment is needed to reveal the cultural beliefs, clients: (1) Andrews/Boyle Transcultural Nursing the context of the illness, and the social structure in Assessment Guide for Individuals and Families, which the person exists. Information gained from (2) Andrews/Boyle Transcultural Nursing a cultural assessment is crucial in formulating a Assessment Guide for Groups and Communities, diagnosis, preparing a culturally appropriate plan and (3) Boyle/Baird Transcultural Nursing of care, and possibly adapting the intervention to Assessment Guide for Refugees. one that is mutually acceptable to both the pro- Cultural assessment also involves integrating vider and recipient. With such adjustments, there biological variations into all relevant clinical is a greater likelihood that the plan will be imple- skills checklists. For example, skin color is one of mented and the expected health outcomes the most significant biological variations when achieved, thus contributing to decreasing the providing culturally competent care. The assess- health disparities seen in culturally diverse ment of the skin for rashes, sclera for jaundice, populations. presence of cyanosis, or capillary refill can all be A cultural assessment can be conducted with more challenging in persons with darker pigmen- varying degrees of detail depending on a number tation. In such cases, a careful baseline examina- of factors: the needs of the individual seeking tion best performed in bright daylight is care, the familiarity and clinical experience of the recommended during the initial evaluation. If the health-care practitioner with the culture of the clinician is unaware of normal variations, not only population involved, and the availability of inaccurate assessment but also detrimental effects resources, such as interpreter services and the can result. For example, the presence of Mongolian time the health-care practitioner can devote to the spots, common in a number of ethnic groups, may assessment. The process begins with a face-to- be interpreted erroneously as signs of child abuse face interview in which the health-care practitio- and the parents subsequently reported to the ner uses active listening skills to establish rapport, authorities. Giger and Davidhizar (2008) provide build trust, and demonstrate respect, which is detailed descriptions on the biological differ- essential if individuals are to share beliefs and ences, enzymatic and drug metabolism variations, practices they may perceive as different from the and disease susceptibilities among people in 23 practitioner. The next step is to frame open-ended racial or ethnic groups. This book serves as a use- questions and then delineate the issues to be ful resource for clinicians of all specialty areas. addressed so that interventions and rehabilitation If the health-care practitioner serves a signifi- plans can be tailored to the beliefs of the indi- cant number of a particular racial or ethnic popula- vidual. An example of an open-ended question is: tion, then it would be useful to design a cultural 19 Integrating Culturally Competent Strategies into Health Care Practice 177 assessment tool specifically designed for that pop- appreciated. Finally, all potential solutions are ulation. Balaratnasingam et al. (2015) describe the discussed and a plan of care developed, with the process of developing, implementing, and evaluat- clients suggesting their preferences for care. ing two cultural assessment tools to assess the When there are incongruences between cul- mental health and social and emotional well-being tural beliefs and practices and institutional stan- of Aboriginal and Torres Strait Islanders. In their dards of practices, usual procedures, and policies, practice, they found that current tools used for the creativity and flexibility are required. With dominant culture lacked normative data on their patient safety being nonnegotiable, options can population, relied heavily on written responses in be explored as to how to adapt usual policies and English, and lacked cultural relevance. Early eval- procedures to accommodate the patient’s beliefs. uations of their new tools suggest they were effec- The classic example is the use of intraoperative tive and easy to use. The authors acknowledged normovolemic hemodilution or “bloodless” car- the lack of generalizability of their tool because it diopulmonary bypass (CPB) for persons of was tested only in the clinical service where it was Jehovah’s Witnesses faith whose beliefs forbid developed. However, the description of their pro- the use of blood during surgery (Marinakis et al. cess of designing a culture-specific assessment 2016; McCartney et al. 2014). This change of tool may be beneficial to other clinicians. procedure not only avoided harmful adverse effects of the use of blood products for persons of Jehovah’s Witnesses faith but also led to the use 19.4.2 Negotiation or Shared of “bloodless” CPB as a routine procedure in Decision-Making many other eligible patients. Another example is adapting hospital visiting hours rules to accom- The purpose of the cultural assessment is to gain modate cultural and family customs that require a an accurate and comprehensive picture of the larger number of visitors and longer hours than context of the individual, family, and community hospital policy dictates. Family support is an so that the care decisions made are specific, important ingredient of the healing process, so meaningful, and beneficial to them. The infor- flexibility in visiting hours whenever possible is mation collected from the cultural assessment is warranted for the benefit of the patient rather than the baseline from which negotiating a plan of solely for staff routines. However, some issues care begins. The practitioner also needs a knowl- may be more complex to negotiate. Placing a edge of the culture and culturally competent lighted candle in a dying patient’s oxygen-filled communication skills in order to initiate the room may require extra flexibility and creativity decision-making process. Access to expert cul- to explore a compromise in which an at least tural consultants or peers with the appropriate some portion of the request is granted. In this cultural knowledge and skills can also be useful case, one suggestion might be to allow the lighted to assist in this process (Marion et al. 2016; candle immediately upon the patient’s death and Owiti et al. 2014). once the oxygen has been discontinued (Marion The culturally competent practitioner, pre- et al. 2016). pared with the assessment data and cultural The aim of mutual decision-making is to knowledge and skills, begins discussion with a design a plan of care that is beneficial to the summary of the practitioner’s interpretation of health of the client and is feasible within the envi- the data and clinical situation. Then the clients, as ronmental, social, and cultural context of the cli- in the case of the individual, family, and commu- ent. If the client is a partner in designing the plan, nity members, are offered the opportunity to there is greater likelihood that the client will be identify and correct any misinterpretations of the motivated to implement the plan. Designing and practitioner’s interpretation. Next, all parties par- implementing a culturally competent plan of care take in identifying the nature, meaning, and sig- has the potential of reducing racial and ethnic nificance of the problem so that the full context is disparities in health outcomes. 178 M. Douglas

19.5 Recommendations competent care. To accomplish this, accountabil- for Culturally Competent ity for culturally competent practice should be Practice made at the executive level of the organization, starting with writing it into its mission statement. 19.5.1 Direct Care Providers If a substantial portion of population served is racially and ethnically diverse, the organization Direct care providers, whether they are a physi- should establish a baseline of health data on those cian, clinical nurse, physical or occupational within its catchment area so that health programs therapist, or other direct caregiver, are the first can be designed to address those with the greatest point of an encounter that a person from an ethni- morbidity and mortality outcomes. cally diverse population has with the health-care Organizational policies and procedures should system. Therefore, it is the initial greeting, which reflect a respect for the cultural beliefs and prac- can be culturally defined, that begins the process tices of the community it serves and a willingness of establishing a trusting relationship in which to partake in shared mutual decision-making in the person can feel safe to share disparate view- the event of conflicting cultural beliefs. points and practices. The culturally competent Recruitment of community members from practitioner is knowledgeable and respectful of racially and ethnically diverse populations to the person’s cultural beliefs and practices and become permanent members on such possesses the cultural humility to admit unfamil- organization-wide committees as the ethics com- iarity and seek expert opinions when needed. mittee, patient education committee, or nursing Direct care providers have the responsibility to practice committee would be helpful in incorpo- participate in educational opportunities about the rating cultural relevance, content, and sensitivity cultural knowledge that they lack about the popu- into the policies and procedures. lations they serve. Continuing education courses Budget allocations are necessary for interpret- and service learning experiences in the commu- ers to work with patients and translators to nities are some ways to improve their knowledge develop patient education materials and impor- base. tant standard forms, for example, the informed An essential element of care of all direct care consent form (Marrone 2016) for procedures or providers is assessment. By conducting a cultural discharge instructions. Funds are also needed for assessment, the culturally competent health-care signage in various languages around the organi- provider can determine the person’s language zation to guide those who are unfamiliar with the preference and the need for interpreters, identify dominant language. the designated decision-maker within the family, Administrators are also responsible for pro- and ascertain the person’s perceptions of the viding the funds and opportunity for staff to cause of the current health problem and any cul- attend education and training in culturally com- turally prescribed treatment modalities. This petent practice, for example, during orientation information is crucial in formatting a plan of care and continuing education classes. Following and negotiating any adaptations in the event of these classes, the administrators are responsible cultural conflicts. for supervising the staff and evaluating whether effective cross-cultural practice is being delivered. 19.5.2 Health-Care System Administrators 19.5.3 Educators An important function of administrators within a health-care organization is to provide the staff At the academic level, students should be exposed with the resources it needs to deliver culturally to general cultural content at their earliest 19 Integrating Culturally Competent Strategies into Health Care Practice 179

opportunity, in their basic prerequisites for pro- culturally competent care. In addition, these edu- fessional schools. Then, in each specialty, cul- cators can participate on practice committees, tural-specific beliefs in their area of practice patient education committees, and policy and pro- should be integrated into the coursework and cedure committees, among others, to integrate practical experiences. Incorporating cultural case elements of culturally competent care into their studies in simulation labs allows students to respective contents. The educators can also assist explore the cultural components of care in a safe supervisors to develop mechanisms and perfor- environment. In addition, student clinical prac- mance evaluation tools to evaluate whether the tice should include service learning experiences staff is performing culturally competent practice. with racial and ethnic groups that have high inci- dences of negative health outcomes. These experiences can be both within their own communities 19.5.4 Researchers or abroad, where students have the opportunity to observe health-care delivery models that are Much of the cross-cultural research done to date adapted to the needs of a different cultural group. has been describing the cultural beliefs, norms, Educators in both academic and clinical set- and practices of specific cultural groups. tings are increasingly using simulation modules Although this descriptive research is necessary, in labs to teach clinical skills, but where it is yet insufficient upon which to base practice. resources are limited, role-playing and manne- Much more research is needed to design and test quins also serve. Cultural competence skills can interventions to determine whether the interven- also be taught through simulations, in which the tion is capable of sufficient improvement to students are presented with cross-cultural situa- affect the racial and ethnic disparities in health tions and feel “safe” to negotiate cultural con- outcomes. Furthermore, scores of educators flicts before going into the practice setting have tested whether their students have greater (Roberts et al. 2014; Gallagher and Polanin “cultural sensitivity” and cultural knowledge 2015). Simulation content can begin with a pre- after their educational offerings, but we don’t liminary cultural self-assessment (“What is know whether this translates into improved out- your cultural heritage”?) and a module on the comes for the patients they care for. In both cultural knowledge of some of the populations these areas of intervention testing and educa- the students will be caring for later in the clini- tion, research on culturally competent practice cal setting. A module on performing a cultural is still in its infancy. assessment can also be part of the preparation. Another critical need in the area of culturally After this preparation, the student is exposed to competent practice is to determine whether cer- simulated experiences that portray realistic clin- tain traditional medicine practices are safe. If the ical scenarios. Biological, cultural, social, and practitioner is to be able to negotiate with a per- physical characteristics as well as cultural con- son who wishes to use a complementary/alterna- flicts are integrated. The students are asked to tive or traditional medicine practice, the perform a cultural assessment using culturally practitioner must be aware of its safety or adverse sensitive interview techniques and negotiate any effects. Combining some herbal medicines with cultural conflicts that present themselves. To conventional pharmacologic agents can have conclude the session, debriefing and self-reflec- serious consequences. In recent years, the World tion is a final important stage in the process of Health Organization and the National Institutes learning cultural competence. of Health, among others, have begun to compile a For educators teaching within a health-care database on these folk medicines. Much more organization, the primary responsibility is to research is needed on their interactions with an develop and coordinate in-service and continuing ever-increasing number of drugs put on the mar- education programs to prepare staff to provide ket by pharmaceutical companies. 180 M. Douglas

Conclusion Appendix: Purnell Cultural Health and illness are culturally defined. Assessment Tool(version 2.1) Providing culturally competent practice involves using knowledge of the cultures of An extensive cultural assessment is rarely com- the populations served in combination with pleted in the clinical setting because of time and the skills of cross-cultural communication, other circumstances. A seasoned clinical practi- cultural assessment, and negotiation for tioner will know when further assessment is mutual care decisions. Health-care providers required. Thus, this tool should be used as a are responsible for learning about the cul- guide. Shaded items in italics are part of any tures of the diverse populations they care for standard assessment. Other items may also be in order to provide culturally competent part of a standard assessment, depending on the practice. However, while knowledge is nec- organization, setting, and clinical area. essary, it is insufficient. The health-care practitioner uses that knowledge to develop Cultural assessment question Comments cross-cultural communication skills (Chap. Overview, inhabited localities, and topography 14) as the first step in adapting knowledge to Where do you currently live? practice. Conducting a baseline cultural What is your ancestry? Where were you born? assessment requires this knowledge and these How many years have you lived in this skills in order to establish an atmosphere of country? openness and respect that allows the individ- Were your parents born in this country? ual to share beliefs and practices that may be What brought you (your parents/ unfamiliar to the health-care providers. The ancestors) to this country? ultimate goal is to integrate the cultural Describe the land or countryside where you live. Is it mountainous, swampy, knowledge with the communication skills etc.? and cultural assessment data to negotiate a Have you lived in other places in the mutually agreed upon plan of care that is fea- United States/world? sible within the sociocultural context of the What was the land or countryside like person. An understanding of the social deter- when you lived there? minant of health, particularly for minority What is your income level? Does your income allow you to afford populations who have limited financial and the essentials of life? community resources, is also necessary when Do you have health insurance? negotiating a plan of care that the person is Are you able to afford health insurance able to accomplish. If the cultural beliefs and on your salary? practices and the sociocultural context of the What is your educational level (formal/ person are incorporated into the treatment informal/self-taught)? plan, and if the person is motivated to adhere What is your current occupation? If retired, ask about previous to a feasible plan, then the potential for occupations achieving the desired health outcome is more Have you worked in other occupations? probable. It is only with improved health out- What were they? comes for racially and ethnically diverse Are there (were there) any populations that the disparities will decrease health hazards associated with your job(s)? and the health of their communities improve. Have you been in the military? If so, in Culturally competent practice shares these what foreign countries were you goals. stationed? 19 Integrating Culturally Competent Strategies into Health Care Practice 181

Cultural assessment question Comments Cultural assessment question Comments Communications What should children not do to make a What is your full name? good impression for themselves and for What is your legal name? the family? By what name do you wish to be What are children forbidden to do? called? What should adolescents do to make a What is your primary language? good impression for themselves and for Do you speak a specific dialect? the family? What other languages do you speak? What should adolescents not do to make a good impression for themselves Do you find it difficult to share your and for the family? thoughts, feelings, and ideas with family? Friends? Health-care What are adolescents forbidden to do? providers? What are the priorities for your family? Do you mind being touched by friends? What are the roles of the older people in Strangers? Health-care workers? your family? Are they sought for their How do wish to be greeted? advice? Handshake? Nod of the head, verbal Are there extended family members in greeting only, etc.? your household? Who else lives in your Are you usually on time for household? appointments? What are the roles of extended family Are you usually on time for social members in this household? What gives engagements? you and your family status? Observe the patient’s speech pattern. Is Is it acceptable to you for people to the speech pattern high- or low- have children out of wedlock? context? Note: patients from highly Is it acceptable to you for people to live contexted cultures place greater value together and not be married? on silence Is it acceptable to you for people to Observe the patient when physical admit being gay or lesbian? contact is made. Does he/she withdraw What is your sexual preference/ from the touch or become tense? orientation? (ask only if appropriate How close does the patient stand when and later in the assessment after a talking with family members? With modicum of trust has been established) health-care providers? Workforce issues Does the patient maintain eye contact Do you usually report to work on time? when talking with the nurse/physician, Do you usually report to meetings on etc.? time? Family roles and organization What concerns do you have about What is your marital/partner status? working with someone of the opposite How many children do you have? gender? Who makes most of the decisions in Do you consider yourself a “loyal” your family? employee? How long do you expect to What types of decisions do(es) the remain in your position? female(s) in your family make? What do you do when you do not know What types of decisions do(es) the how to do something related to your male(s) in your family make? job? What are the duties of the women in the Do you consider yourself to be family? assertive in your job? What are the duties of the men in the What difficulty does English (or family? another language) give you in the workforce? What should children do to make a good impression for themselves and for What difficulties do you have working the family? with people older (younger) than you? 182 M. Douglas

Cultural assessment question Comments Cultural assessment question Comments What difficulty do you have in taking Nutrition directions from someone younger/older Are you on a special diet? than you? Are you satisfied with your weight? What difficulty do you have working Which foods do you eat to maintain with people whose religions are your health? different from yours? Do you avoid certain foods to What difficulty do you have working maintain your health? with people whose sexual orientation is Why do you avoid these foods? different from yours? Which foods do you eat when you are What difficulty do you have working ill? with someone whose race or ethnicity Which foods do you avoid when you is different from yours? are ill? Do you consider yourself to be an Why do you avoid these foods (if independent decision-maker? appropriate)? Biocultural ecology For what illnesses do you eat certain Are you allergic to any medications? foods? What problems did you have when you Which foods do you eat to balance your took over-the-counter medications? diet? What problems did you have when you Which foods do you eat every day? took prescription medications? Which foods do you eat every week? What are the major illnesses and Which foods do you eat that are part of diseases in your family? your cultural heritage? Are you aware of any genetic diseases Which foods are high-status foods in in your family? your family/culture? What are the major health problems in Which foods are eaten only by men? the country from which you come (if Women? Children? Teenagers? appropriate)? Elderly? With what race(s) do you identify? How many meals do you eat each day? With what ethnic group(s) do you What time do you eat each meal? identify? Do you snack between meals? Observe and document skin coloration and physical characteristics What foods do you eat when you snack? Observe for and document physical handicaps and disabilities. What holidays do you celebrate? High-risk health behaviors Which foods do you eat on particular holidays? How many cigarettes a day do you smoke? Who is present at each meal? Is the entire family present? Do you smoke a pipe (or cigars)? Do you primarily eat the same foods as Do you chew tobacco? the rest of your family? For how many years have you smoked/ Where do you usually buy your food? chewed tobacco? Who usually buys the food in your How much alcohol do you drink each household? day? Ask about wine, beer, spirits Who does the cooking in your How many energy drinks do you household? consume each day? How frequently do you eat at a What recreational drugs do you use? restaurant? How often do you use recreational When you eat at a restaurant, in what drugs? type of restaurant do you eat? What type of exercise do you do each Do you eat foods left from previous day? meals? Do you use seat belts? Where do you keep your food? What precautions do you take to Do you have a refrigerator? prevent getting sexually transmitted infections or HIV/AIDS? How do you cook your food? 19 Integrating Culturally Competent Strategies into Health Care Practice 183

Cultural assessment question Comments Cultural assessment question Comments How do you prepare meat? What is your preferred burial practice? How do you prepare vegetables? Interment, cremation? What type of spices do you use? How soon after death does burial What do you drink with your meals? occur? Do you drink special teas? How do men grieve? Do you have any food allergies? How do women grieve? Are there certain foods that cause you What does death mean to you? problems when you eat them? Do you believe in an afterlife? How does your diet change with each Are children included in death rituals? season? Spirituality Are your food habits different on days What is your religion? you work versus when you are not Do you consider yourself deeply working? religious? Pregnancy and childbearing practices How many times a day do you pray? How many children do you have? What do you need in order to say your What do you use for birth control? prayers? What does it mean to you and your Do you practice meditation, such as family when you are pregnant? TM, mindfulness meditation, etc.? What special foods do you eat when What gives strength and meaning to you are pregnant? your life? What foods do you avoid when you are In what spiritual practices do you engage pregnant? for your physical and emotional health? What activities do you avoid when you Health-care practices are pregnant? In what prevention activities do you Do you do anything special when you engage to maintain your health? are pregnant? Who in your family takes responsibility Do you eat nonfood substances when for your health? you are pregnant? Who takes care of family members Who do you want with you when you when they are sick? deliver your baby? What over-the-counter medicines do In what position do you want to be you use? when you deliver your baby? What herbal teas and folk medicines do What special foods do you eat after you use? delivery? For what conditions do you use herbal What foods do you avoid after medicines? delivery? What do you usually do when you are What activities do you avoid after you in pain? deliver? How do you express your pain? Do you do anything special after How are people in your culture viewed delivery? or treated when they have a mental Who will help you with the baby after illness? delivery? How are people with physical What bathing restrictions do you have disabilities treated in your culture? after you deliver? What do you do when you are sick? Do you want to keep the placenta? Stay in bed, continue your normal What do you do to care for the baby’s activities, etc.? umbilical cord? What are your beliefs about Death rituals rehabilitation? What special activities need to be How are people with chronic illnesses performed to prepare for death? viewed or treated in your culture? What special activities need to be Are you averse to blood transfusions? performed after death? Is organ donation acceptable to you? Would you want to know about your Are you listed as a potential organ impending death? donor? 184 M. Douglas

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Violeta Lopez

Francesca is a 19-year-old woman with a second- has worked as a primary school teacher for the ary education who, only a year ago, joined her past 20 years with an annual salary of US$34,390. American husband she met online. After 6 In the area where they live, Asians comprise only months of online communications, her husband about 2.6% of the population and has only a very decided to visit Francesca in the Philippines to small Filipino community. The closest Asian gro- personally meet her and to ask her parents’ per- cery store is 2 ½ hours drive from her home. The mission to marry her. Francesca comes from a nearest public hospital is 3 miles away, but a spe- small fishing village in the Philippines. Her father cialist hospital is about 3 hours by car. There are, is a fisherman and her mother is a full-time however, several health clinics near her home, housewife. She has four brothers and three sisters which require appointments to see a doctor. There and she is the fifth child in the family. She did not are a few walk-in clinics run by practical and pursue further studies due to the high cost of get- auxiliary nurses and government-funded clinics ting a university degree, like her brothers who for basic checkups for low-income women and also only completed secondary schooling. Her children. sisters are completing their primary and second- Francesca became pregnant soon after immi- ary schooling at a public school, which is 40 min grating to the USA. Since she is isolated from her by foot from their home. As the oldest child liv- family and social support from home, and has not ing with her parents, she helped her father sell yet made friends or developed a social support fish in the local market. Her four brothers are network in their neighborhood, which is not rep- already married and living in a nearby village. resentative of her culture, she is unaware of the After gaining her father’s permission to marry, available maternity services. Francesca has s a Francesca and her American husband moved to a strong belief in family togetherness. Therefore, small city in the southeast region of the USA. Her Francesca requested her husband pay for her husband owns his own two-bedroom house. He is mother’s airfare to come to the USA to help her a divorced man with one 24-year-old son who is during her pregnancy and after delivery. Her married with a 3-year-old daughter. Her husband mother arrived just 1 week before her delivery. Her husband made an appointment for her to V. Lopez, Ph.D., R.N., FACN, FAAN attend an antenatal clinic nearby, and once her Alice Lee Centre for Nursing Studies, mother arrived, she attended the clinic accompa- Yong Loo Lin School of Medicine, nied by her mother. At full term of her pregnancy, National University of Singapore, Singapore, Singapore she was admitted to the hospital for her first e-mail: [email protected] delivery under the care of her obstetrician. She

© Springer International Publishing AG, part of Springer Nature 2018 187 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_20 188 V. Lopez was very anxious, felt inexperienced, and was from the uterus as well as in restoring the pelvic needing support from the nurses and most of all bones to their original position. Some traditional from her mother. Her husband was not present in practices involve drying out of the womb, or the delivery. Although she can speak English “mother roasting”, in which the woman lies well, at times of pain due to the contractions, she beside a stove for 30 days, squats over a burning yelled in Tagalog (Filipino official language), clay stove, or sits on a chair over a heated stone which the nurses could not understand. This hos- or a pot of steaming water with herbs. They are pital situation was distinctly different from the not even allowed to go out of the house for 40 practice in the Philippines where midwives are days so as not to catch cold as keeping the body responsible for attending to the whole childbirth warm will hasten recuperation from childbirth. process in small hospitals and clinics. In the After 10 days, the mother may have a sponge provinces, traditional birthing women (hilot) are bath using warm water boiled with leaves of any used rather than midwives or obstetricians citrus fruit trees, such as lemon, lime, or grape- because of the expense associated with hospital fruit. It is only after 40 days that the new mother delivery. is allowed to take a full bath, using warm water The delivery was uneventful and she delivered infused with citrus fruit leaves or warm boiled a healthy baby boy. Her mother asked the doctor water with ginger to keep the body warm; at this if she could have the placenta to take home, but time, she may also wash her hair with warm her request was refused. In the Philippines, espe- water infused with rosemary leaves (de Leon cially in the area where Francesca was from, the 2016). placenta must be buried, as it signifies the end of Food and drinks are always served hot to a labor pain, delivery, and blood loss. As for post- new mother. She is served herbal soups prepared partum care, Francesca’s mother insisted on fol- with pork or chicken bones and boiled with lowing and obeying the rules set by her mother sulfur-rich leaves such as watercress, morning and grandmother and other elderly women in glory, broccoli, cabbage, malunggay (moringa), their home village out of respect and obedience and saluyot (no English translations). Cold foods to their traditional beliefs and practices. such as turnips and cucumber are avoided as these will not help the uterus to contract. Sour foods such as tamarind and oranges are forbidden 20.1 Cultural Issues as this will cause the breast milk to curd or to stop breast milk production altogether. A key concept of indigenous health is the balanc- Newborn babies are also sponged with warm ing of the hot and cold of the body and of the water infused with herbs and not bathed fully food of postpartum women (McBride 2001). submerged in water until 40 days, the same as the Childbirth is considered as a cold process and mother. A tight abdominal binder over the umbil- maintaining the body heat after childbirth is ical cord is also applied until the cord is dried and important. Drinking cold water or any cold liq- falls off. These practices are important to balance uids is forbidden as it is believed to cause relapse the hot and cold condition of the body. Breast when one is ill or cause postpartum hemorrhage. feeding is adopted and encouraged immediately After childbirth, the women must keep warm, after birth as the most economical way to provide wear heavy clothes or wrap themselves in blanket nutrition to the baby; nursing is maintained as and always wear socks. They are not allowed to long as 2 years and as long as there is sufficient bathe or wash their hair for 10 days, as this will breast milk. cause ill health and rheumatism in old age. They Immunization is mandatory and provided free tightly bind their abdomen to prevent bleeding of charge by the Philippine government. Other and help the uterus to contract. They can also than the mandatory immunization (BCG, DPT, receive healing massages with warm coconut oil, Polio, Hepa-B, MMR) for infants after birth to 9 which is used to assist in expelling blood clots months (PFV 2016), school children from grades 20 Case Study: Perinatal Care for a Filipina Immigrant 189

1 to 7 are provided free immunization for mea- have settled permanently in the USA (World sles, rubella, tetanus, and diphtheria every August Population Review 2017). The Philippines con- each year and for females ages 9–10 years of age sists of a diverse range of ethnic groups, with are vaccinated against HPV for free (PCHRD 81% practicing Roman Catholics, which is heav- 2015). Hepatitis-B, H. influenza type B, and ily influenced by its history as part of the Spanish other types of influenza vaccinations may be empire for 377 years between 1521 and 1898 determined by the Secretary of Health (Republic (Philippines History 2017). The official language Act No. 10152 2010). is Filipino (or Tagalog). The Philippines is also In the Filipino culture, pregnancy and delivery composed of 110 ethnolinguistic tribes that is a celebration, but care for the mother and baby speaks 70–80 dialects, such as Cebuano, Waray, must follow traditional beliefs, values, and prac- Ilonggo, Ilocano, Bicolano, etc. More than half tices. The mother and grandmother provide great of Filipinos speak fluent English as this is the lan- support for the pregnant and postpartum women guage used in colleges, universities, the courts, in the Philippines. This was especially important and the government. The Filipinos also use for Francesca’s first childbirth, as her family “Taglish” language which is a mixture of Filipino beliefs play a role in health maintenance and and English. maintaining health, and is viewed as a family The literacy rate for adults 15 years and above responsibility (Darling et al. 2005). is 95.4% (Unicef 2017). Filipinos regard educa- As Francesca only recently arrived in the tion as the path to upward mobility, and education USA, she was newly exposed to a different cul- is compulsory until 12 years of age. A university ture. The long process of acculturation requires degree is necessary to obtain positions that prom- that she will need to adapt and possibly readjust ise security and advancement in a profession. her attitudes, beliefs, values, and mores about However, the Department of Education reports many issues, especially in pregnancy, giving that children from the poorest 40% of the popula- birth, and health care after birth. Such acculturation do not even attend primary school, despite the tion can bring about psychological shock because compulsory requirement (Clarke 2015) it may be socially and culturally different from The Philippines is considered a low- to what she believes to be her customs and tradi- middle-income country, with a GDP of US$159.3 tions in childbirth practices (Ea 2015). Adding to billion. Philippines GDP per capita averaged this stress, Filipino women living in Western US$2753.30 in 2016 and is equivalent to 22% of countries have often been stigmatized because of the world’s average. In the Philippines, 70% of their reputation as “mail-order brides,” and as resources and capital are held by the top 10% of such, they have experienced social isolation from the population, while 50.5% live below the pov- their family and lack the ability to develop impor- erty line. Among these 50.5%, 70% of the women tant social support networks in their new adopted live in poverty-like conditions. Unemployment country (Kelaher et al. 2001). rate as of January 2016 was 5.8%, and among the unemployed persons, 63.4% were males. The minimum wage is between P300 to P 500 per day 20.2 Social Structural Factors (US$6 to US$10 per day) (Philippine Statistics Authority 2016). The Philippines is a country of 7107 islands Life expectancy in the Philippines is 70 years located on the Pacific Rim of Southeast Asia, for females and 64 years for males. The Philippine with a population of 103,406,752 as of April Department of Health (2016) reports that heart 2017, with 44.8% of the population living in disease is the leading cause of death followed by urban areas. Moreover, there are approximately diseases of the vascular system (stroke), malig- 10.2 million overseas Filipino workers (in United nant neoplasms, pneumonia, and diabetes melli- Arab Emirates, Qatar, Saudi Arabia, Japan, and tus. Tuberculosis remains the sixth cause of Australia) in addition to over 3.5 million who death. As of 2016, the infant mortality rate was 190 V. Lopez

21.9 deaths per thousand live births, and the five ters’ wishes to seek a better life outside their cur- leading causes of infant mortality are bacterial rent economic situation. Even though the gross sepsis, pneumonia, respiratory distress, congeni- domestic product (GDP) growth rate rose from tal malformations of the heart and disorders 5.5% in the first half of 2015 to 6.9% in the first related to short gestation and low birth weight. half of 2016 (World Bank 2016a, b), medium- The maternal mortality rate was 114 per 100,000 term economic risks persist. Persistent vulnera- live births; the most common causes of maternal bility of the agricultural sector, unresolved deaths are hemorrhage, infection, obstructed constraints on private investment, a lack of com- labor, hypertensive disorders in pregnancy, and petition in major sectors, and structural deficien- complications of unsafe abortion (Central cies in the business environment continue to Intelligence Agency 2017). suppress sufficient growth to inspire hope for The national health-care law provides all citi- those in dire poverty. zens with basic health care at no cost through subsidies. Children received immunizations at no costs. Public hospitals and health centers provide 20.3 Culturally Competent services to everyone free of charge. Patients are Strategies Recommended allowed to have companions with them in the hospitals to assist with simple nursing chores, To address Francesca’s concerns related to her such as giving baths and getting food trays. The postpartum care, nurses must utilize cross- Traditional and Alternative Medicine Act was cultural knowledge and culturally sensitive skills legislated to improve the quality and delivery of in implementing culturally congruent nursing health-care services to the Filipino people care at three levels (Douglas et al. 2014). It is through the development of traditional and com- important to meet the diverse needs of patients plementary/alternative medicine (TCAM) and its and their families (Douglas et al. 2011). integration into the national health-care delivery system (Romualdez et al. 2011). Transnational marriages are an alternative to 20.3.1 Individual-/Family-Level poverty. Foreign brides to Western men from the Interventions USA, Australia, and Canada usually come from Indonesia, Vietnam, Thailand, and the • Conduct a thorough assessment of the physi- Philippines (Shu et al. 2011). Men using mail- cal, psychological, and cultural factors that order websites seeking foreign brides have may affect Francesca’s first childbirth expressed their disappointments with modern experience. American women as they are more demanding • Identify the Filipino pregnant women’s cul- and not willing to take on the responsibility of a ture, which can include their values, beliefs, “traditional” wife. Thus, they believe in marry- traditions, and practices in childbirth and ing an Asian woman with the traditional values puerperium. of obedience and subservience (Minervini and • Respect the presence of her mother in the McAndrew 2006). The increasing prevalence of delivery room, and understand the signifi- mail-order brides in the USA who were procured cance associated with her wanting to take the through web pages, although outlawed in the placenta home with her. Philippines, continue to flourish. Women in the • Ensure that culturally sensitive care is planned Philippines represent the largest marriage mar- and implemented in collaboration with the ket for mail-order brides to foreign men (The multidisciplinary team and which is inclusive Manila Times 2015). Many Filipino families are of the patient, her family, and their chosen cul- under desperate economic circumstances. Many tural support networks. parents of Filipino women view the USA as a • Whenever possible, foods should be chosen land of opportunity and will support their daugh- for Francesca that not only meet her meta- 20 Case Study: Perinatal Care for a Filipina Immigrant 191

bolic needs but also her cultural consider- 20.3.3 Societal Level Interventions ations. Recommended foods include shell fish (clams and mussels) as they are good for • Midwifery education providers should ensure breast milk production and green leafy vege- that cultural competence and cultural sensitiv- tables (moringa, spinach, watercress, morn- ity is embedded within their curriculum ing glory, broccoli, etc.). Any sour foods framework. (tamarind, oranges, turnip, etc.) are prohib- • The local government could provide support ited as they are believed to cause breast milk to the Filipino community and support groups to curd or stop breast milk production to hold workshops on Filipino culture in gen- altogether. eral and more specifically on health beliefs • Determine the patient and family’s preferred and practices. language for verbal communication, making • As there is no Filipino community where use of trained interpreters or qualified transla- Francesca lives, collaborate with the Asian tors when necessary. community to coordinate and provide parental- and child-care support. • Collaborate with the medical clinics, pharma- 20.3.2 Organizational-Level cies, and grocery stores to address the needs of Interventions their Asian constituents.

• Consider one’s own culture, values, beliefs, Conclusion and possible prejudices that may impact the Childbirth should be a celebration, especially provision of care. Set these aside to ensure for the mother who has carried the pregnancy equitable care for the immigrant pregnant for nine months. For the immigrant and as a woman. mail-order bride who may experience stigma- • Midwives should possess appropriate knowl- tization, midwives and nurses should under- edge, skills, and attributes to respect, advocate stand the sociocultural factors associated with for, and effectively respond to the cultural the long process of acculturation to the new needs of the Filipino pregnant women and society and health-care practices. Respecting their families. the women’s beliefs and values, while integrat- • Analyze concerns and issues in providing ing the woman’s unique cultural practices into transcultural care to individuals, families, her care whenever possible, will ultimately groups, communities, and institutions. assist in providing culturally competent care. Antenatal interviews of Filipino women should include their beliefs and values and practices of childbirth including infant care, breastfeeding, and immunization. References • Provide ongoing educational workshops for Central Intelligence Agency (2017) Maternal mortal- nurses and midwives and other health profes- ity rate. The World Fact Book. https://www.cia.gov/ sionals for effective cross-cultural practice. library/publications/the-worldfactbook/fields/2223. • Organizational policies should include html. Accessed 12 July 2017 respecting the women’s and family’s vulnera- Clarke N (ed) (2015) Education in the Philippines. World education news and reviews, June 7, 2015. http://wenr. bility and the need for culturally sensitive care wes.org/2015/06/education-philippines. Accessed 3 so as to establish trust. Apr 2017 • Health-care organizations should provide Darling N, Cumsille P, Peña-Alampay L (2005) Rules, information booklets or brochures about legitimacy of parental authority and obligation to obey in Chili, the Philippines, and the United States. New Filipino health-care beliefs and practices Dir Child Adolesc Dev 108:47–60 including endorsed and prohibited foods dur- De Leon RN (2016) Herbal remedies for beauty and ing illness and childbirth. health. S.G.E. Publishing Inc., Valenzuela City 192 V. Lopez

Department of Health (2016) Philippine health picture vaccine.org/vaccination-schedules/childhood-immu- 1993-2013. http://portal.doh.gov.ph/node/198.html. nization-schedule. Accessed 4 Aug 2017 Accessed 12 July 2016 Philippines History (2017) Timeline of Philippines his- Douglas M, Pierce J, Rosenkoetter M, Pacquiao D, tory. http://www.philippine-history.org/timeline.htm. Callister L, Hattar-Pollara M, Purnell L (2011) Accessed 12 July 2017 Standards of practice for culturally competent nursing Republic Act No. 10152 (2010) An Act providing for man- care: 2011 update. J Transcult Nurs 22(4):317–333 datory basic immunization services for infants and chil- Douglas M, Rosenkoetter M, Pacquiao DF, Callister LC, dren, repealing for the purpose presidential decree No. Hattar-Pollara M, Lauderdale J, Milstead J, Nardi 996. As amended. Official Gazette of the Philippines. D, Purnell L (2014) Guidelines for implementing Congress of the Philippines, Metro Manila, Philippines culturally competent nursing care. J Transcult Nurs Romualdez AG, dela Rosa JFE, Flavier JDA, Quimbo 25:109–121 SLA, Hartigan-Go KY, Lagrada LP, David LC (2011) Ea E (2015) Acculturation, acculturative stress and Health systems in transition. Philippines Health Rev health and health-related outcomes among Filipino 1(2):106–116 Americans. Nurs Res 64:E29–E39 Shu B-C, Lung F-W, Chen C-H (2011) Mental health of Kelaher M, Potts H, Manderson L (2001) Health issues female foreign spouses in transnational marriages in among Filipino women in remote Queensland. Aust J southern Taiwan. BMC Psychiatry 11:4. http://www. Rural Health 9:150–157 biomedcentral.com/1471-244X/11/4 McBride M (2001) Health and health care of Filipino The Manila Times (2015) Male order brides. http://www. American elders. http://stanford.edu/group/ethnoger. manilatimes.net/male-order-brides/158083/. Accessed Accessed 21 March 2017 12 July 2017 Minervini BP, McAndrew FT (2006) The mating strate- UNICEF (2017) As a glance: Philippines. https://www. gies and male preferences of mail order brides. Cross unicef.org/infobycountry/philippines_statistics.html. Cult Resarch 40:111–129 Accessed 3 Apr 2017 Philippine Council for Health Research and Development World Bank (2016a) World development indicators. (PCHRD) (2015) DOH Health launces nationwide http://databank.worldbank.org/data/download/site- school immunization program. http://www.pchrd.dost. content/wdi-2016-highlights-featuring-sdgs-booklet. gov.ph/index.php/news/library-health-news/4772- pdf. Accessed 3 Apr 2017 doh-launches-nationwide-school-immunization-pro- World Bank (2016b) Philippine economic update gram. Accessed 4 Aug 2017 (October 2016): outperforming the region and manag- Philippine Statistics Authority (2016) Employment rate ing the transition. http://www.worldbank.org/en/news/ in January 2016 is estimated at 94.2 percent. https:// feature/2016/10/03/philippine-economic-update-octo- psa.gov.ph/content/employment-rate-january-2016- ber-2016-outperforming-the-region-and-managing- estimated-942-percent. Accessed 3 Apr 2017 the-transition. Accessed 3 Apr 2017 Philippines Foundation for Vaccination (PFV) (2016) World Population Review (2017) Philippines population Childhood immunization schedule. http://www.phil- 2017. http://worldpopulationreview.com/countries/ philippines-population/. Accessed 3 Apr 2017 Case Study: Maternity Care for a Liberian Woman 21

Jody R. Lori

Bendu is a 33-year-old woman whose husband received care during her own three pregnancies. and two of her six children died during the Ebola Martha accompanies Bendu to her first visit. crisis. Her husband was a subsistence farmer, and Bendu knows very little English as Kru was spo- they lived in a rural, remote village in central ken in her rural village, and she only attended Liberia. After her husband and children died, school through the fourth grade. Martha must Bendu was unable to make enough money to care serve as her interpreter when she is seen by the for herself and the rest of her family by working health-care provider. the farm. Her children had to stop attending school Bendu gave birth to all six of her children at because she didn’t have the money for books or home with the help of a traditional midwife. Her school uniforms. Many of the villagers stigma- younger sister died during childbirth after she tized her and her children as Ebola survivors and was in labor for 3 days in the village and finally would not help the family. Neighboring families transferred to the district hospital 25 miles away. who once shared parenting responsibilities and She underwent a cesarean section, but both she supported one another shunned Bendu and her and the baby died within 24 h of admission. This children. She was very isolated and alone. In addi- has made Bendu suspicious of hospitals, and she tion, Bendu was pregnant when her husband died believes that all they do is “cut on you” when you and is now nearing her seventh month gestation. go to a hospital during labor. Her brother Steven helped arrange for Bendu and her remaining four children to join his family in the capital city of Monrovia. As the oldest boy 21.1 Cultural Issues in the family, Steven had been sent to attend secondary school in the capital. He now works as a All indigenous groups in Liberia are patrilineal waiter at a hotel in the city that caters to foreign- and male dominated. Gender roles often place ers working in the country since the Ebola out- women in lower positions within the family and break. Steven’s wife, Martha, arranged a prenatal society, restricting women from educational and appointment for Bendu at the clinic where she employment opportunities in favor of males in the family. Children are highly valued, and most couples J. R. Lori, Ph.D., C.N.M., F.A.C.N.M., FAAN will have many children considering it “God’s PAHO/WHO Collaborating Center, will.” Having many children gives women a School of Nursing, University of Michigan, Ann Arbor, MI, USA respected place in the society. The total fertility e-mail: [email protected] rate for Liberia is 4.7 children per woman with a

© Springer International Publishing AG, part of Springer Nature 2018 193 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_21 194 J. R. Lori markedly higher rate (6.1 children per woman) must obtain permission from their husband or a among rural women (LISGIS et al. 2014). male elder. There is a distrust or disbelief in the ben- Households often consist of extended family efits of the care received within the formalized members. It is not uncommon for children from health-care system, especially surrounding child- rural areas to be sent away from parents to live birth. Because women often seek care late for preg- with relatives in urban areas to attend school after nancy-related problems, they present with more primary school because of the lack of educational severe complications. Many rural Liberians believe facilities in rural areas. if a woman goes to the hospital for childbirth, she Secret societies, also known as bush schools, will die (Lori and Boyle 2011). are prevalent throughout Liberia. These schools There are many food taboos (foods to avoid are part of Liberia’s cultural heritage and attended during pregnancy) and special foods women eat by thousands of youngsters annually in rural during pregnancy. Women in rural Liberia often Liberia. The Sande society, for girls, is the place rely on the use of country medicine or herbs for where young girls learn domestic skills, such as health problems during pregnancy. There is an how to cook, clean, care for their family and future acceptance and comfort with traditional healers husband, as well as moral lessons such as respect- and indigenous practitioners who have long- ing elders and religious teachings. It is also the standing legitimacy within communities. place where female genital mutilation (FGM) There is also a strong belief that certain mem- takes place. Initiation into the Sande society is an bers of society enjoy supernatural powers not important social process for girls in Liberia. They afforded by all humans. Anyone can have these are not considered part of the larger group in their powers and there is no way to identify who has village until they have attended the bush school them. These powers may be passed down from a and gone through the initiation of FGM. family member, or a person may be part of a soci- Undergoing FGM makes them a respected mem- ety that bestows supernatural powers to its member of the society. Children usually attend these bers. These powers may be used to witch or schools between the ages of 4 and 12 years old. bewitch another person, such as casting a spell on Female genital mutilation can affect a woman’s them to complicate their pregnancy, cause an ill- long-term health associated with childbearing. ness or even death. Women who have undergone FGM are at risk for multiple childbirth complications, such as obstructed labor, uterine rupture due to the 21.2 Social Structural Factors obstructed labor, fistula formation, and incontinence of urine and stool. Liberia, located in West Africa, has a total popula- Ritualistic cicatrization (scarification) is also tion of approximately 4.5 million (World Health often done to both women and men. These are Organization 2015). Liberia’s social and health intentional superficial cuttings on the face, back, structures were devastated during 14 years of civil and other areas of the body that takes place in the and rebel wars, which ended in a comprehensive bush schools. They are considered body decora- peace agreement in 2003 (United States Institute of tion that identify social origins. In West Africa Peace 2003). Then, a decade later, the 2014–2015 they are used for identification of ethnic groups Ebola outbreak further weakened an already failing and families and also to express personal beauty. health system. The World Health Organization They are considered by some tribes as testimony (2016a, b) reports the total number of cases attrib- that a woman will be able to withstand the pain of uted to Ebola in West Africa surpassed 28,000 with childbirth (Rand African Art 2002). the death toll over 11,000 in the three countries of Men are not permitted to be present at the birth Guinea, Liberia, and Sierra Leone. of their children, and women are not permitted to Liberia was designated one of the “fragile” give birth inside the house when there are male chil- countries targeted by the Global Financing Facility dren living in the household. To seek health care or (GFF) in 2015 and is ranked tenth in the world for assistance with a problem during pregnancy, women maternal mortality. The maternal mortality rate is 21 Case Study: Maternity Care for a Liberian Woman 195 estimated at 1072 deaths per 100,000 live births, • Develop a trusting relationship with the preg- placing a woman’s lifetime risk of dying from a nant woman. Listen to her needs and fears— pregnancy-related complication at 1 in 31. anticipate that this may take more time than In Liberian culture, women often have less with women who are familiar with the formal personal autonomy, less freedom, and less health-care system. Use terminology that is access to information than their male counter- consistent with a client’s educational level. parts. The literacy rate for females is 48% with Share decision-making. 33% of women having no education (LISGIS • Obtain a careful health and obstetric history. et al. 2014). Address her beliefs surrounding care for her- Culture has a profound influence on child- self during pregnancy, labor, and delivery. birth. Liberian society has left Bendu with little Offer choices that do not conflict with her cul- authority or autonomy to advocate for herself. tural beliefs whenever possible (Esegbona- While biomedical knowledge is privileged over Adeigbe 2011). Document the client’s other ways of knowing in systems modeled on preferences in the medical record. western medicine, it is not necessarily the author- • Be familiar with managing the care of women itative knowledge (Jordan 1997) for childbearing with FGM (World Health Organization women in Liberia. 2016b). Be prepared to provide appropriate care at the time of delivery to prevent and treat potential complications resulting from FGM. 21.3 Culturally Competent • Provide continuity of care whenever possible, Strategies Recommended allowing the client to see the same provider throughout her pregnancy. Minority ethnic groups, used to traditional birth • Exercise self-reflection on your own cultural attendants caring for them during pregnancy, are worldview. likely to experience problems when presenting for perinatal care in the formalized health-care 21.3.2 Organizational Level system A lack of understanding or experience with Western-modeled medicine often contrib- • Provide gender-aligned interpretation services utes to distrust of the health-care system (Lori whenever possible. and Boyle 2011). There are often conflicting • Provide in-service training and educational beliefs, understandings, values, and expectations workshops to providers and staff to become of both providers and pregnant women seeking educated about the culture, beliefs, and healthcare (Wojnar 2015). Navigating a formal system care practices of all ethnic communities within of health care for the first time can be challenging the country. and frightening—especially for those fleeing • Provide in-service training and educational from unstable or violent situations. workshops for health-care providers and all staff regarding the care of women with FGM (World Health Organization 2016b). 21.3.1 Individual-/Family-Level • Develop simple, picture-focused educational Interventions materials for clients who do not read or understand English. • Providers need to be conscious of individual cultural differences in the populations they care for at the same time avoiding stereotyp- 21.3.3 Societal Level ing. Become informed about nutritional practices and cultural traditions and when these • Collaborate with community associations and conditions and practices can be harmful to the social networks for women in the community mother or fetus. Take a holistic, evidence- (Dyer 2016). Become familiar with in-country based approach to care. programs related to FGM. 196 J. R. Lori

• Work with local, district, and ministry offi- Esegbona-Adeigbe S (2011) Acquiring cultural com- cials to ensure full coverage for pregnancy and petency in caring for black African women. Br J Midwifery 19(8):489–496 childbirth to prevent barriers for women to use Jordan B (1997) Authoritative knowledge and its con- the formal health-care system. struction. In: Davis-Floyd RE, Sargent C (eds) Childbirth and authoritative knowledge: cross-cultural Conclusion perspectives. University of California Press, Berkley, pp 55–79. ISBN: 9780520207851 Pervasive fear, distrust, and stigma surrounded Liberia Institute of Statistics and Geo-Information Bendu’s life prior to her move to the capital city Services (LISGIS), Ministry of Health and Social of Monrovia. Her marginalization within her Welfare [Liberia], National AIDS Control Program own community and her limited education are [Liberia], and ICF International (2014) Liberia demographic and health survey 2013. Liberia Institute of factors contributing to her vulnerability. Statistics and Geo-Information Services (LISGIS) and Bendu’s lack of individual rights, autonomy, ICF International, Monrovia and independence makes her especially vulner- Lori JR, Boyle JS (2011) Cultural childbirth practices, able in advocating for her health-care needs. beliefs, and traditions in postconflict Liberia. Health Care Women Int 32(6):454–473. https://doi.org/10.10 To engage in culturally competent practice, 80/07399332.2011.555831 providers must become familiar with the Rand African Art (2002) Scarification and cicatrisation unique populations they care for with special among African cultures. Retrieved from http://www. attention to the political, social, and cultural randafricanart.com/Scarification_and_Cicatrisation_ among_African_cultures.html context of childbirth including practices, United States Institute of Peace (2003). Peace agree- beliefs, and traditions that influence health ments: Liberia. Retrieved from https://www.usip.org/ and illness. Cultural knowledge is critical to publications/2003/08/peace-agreements-liberia our understanding and care of minority ethnic Wojnar DM (2015) Perinatal experiences of Somali couples in the United States. J Obstet Gynecol Neonatal Nurs groups during pregnancy and childbearing. 44(3):358–369. https://doi.org/10.1111/1552-6909.12574 Recognizing and respecting cultural diversity World Health Organization (2015) Liberia. Retrieved can have a lasting impact on a woman’s life. from http://www.who.int/countries/lbr/en/ World Health Organization (2016a) Ebola data and statistics. Retrieved from http://apps.who.int/gho/data/ view.ebola-sitrep.ebola-summary-latest?lang=en References World Health Organization (2016b) WHO guidelines on the management of health complications from Dyer JM (2016) Women in migration: best practices in mid- female genital mutilation. Retrieved from http:// wifery. In: Anderson BA, Rooks JP, Barroso R (eds) Best www.who.int/reproductivehealth/topics/fgm/ practices in midwifery: using the evidence to implement management-health-complications-fgm/en/ change. Springer, New York, pp 169–182 Case Study: Care of a Malay Muslim Woman in a Singaporean 22 Hospital

Antoinette Sabapathy and Asmah Binti Mohd Noor

Rosna, a 25-year-old Malay Muslim woman, is a enjoys her work and although she is willing to marketing executive in a fairly large company have the four children her husband wants, she located in Singapore. She enjoys her work and would also like to continue working. has been in the same company for the last 5 years. In view of the situation, the nurse decided She is married to a 30-year-old technician. Her to finish examining Rosna. She then arranged mother and mother-in-law take turns looking for Rosna to see her obstetrician before con- after her 4-year-old son while she is at work. tacting Rosna’s husband. An ultrasound was She is now 14 weeks pregnant with her sec- performed on Rosna and the fetus was viable. ond child. She was brought to the emergency The obstetrician gave her a 7-day medical department by her colleagues as she had vaginal leave with an appointment to return in a week’s bleeding. She appeared very anxious and had time. tears in her eyes as she was being examined. As The nurse then contacted Rosna’s husband to she was obviously distressed, the nurse examin- tell him that Rosna was ready to return home. ing her asked her if she wanted to call her hus- The nurse also informed the husband that Rosna band. Rosna became agitated and started to cry. was rather anxious about her baby and was rather On further probing, Rosna confided that she was teary, and as such, having him to comfort her afraid to call her husband as he and the family would be most helpful. The nurse also informed would accuse her of trying to miscarry. They had the husband that he could speak with the doctor been asking her to have another child for the last to get more information if that would help him 3 years. comfort his wife. The husband replied that he She has not been using any birth control meth- would consider it and said that he would come ods, but it still took her 3 years to conceive this immediately. Rosna heard the conversation and pregnancy. However, her husband and family felt was happy to hear what the nurse had to say. she was not trying hard enough and they would While waiting for her husband to arrive, the prefer her to stop working so that she could con- nurse offered Rosna Milo, a hot chocolate malted centrate on being a wife and mother. Rosna milk drink that is popular among pregnant women as it is considered nutritious, and a chicken sandwich as Rosna had missed lunch. She assured Rosna that the sandwich was halal. Rosna appre- A. Sabapathy, R.N., S.C.M., C.N.M, W.H.N.P. (*) ciated the nurse’s assurance regarding the halal Gleneagles Hospital, Singapore, Singapore food and accepted the snack gratefully because A. B. M. Noor, M.S.C., R.N., N.I.C.U. she was hungry. Nanyang Polytechnic, Singapore, Singapore

© Springer International Publishing AG, part of Springer Nature 2018 197 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_22 198 A. Sabapathy and A. B. M. Noor

22.1 Cultural Issues process. They can then make up the lost days when they are well (Ramadan 2017) in addition The Malay Muslim culture views the husband as to making religious donations (MUIS 2015a, b). head of the family and although the Malay Muslim Unlike the Chinese, there is no balancing of woman is respected and has made significant prog- Yin and Yang for the Malay Muslims. However, ress, as a wife, she is still expected to respect the Asian women tend to avoid cold drinks during husband and submit to him. As Ramadan (2017) pregnancy and this applies to Muslim women says “It is as though the aspirations of the female too. Hot drinks are considered soothing and do were implicitly the same as those of the men”. And not induce cramps. according to Maqsood (2008) “… even if she is The Muslims believe that babies are gifts from more intelligent, more educated, or more spiritu- God; this belief has remained unchanged to the ally and morally gifted than him, she must agree to present day (Maqsood 2008). The Muslim reli- obey him”. Additionally, Imam Ali Ibrahim (2014) gion encourages its followers to marry and to states that “The Jihad of a woman is to take care of populate the earth (Majlis Ugama Islam Singapura her husband well”. Therefore, in the majority of (MUIS) 2017). This is demonstrated in the differ- Muslim homes, the husband’s aspirations take pre- ences of the average number of children born by cedence over the wife’s. ethnic groups. In 2015, the Malay Muslims had an In Singapore, the Malay Muslim women are average of 2.64 children, while the Chinese had free to work outside the home and move around 1.23 children and the Indians had 1.94 children. unaccompanied by a male relative. She can choose Abortions are not allowed and considered sinful not to wear the tudong and the burqa prior to mar- in the Muslim religion. riage. Many women tend to wear the tudong with Healthcare personnel should also be aware of secular clothes. The Majlis Ugama Islam the dietary restrictions when caring for the Singapura (MUIS), a statutory board, tasked with Muslim patients. The food should be free of pork seeing to the interests of the Muslims and to advise and be certified halal (Elnakib 2017). Foods are the president on Muslim matters, states that “It is considered “HALAL” if it does not contain any compulsory for Muslim women to wear the Hijab” components or products of animals that are and advised that the woman should take a job that considered non-halal by Syariah law or animals enables her to wear the tudong (2015). that are not slaughtered according to Syariah law; Usually, after marriage, the husband’s prefer- foods must be processed or manufactured using ence takes precedence. The Muslim husbands do equipment and facilities that are free from con- take an active role in the woman’s health and are tamination or from forbidden ingredients, such as involved in the final decision-making. So the alcohol. Additionally, the crockery and cutlery adoption of the Muslim rules and regulations is must be differentiated from those used for very much dependent on individual preference. non-Muslims. Many of the beliefs about prenatal care are There are some types of food, e.g., mutton, passed on from mothers to daughters. Pregnant cuttlefish, and pineapples, that Muslim pregnant women are exhorted to stay indoors after sunset. women tend to avoid as they believe that these It is believed that there are unclean spirits that foods cause harm to the fetus. They believe that prey on pregnant women after sunset. Pregnant eating mutton may result in the baby having sei- women must ensure that their activities do not zures (A. Mohamad Noor, personal communica- put their unborn child at risk. They do go for pre- tion, April 27, 2017). natal care and will take supplements as long as the contents do not contain lecithin from animals for example pigs. 22.2 Social Structural Factors Pregnant women may break their fast if they feel it poses a danger to themselves or their Singapore is an island in the heart of Southeast unborn child. If breastfeeding, they can also Asia, between Malaysia and Indonesia, with a break their fast if it impacts the breastfeeding population of more than 5.7 million as of 2016. 22 Case Study: Care of a Malay Muslim Woman in a Singaporean Hospital 199

Its population comprises 74.2% Chinese, 13.3% for the Muslim patients. Each room also has an Malay, 9.1% Indian, and 3.3% other ethnicities arrow on the ceiling indicating the direction they (Singapore Demographics Profile 2016). should face while praying. The direction faces Corresponding to the different ethnic groups, it Mecca and they are praying toward the Kaaba in has four official languages, namely, English, Mecca, the holiest place for the Muslims. Malay, Mandarin, and Tamil. Most Singaporeans are bilingual in English and a second language, commonly Mandarin, Tamil, or Malay (Singapore 22.3.1 Individual-/Family-Level Demographics Profile 2016). Interventions Despite being in the minority, the Malay population is well regarded and favored. Their prog- • On admission, if unfamiliar with the patient’s ress reflects the island’s progress. The average cultural identity and religious status, conduct household income for the Malays has increased an in-depth cultural assessment. from a total of $3151 in 2000 to $4575 in 2010. • Respect the person’s view of family and At a recent rally of the ruling People’s Action procreation. Party, the Minister of State for Defense and • Provide interventions to unite the family National Development, Mr. Mohamad Maliki regardless of personal beliefs. Osman, stated that the “Malay community’s tre- • Provide education of early pregnancy precau- mendous progress over the years is a reflection of tions and possible complications. Singapore’s success” as the Malays “have • Ensure dietary requirements, such as halal excelled academically, with more Malays these food, are met. days graduating with first-class honours” (2015). The Muslim religious beliefs and practices are well protected and upheld in Singapore. 22.3.2 Organizational-Level There are 71 mosques to meet the needs of the Interventions Muslims all over the island (MUIS 2015a, b). Any disrespect shown to Muslims is punishable • Provide signage, educational information by law. materials in the major languages. • Printed information should take into account the religious sensitivities of the Muslim population. 22.3 Culturally Competent • Provide training for staff to ensure they are Strategies Recommended familiar with the Muslim cultural and religious practices. The Malay Muslim community is well estab- • Provide interpreters as necessary. lished in Singapore and is valued. Their religious • Ensure kitchen premises has an area that is beliefs and practices are respected and upheld. As “HALAL” certified and manned by Muslims. such, all healthcare personnel must be competent and are expected to be competent in providing culturally appropriate and effective care. Nursing 22.3.3 Community Societal Level students are taught culturally appropriate care Interventions from the first year of their program. They are taught that the father will pray into the ear of his • Collaborate with the religious committees so newborn immediately after birth, and as part of that the hospital can access their knowledge providing culturally appropriate care, nurses and expertise. should facilitate this religious practice. Muslims • Advocate for community and federal legisla- also bury their dead on the same day and last rites tion that mandates maternity care is delivered are expedited. Each hospital also has a list of reli- in a culturally appropriate manner and that gious personnel appropriate for the religion of allows culturally specific practices and taboos their patients that they can contact, e.g., the ustaz be respected whenever it is safe and practical. 200 A. Sabapathy and A. B. M. Noor

Ibrahim A (2014) Principles of marriage and family Conclusion ethics. Lulu Press, Raleigh. Retrieved from https:// In the Malay Muslim community, healthcare www.al-islam.org/principles-marriage-family-ethics- personnel must remember that the males are the ayatullah-ibrahim-amini head of the household and regardless of their Majlis Ugama Islam Singapura (MUIS) (2015a) own beliefs, decisions regarding the women’s Frequently asked questions on Ramadan. Retrieved from http://www.muis.gov.sg/officeofthemufti/docu- health must be made in collaboration with their ments/FAQ%20english%20ramadan.pdf husbands. The women will consult their hus- Majlis Ugama Islam Singapura (MUIS) (2015b) bands with regard to treatments, and obtaining Strengthening institutions, empowering community: the husbands’ support from the beginning will annual report 2015. Retrieved from http://www.muis. gov.sg/documents/Annual_Reports/MUIS_AR_2015- facilitate the treatment process. This knowl- Full-FA-LR.pdf edge and acceptance of the Malay Muslim cul- Majlis Ugama Islam Singapura (MUIS) (2017) Guidelines ture will result in the husband’s support of his to preparation & handling of halal food. Retrieved wife, maintain family harmony and encourage from http://www.muis.gov.sg/halal/Consumer/guide- to-halal-food-preparation.html the use of the healthcare facilities. Maqsood RW (2008) Islam : understand the religion behind the headlines. HarperCollins, London Progress of Malays reflects S’pore’s success. Retrieved from http://www.straitstimes.com/politics/progress-of- References malays-reflects-spores-success Ramadan T (2017) Islam: the essentials. Penguin Random Elnakib S (2017) Understanding the diverse culinary tradi- House, London tions of Islam. Retrieved from http://www.eatrightpro. Singapore Demographics Profile (2016). Retrieved from org/resource/news-center/in-practice/dietetics-in-action/ http://www.indexmundi.com/singapore/demograph- understanding-the-diverse-culinary-traditions-of-islam ics_profile.html Part VI Guideline: Cultural Competence in Health Care Systems and Organizations Building an Organizational Environment of Cultural 23 Competence

Marilyn “Marty” Douglas

Guideline: Healthcare organizations should provide the structure and resources necessary to evaluate and meet the cultural and language needs of their diverse clients.

23.1 Introduction such as insurance status, patient income, severity of disease, comorbid illnesses, age, gender, An individual cannot stay healthy solely through and where the care was provided, the majority personal effort but rather needs the support sys- of studies found that minorities were less likely tem of family and friends, fresh foods, safe to receive the care they needed, including clini- streets, and clean air and water to maintain health. cally necessary procedures. These inequalities Similarly, healthcare providers cannot provide were found across illnesses as varied as cancer, culturally competent care without an organiza- mental illness, cardiovascular disease, diabetes, tional infrastructure that provides the framework and HIV/AIDS as well as routine treatments for and tools to implement that care. Healthcare common health problems. Ultimately, this organizations and agencies are responsible for inequality of care results in disparities in health- providing that infrastructure so healthcare pro- care outcomes between Whites and minority fessional can deliver safe, culturally congruent, populations that persist to the present day and compassionate care to all who seek its (AHRQ 2016). services. The IOM Report identifies three main cate- More than 15 years ago, the Institute of gories of causes of these racial and ethnic Medicine in the United States published the minority health disparities. The first are patient- report Unequal: Confronting Racial and Ethnic level variables, which, other than access-related Disparities in Health Care (Smedley et al. factors, include mistrust, a misunderstanding of 2003). The IOM committee reviewed more than provider’s instructions, a poor cultural match 100 studies that investigated the quality of care between the minority patient and provider, poor delivered to racial and ethnic minorities. Despite prior interaction with the healthcare system, or the fact that many variables were controlled, just a lack of knowledge of how to use the healthcare system. In the second category are M. Douglas, Ph.D., R.N., FAAN provider-level variables, including provider bias School of Nursing, University of California, against minorities, provider’s uncertainty when San Francisco, San Francisco, CA, USA interacting with minorities, and provider stereo- e-mail: [email protected], [email protected] types about the health beliefs, behaviors, and

© Springer International Publishing AG, part of Springer Nature 2018 203 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_23 204 M. Douglas health of minority groups. The final category of dures that are trusted by the providers, and (5) causes of disparities in healthcare include training that is meaningful and that explains healthcare system level variables, such as the how to deal with cross-cultural situations. After availability and financing of services, language the IOM report was published, a number of pro- barriers, and the location and times of service fessional organizations and governmental agen- delivery. The first two categories have been cies developed toolkits and standards to guide addressed in previous chapters. This chapter organizations in becoming culturally compe- will concentrate on the healthcare system vari- tent. Table 23.1 provides web addresses to ables and what measures can be taken to con- access some of these toolkits. In addition, the struct an environment in which cultural CLAS Standards provide a blueprint for organi- competence can be practiced. zations to implement culturally competent care (US Department of Health and Human Services 2013). 23.2 Strategies for Building a Culturally Competent Healthcare System 23.2.1 Organizational Structure

In order to effect a sustained change at the orga- 23.2.1.1 Leadership nizational level, several key elements are Commitment from the executive leadership of a needed: (1) leadership from the top, (2) demon- healthcare institution or agency is the essential strated accountability, (3) policies in place that first step to integrating health equity and health are communicated to employees, (4) proce- disparities focus into organizational practices.

Table 23.1 Toolkit for designing a culturally competent organization Organization/agency Title Source American Hospital Equity of Care: A Toolkit for http://www.hpoe.org/resources/ Association Eliminating Health Care ahahret-guides/1788 Disparities or http://www.hpoe.org/Reports-HPOE/ equity-of-care-toolkit.pdf Association of American Assessing Institutional Culture https://www.aamc.org/initiatives/diversity/ Medical Colleges and Climate learningseries/335954/cultureclimatewebcast. html Center for Medicare and A Practical Guide to https://www.cms.gov/About-CMS/Agency- Medicaid Services Implementing the National CLAS Information/OMH/Downloads/CLAS- Standards: For Racial and Ethnic Toolkit-12-7-16.pdf and Linguistic Minorities, People with Disabilities and Sexual and Gender Minorities Health Research and Improving Health Equity Through http://www.hret.org/health-equity/index.shtml Educational Trust Data Collection and Use: A Guide and for Hospital Leaders http://www.hretdisparities.org Massachusetts General Improving Quality and Achieving https://mghdisparitiessolutions.files.wordpress. Hospital, The Disparities Equity: A Guide for Hospital com/2015/12/improving-quality-safety-guide- Solution Center Leaders hospital-leaders.pdf US Department of Health HHS Action Plan to Reduce https://minorityhealth.hhs.gov/npa/files/plans/ and Human Services Racial and Ethnic Health hhs/hhs_plan_complete.pdf (HHS). Office of Minority Disparities, A Nation Frees of Healths Disparities in Health and Health Care 23 Building an Organizational Environment of Cultural Competence 205

It is the responsibility of the leadership to 23.2.1.4 Care Delivery incorporate these principles into the mission Depending on the nature of the diverse popula- and vision of the organization. The board of tion served, some departments may need to directors should reflect the diversity of the pop- expand options for care delivery. For example, ulation served so that the healthcare needs of clinic hours may need to be expanded to eve- vulnerable groups within their geographic area nings and weekends if it is found that many of can be identified and addressed by programs the minority patients hold multiple jobs with designed and funded by the leadership. It is limited opportunity to take time off during reg- also the responsibility of the leadership for ular business hours. Community outreach clin- developing and implementing policies and pro- ics within ethnic neighborhoods may be needed cedures assuring quality of care is delivered to to facilitate access to healthcare services. culturally diverse populations and that these Dietary services may need to expand their policies are integrated throughout the organiza- options for food choices, for example, kosher tion (Weech-Maldonado et al. 2018). These foods, more vegetarian options, and ethnic include policies that address discrimination and foods. Maternity services may need to incorpo- bias of the institution as a whole and staff in rate new procedures to accommodate traditional particular. practices for labor and delivery. Examples of institutional barriers to access of maternity ser- 23.2.1.2 Central Diversity Committee vices in China (Kyei-Nimakoh et al. 2017), sub- The creation of a multidisciplinary committee Saharan Africa (Listyowardojo et al. 2017), directly accountable to chief executive is needed Indonesia (Kurniati et al. 2017), and Australia to coordinate and direct all activities related to (Hughson et al. 2017) illustrate this need to the delivery of culturally competent care. Its review policies and procedures in the way care functions are to assess what is being done, is delivered. The general wards and intensive address disparities, address data collection, coor- care units may need to be more flexible with dinate diversity activities, and develop a strategic visiting hours because some cultures require all plan. family members to accompany an ill family member. Each institution and agency needs to 23.2.1.3 Organizational address its own policies and procedures for its Self-Assessment services depending on the findings of their A first step in developing a strategic plan for cul- institutional assessment. tural competence is to assess the current level of services. An organizational self-assessment will give the organization the information it needs to 23.2.2 Data Collection understand its capacity for offering effective communication that meets the needs of individu- 23.2.2.1 Demographic Data als accessing the organization’s services. One In order to determine whether disparities of example of such an organizational assessment care exist within both the institution and the tool is provided below in Appendix 1 Cultural community it serves, healthcare organizations Assessment of an Organization, Institution, or need to collect the racial and ethnic affiliations Agency (Andrews 2016). Another source of of their patients and citizens as well as their pri- guidelines to assess organizational cultural com- mary language and literacy capabilities. petence in the areas of administration, human According to the American College of resources, education, nursing department, and Physicians position paper on racial and ethnic dietary services is provided by Purnell et al. disparities in healthcare, “an ongoing dialogue (2011). with surrounding communities can help a 206 M. Douglas healthcare organization integrate cultural man to guide future interactions with persons beliefs and perspectives into healthcare prac- from these populations. tices and health promotion activities” (American College of Physicians 2010). While 23.2.2.4 Electronic Health Records most hospitals do collect basic race and ethnic- (EHR) or Medical Record ity data on their own patients and a large major- In addition to demographic racial and ethnic data, ity collect data on their patients’ primary other cultural variables should be included in the language, there is a lack of standardization of medical record. For example, depending on the what is collected. For example, they may have a population served, the following items could be racial category of Black, but this would include included in an intake or admission assessment: African Americans, Caribbean Blacks, and ref- primary language spoken, facility with dominant ugees of a number of African countries. language, preferred greeting, principal decision- Similarly, a category of Whites would include maker, preferred food and beverage choices, the Irish, German, and Eastern Europeans and not use of herbal teas, or other alternative or differentiate between multigeneration complementary therapies. Other traditional prac- Americans and new immigrants. All have tices can be integrated into the electronic health unique cultural needs. The toolkit developed by record. For example, many persons of Asian heri- the Health Research and Educational Disparities tage prefer warm beverages rather than cold ones Trust, as listed on Table 23.1, is particularly when ill. Therefore, hot/warm teas are preferred useful in delineating the specifics of data col- over cold drinks both with and between meals. lection for identifying disparities in care Having the person’s preferences recorded on (Hasnain-Wynia et al. 2007). admission assists the healthcare provider design an individualized plan of care. 23.2.2.2 Health Outcome Data Collecting the racial and ethnic demographic data is only the first step. Correlating these with 23.2.3 Communication the health outcomes of the population served is vital to assessing the healthcare needs of the 23.2.3.1 Interpreter Services community. Combining the demographic and Using family members as ad hoc interpreters health outcome data of their community will when a patient does not speak the dominant lan- guide the healthcare organization in planning for guage is ill-advised. The patient may not wish to new programs to address the disparities in health divulge sensitive health information to the fam- outcomes. It will also help in identifying key ily member acting as an interpreter, who may be quality indicators that need to be measured and a young child or an abusive spouse. And the then stratifying them according to race and family member interpreter may not wish to con- ethnicity. vey information from the healthcare provider to the patient, such as a diagnosis of cancer or 23.2.2.3 Patient Satisfaction Data other terminal diagnosis. Instead, certified inter- In order to determine whether the services that preters are recommended, whether they are the organization is providing are appropriate and face-to-face or through phone or other technolo- effective, patient satisfaction survey data should gies. Chapter 14 provides a more extensive dis- be stratified and analyzed according to racial and cussion on the use of interpreters and other ethnic populations. These results can be corre- technologies that can be used to bridge the lan- lated with health outcome data on these popula- guage barrier between patients and healthcare tions to identify areas that can be improved and providers. determine which new programs need to be In a systematic review of culturally appropriate designed to meet the needs of this population. interventions in a population of culturally and lin- These data can be used by the patient ombuds- guistically diverse (CALD) communities, 23 Building an Organizational Environment of Cultural Competence 207

Henderson et al. (2011) found that in the experi- drawn from the minority communities in the mental group using full-time, trained interpreters geographic area they serve. They may be helpful who were available 24 h per day, there was a sig- in designing programs and services that are nificant increase in clinical service usage, in the more culturally appropriate to the diverse com- number of prescriptions written and rectal exams munity they serve. One example would be to performed as compared to the control group in assess the value of expanding the types of which family member interpreters were used. From acceptable signatures for consent forms to the results of this study, they concluded that there is include the family decision-maker; in many cul- an increase in health services when an interpreter tures, the individual does not make such a major service is used for CALD communities. However, decision as surgery by themselves but rather more studies comparing the use of interpreter ser- requires consultation and approval of the family vices are needed to confirm their conclusion. decision-maker. In Chap. 31, the advantages and challenges of a multicultural workforce are 23.2.3.2 Signage described, as well as strategies for building a Negotiating the numerous hallways of a large workforce composed of multiethnic members of healthcare organization is difficult enough if a the population it serves. person speaks the dominant language. It is so much more difficult if a person and family mem- 23.2.4.2 Performance Evaluations bers are not only less familiar with medical terms In order to integrate cultural competency into all but also have limited proficiency in the dominant levels of service, the institution needs to assure language. Therefore, the signage throughout the the accountability of all its staff to its mission organization should be in as many languages as and vision. At both the organizational and indi- the populations they serve. To assure adequate vidual level, cultural competence requirements communication, the language on the signs should and performance measures should be included in be verified by members in the community so that job descriptions, functional statements, perfor- the dialect is accurate. mance evaluations, and promotion criteria. These performance measures should be included 23.2.3.3 Patient Education for all staff, from the upper levels of manage- Another function of the interpreter services is to ment to all professional care givers and to the translate patient education materials into the lan- nonprofessional staff who have contact with guages of the population served. These may be patients. any written information, consent forms for medical treatments, tests and research, diets, discharge instructions, and even clarifying prescriptions. 23.2.5 Cultural Competency For example, the word “once” in Spanish means Education 11, in English it means 1. The difference in dosage taken can be catastrophic. Patient education Regardless of the type or amount of patient- videos should also be translated and include employee contact, an awareness of cultural actors of similar race and ethnicity of the popula- beliefs and attitudes can create either a welcom- tions served. ing or negative environment. Cultural competency education helps healthcare providers be responsive to diverse cultural beliefs and prac- 23.2.4 Multicultural Workforce tices, preferred languages, literacy levels, and other patient needs. All employees, including the 23.2.4.1 Recruitment and Retention professional clinical staff, nonprofessional staff One way to reduce institutional barriers to cul- who have contact with patients or families, and tural competence is to recruit healthcare profes- even executive staff, should have cultural compe- sionals, administrators, and policy-makers tency training. Educational sessions can be 208 M. Douglas adapted to each group. For example, for the pro- allocated for hiring of interpreters, cultural fessional clinical staff who obviously will have competence training for all staff, production the most in-depth interactions with diverse popu- of multilingual written materials and videos lations, content should be more comprehensive. for patient education, consent forms and An example of key concepts to be included in patient satisfaction surveys, adding multilin- cultural competence training for professional gual signage throughout the institution, and staff are given below in Appendix 2. In Chap. 6, a supplemental recruitment of diverse staff, more thorough discussion of the content of cul- among others. In a culturally competent orga- tural competence training is provided. nization, these costs can be offset by improved The executive level managers also would ben- health outcomes for members of racial and efit from cultural competency training.ethnic minority and reflected in such high-cost Knowledge of the degree of racial and ethnic dis- quality measures as reduced hospital length of parities in health outcomes, on a national level stay, reduced emergency department length- and particularly in the area served by the institu- of-stay for treatment-and-release patients, tion, would provide rationale for program plan- reduced 30-day readmissions, and reduced ning and budget allocations. In addition, it would 72-h revisits to the emergency department. On guide the plan for data collection on the diverse balance, it is not only morally and ethically populations served and assist in the strategic responsible for an organization to provide cul- planning process. turally competent care, but it is also fiscally Cultural competence training should also be responsible to do so. provided for nonprofessional staff, e.g., admission and ward clerks, unlicensed assistive care providers, food service personnel, cashiers, or 23.2.7 Community and Cross-Sector those performing housekeeping services on the Collaboration wards. Their orientation training should at a minimum include elements of cultural awareness Healthcare institutions exist to serve the peo- exercises and basic communication styles, such ple in its community. Therefore, community as forms of address, spatial distance when speak- engagement can accomplish at least four goals: ing with others, the use of eye contact, the use of to build trust between community members gestures, etc. and the healthcare providers, to assess the Orientation and continuing education sessions needs of the community, to design ways to should be face-to-face and interactive, with role- enable access to healthcare, and to meet the playing using patient vignettes of real situations healthcare needs of the community. Members and time for group discussions that augment the of the community need to be seen as equal didactic portions of the classes. Simply complet- partners in assuring a healthy society. They ing an online module is insufficient to preparing should be recruited to serve on the organiza- staff for real cross-cultural encounters. Recently, tion’s board of directors and participate with there has been a trend to shift from using the term full membership in such groups as the “diversity” training to naming it “unconscious “Diversity” Committee, Patient Education bias” training, where the emphasis is placed on Committee, Research Committee, Nutrition learning strategies to recognize and neutralize Committee, Ethics Committee, and others with prejudices (Lipman 2018). relevance to cultural differences in healthcare delivery. They can assist with cultural competency curriculum development and in deliver- 23.2.6 Fiscal Resource Allocation ing the training sessions. They can collaborate in analyzing patient satisfaction surveys and in Building a culturally competent organization identifying the rationale for both positive and requires not only specific personnel but also negative comments made by the community fiscal resources. Budget allocations need to be members. 23 Building an Organizational Environment of Cultural Competence 209

Enlisting the help from community health ness case can be made that these strategies workers has been found to be beneficial when yield a greater benefits-to-costs ratio. Besides working with culturally and linguistically diverse greater patient satisfaction survey results from populations (Henderson et al. 2011). For exam- diverse populations, culturally competent care ple, these community health workers can serve as yields decreased hospital readmissions, a healthcare resource for the population, as well decreased length of stay in both the emergency as assist discharged patients with implementing department and hospital, decreased emer- their plan of care, or collaborate with the organi- gency department revisits within 72 h, and zation to operate an off-site clinic. improved health outcomes. Those benefits far Besides collaborating with the local commu- outweigh the costs of investment in training of nity, organizations must unite with other com- the workforce, hiring interpreters, and adding munity groups with similar priorities to have multilingual signage. Healthcare organiza- greater political power to make policy changes tions, regardless of size, are responsible for to help reduce racial and ethnic disparities in providing services that are respectful of and healthcare. By forming stakeholder coalitions responsive to all individuals’ cultural health of many institutions and agencies with similar beliefs and practices, preferred languages, goals, they can build leadership capacity across health literacy, and communication needs. By sectors, share best practices for reducing health building a structure of cultural competence, disparities, collaborate to assure consistency in the organization is meeting these needs. data collection and survey results, and share technical support (Espinoza et al. 2017). By establishing a cohesive partnership of such organizations, they can serve as a forum for Appendix 1: Cultural Assessment sharing information and resources, as well as of an Organization, Institution, or undertaking collaborative projects designed to Agency reduce health disparities and yield more generalizable results than solely the community in Demographic/Descriptive Data which a single organization provides care. Considering that the causes of health disparities • What types of cultural diversity are repre- are complex and, in many cases, are embedded sented by clients, families, visitors, and others in social determinants of health, coalitions of significant to the clients? Indicate approxi- many sectors are needed to develop strategies to mate numbers and percentages according to eventually eliminate health disparities and the conventional system used for reporting achieve equity. census data. • What types of cultural diversity are repre- Conclusion sented? What types of diversity are present Quality of care must be equivalent to equity of among patients, physicians, nurses, X-ray care. In order for healthcare providers to technicians, and other staff? Indicate approxi- deliver culturally competent care, they must mate numbers and percentages by department be able practice within an environment that and discipline. enables and facilitates healthcare delivery to • How is the organization, institution, or agency diverse populations. Without this support, the structured? Who is in charge? How do the healthcare provider will be unable to ade- administrators support cultural diversity and quately deliver culturally competent care at interventions to foster multiculturalism? the point-of-care level. Healthcare organiza- • How many key leaders/decision-makers tions are responsible for providing this within the organization, institution, or agency structure. come from culturally diverse backgrounds? Despite the initial expenses of building a • What languages are spoken by patients, fam- culturally competent organization, the busi- ily members or significant others, and staff? 210 M. Douglas

Assessment of Strengths the organization, institution, or agency? Do patient satisfaction data indicate that clients • What are the cultural strengths or positive from various cultural backgrounds are characteristics and qualities? satisfied or dissatisfied with care? How are • What institutional resources (fiscal, human) the quality outcomes the same or different are available to support multiculturalism? for individuals of various races and • What goals and needs related to cultural diver- ethnicities? sity already have been expressed? • How adequate is the system for translation • What successes in making services accessible and interpretation? What materials are and culturally appropriate have occurred to available in the client’s primary language date? Highlight goals, programs, and activi- (in written and in other forms, such as ties that have been successful. audiocassettes, videotapes, computer pro- • What positive comments have been given by grams)? How is the literacy level of clients clients and significant others from cultur- assessed? ally diverse backgrounds about their experi- • Are educational programs available in the lan- ences with the organization, institution, or guages spoken by clients? agency? • Are cultural and religious calendars used in determining scheduling for preadmission testing, procedures, educational programs, Assessment of Community Resources follow-up visits, or other appointments? • Are cultural considerations given to the • What efforts are made to use multicultural acceptability of certain medical and surgical community-based resources (e.g., community procedures (e.g., amputations, blood transfu- organizations for ethnic or religious groups, sions, disposal of body parts, and handling of anthropology and foreign language faculty various types of human tissue)? and students from area colleges and universi- • Are cultural considerations a factor in admin- ties, and similar resources)? istering medicines? How familiar are nurses, • To what extent are leaders from racial, ethnic, physicians, and pharmacists with current and religious communities involved with the research in ethnopharmacology? institution (e.g., invited to serve on boards and • If a client dies, what cultural considerations advisory committees)? are given during post-mortem care? How are • To what extent is there political and economic cultural needs associated with dying addressed support for multicultural programs and with the family and others significant to the projects? deceased? Does the roster of religious representatives available to the nursing staff include traditional spiritual healers such as shamans Assessment of Weakness/Areas and medicine men/women as well as rabbis, for Continued Growth priests, elders, and others?

• What are the organization’s weaknesses, limitations, and areas for continued growth? Assessment from an Institutional • What could be done to better promote Perspective multiculturalism? • To what extent do the philosophy and mission Assessment from the Perspective statement support, foster, and promote multi- of Clients and Families culturalism and respect for cultural diversity? Is there congruence between philosophy/mis- • How do clients (and families/significant sion statement and reality? How is this others) evaluate the multicultural aspects of evident? 23 Building an Organizational Environment of Cultural Competence 211

• To what extent is there administrative support Assessment of Need and Readiness for multiculturalism? In what ways is support for Change present or absent? Provide evidence to support this. • Is there a need for change? If so, indicate who, • Are data being gathered to provide documen- what, when, where, why and how. tation concerning multicultural issues? Are • Who is in favor of change? Who is against it? there missing data? Are data disseminated to • What are the anticipated obstacles to appropriate decision-makers and leaders change? within the institution? How are these data • What financial and human resources would be used? necessary to bring about the recommended • Are opportunities for continuing professional changes? education and development in topics pertaining to multiculturalism provided for nurses Source: Andrews MM. (2016) Cultural and other staff? Diversity in the Health Care Workforce. In: M • Are there racial, ethnic, religious, or other ten- Andrews & J Boyle, eds., Transcultural Concepts sions evident within the institution? If so, in Nursing Care, 7th ed. Philadelphia, PA: Wolters objectively and nonjudgmentally assess their Kluwer. pg. 383. Reprinted with Permission. origins and nature in as much detail as possible. • Are adequate resources being allocated for the Appendix 2: Key Concepts purpose of promoting a harmonious multicul- for Organizational Orientation tural healthcare environment? If not, indicate and Continuing Education Training areas in which additional resources are in Cultural Competence needed. for Professional Clinical Staff • What multicultural library resources and audiovisual and computer software are avail- • Definition of culture, ethnicity, cultural sensi- able for use by nurses and other staff? tivity and culturally competent care • What efforts are made to recruit and retain • Critical reflection nurses and other staff from racially, ethnically, (a) Exercises to identify one’s own heritage and religiously diverse backgrounds? What and unconscious biases other types of diversity (e.g., sexual orienta- (b) Stereotyping versus generalizing tion) are fostered or discouraged? (c) Ethnocentrism • How would you describe the cultural climate (d) Assimilation into dominant culture of the institution? Are ethnic/racial/religious • Cultural variations in modes of communication jokes prevalent? Are negative remarks or com- (a) Differences in greetings, e.g., formal ver- ments about certain cultural groups permit- sus informal ted? Who is doing the talking and who is (b) Verbal language listening to negative comments/jokes? (c) Non-verbal language, i.e., body language • Are human resources initiatives pertaining (d) Interpreters versus translators to advertising, hiring, promotion, and per- • Cultural differences in health beliefs and formance evaluation free from discrimi- practices nation? (a) Select examples from ethnic populations • Are cultural and religious considerations most frequently served reflected in staff scheduling policies for nurs- (b) Select examples of health problems of ing and other departments? ethnic populations most frequently served • Are policies and procedures appropriate from (c) Select beliefs and practices applicable to a multicultural perspective? What process is specific clinical area, e.g., maternity used for reviewing them for cultural appropri- (d) Provide clinical experiences with ethnic ateness and relevance? populations 212 M. Douglas

• Biological variations among racial and ethnic org/initiatives/diversity/learningseries/335954/cultu- populations reclimatewebcast.html. Accessed 21 Jan 2018 Center for Medicare and Medicaid Services (2016) A (a) Assessment of skin conditions in different practical guide to implementing the National CLAS racial populations Standards: for racial and ethnic and linguistic minori- (b) Assessment of cyanosis and jaundice in ties, people with disabilities and sexual and gen- different racial populations der minorities. https://www.cms.gov/About-CMS/ Agency-Information/OMH/Downloads/CLAS- • Dietary practices among various ethnic Toolkit-12-7-16.pdf. Accessed 16 Jan 2018 populations Espinoza O, Coffee-Borden B, Bakos AS, Nweke O (a) For example, kosher foods for Jewish (2017) Implementation of the National Partnership for patients Action to End Health Disparities: a three-year retrospective. J Health Dispar Res Pract 9(OMH Special (b) For example, no pork for Muslim patients Issue 6):20–36 (c) Balance of “hot” and “cold” for many Hasnain-Wynia, R, Pierce D, Haque A, Hedges Greising Asian groups C, Prince V, Reiter J (2007) Health research • Use of traditional remedies (complementary and educational trust disparities toolkit. http:// www.hretdisparities.org. Accessed 23 Jan 2018 and alternative medicines) Health Research and Educational Trust (2011) Improving (a) Select examples from ethnic populations health equity through data collection and use: a guide most frequently served for hospital leaders. Health Research & Educational (b) Interactions with prescription medicines Trust, Chicago. http://www.hret.org/health-equity/ index.shtml. Accessed 23 Jan 2018 (ethnopharmacology) Henderson S, Kendall E, See L (2011) The effectiveness • Small group discussion of case studies that of culturally appropriate interventions to manage or integrate principles of cultural competence prevent chronic disease in culturally and linguistically (a) Identify cultural conflict diverse communities: a systematic literature review. Health Soc Care Community 19(3):225–249 (b) Develop a plan of care or solutions to Hughson JA, Marshall F, Daly JO, Woodward-Kron R, conflict Hajek J, Story D (2017) Health professionals’ views (c) Present plan to whole group on health literacy issues for culturally and linguistically diverse women in maternity care: Barriers, enablers and the need for an integrated approach. Aust Health Rev 30:2017. https://doi.org/10.1071/ References AH17067 Kurniati A, Chen CM, Efendi F, Berliana SM (2017) Factors Agency for Healthcare Research and Quality (AHRQ) Influencing Indonesian Women’s Use of Maternal (2016) 2015 National Healthcare Quality and Health Care Services. Health Care Women Int 20:2017. Disparities report and 5th anniversary update on the https://doi.org/10.1080/07399332.2017.1393077 National Quality Strategy. U.S. Department of Health Kyei-Nimakoh M, Carolan-Olan M, McCann TV (2017) and Human Services, Rockville, May 2015. AHRQ Access barriers to obstetric care at health facilities in Publication No. 16-0015. https://www.ahrq.gov/ sub-Saharan Africa-a systematic review. Syst Rev 6: sites/default/files/wysiwyg/research/findings/nhqrdr/ 110–126. https://doi.org/10.1186/s13643-017-0503-x nhqdr15/2015nhqdr.pdf. Accessed 16 Jan 2018 Lipman J (2018) How diversity training infuriates men American College of Physicians (2010) Racial and eth- and fails women. TIME Magazine, 5 Feb 2018, vol nic disparities in health care, updated 2010. American 191, no 4, pp 17–19. TIME Inc., New York College of Physicians, Philadelphia. https://www. Listyowardojo TA, Yan Z, Leyshon S, Ray-Sannerud B, acponline.org/system/files/documents/advocacy// Yu XY, Zheng K, Duan T (2017) A safety culture current_policy_papers/assests/racial_disparities.pdf. assessment by mixed methods at a public maternity Accessed 26 Jan 2018 and infant hospital in China. J Multidiscip Healthc American Hospital Association (2015) Equity of care: a 10:253–262 toolkit for eliminating health care disparities. http:// Massachusetts General Hospital (2015) Improving qual- www.hpoe.org/resources/ahahret-guides/1788. ity and achieving equity: a guide for hospital lead- Accessed 23 Jan 2018 ers. https://mghdisparitiessolutions.files.wordpress. Andrews MM (2016) Cultural diversity in the health care com/2015/12/improving-quality-safety-guide-hospi- workforce. In: Andrews M, Boyle J (eds) Transcultural tal-leaders.pdf. Accessed 23 Jan 2018 concepts in nursing care, 7th edn. Wolters Kluwer, Purnell L, Davidhizar RE, Giger JN, Strickland OL, Philadelphia, p 383 Fishman D, Allison DM (2011) A guide to developing Association of American Medical Colleges. Assessing a culturally competent organization. J Transcult Nurs institutional culture and climate. https://www.aamc. 23(1):7–14 23 Building an Organizational Environment of Cultural Competence 213

Smedley BD, Stith AY, Nelson AR (eds), Committee on U.S. Department of Health and Human Services (HHS). Understanding and Eliminating Racial and Ethnic Office of Minority Health. HHS action plan to reduce Disparities in Health Care, Board on Health Sciences racial and ethnic health disparities, a nation frees of Policy, Institute of Medicine (2003) Unequal treat- disparities in health and health care. https://minori- ment: confronting racial and ethnic disparities in tyhealth.hhs.gov/npa/files/plans/hhs/hhs_plan_com- health care. National Academies Press, Washington, plete.pdf. Accessed 15 Jan 2018 DC. https://doi.org/10.17226/10260. https://www.nap. Weech-Maldonado R, Dreachslin JL, Epané JP, Gail J, edu/download/10260; https://www.ncbi.nlm.nih.gov/ Gupta S, Wainio JA (2018) Hospital cultural compe- books/NBK220358/. Accessed 4 Jan 2018 tency as a systematic organizational intervention: key U.S. Department of Health and Human Services (HHS), findings from national center for healthcare leadership Office of Minority Health (2013) National Culturally diversity demonstration project. Health Care Manag and Linguistically Appropriate Services (CLAS) stan- Rev 43(1):30–41 dards. https://www.thinkculturalhealth.hhs.gov/clas/ standards. Accessed 3 Jan 2018 Case Study: Culturally Competent Strategies Toward Living Well 24 with Dementia on the Mediterranean Coast

Manuel Lillo-Crespo and Jorge Riquelme-Galindo

Barbara is a 65-year-old Scottish woman who The nearest British Community was in a big town arrived in Spain with her husband John and two by the sea where the only British Expats’ pet dogs. They planned to permanently live in a Association was located. rural area on the Mediterranean Coast, which has Six months after being settled in their new been traditionally selected by the retired elderly home, the couple experienced a medical crisis. population from Central and Northern European Barbara had gone missing for 6 h. Her husband countries as a place to live when they are still John finally found her, completely disoriented active and healthy. The Scottish middle-income and standing in the middle of a field. John decided couple were retired in an urban Scottish area for to take her to the nearest public health center, 1 year before relocating. They then decided to where the staff recommended they go to the near- move to the sunny coastal area of Southeast est Spanish public hospital, 20 km away. When Spain, investing their life savings in a country they arrived at the hospital, they were told she did house in the village where they vacationed every not qualify for care because her condition was year. For them Spain was an affordable country not seen as an emergency, and she did not have where their savings would be worth more; it had either the Spanish public insurance card or the a lower cost of living and a higher quality of life insurance plan provided by the European Union and was perceived as a safe place to live. They for European population mobility. had even heard from other expats that healthcare John was given the option to pay cash for the costs were assumed by the Spanish government, healthcare services in the meantime. But John and healthcare was considered as high quality as refused to do so, recalling that he had a contract any in Europe. They settled in the countryside with an international health insurance, which he with their pets, in a rural area with 1100 inhabit- set up years ago when they started visiting Spain ants, with widely separated properties. There on vacations. Now, however, he also realized that were no other foreign residents living nearby. he could neither speak Spanish fluently enough to explain Barbara’s situation to the staff nor M. Lillo-Crespo, Ph.D., M Anthro, M.S.N., R.N. (*) could he sufficiently understand what he was Department of Nursing, Faculty of Health Sciences, being told. Complicating matters, the Spanish University of Alicante, Alicante, Spain staff could not speak English well enough to Clinica Vistahermosa Hospital, Alicante, Spain communicate adequately with John and Barbara. e-mail: [email protected] John barely managed to understand the hospital J. Riquelme-Galindo, M.S.N, R.N. staff’s explanation about the steps to take toward Department of Nursing, Faculty of Health Sciences, receiving any type of public healthcare in Spain. University of Alicante, Alicante, Spain

© Springer International Publishing AG, part of Springer Nature 2018 215 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_24 216 M. Lillo-Crespo and J. Riquelme-Galindo

Being in this crossroads situation, John felt resulted in her being confused about times for alone and overwhelmed. He called the telephone appointments and activities. She found this upset- number written on the back of the private health ting at times, and sometimes made her reluctant to insurance card to ask where they qualified to go out with her husband and participate in the receive a professional assessment for Barbara. activities planned by the retired foreigners’ com- He then drove another 10 km to the private munity. She begun to use timetables and reminders healthcare center approved by their insurance and became more reliant on John to prompt her. company. After Barbara was examined by a phy- From the beginning, the couple decided not to sician, the staff explained that their insurance communicate Barbara’s diagnosis to their son coverage had some limitations; that is, neurologi- and daughter, both who were living in Scotland. cal conditions were excluded due to their age and This decision consequently caused an increased their family’s medical history that they reported sense of isolation. She complained that they lived when they contracted the insurance 3 years ago. very far away from other people and that she Therefore they were responsible for 100% pay- could not even practice her Anglican faith as ment for Barbara’s consultation. She was diag- most churches in Spain were Catholic. Moreover, nosed with presumed dementia, onset of the Spanish economic recession made it difficult unspecified type. More tests would be needed to for them to sell their property and move to an be more specific. area with better access to healthcare. Being confused and unsure, John decided to go home and assume a “watch and wait” strategy to see how Barbara progressed. Over the next 6 24.1 Cultural Issues months, Barbara experienced progressively more episodes of memory loss. She was eventually Dementia is a major public health concern across diagnosed with Alzheimer’s disease at the same Europe, and the number of people with dementia private hospital as her original visit, despite the is predicted to increase from 9.95 million in 2010 fact that John was responsible for payment for all to 18.65 million by 2050 (Prince et al. 2013; scans and other tests. Wortmann 2012). The Scottish culture is consid- Meanwhile, John began to explore the process ered to be more of an individualistic culture as for obtaining a Spanish public healthcare insur- compared to the family-centered Spanish culture ance and other possible sources of support. in which caring is traditionally a female responsi- However, the political situation of the United bility, although Scotland is one of the European Kingdom breaking away from the European regions where more policies and rules regarding Union (Brexit) and the restrictive financial situa- dementia have been developed, including the so- tion in Spain posed additional barriers and chal- called dementia-friendly communities. On the lenges to obtain health insurance. At the same other hand, in Spain, care of the elderly, even of time, Barbara’s disease was worsening. They those with neurodegenerative diseases, has tradi- were hardly able to pay their bills every month, tionally been considered as a family issue until and they could see how their Spanish dream was very recently. In fact, just 11 of the 28-member vanishing. She was prescribed a medication to countries of the European Union have national decrease the progression of the disease, which dementia plans that address dementia awareness was not covered by any insurance or support. raising, education, diagnosis and treatment, and John even searched for different types of support home, institutional, and residential care at the Public Health Centre nearby and from the (Alzheimer Europe 2014). Spain is not one of Town Council, but he was denied because such these countries with such a national plan. funding support was restricted to use by the The Palliare Project Policy Review, which stud- Spanish population. ied seven countries, including Scotland and Spain, Barbara had a lot of insight into her condition. revealed that Finland and Scotland had the most She was aware that she was losing track of time as established and comprehensive national dementia well as finding it difficult to tell time, which action plans in Europe (Tolson et al. 2016). 24 Case Study: Culturally Competent Strategies Toward Living Well with Dementia 217

Moreover, Spanish culture has traditionally pro- more are responsible for full payment for these moted that the elderly remain in their homes, sur- services, whereas the costs are prorated for those rounded by their beloved ones (Cox and Monk with an intermediary income. 1993). In contrast, those who do not care for their There is no current nationwide law covering elderly relatives are not well regarded in Spain. the provision of any primary social service spe- Consequently, the Spanish government histori- cifically for persons with dementia. Each of cally has not assumed this responsibility. Spain’s 17 autonomous regions has developed its Furthermore, some authors have stated that fam- own laws based on the National Dependency ily or home care seems to decrease the disease Law’s framework. Because decrees and regula- progression, promoting the person’s routine and tions concerning social services are established stabilization, making the person feel comfortable by each autonomous region and further inter- in their own known environment (Fratiglioni preted by town councils, there is a lack of unifor- et al. 2004; Dawson et al. 2015). mity in the policies regarding care of the elderly. The Spanish Institute for the Elderly and Consequently, Spanish citizens do not have a Social Services (IMSERSO), a division of the legally established constitutional right to social Ministry of Health, reported in 2016 that 8.7 mil- services regarding elder care. Support for the lion of the country’s total population were over elderly is only understood under a proven depen- the age of 64 (Instituto Nacional de Estadística de dency situation and is determined by the person’s España 2016a). However, those statistics do not income level. Thus, the Public National Health include the high rates of elderly foreign popula- Service in Spain does not cover social and com- tion settled on the Mediterranean Coast. The munity care since these services are regarded as southeastern province, where Barbara and John the family’s responsibility. Only a primary decided to retire, has the highest percentage of healthcare service that includes home visits, elderly foreigners who emigrate mainly from which is not comparable to the Community Central and Northern Europe (Instituto Nacional Nursing Services provided in other countries de Estadística de España 2016b). Furthermore, such as the United Kingdom, is available and among the elderly living in their homes, the inci- only for people with Spanish nationality. The dences of isolation and the previously unseen limited range of these services underscores the phenomenon of elderly abandonment are also traditional emphasis on treatment based on increasing. Since care of the elderly is a family pathology but excludes prevention and health obligation, and not the government’s responsibil- promotion policies. Moreover, the Spanish ity, the Spain’s Primary Health System is not healthcare and social welfare systems are inde- directly focused on this problem, and in Barbara’s pendent in their decision-making process. The case, the differences between her individualistic National Health and Social Systems provide culture and the family-centered Spanish culture users with a wide yet insufficient range of ser- make living with dementia much more difficult. vices. Funding and regulations from the national Whereas Spanish patients living with dementia Dependency Law allowed local councils to pro- rely on their families for care and do not expect vide the following services: care homes for low- government services for assistance, Barbara and income and high-dependent populations, John are left with little or no resources. additional training and resources for hospital- based professionals caring for patients in the acute stages of dementia, and respite home care, 24.2 Social Structural Factors which provides nonprofessional caregiver’s support in the form of domestic chores in the homes The recently implemented Dependency Law in of middle-stage dementia dependent populations. Spain (de Estado 2006) fully funds home-based In the case of Barbara, she did not qualify for any care services or financial support for Spanish citi- of these services because she lacked Spanish citizens who receive a minimum pension. Those zenship, and her private health insurance did not with an income twice the minimum pension or fully cover all of her needs. 218 M. Lillo-Crespo and J. Riquelme-Galindo

24.3 Culturally Competent • Provide support after the diagnosis is made Strategies Recommended with an appropriate and personalized care plan, which is integrated and multidisciplinary, Elderly Central and Northern European retirees including the evaluation for home adaptation. living on the Mediterranean Coast in Spain • Provide as much personal control as possible, could be considered as potentially at risk for the enabling those with dementia and their care- onset of neurodegenerative diseases and their givers to exert control over their own care and consequences but without access to the health their lives, even in advanced stages, including services they require. Because the Spanish at the end of life. Health System considers elder care a family • Provide patient with information about social responsibility, foreign retirees who are sepa- and religious support and associated networks rated from the families are left without the ser- in the community nearby. vices they would have expected in their native • Secure a referral to health and social services countries. The following are recommendations to help Barbara and John apply for health to enable the development of strategies that are insurance and other social programs and aids culturally appropriate, adequate, and effective regarding dementia. in the case of Barbara and John, who represent a • Provide education on active and healthy habits current situation of retirees living on the related to basic needs and according to her Mediterranean Coast, by following the guide- disease progression in the preferred language lines for implementing culturally competent and considering her preferences. nursing care (Douglas et al. 2014). • Provide persons diagnosed of dementia and their caregivers with a positive practice approach and guidelines, such as the European 24.3.1 Individual-/Family-/Caregiver- Palliare Best Practice Statement (Homerova Level Interventions et al. 2016).

• Before diagnosis and on admission to the healthcare systems: conduct an in-depth 24.3.2 Organizational-Level assessment of the person’s cultural identity, Interventions linguistic preferences, environmental, occupational, socioeconomic, background, and edu- • Prevent potential risks, errors, complications, cational status, including family roles and a and harmful events for the person affected and gender-based scope. caregivers by assigning a managerial-level • Before diagnosis and on admission to the task force to oversee diversity-related issues healthcare systems: conduct an in-depth within the organization. assessment of the main caregiver’s identity, • Provide high-quality and compassionate cul- linguistic preferences, and their experience turally congruent care in all the contexts and and background regarding the disease. organizations ensuring that mission and orga- • Once a diagnosis is made: provide patient and nizational policies reflect respect and values main caregiver/s with information about the related to diversity and inclusivity. services provided for patients with that diag- • Include cultural competence as a compulsory nosis at different levels (national, regional, requirement in the organization’s job descrip- local, and community). Include the procedures tions, performance evaluations, and manage- and the required documentation needed to ment and quality improvement indicators. apply for such services. • Provide persons with dementia with flexible, • Be aware of the social stigma of the diagnosis appropriate, timely, and evidence-based care and the effect on the person, the patient’s fam- monitored by skilled staff whether at home, in ily, and the community. hospital, or in a care home. 24 Case Study: Culturally Competent Strategies Toward Living Well with Dementia 219

• Promote social impact research (stated below) • Expand dementia education and training for by including professionals from different health and social care staff who should be fields and cultures to improve the relevancy, made aware of the signs of dementia and how availability, and quality of data on dementia best to support persons with the condition and care and support. their families and caregivers, thus establishing • Establish organization-wide committees to dementia-friendly communities and societies. address the promotion of culturally competent • Design education modules that make use of care delivery to all patients, especially of those modern technology, communication, and net- persons from other cultures who reside in the working to support learning in a virtual envi- organization’s service area. ronment through membership of a facilitated • Enlist community members from diverse cul- virtual international community of practice, tures to participate in the organization’s pro- such as the Palliare Community of Practice gram planning and decision-making. (University of the West of Scotland 2015). • Allocate financial resources to fund certified • Collect demographic, socioeconomic, and interpreters in the major languages of the pop- health data, including morbidity and mortality, ulations served. of the Central and Northern European popula- • Provide a certified interpreter when the patient tions settled in the Mediterranean Coast. has limited language proficiency in the language that is different from the healthcare Conclusion providers. Several social structural factors and important • Provide signage and printed materials on mul- cultural differences and issues had enormous tiple conditions in the major languages of the impact on Barbara’s health and illness experi- populations served. ence and also on her main caregiver John. In • Partner with local associations and international addition, this case illuminates a current situa- health agencies to exchange and provide infor- tion that is evolving in Spain today. Both mation on dementia care and its relevance. Barbara and John lacked the services for the • Design interprofessional higher education mod- elderly that they were accustomed to in their ules on dementia care, including experiential native country. Complicating the situation were learning with patients from different cultures. the inconsistencies perceived in services and a • Measure the impact and patient satisfaction of lack of social support and aids because of their the strategies developed to determine the cultural background and expectancies. All these appropriateness and effectiveness of services. factors create cumulative risks and vulnerability as well as increase Barbara’s dependence on others. In order to promote her health, strate- 24.3.3 Community- and Societal- gies should be focused on creating a positive Level Interventions society where people can live well with dementia, respecting the context and culture, and on • Establish a partnership with the Retired fostering a greater global collaboration and European Associations to assist with health leadership among healthcare professional to education regarding dementia, including improve the lives of those affected. potential risk populations and caregivers. • Collaborate with the retired European community living in the area to organize work- References shops and sessions about living with dementia. Alzheimer Europe (2014) National policies covering • Collaborate with the retired European com- the care and support of people with dementia and their carers-Sweden, Dementia in Europe Yearbook munity in working toward an environment that as part of Alzheimer Europe’s 2013 Work Plan. fosters healthy and active lifestyles. [online] Available at: http://www.alzheimer-europe. 220 M. Lillo-Crespo and J. Riquelme-Galindo

org/Policy-in-Practice2/Country-comparisons/ documents/2015/12/dementia-palliarebest-practice- National-policies-coveringthe-care-and-support- statement-web.pdf. Accessed 15 April 2017 of-people-with-dementia-andtheir-carers/Sweden. Instituto Nacional de Estadística de España (2016a) Basic Accessed 15 April 2017 demographic indicators. Available at: http://www.ine. Cox C, Monk A (1993) Hispanic culture and family es/dynt3/inebase/index.htm?padre=1365. Accessed 15 care of Alzheimer’s patients. Health & Social Work April 2017 18(2):92–100 Instituto Nacional de Estadística de España (2016b) Dawson A, Bowes A, Kelly F, Velzke K, Ward R (2015) Población Extranjera según nacionalidad en la pro- Evidence of what works to support and sustain care vincia de Alicante, 2016. Available at: http://www. at home for people with dementia: a literature review ine.es/jaxi/Datos.htm?path=/t20/e245/p04/provi/ with a systematic approach. BMC Geriatr 15(1):59 l0/&file=0ccaa002.px. Accessed 15 April 2017 de Estado J (2006) Ley 39/2006, de 14 de diciembre, de Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Promoción de la Autonomía Personal y Atención a las Ferri CP (2013) The global prevalence of dementia: personas en situación de dependencia. Boletín Oficial a systematic review and metaanalysis. Alzheimers del Estado 299:15 Dement 9(1):63–75. https://doi.org/10.1016/j.jalz. Douglas MK, Rosenkoetter M, Pacquiao DF, Callister 2012.1.9.0072 LC, Hattar-Pollara M, Lauderdale J, Purnell L (2014) Tolson D, Fleming A, Hanson E, Abreu W, Crespo Guidelines for implementing culturally competent ML, Macrae R, Jackson G, Hvalič S, Routasalo P, nursing care. J Transcult Nurs 25(2):109–121 Holmerová I (2016) Achieving prudent dementia care Fratiglioni L, Paillard-Borg S, Winblad B (2004) An (palliare): an international policy and practice impera- active and socially integrated lifestyle in late life tive. Int J Integr Care 16(4):18 might protect against dementia. Lancet Neurol 3(6): University of the West of Scotland (2015) Palliare project 343–353 2015. Available at: http://www.uws.ac.uk/palliarepro- Homerova I, Waugh A, Macrae R, Sandvide A, Hanson E, ject/. Accessed 15 April 2017 Jackson G, Watchman K, Tolson D (2016) Dementia Wortmann M (2012) Dementia: a global health priority- palliare best practice statement. University of the West highlights from an ADI and World Health Organization of Scotland. Available at: http://dementia. uws.ac.uk/ report. Alzheimers Res Ther 4(5):40 Case Study: Culturally Competent Healthcare Organizations 25 for Arab Muslims

Stephen R. Marrone

Mustafa is a 55-year-old man who emigrated from Lebanon, Syria, Yemen, Iraq, and Palestine, from a small desert city in the eastern province of the more recent immigrants fleeing war in their the Kingdom of Saudi Arabia 20 years ago to a countries. The dominant languages spoken in the metropolitan area of the United States that has a general community are English, Arabic, Spanish, large Arab Muslim population. He is a smoker and Polish (Pew Research Center 2013; with a history of hypertension, obesity, and type U.S. Census Bureau 2015). 2 diabetes. As such, Mustafa emigrated to the The median annual household income in the United States in order to seek better healthcare, region is just under US$50,000; however, about to provide his children with a good education, 30% of the population lives in poverty. In spite of and for the family to enjoy a more relaxed the median household income being higher than lifestyle. that of the region, the number of people living in Mustafa lives with his wife in a predominantly poverty also exceeds that of the geographic levels Arab Muslim community in the Midwestern of the region (Pew Research Center 2013; United States that has a population of almost U.S. Census Bureau 2015). Like Mustafa and his 100,000, where more than 40% of the people are wife, many Arabs and Arab Muslims who emi- of Middle Eastern ancestries. The racial and eth- grated to this region 15–20 years ago have estab- nic composition of the community is approxi- lished themselves within the community over mately 85% Caucasian, 4% Black/ time and currently benefit from annual incomes African-American, 0.5% Native American, 2% that are higher than the median for the region. Asian, 0.5% non-Hispanics of some other race, Yet, more recent immigrants who are on the 5.0% reporting two or more races, and 3.4% upward economic trajectory live either in or at Hispanic or Latino. Approximately, half of the borderline poverty levels. Caucasian population claim Irish, German, Mustafa and his wife have three children, two Polish, or Maltese ancestry. The small African- sons and one daughter, all of whom live nearby. American population includes those whose As the eldest male of the family, Mustafa is con- ancestors came from the rural South. Middle sidered the patriarch and primary decision-maker. Eastern ancestries include immigrants primarily The children were born in Saudi Arabia and were 16, 13, and 12 years old, respectively, when they emigrated to the United States. To prepare the S. R. Marrone, Ed.D., R.N.-B.C., N.E.A.-B.C., C.T.N.-A. children for life in America, Mustafa and his wife Harriet Rothkoft Heilbrunn School of Nursing, Long Island University of Nursing, Brooklyn, NY, USA hired an English language tutor for them so that, e-mail: [email protected] by the time the children arrived in the United

© Springer International Publishing AG, part of Springer Nature 2018 221 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_25 222 S. R. Marrone

States, they had basic English speaking, reading, maker of the family. Because of his limited and writing skills. English proficiency, Mustafa was offered inter- Mustafa and his wife have a primary school preter services, but he refused for fear that the education and can speak, read, and write in interpreter would discuss his condition with the Arabic. However, they do not speak, read, or larger community. Thus, Mustafa relied on fam- write English fluently. They require an Arabic ily members to interpret for him. language interpreter and translated English to Mustafa seeks care at this hospital in particu- Arabic written materials in order to actively par- lar because he feels that his culture care needs are ticipate in the decision-making process. However, met and respected. For example, the hospital’s their children are university educated, employed, governance structure, as evidenced by its mis- and speak English fluently. sion, vision, values, and strategic plan, supports Mustafa’s family is well-respected in the com- diversity and inclusion among its consumers and munity for their strong Muslim faith, sense of within the healthcare team. family values, and generosity. However, due to To diversify all levels of its workforce that limited English proficiency, Mustafa and his wife reflects the demographics of the service area, have been marginalized within the larger com- from the frontline to the boardroom, the hospital munity, thus relying primarily on traditional life- actively recruits Arabs, Muslims, Irish, Polish, ways to navigate safely through their day-to-day Maltese, Black/African-Americans, Hispanics, activities. and Native Americans. For instance, in addition Many Arabs in the community own and oper- to mainstream nursing and healthcare organiza- ate businesses that provide services in both tions and journals, nursing recruitment and net- English and Arabic and offer foods and merchan- working efforts target organizations and their dise that appeal to Arab Muslims. Grocery stores respective journals, such as the National Arab offer fresh and packaged products that reflect the American Nurses Association, the National diverse demographics of the community at large. Black Nurses Association, the National Fresh produce and meats are readily available, Association of Hispanic Nurses, the Association and there are many stores that cater exclusively to of Men in Nursing, and advertisements in the needs of the Arab community. Minority Nurse. The community is considered to be safe even Through signage and written materials avail- though its crime rate is slightly above the national able at all points of entry into the hospital, con- average. Although the property crime rate is sumers are informed of the language services that higher than the national average, there is little are offered and how to access them. Language reported use of force against victims (Sperling services, both interpreter and translation services, 2017). The neighborhood has adequate educa- reflect the major languages of the service area, tion, transportation, and healthcare services. Arabic, Spanish, Polish, and Maltese. To ensure Two years ago, Mustafa suffered a stroke that that programs and services meet the consumers’ resulted in residual left-sided hemiparesis, impaired needs, respect for diversity and inclusion are inte- cognition, and slurred speech resulting in his reluc- grated into the hospital’s shared governance infra- tance to be seen in public due to his limited physi- structure and critical decision-making teams such cal and cognitive abilities. These changes disrupted as the ethics committee, patient education com- the family’s social dynamic and decision-making mittee, and human resource practices that address structure as his eldest son Faisal must now serve as conflict management and resolution. head of the family by proxy. Specific to the Arab Muslim population, dur- Mustafa is being admitted to the hospital with ing the holy month of Ramadan, when Muslims a diagnosis of pneumonia. Due to his limited fast from dawn until sunset, clinic hours, medica- ability to verbally express himself, he acknowl- tion administration times, and visiting hours are edged his eldest son Faisal as the key decision- adjusted to reflect the change in eating and 25 Case Study: Culturally Competent Healthcare Organizations for Arab Muslims 223 sleep/wake patterns. Halal meals are also avail- material security, obedience, and ambition able at all times for Muslim patients, families, (Miller and Feinberg 2002). Since typical Arab and staff, and an imam is available to advise staff worldviews stipulate that males serve as family on the care of Muslims and minister to the spiri- guardians, the eldest male is characteristically tual needs of Muslim patients and staff. the key decision-maker who assumes responsi- Prior to his illness, Mustafa owned and oper- bility for communicating information to the rest ated a Middle Eastern clothing and textile shop of the family (Kulwicki and Ballout 2013). that catered to customers from both the Arab and When the eldest male of the family is no longer general communities. To meet the customer’s able to ensure family stability and security and needs, Mustafa employed Arabic-English-function as the key decision-maker, individual speaking friends to translate for non-Arabic- and family dishonor may ensue. speaking customers. Whenever possible, Modesty is one of the core values in Islam. Mustafa’s sons would also help out in the shop. Visiting the sick is considered a communal obli- However, consistent with fundamental Saudi tra- gation and fervently practiced by Arab Muslims dition, Mustafa’s wife did not work outside of (Islam Questions and Answers 2017; Kulwicki the home, and his daughter did not help out in and Ballout 2013; McFarland and Wehbe-Alamah the shop. 2015). The family and the patient would be Although Mustafa is presently unemployed embarrassed and feel shame if visitors were not due to his illness, he does have adequate private permitted or asked to leave. health insurance coverage that he purchased for As a fatalistic culture, Arab Muslims have himself and his family when self-employed. strong belief that all things depend on Allah’s Coordinated by the hospital case manager and will (In Sha”llah) and stipulates that only Allah social worker, Mustafa receives hospital-based can predict the future. Prayer is performed five home care from a team that includes Arabic- times each day. As the second pillar of Islam, speaking nurses, home health aides, physical and prayer is a fundamental requirement of all occupational therapists, and a social worker, all Muslims. Although there are no official excep- of whom are male. Mustafa and his family also tions excusing adult Muslims from performing receive help and support from the local stroke daily prayers, people who are ill or traveling, for support group (National Stroke Association example, may modify the prayer rituals as 2017) and the Imam, a Muslim religious leader, described below. in the community. Hygiene is an intrinsic value of Islamic law whereby the left hand is considered dirty, while the right hand is considered clean. Wudu, the 25.1 Cultural Issues ritual washing of the hands, mouth, nasal cavity, face, forearms, hair, and feet before prayers, is Arab culture is recognized as a high-context cul- performed before each prayer. Muslims who ture whereby the needs of the group or commu- cannot perform Wudu may substitute nity are valued over those of the individual. Tayammum, the rubbing of sand with both palms Consequences of the actions of individual family and sweeping it over the face and back of the members will have consequences, positive and hands. People who are unable to perform negative, for the entire family and, in the Arab Tayammum are exempted and can still perform community, typically influence the family’s prayers (Kulwicki and Ballout 2013; McFarland honor, respect, reputation, social status, esteem, and Wehbe-Alamah 2015). Muslims are also and shame within the community. expected to face Mecca when performing prayer. Family honor, respect, and reputation are par- If this is not possible, Muslims will also ask for amount and based on attributes, such as faith, privacy and quiet in order to perform the prayer modesty, protecting family, social stability, rituals. 224 S. R. Marrone

25.2 Social Structural Factors ination feature as significant social determinants of health. Nevertheless, Saudi/Arab culture and In the US, the majority of Arabs reside in Los sedentary lifestyle pose substantial challenges to Angeles, Detroit, New York, New Jersey, health and well-being and require support from Chicago, and Washington D.C. (Arab American the broader society and healthcare systems. Institute 2012). As a result of the September 11, 2001 attacks in the United States, public attitudes toward Arabs typically blur the distinctions 25.3 Culturally Competent among Arabs, Muslims, Islamists, and terrorists, Strategies Recommended regarding them as one and the same (Middle East Report, 2004) and often in a manner that openly To provide culturally congruent care to Mustafa advocates the de facto criminalization of all and his family, the following recommendations are Arabs (Middle East Report, 2004). As a result, offered (Kulwicki and Ballout 2013; OMH 2013). Arab Muslims in the United States are one of the populations most at risk for being victims of verbal and physical assault, discrimination, and eth- 25.3.1 Individual-/Family-Level nic profiling. Interventions Saudi Arabia is consistently ranked among one of the richest countries in the world (Sharma • On admission, conduct a comprehensive cul- 2017), with a more sedentary lifestyle as one tural health assessment that includes cultural consequence. Diabetes, hypertension, hypercho- health beliefs and practices, preferred lan- lesterolemia, smoking, and obesity are among the guage, health literacy, faith-based needs, and leading health issues affecting Saudis. The preva- preferred communication and decision- lence of diabetes is 14.8% for males and 11.7% making practices. for females; for hypertension, it is 17.7% for • Offer Arabic language assistance services at males and 12.5% for females; and for hypercho- all points of care that ensure privacy and lesterolemia, it is 9.5% for males and 7.3% for confidentiality. females (IHME 2017). Despite the increased • Offer the services of an imam upon admission awareness of the hazards of smoking, smoking is and throughout the hospitalization. also increasing in the Arab community. Overall, • Recognize the potential stigma attached to 21.5% of men currently smoke, of which 20.9% Mustafa, as the eldest male, who can no lon- smoke shisha, an aromatic tobacco smoked using ger serve as key decision-maker for the a hookah, a stemmed device used for smoking family. tobacco. Obesity in the Arab community is also • Assign only male nursing staff to care for related to the cultural value equating overweight Mustafa, if possible, especially for intimate with prosperity, with almost half of women and procedures. 23% of men reported being physically inactive • If male nursing staff are not available, alter- (Daoud et al. 2015; IHME 2017). natives may include the following: (1) a The Arab Muslim community where Mustafa female nurse may provide care that does not resides illustrates the environmental and socio- involve physical contact such as administer- economic issues that contribute to the vulnera- ing medications or hourly rounding, (2) a bility of this population. Although Mustafa does male staff member such as a unit clerk or not live in poverty, he can understand basic patient care technician may accompany and health information; has access to healthcare ser- assist the female nurse in providing care that vices, insurance coverage, and healthy foods; includes physical contact, and (3) Mustafa and lives within a supportive family and social can arrange for a male private duty nurse or structure. However, he does live in a large metro- certified nursing assistant to assist with inti- politan area where pollution, crime, and discrim- mate care needs. 25 Case Study: Culturally Competent Healthcare Organizations for Arab Muslims 225

• Relax visiting hour restrictions to accommo- input from members of the respective commu- date the Arab Muslim need to visit the sick. nities. Leadership development workshops • Consider the right-handed preference when should emphasize the requisite knowledge providing care to Arab Muslims. and skills for leading interprofessional, multi- • Provide education to Mustafa and his family cultural teams. on stroke, obesity, hypertension, diabetes, • Evaluate cultural competence of all levels of hypercholesterolemia, and the hazards of a staff during, orientation, and periodically, at sedentary lifestyle provided by the National least annually, throughout the terms of Center on Health, Physical Activity, and employment. Provide remediation, as needed. Disability (NCHPAD, 2017). • Collect and maintain demographic data to • Provide privacy and support for Mustafa and monitor and evaluate the impact of culturally his family to complete daily prayer rituals. and linguistically appropriate services on • Maintain communication with the home health equity and outcomes and to inform ser- health agency to support a smooth transition vice delivery. from inpatient to home care upon discharge. • Partner with the community to design, imple- • Offer caregiver support and resources to the ment, and evaluate policies, practices, and ser- family to relieve caregiver burden and com- vices to ensure cultural and linguistic passion fatigue. appropriateness. • Include cultural and language competencies in the job descriptions and performance evalua- 25.3.2 Organizational-Level tions of into all levels of staff from frontline to Interventions executive. • Plan special events to increase awareness of • Create and sustain an organizational governance the customs, values, beliefs, and culture care and leadership infrastructure that promotes the needs of the dominate groups within the ser- provision of culturally and linguistically appro- vice area. Events should coincide with special priate healthcare services as evidenced by mis- days for each group such as Ramadan, Eid al- sion and vision statements, values, and strategic Fitr, and Eid al-Adha for Muslims, Cinco de plans, which support diversity and inclusion Mayo for people of Mexican descent, Black among its consumers, within the healthcare History Month, St. Patricks’ Day for people team, and for students and faculty. of Irish heritage, and Polish American • Integrate culturally and linguistically appropri- Heritage Day. ate goals; standard operating procedures, poli- • Review and revise policies and procedures cies, and practices; and management related to visiting and visiting hours, medica- accountability into the organization’s operation administration practices, religious ser- tional strategic plans, outcomes measurements, vices and practices, and language assistance and continuous quality improvement initiatives. services that reflect the needs of the demo- • Educate governance, leadership, and the graphics of the service area and the healthcare workforce in culturally and linguistically team. Human resource policies must also appropriate practices. Principles and practices include strategies that address culturally of cultural competence and language assis- related conflict management and resolution. tance services must be integrated into initial • Incorporate diversity and inclusion strategies orientation and ongoing education programs into the organization’s shared gover- for all levels of staff. Workshops that address nance infrastructure and interprofessional the culture care needs of the dominant cultural decision-making teams such as the ethics and linguistic populations within the service committee, patient education committee, and area should be offered on an ongoing basis. human resource practices that address con- The design of such programs should include flict management and resolution. 226 S. R. Marrone

• Ensure the initial and ongoing competence of implement services that respond to the diver- individuals providing language assistance ser- sity in the service area. vices that reflect the preferred languages of • Establish a partnership with the Arab American the population in the service area. Institute in order to support healthcare policy • Allocate resources to support a diverse gover- and program development for Arab Muslims nance, leadership, and workforce that reflect at the national level. the population in the service area. For example, • Partner with the Arab Muslim community to to meet the needs of Arab Muslims, partner organize health fairs to address lifestyle issues with the National Arab American Nurses that affect the Arab Muslim population. Association and the Association of Men in • Collaborate with the Arab Muslim community Nursing to recruit Arab, Muslim, Arabic- to develop programs and services that pro- speaking, and men into the nursing workforce. mote healthy lifestyles. • Establish an interprofessional Diversity and • Communicate the organization’s culturally Inclusion Council to address and monitor the and linguistically appropriate programs and delivery and outcomes of the provision of cul- services to key internal and external stake- turally competent care that includes members holders via print, visual, oral, and social who reflect the population of the service area: media. Arabs, Muslims, Irish, Polish, Maltese, Black/ African-American, Hispanic, and Native Conclusion American. Several cultural and social structural factors • Provide signage, printed, and multimedia influence Mustafa’s health and illness materials on common health conditions and experience. Mustafa has a primary school support services in the major languages of the education, a limited English proficiency, a population served, namely, Arabic, Spanish, sedentary lifestyle, and multiple comorbidi- Polish, and Maltese. ties that resulted in stroke. These limited his • Include items on patient satisfaction surveys ability to fully participate in his care, hin- to determine if the care provided was per- dered his being involved in the larger metro- ceived as culturally sensitive and in the politan community, and prevented him from patient’s preferred language. Include items on working and being fully engaged in family staff satisfaction surveys that address if the decision-making. The stigma associated with practice environment is inclusive. no longer being the key decision-maker for • Partner with local Arab Muslim community the family can potentially isolate Mustafa centers, mosques, hookah lounges, markets, from his family and the Arab Muslim com- businesses, and local, regional, and national munity. This stigma may also extend to his media to provide information in English and family as well. Arabic on the dangers of sedentary lifestyles. In aggregate, these factors create risks to • Ensure the 24/7 availability of an imam who Mustafa’s health and well-being. Culturally can advise and minister to the spiritual care competent care strategies should emphasize and dietary needs of Muslim patients, fami- holistic care related to managing Mustafa’s lies, and staff. medical condition as well as the cultural and social determinants of health and lifestyle issues. These can impact his condition, pre- 25.3.3 Community Societal-Level vent hazards of immobility, maximize his Interventions ability to contribute to the family decision- making, and access and use of organizational • Conduct regular assessments of the commu- and societal resources to minimize his margin- nity’s health outcomes and population-based alization from the Arab Muslim community social determinants of health to plan and and within his family. 25 Case Study: Culturally Competent Healthcare Organizations for Arab Muslims 227

References National Center on Health, Physical Activity and Disability [NCHPAD] (2017) Building Healthy Inclusive Communities through the National Center Arab American Institute [AAI] (2012) Arab American on Health, Physical Activity and Disability. Retrieved demographics. Retrieved from http://www.aaiusa.org/ from http://www.nchpad.org/403/2216/Sedentary~Lif demographics/ estyle~is~Dangerous~to~Your~Health Daoud N, Hayek S, Muhammad AS, Abu-Saad K, Osman National Stroke Association (2017) Stroke support A, Thrasher JF, Kalter-Leibovici O (2015) Stages of groups. Retrieved from http://www.stroke.org/stroke- change of the readiness to quit smoking among a ran- resources/stroke-support-groups dom sample of minority Arab-male smokers in Israel. Office of Minority Health [OMH] (2013) The national BMC Public Health. 15:672. https://doi.org/10.1186/ standards for culturally and linguistically appropri- s12889-015-1950-8 ate services in health and health care. Retrieved from Institute for Health Metrics and Evaluation [IHME] (2017) http://minorityhealth.hhs.gov/omh/browse.aspx?lvl= Saudi health interview survey finds high rates of chronic 2&lvlid=53 diseases in the Kingdom of Saudi Arabia. Retrieved Pew Research Center (2013) World’s Muslim population from http://www.healthdata.org/news-release/saudi- more widespread than you might think. Retrieved from health-interview-survey-finds-high-rates-chronic-dis- http://www.pewresearch.org/fact-tank/2013/06/07/ eases-kingdom-saudi-arabia worlds-muslim-population-more-widespread-than- Islam Questions and Answers (2017) Visiting the sick: you-might-think/ some etiquettes. Retrieved from https://islamqa.info/ Sharma R (2017) Top 10 richest Arab countries. Retrieved en/71968 from http://www.trendingtopmost.com/worlds-popu- Kulwicki AD, Ballout S (2013) People of Arab heri- lar-list-top-10/2017-2018-2019-2020-2021/travelling/ tage. In: Purnell LD (ed) Transcultural heath care: a richest-arab-countries-best-famous-beautiful-amaz- culturally competent approach, 4th edn. PA Davis, ing-wonderful/ Philadelphia, pp 159–177 Sperling (2017) Sperling’s best place. Dearborn, Michigan. McFarland MR, Wehbe-Alamah HB (2015) Leininger’s http://www.bestplaces.net/crime/city/michigan/dearborn culture care diversity and universality: a worldwide United States Census Bureau (2015) US and World nursing theory, 3rd edn. McGraw-Hill, New York Population Clock. Retrieved from https://www.census. Miller TAW, Feinberg DG (2002) Culture clash. Public gov/popclock/?intcmp=home_pop Perspective, March/April, pp 6–9 Case Study: A Lebanese Immigrant Family Copes with 26 a Terminal Diagnosis

Anahid Kulwicki

Samira, an 18-year-old female, has been com- parents, with the help of her uncle who has good plaining from extreme lethargy, loss of weight, English conversational skills, took her to the hos- and spiking temperature with unknown cause. pital for further evaluation. Samira’s parents do not have health insurance After a series of tests, the pediatrician at the as Mr. Habib, Samira’s father, who was a store medical center emergency department recom- owner in his home country, could not find a job in mended that Samira be admitted to the hospital the United States. The only employment he was for further evaluation as he suspected her life was able to secure was working as a dishwasher in a in danger. After 3 days of hospitalization and sev- local restaurant, which paid him minimum wage. eral tests, Samira was diagnosed with acute lym- He has no health insurance. Concerned about tak- phocytic leukemia (ALL). ing Samira to the doctor due to their financial The physician informed Mr. Khalil about condition, Samira’s parents were hoping that Samira’s diagnosis and asked that he explain to with the help of home remedies and some over- the parents, who did not speak English, about the-counter medications, Samira’s condition will Samira’s health status. Mr. Khalil was alarmed improve. with the news and did not have the courage to However, despite all their efforts, Samira’s inform his sister and brother-in-law about condition was getting worse. Finally, Samira’s Samira’s diagnosis. He thought if he told his sis- parents decided to borrow money from an uncle, ter and brother-in-law that Samira has cancer, the Mr. Khalil, and take Samira to a local pediatri- family will not be able to cope with the news as cian. After examining Samira and reviewing her in his culture cancer is believed to be terminal blood test results, the pediatrician asked the par- disease. Instead, he told his sister and brother-in- ents to take Samira to the nearby children’s hos- law that Samira had a severe infection and that pital emergency room for further tests. He she needs to stay in the hospital to be treated for suspected Samira’s condition was serious due to a little while longer. the very high white blood cell count. Samira’s After a week of hospitalization, Samira’s parents asked Mr. Khalil as to why their daughter was not getting better. Mr. Khalil informed Mr. Habib in private that Samira was diagnosed with “that disease.” Mr. Khalil explained that A. Kulwicki, Ph.D., R.N., FAAN according to Samira’s doctor, Samira may die School of Nursing, Byblos Campus, Lebanese American University, Byblos, Lebanon within 3 months due to the severity of her e-mail: [email protected] condition.

© Springer International Publishing AG, part of Springer Nature 2018 229 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_26 230 A. Kulwicki

Mr. Habib was very distraught about the know. Samira’s mother insisted that Samira not news. He asked Mr. Khalil not to tell his wife know about her disease. She explained that about Samira’s diagnosis for fear that she will Samira will be depressed, and lose hope and will not take the news well. Mr. Habib was very upset to live if she knew she had cancer. The nurse when he heard that Samira’s doctor was acting as informed the doctor about her conversation with God by indicating that Samira had 3 months to Samira’s mother. The doctor and the nurse both live. He insisted to find another doctor to treat decided to contact the social worker who is famil- his daughter because he did not trust a doctor iar with the Arab culture to help Samira and her who acted as God, hoping that another doctor family deal with her illness. The nurse was aware will be more compassionate and more optimistic that Samira belonged to the Muslim religion and about the condition of his daughter. Mr. Khalil contacted the imam to visit Samira’s family for tried to comfort Mr. Habib by stating that his spiritual support. In addition, the nurse, the phy- daughter was in the best medical center cared by sician, along with the social worker and the imam the best doctors and changing doctors will not met with the hospital ethics committee to discuss change the prognosis of his daughter. He the ethical considerations in caring for Samira explained to him that Samira’s mother should be and her family. informed. Mr. Habib insisted that neither Samira nor anyone in the family should know about Samira’s condition. He thought giving such bad 26.1 Cultural Issues news to his daughter and wife will probably kill them both from grief. He wanted Samira and his In the Arab culture, as in many other cultures, the wife to be hopeful that Samira’s condition will family is the fundamental unit in society. be better. He believed only God can determine Immediate and extended family members are when his daughter will die and that he should closely engaged in family matters especially help her and his wife to stay upbeat and not give when facing difficult situations (Kulwicki and up hope. Ballout 2013). Collective decision-making is the A week has gone by, and all tests results indi- norm rather than individuals making their own cated that Samira was not responding to the treat- decision as in the United States (Kulwicki and ment as her condition was much more advanced Ballout 2013). Although the family structure than what was initially thought by the medical among Arab immigrants is changing from that of team. Mr. Habib and Mr. Khalil finally decided to an extended family to nuclear family where deci- tell Mrs. Habib about Samira’s condition, while sions are jointly made by males and females in Samira was taken from her room for additional the family, patriarchal family structure continues tests. Mr. Habib explained to his wife that Samira to be common where males are primarily bread- had “that disease.” When Mrs. Habib heard the winners and females are the caregivers or nurtur- news, she started screaming and beating on her ers. Gender roles are clearly defined and regarded chest and asking for God’s help in curing Samira as complementary division of labor (Kulwicki from “that disease.” She blamed herself for bring- and Ballout 2013). Decisions are primarily made ing the problem on by putting her family through by men, and the responsibility for family mem- immigration as she heard that stress can cause bers’ well-being usually rests with men. Women “that disease.” and children are considered emotionally fragile Samira, who had limited English-speaking and are protected from emotional stress and skills, became more and more concerned as she spared from being informed about bad news, started losing her hair and feel weaker. She asked such as the diagnosis of a terminal disease or the nurse whether she would ever get out of the death. Although Muslims accept death as being hospital. The nurse was alarmed that Samira was inevitable, the timing of death is considered to be not informed about her condition and asked the will of God, and individuals are expected not Samira’s uncle to request the family let Samira to give up hope (Kulwicki 2011). In the health- 26 Case Study: A Lebanese Immigrant Family Copes with a Terminal Diagnosis 231 care context, family members collectively make American Institute 2010) than among many decisions about patient’s treatment (Kulwicki other immigrant groups, many new immigrants and Ballout 2013; Ahmad 2004). Spiritual sup- who come from lower socioeconomic back- port is readily accepted by Muslim patients and is grounds and war-torn countries may not have the considered desirable by most patients (Lawrence educational preparation, English language skills, and Rozmus 2001). Most Arab health-care pro- health literacy, and access to quality health-care viders and families do not consider disclosure of services. Consequently, their cultural beliefs, serious health conditions acceptable, especially norms, and practices may be substantially differ- in cases of terminal illness. Many believe that ent than those of the Americans, American such disclosure is unnecessary and inhumane to health-care providers, and even to some extent to the patients’ emotional well-being and withhold the more acculturated Arab American immi- such information out of concern for patient grants (Hassouneh and Kulwicki 2007). beneficence (Pentheny O’kelly et al. 2011). Such Although medical care is excellent in the bad news can only lead to patients’ depression major cities in Lebanon where Samira’s parents and facilitate death, as they may lose hope to live. were raised, access to medical care in the rural Opposing views regarding disclosure of a areas is difficult both financially and geographi- patient’s diagnosis and prognosis can cause con- cally. Health insurance is available for individu- flict between health-care providers and the fami- als who work for private and Lebanese lies of patients with terminal diseases in the Arab governmental agencies. Individuals who do not culture. In the United States, American health- have health insurance and are unable to pay for care values are based on the Patient Self- health care are cared for by the governmental Determination Act (1990) that protects individual health-care system. However, the process of eli- rights to be informed about their health condi- gibility for care may be difficult. Patients are tion, make informed decisions, and determine required to pay a portion of the cost. their treatment choices. Individualism is one of Patients who do not have the financial means the core values of the American culture, whereas usually wait until their health condition becomes collectivism is a core value of the Arab culture. In severe. In the case of cancer, most patients are in a culture where collectivism is the norm, the advanced stages of the disease when admitted to decision of disclosure of patient’s terminal illness the hospital. Hence, among the poor and illiterate rests with the family (Hassouneh and Kulwicki populations, the diagnosis of cancer is considered 2009). These differing views can create friction a terminal disease. Therefore, the mere use of the between health-care providers and patients and word cancer invokes fear in people. For this rea- their families. It is important that health-care pro- son, many avoid using the word cancer and viders understand cultural norms regarding dis- instead refer to it as “that disease” or “the bad closure of a patient’s illness to avoid undue stress disease” or use the phrase “God keep you away for the families and to the patients under their from that disease.” care. Culturally sensitive communication strate- In the culture where Samira’s parents came gies in informing their terminally ill patients and from, doctors often make decisions about treat- their families need to be developed and implement for a patient’s condition. Families and mented (Doumit and Abu-Saad 2008; Chittem patients depend on the doctor’s expertise and defer and Butow 2015). all treatment modalities to the physician (Kulwicki 2008a, b). Decisions about disclosure of illness are made by the family, and doctors often respect the 26.2 Social Structure Factors family’s decision and defer disclosure of a terminal illness to the family members. Although most Arab immigrants are successful For new immigrants in the United States, the in the United States and high educational attain- socioeconomic conditions of Arabs are similar to ment is more prevalent among Arabs (Arab those in their country of origin. Most do not have 232 A. Kulwicki health insurance due to unemployment or under- • Avoid generalizations as each patient is unique employment. There are several community agen- and some cultural norms, social structure, cies available in highly populated Arab immigrant gender differences, spiritual beliefs, and views communities where primary health care and about life and death may be different between social services are available, but in areas where individuals of the same culture. the number of Arab immigrants is few, accessing • Assess communication styles of the patient quality and culturally competent care may be a and their families. challenge. • Be informed that there may be intra-ethnic differences as Arabs come from different countries with different expectations from 26.3 Culturally Competent health-care system. Strategies Recommended • Be sensitive to areas of conflicts between the culture of the health-care provider and the cul- Arab immigrants like many other immigrants in ture of the patient and avoid them by a thor- the United States are considered a vulnerable pop- ough assessment. ulation due to their lack of economic resources, • Establish a trusting relationship with the experiences of war prior to immigration, lack of patient and their families through open health literacy, inability to speak English, and dif- communication. ference in cultural norms and religious beliefs • Make sure that a social worker who speaks the between the American mainstream culture and language of the patient and understands the Arab culture that create barriers in health-care uti- culture is available when needed. lization (Kulwicki et al. 2010). It is important that • Assess the spiritual needs of the patient health-care professionals understand the culture and their families and ask if they would like and develop appropriate interventions to avoid the help of a spiritual leader at times of further disparities in access and quality of health need. care for this population (Kulwicki et al. 2000). • Assess patient’s norms, rituals, beliefs, and Because Arab Americans come from 22 different practices about death and dying. countries with diverse socioeconomic, cultural, • Assess the patient’s family structure. Ask who religious, and health-care experiences, it is impor- makes decisions for the family. tant that the health-care providers be sensitive to • Assess patients and patient’s family experi- intra-ethnic differences while planning and imple- ences and expectations from the health-care menting culturally competent services for Arab providers. American immigrants in the United States. • Make sure an interpreter is available when Health-care providers are urged to consider the needed. following recommendations when caring for Arab • Provide audiovisual materials in the language American patients: of the patient if available and if the patient does not speak English or is illiterate in their own language. 26.3.1 Individual-Level Interventions • Provide written materials that may familiarize patients and the family members to better • Complete a thorough assessment of the cul- understand the rules and policies of the health- tural norms, social structure, educational care system. preparation, and spiritual beliefs of each • Provide written materials about the resources patient and their families. that are available to them, and make sure that • Assess the family structure and gender role the patient and family are aware how to access differences. those services. • Assess patients and their families’ preferences • Assess issues surrounding confidentiality. in the decision-making process related to care. Some patients or patient’s families may not 26 Case Study: A Lebanese Immigrant Family Copes with a Terminal Diagnosis 233

want to discuss their health conditions with 26.3.3 Community- and Societal- individuals from their own culture for fear that Level Interventions information may be shared with community members. • Establish a collaborative relationship with • Make sure that patients and their families Arab community health centers if available. understand that everything they say is held • Plan, develop, and implement community confidential and is not shared with anyone health fairs in partnership with community except with individuals caring for them. leaders. • Provide educational materials to the patient • Provide online or include health information regarding the diagnosis of the patient after resources on hospital website. making sure that the family members are com- • Have hospital representative on health advi- fortable with the information shared. sory committees or coalitions serving Arab • Check with patient and their families to make American population. sure they understand the information given to • Include community leadership on the advisory them or if they have questions. board of the hospital. • Provide consistent culturally tailored health promotion materials to the communities with a 26.3.2 Organizational-Level large number of Arab American immigrants. Interventions • Employ community members in the hospitals and/or health-care centers. • Partner with community service organizations that provide health care to the Arab immigrants. If none exists in the immediate geo- Conclusion graphic vicinity, partner with national It is important for health-care providers to be organization(s). aware that culture is dynamic and that cultural • Partner with American Arab Nurses norms and beliefs continuously change and Association and Arab American Medical evolve as the context in which cultural groups Association to access community health pro- live, work, and age. What may be true in a fessionals when needed. given cultural group 10 years ago may not be • Develop a resource guide for services that can applicable in the current situation. It is there- be shared with the patients. fore imperative that health-care providers con- • Develop audiovisual materials or use library tinuously learn the social determinants of resources in obtaining materials for patients health and its impact on a given population. A who do not read in English and Arabic recent study regarding truth telling or disclo- languages. sure of cancer diagnosis indicated that a • Conduct training programs for health majority of the surveyed population preferred professions. that such information be shared with the • Include Arab community leaders on the hospi- patient directly rather than having family tal advisory board. members make that decision (Farhat et al. • Provide a certified interpreter. 2015). This was attributed to the availability • Establish a list of Arab health professionals of public awareness about cancer. Changes within the hospital and within the community were also reported in the attitudes and prac- for referral. tices of physician in truth telling and disclo- • Include an Arab American cultural expert on sure. The study pointed out that younger or the hospital ethics committee. recent graduates were more open to disclosing • Employ Arab American health-care providers the diagnosis to the patient compared to the such as nurses, doctors, receptionists, and older physicians (Naji et al. 2015). Similar social workers from the communities served. changes have been reported in the literature 234 A. Kulwicki

where individuals are more aware of their tion of the patient’s backgrounds, and the abil- health and health-care services than previous ity of health-care providers to address the generations due to greater efforts made in edu- disclosure in a culturally skilled manner. By cating the public. doing so, the quality of the health-care services Organizational and community level efforts for ethnically vulnerable populations can be in educating vulnerable populations about improved, and disparities in health status and cancer, signs and symptoms, treatment modal- access to care can be significantly reduced. ities, and cancer survival rate can help dispel myths about the deadliness of the disease and promote early detection and treatment. In addition, organizational and public education References efforts in care of terminally ill patients, implications of disclosure, and truth telling can Ahmad NM (2004) Arab-American culture and health care. http://www.case.edu/med/epidbio/mphp439/ assist patients and families to better cope with Arab-Americans.html. Accessed 15 Jan 2007 terminal illness and facilitate quality of life for Arab American Institute (2010) Demographics. http:// cancer patients. www.aaiusa.org/arab-americans/22/demographics. It is important that health-care profession- Accessed 15 Nov 2010 Bou Khalil R (2013) Attitudes, beliefs and perceptions als develop expertise in preparing educa- regarding truth disclosure of cancer-related informa- tional materials that are tailored to the tion in the Middle East: a review. Palliat Support Care cultural, linguistic, and literacy levels of the 11(1):69–78 populations they serve using a variety of edu- Chittem M, Butow P (2015) Responding to family requests for nondisclosure. The impact of the cational approaches such as written, oral, oncologist’ cultural background. J Can Res Ther 11: digital, or audiovisual materials that can 174–180 serve the needs of a diverse population. Doumit MA, Abu-Saad HH (2008) Lebanese cancer Promoting health literacy in immigrant popu- patients: communication and truth-telling preferences. Contemp Nurse 28:74–82 lations is imperative to avoid conflict between Farhat F, Othman A, El Baba G, Kattan J (2015) health-care providers and patients from cul- Revealing a cancer diagnosis to patients: attitudes of tures other than their own. patients, families, friends, nurses, and physicians in Research indicates that disclosure and truth Lebanon-results of a cross sectional study. Curr Oncol 22(4):e264–e272 telling is becoming more common in the Arab Hassouneh DM, Kulwicki A (2007) Mental health, dis- world than decades ago. However, it is essen- crimination, and trauma in Arab Muslim women liv- tial that health-care providers understand that ing in the US: a pilot study. Ment Health Relig Cul in some cultures, disclosure of illness may 10(3):257–262 Hassouneh P, Kulwicki A (2009) Family privacy as pro- still be controversial (Bou Khalil 2013) and tection village: a qualitative pilot study of mental ill- that health-care professionals must take into ness in Arab-American Muslim women. In: Piedmont consideration the social determinants of health R, Village A (eds) Research in the social scientific of their patients before they make decisions study of religion. Brill, Boston, pp 195–216 Kulwicki A (2008a) Culture and ethnicity. In: Potter that may be detrimental to their patients’ well- P, Perry A (eds) Fundamentals in nursing, 7th edn. being. In the case of Samira, it was important CV. Mosby, St. Louis, pp 106–120 that the health-care professionals assess the Kulwicki A (2008b) Patient education. In: Nasir LS, social structure of the patient, understand the Abdul-Haq AK (eds) Caring for Arab patients: a bio- psychosocial approach. Radcliffe Publishing, Oxford, family dynamics, and consider their socio- pp 235–246 economic conditions, their health beliefs, Kulwicki A (2011) Islam’s influence on health in the fam- perceptions, and experiences before they ily. In: Craft-Rosenberg M, Pehler S (eds) Encyclopedia impose American health-care values on their of family health. Sage, Thousand Oaks, pp 676–678. https://doi.org/10.4135/9781412994071.n225 patients. Truth telling and disclosure of termi- Kulwicki A, Ballout S (2013) People of Arab heritage. In: nal illness can be accomplished if there is open Purnell L, Paulanka B (eds) Transcultural health care, communication, understanding and apprecia- 3rd edn. F. A. Davis, Philadelphia 26 Case Study: A Lebanese Immigrant Family Copes with a Terminal Diagnosis 235

Kulwicki A, Miller J, Schim S (2000) Collaborative part- Lawrence P, Rozmus C (2001) Culturally sensitive care nership for culture care: Enhancing health services for of the Muslim patient. J Transcult Nurs 12:228–233 the Arab community. J Transcult Nurs 11(1):31–39 Naji F, Hamadeh G, Hlais S, Adib S (2015) Truth disclosure Kulwicki A, Aswad B, Carmona T, Ballout S (2010) to cancer patients: shifting attitudes and practices of Barriers in the utilization of domestic violence Lebanese physicians. AJOB Empir Bioeth 6(3):41–49 services among Arab immigrant women: perceptions Pentheny O’kelly C, Urch C, Brown E (2011) The impact of professionals, service providers & community of culture and religion on truth telling at end of life. leaders. J Fam Viol 25(8):727–735 Nephrol Dial Transplant 26(12):3838–3842 Part VII Guideline: Patient Advocacy and Empowerment Advocacy and Empowerment of Individuals, Families and 27 Communities

Dula Pacquiao

Guideline: Nurses shall recognize the effect of healthcare policies, delivery systems, and resources on their patient populations and shall empower and advocate for their patients as indicated. Nurses shall advocate for the inclusion of their patient’s cultural beliefs and practices in all dimensions of their healthcare when possible. Douglas et al. (2014: 113)

27.1 Introduction Eleanor Roosevelt, who chaired the UN Commission that drafted the document, empha- In 1948, the UN General Assembly proclaimed sized the ubiquity of the need for human rights the Universal Declaration of Human Rights protection in all places, such as home, school, (UDHR) in order to achieve peace in the world. work, and neighborhood, “such are the places Human rights are deemed as fundamental, uni- where every man, woman, and child seeks equal versal, and inalienable rights of all people that justice, equal opportunity, and equal dignity need to be protected. UDHR upholds the inherent without discrimination. Unless these rights have equality in dignity and rights of all human beings meaning there, they have little meaning any- (Article 1) and protection from discrimination where.” She underscored the responsibility of based on ascribed and acquired statuses (Article everyone for protecting these rights, “without 2). The right to security, economic, and social concerted citizen action to uphold them close to and cultural rights are considered indispensable home, we shall look in vain for progress in the for development of human potential (Article 22). larger world” (Roosevelt 1958). Article 25 proclaims the rights of individuals and their families to a standard of living adequate for health and well-being (e.g., food, clothing, hous- 27.2 Need for Advocacy ing, medical care, and necessary social services) and security in the event of unemployment, sick- UDHR was the impetus for advocacy embodied ness, disability, widowhood, old age, or other cir- in the definition of nursing and its code of eth- cumstances beyond their control. Other articles ics. The fundamental responsibilities of nursing have implications in the provision of care such as to promote and optimize health, prevent illness the right to privacy, education, and freedom of and injury, and alleviate suffering are prescribed movement (UNHRC 1948). by the International Council of Nurses (ICN 2012) and the American Nurses Association (ANA 2010). The Preamble to ICN’s Code of Ethics for Nurses states, “Inherent in nursing is a D. Pacquiao, Ed.D., R.N., C.T.N-.A., T.N.S. respect for human rights, including cultural School of Nursing, Rutgers University, Newark, NJ, USA rights, the right to life and choice, to dignity and School of Nursing, University of Hawaii, Hilo, to be treated with respect [regardless] of age, Hilo, HI, USA colour, creed, culture, disability or illness, gender,

© Springer International Publishing AG, part of Springer Nature 2018 239 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_27 240 D. Pacquiao sexual orientation, nationality, politics, race or port a cause or position (Oxford Dictionary social status” (ICN 2012: 2). It sets the obliga- 2017). Central to advocacy is the concept of vul- tion for nurses to advocate for equity and social nerability or circumstances threatening a per- justice in resource allocation, access to health- son’s autonomy. Vulnerability can exist in an care, and other social and economic services individual, families, communities, and popula- (ICN 2012). The American Nurses Association tions. Although the role of patient advocate is Code of Ethics ( 2015) stipulates that the nurse often ascribed to helping professions such as promotes, advocates for, and strives to protect nursing and social work involved in caring for the the health, safety, and rights of the patient sick and vulnerable individuals, patient advocacy (Proposition 3) (Winland-Brown et al. 2015). also includes the work of policymakers, legal The need for advocacy is inherent in humans professionals, and activists to improve healthcare as social beings whose identities, shared mean- for people marginalized by socially stigmatizing ings, and life experiences are shaped by the illnesses (Gilkey and Earp 2009). social arrangements of power and statuses (Rose 1990). Advocacy is needed as one’s ability to 27.2.1.1 Patient and Health Advocacy compete, negotiate, and secure one’s “place” in In nursing, patient advocacy can be on behalf of society is differentially structured by the social an individual, family, community, group, or pop- structural conditions. A particular individual’s or ulation (ICN 2012; Winland-Brown et al. 2015). group’s “place” within the social order is pat- Patient advocacy has evolved toward health terned by factors such as race, gender, ethnicity, advocacy to protect people who are vulnerable or and socioeconomic status. These factors impact discriminated against and empower those who growth, development, and life chances not only need a stronger voice by enabling them to express of the present but also of future generations. their needs and make their own decisions (Carlisle Hence, one’s “place” in society determines the 2000). According to the World Health degree of exposure to risks and social privileges Organization (1995), advocacy for health is a one can enjoy. combination of individual and social actions to There is ample evidence of health inequities gain political commitment, policy support, social attributed to social inequalities that create cumu- acceptance, and systems support for a particular lative disadvantages in populations within local, health goal or program. Such action may be taken national, and global contexts (see Chap. 1). on behalf of individuals and groups to create life Causes and effects of social inequalities in health conditions conducive to health and the achieve- maybe located mainly in the social structure and ment of healthy lifestyles (Nutbeam 1998). the environment or within the individual, but Health promotion may be carried out without the both are closely linked with each other. intended recipient or recipients asking for it Individualistic explanations of health inequalities (Seedhouse 2004). in terms of unhealthy lifestyles and choices con- Health advocacy encompasses direct service tinue to exist, but there is increasing evidence on to the individual or family as well as activities the harmful impact on health of poverty, depriva- that promote health and access to healthcare in tion, and social exclusion at both individual and communities and the larger public. Advocates population levels (Wilkinson 1996; Davey Smith support and promote the rights of the patient in et al. 1999). healthcare, help build capacity to improve community health, and enhance health policy initiatives focused on available, safe, and quality care. 27.2.1 Definitions of Advocacy Health advocates are best suited to address the challenge of patient-centered care in our complex Advocacy is a process of acting for or on behalf healthcare system. Today, advocates for the of others who are unable to do so for themselves well-being of populations are needed. Health (Bennett 1999). To advocate is to plead or sup- advocates are found working in a wide range of 27 Advocacy and Empowerment of Individuals, Families and Communities 241 agencies and sectors striving to improve health of the vulnerable (Gilligan 2008; Noddings 1984). entire populations, defined communities or Tronto (2012) identifies the four elements of ethi- groups, and single individuals. cal care as attentiveness, responsibility, compe- According to Rees (1991), health advocacy tence, and responsiveness. Advocacy is built on a aims for protection of the vulnerable (repre- caring interpersonal relationship and a sense of sentational advocacy) and empowerment of obligation to care for others. It requires careful the disadvantaged (facilitational advocacy). attention to the power relationships that influence Representational advocacy can take place at the the individual’s well-being and affirmation of the level of both cases and causes. Case advocacy responsiveness of care by the individual. Since encompasses activities to represent the under- the time of Florence Nightingale, the nursing privileged, disadvantaged, or sick to promote profession has maintained its advocacy for pro- their rights or redress power imbalances. Cause viding a safe and caring environment that pro- advocacy addresses the structural determinants motes the patient’s health and well-being of health inequities and barriers to health (Selanders and Crane 2012). beyond the control of individuals. Facilitational Advocacy is also founded on the principle of advocacy promotes community participation justice and fairness by ensuring that each person and development as well as empowerment of is given his or her due. Justice and fairness are disadvantaged individuals or groups to repre- closely related and often used interchangeably. sent themselves and lobby for their own health Individuals should be treated the same, unless needs (Rees 1991). Health advocacy may they differ in ways that are relevant to the situa- include challenging powerful anti-health inter- tion in which they are involved (Velasquez et al. ests such as the tobacco lobby; acting as a chan- 1990). According to John Rawls (1971), the sta- nel for mediating and negotiating between bility of a society depends upon the extent to opposing forces in the interests of positive which the members feel that they are being treated health; and forming coalitions to develop a justly. Lack of fairness and unequal treatment common agenda and find mutually achievable have led to social unrest, disturbances, and strife. goals. Social justice is the fair and just relation between the individual and society. The princi- 27.2.1.2 Ethical and Moral ples of social justice provide a way of assigning Foundation of Advocacy rights and duties in the basic institutions of soci- As discussed earlier, UDHR was influential in ety and define the appropriate distribution of ben- creating the movement for advocacy across disci- efits and burdens of social cooperation (Rawls plines and institutions. Rights-based care stems 1971). Social justice is measured by the distribu- from the tenets of human rights emphasizing tion of wealth, opportunities, and social privi- health as a basic right and access to quality and leges as well as risks and disadvantages. The safe healthcare services. Healthcare providers are current global trend in social justice emphasizes obligated to promote patient autonomy and the breaking barriers to social mobility, creating right to make informed choices (Entwistle et al. safety nets, and economic and environmental jus- 2010). Advocacy has its roots in the ethics of care tice. The movement from patient advocacy to emphasizing interpersonal relationships and care health advocacy reflects the growing recognition or benevolence as central to moral action. that health equity is achieved through social Developed by feminists, this ethical theory also structural changes and social justice to amelio- known as care-focused feminism is based on the rate the causes of cumulative disadvantages and assumptions that persons have varying degrees of vulnerability. dependence and interdependence on one another; Presumably the outcome of advocacy is benef- the vulnerable deserve extra consideration based icence as it seeks remedies or solutions to pro- on their vulnerability; and the need to examine mote health and well-being. However, Gadow the situational contexts to safeguard and protect (1989) argues for the difference between 242 D. Pacquiao

beneficence and advocacy. While both seem to the caring process should not only aim to prevent establish their goal of promoting the patient’s harm (non-maleficence) but more importantly best interest, the practice of beneficence assumes transform life conditions to benefit the care recip- that the professional knows with a greater accu- ient (beneficence). The latter is only possible racy and certainty what is in the patient’s best when patients and populations are actively interest. It is assumed that patients’ subjective engaged in the process, allowing their own ability to define their own good is replaced by the thoughts, emotions, and experiences to be fully professional’s objective view. While in certain integrated in the process and outcome of care. situations, some patients might prefer to trust the nurse to provide the most appropriate care when they feel unable to make informed decisions and 27.3 Evolution of Empowerment feel empowered by trusting the care providers. But patients’ autonomy may be threatened when The concept of empowerment is associated with they are unable or prevented from expressing the work of the Brazilian philosopher and educa- their subjective views. There are concerns with tor, Paulo Freire who advocated for emancipa- advocates who assume a paternalistic role in con- tory education to liberate the peasants from the structing people as uninformed, ill-educated, and shackles of poverty and oppression (Shor and in need of the services of interventionists who Freire 1987). He viewed education as instrumen- know better (Carlisle 2000). tal in transforming individuals and society. The risk of fostering dependency, alienation, Freire proposed critical pedagogy as the process and decreased autonomy among those advocated that allows active participation of learners in for is more likely to occur when the advocate uncovering social inequalities and how these assumes that decisions are for the patient’s good impact their lives. The development of critical without a full opportunity for a genuine relation- consciousness (concientization) through educa- ship to develop that can foster mutuality and reci- tion enables individuals to identify, examine, procity of perspectives and goals. A paternalistic and act on the root causes of their oppression stance is tantamount to cultural imposition or (Carroll and Minkler 2000). The role of the imperialism. Cultural imperialism is the practice of teacher is to engage students in active dialogue promoting and imposing a culture, usually that of a in order to question existing norms and power politically powerful nation over a less powerful structure and critically examine how they create society, or by a dominant individual or group over oppression. In participatory education students others and subcultures (Lechner and Boli 2012). are not objects or passive recipients of knowl- According to Leininger (1996) cultural imposition edge from authorities but rather as authors and in patient care occurs when the values of the care creators of knowledge. This state of critical con- provider are forced onto patients and their families. sciousness allows students to engage in active Cultural hegemony objectifies and disregards the dialogue and participate in identifying problems subjective experiences of patients by medical pro- and innovative solutions to change oppressive fessionals such as with vulnerable patients suffer- circumstances. The role of the teacher is not a ing from mental illness (Foucault 1980). giver of facts to be memorized by students but The paternalistic attitude of healthcare work- rather as a facilitator for awakening students’ ers may exist because of limitations imposed by consciousness and enable them to critically the setting and work constraints, and, thus, solu- examine facts in light of their own experiences tions are chosen for expedience and conflict and observations. Critical consciousness is pre- avoidance. Power differences secondary to age, requisite to praxis or practices that can transform knowledge, and socioeconomic and cultural their lives and society. Individual empowerment differences between the advocate and the patient can only flourish when one’s feelings of libera- can hinder development of trust and meaningful tion is shared by others in society. Freire empha- interactions (Murgic et al. 2015). Feminist theory sized the need for individual and community and relational ethics emphasize that the nature of empowerment (Carroll and Minkler 2000). 27 Advocacy and Empowerment of Individuals, Families and Communities 243

Empowerment in health has been given impe- being. There is greater likelihood for sustainable tus by the Ottawa Charter for Health Promotion outcomes through empowerment because it (WHO 1986). Health promotion is defined as the builds individual and community capacity for process of enabling people to increase their con- health achievement. According to Rappaport trol over and to improve their health. Health is (1984), empowerment links individual strengths viewed as a resource for everyday life emphasiz- and competencies, support systems, and proac- ing social and personal resources, as well as tive behaviors to social policy and social change. physical capacities. To reach a state of complete physical and social well-being, an individual or group must be able to identify and realize their 27.3.1 Types of Empowerment aspirations, satisfy their needs, and change or cope with their environment. 27.3.1.1 Patient Empowerment The Ottawa Charter (WHO 1986) identified Patient empowerment is a process in which the three major strategies for health promotion: patients understand their role and are given the (1) advocacy for resources favorable to health knowledge and skills by their healthcare provider including political, economic, social, cultural, to perform a task in an environment that recog- and environmental resources as well as behav- nizes community and cultural differences and ioral and biological changes; (2) enablement or encourages patient participation (WHO 2009). empowerment of individuals and groups to con- Patient empowerment puts the patient in the heart trol the determinants that affect their health in of services. It is about designing and delivering order to reach the highest attainable quality of health and social care services in a way that is life; and (3) mediation through multisectoral and inclusive and enables citizens to take control of multilevel collaboration by all sectors of govern- their healthcare needs (European Network on ment, organizations, and communities. In other Patient Empowerment/ENOPE 2014). Patient words, empowerment is the process through empowerment is a process designed to facilitate which an individual or people gain greater con- self-directed behavior change (Anderson and trol over decisions and actions affecting their Funnell 2010). health; it is both an individual and a community Kaldoudi and Makris (2015) describe patient process (WHO 2009). empowerment as a cognitive process with three Seedhouse (2004) differentiates medical from levels. At the first level, patients need to develop social health promotion. Medical health promo- awareness of their health status, health-related tion seeks to prevent or ameliorate disease, ill- risks, and measures to stay healthy and prevent ness, and injury based on scientific evidence. By illness. The second level is the stage of active contrast, social health promotion seeks to change participation characterized by active engagement the world and challenge the injustices that cause in the healthcare process, seeking feedback, man- ill-health by improving the lives of the least well- aging illness and comorbidities, and accessing off members of society. Seedhouse recommends appropriate resources. At the third level, patients using a variety of approaches as well as flexibility are able to control their health by collaborating in in using different strategies to promote health. decision-making with healthcare providers, Unlike advocacy that tends to be more aligned participating in shared decision-making, and with the health provider or advocate, empower- reframing mind-sets to adapt to new situations. ment is more oriented toward the patient’s point There are four components fundamental to the of view (WHO 2009), thus more patient-centered. process of patient empowerment: (1) understand- Empowerment is both a process and an outcome; ing by patients of their role, (2) acquisition by it is considered an outcome of advocacy. Since patients of sufficient knowledge to be able to empowerment involves active engagement and engage with their healthcare provider, (3) acqui- participation by individuals and communities, sition of relevant skills such as managing illness, they achieve greater autonomy, capacity, and and (4) presence of a facilitating environment self-efficacy in improving their health and well- (WHO 2009). 244 D. Pacquiao

27.3.1.2 Community Empowerment programs, decision-making infrastructure, and Wallerstein and Bernstein (1994) prefer commu- potential resources and partners. Advocacy nity empowerment because it is a social action requires a set of skills including problem- process by which interactions occur in the social solving, communication, influencing, and col- context of human relationships at home, commu- laboration needed to successfully support a nities, and institutions. Community empower- cause or interest on one’s own behalf or that of ment is both a process and an outcome in which another (Tomajan 2012). individuals and groups act to gain mastery over Existing power differences can impair open their lives in the context of changing their social dialogue and individual expression. Power dif- and political environment. Institutions and com- ferences may exist among family members, munities become transformed as people who between patients and health workers, between participate in changing them become trans- genders, and among community members. formed. Rather than putting individuals against Health workers should be aware of their own community and overall societal needs, commu- social status and influence on the social hierar- nity empowerment focuses on both individual chy of the group. Culturally appropriate media- and community change. Community empower- tion and negotiation should be applied to create ment is a basis for healthcare reform as individu- a more equitable distribution of power and allow als are connected and engage with others in the the vulnerable to be heard. Coalitions among community to identify common problems, goals, groups seeking similar remedies may be formed and strategies for personal and social capacity to counterbalance more powerful individuals building to transform their lives (Wallerstein and and groups. Bernstein 1994). The Ottawa Charter for Health Sustaining long-term commitment and Promotion (WHO 1986) recognizes the signifi- engagement of participants is problematic as cance of patient and community empowerment social problems are not likely to have immediate in transforming health of individuals and solutions. Developing mutual trust, consensus, populations. and commitment among diverse individuals and groups takes time. The leadership role of facilitators and advocates is important in developing 27.3.2 Challenges in Advocacy realistic goals that can be implemented, keeping and Empowerment participants on track, and maintaining communication and interest in the project. Adequate There are issues and challenges in community resources are needed to support group participa- empowerment. Individual autonomy maybe tion and engagement over time. threatened when efforts are focused on what benefits the group or community. In mixed groups, less powerful individuals may have less 27.3.3 Studies on Patient autonomy than dominant groups. Different per- Empowerment spectives must be represented, and individuals should be allowed to fully express their opinions Studies on patient empowerment use a variety of during interactions. Health workers should pro- related terms such as patient engagement, self- mote open dialogue and foster mutual trust and management, activation, participation, confidence, reciprocity among participants. Individual and shared decision-making. Several studies have contributions should be recognized along with noted the lack of consensus on the concept of the group’s accomplishments. empowerment and how it is operationalized Health workers may not be prepared for effec- (McAllister et al. 2012). Although a number of tive advocacy and empowerment that requires guiding principles and values of empowerment training and expertise. Advocates should have exist, there is no well-articulated theory of empow- knowledge of the community, history of the erment (Aujoulat et al. 2006). Empowerment stud- problem and the people, relevant policies and ies are difficult to compare because of the ambiguity 27 Advocacy and Empowerment of Individuals, Families and Communities 245 in the outcomes being measured which also limits 2004; Muenchberger and Kendall 2010). Patients the development of valid and reliable instruments with chronic illness who have greater capacity for (Barr et al. 2015; Salmon and Hall 2004). However, self-care are more likely to adhere to the therapeu- there is substantial evidence to support the develop- tic regimen, maintain healthy behaviors, monitor ment of core constructs and strategies of empower- their symptoms, make self-care decisions, manage ment (Coulter and Ellins 2007). Studies have also their emotions, and improve their communication shown that it is both a process and an outcome with with their healthcare provider (Inglis et al. 2010; a range of possible outcomes to be a viable public Peytremann-Bridevaux et al. 2015). Studies of health strategy (Wallerstein 2006). patient empowerment to improve chronic disease care management in general practice and primary 27.3.3.1 Patient Empowerment care have revealed increased satisfaction of both Process and Outcomes patients and professionals, greater adherence to Several studies revealed that increased patient treatment guidelines, and improved clinical out- participation in the health process was associated comes (Collins and Rochfort 2016; Mola 2013). with patients’ favorable judgments about the hos- Self-care interventions for long-term conditions pital and the quality of care they received. Patient improve mental health, care provider-patient com- participation was associated with reduced risk of munication, healthy eating, and patient self-effi- adverse events among patients (Weingart et al. cacy (Lorig et al. 2009). 2011). Significant changes in the provision of care across different care settings were attributed 27.3.3.2 Barriers and Facilitators to increased participation (Crawford et al. 2002). of Patient Empowerment Nygardh et al. (2012) found that shared decision- Patient participation is codetermined by the patient making between providers and patients improved and the healthcare provider and occurs only healthcare quality and patient satisfaction. through reciprocal dialogue and shared decision- When patients are given good-quality decision making (Thompson 2006). Patient-provider com- aids, they are more informed and participate more munication characterized by open communication in decision-making (O’Connor et al. 2009). Patient and collaborative treatment goal setting signifi- education programs teaching self-management cantly improves patient engagement (Hearld and skills are more effective in improving Alexander 2012). Provider-related factors that clinical outcomes than giving only information affect patient participation include patient-pro- (Bodenheimer et al. 2002). When patients gain vider relationship, recognition of patients’ knowl- knowledge about their health, they gain more con- edge, and allocation of sufficient time for fidence (Ludman et al. 2013), become more moti- interaction with the patient. Patient-related factors vated and self-determined, and communicate include level of knowledge, physical and cognitive more freely their health concerns and preferences ability, emotional connections with provider, and with their providers (Chen et al. 2014). Improving differences in beliefs, values, and experiences with patient health literacy and engagement enables healthcare (Vahdat et al. 2014). them to select treatments, manage chronic condi- Henderson (2003) found unwillingness by tions, increase drug safety and infection control, nurses to delegate power and control to their enhance utilization of health services, and patients. Control can be exerted by asking closed- improve health outcomes (Coulter and Ellins ended questions, limiting depth of information 2007). The use of prompts and reminders to per- shared, fostering patient uncertainty, using form specific tasks related to care is associated authoritative and condescending language, or with significant improvement in illness control by being untruthful (Johnson et al. 2007). Nurses in patients (Weingarten et al. 2002). an Iranian hospital identified the following barri- Effective self-management skills can improve ers to patient advocacy: their subordinate status in patient self-efficacy and reduce healthcare costs the organizational and social hierarchy resulting (Wallerstein 2006) because of fewer outpatient in feelings of powerlessness, lack of support from visits and hospital admissions (Holman and Lorig administrators and physicians, laws, code of ethics, 246 D. Pacquiao limited communication, insufficient time, and Latinos and African Americans report worse risks associated with advocacy (Negarandeh et al. patient-provider relationships and communica- 2006). Physicians’ reluctance to encourage patient tion and are less likely to initiate health behav- participation may be due to fear of losing power iors and adhere to treatment than Whites (Wang and control or losing their identity (Ford et al. et al. 2003). Minority patients are less likely to 2002; O’Flynn and Britten 2006). Primary care have opportunities to ask questions during pro- physicians tend to allow more patient participa- vider visits, receive less information on their tion than other specialists (Bettes et al. 2007). treatments, and are less likely to be consulted A significant factor in improving patient out- for their preferences in treatment decisions comes is maximizing patient self-management. (Link and Phelan 1995). Compared to Whites, Other factors include increasing clinician’s African Americans have significantly smaller expertise and skill in educating and supporting social networks (Shaw and Krause 2001). Many patients, team-based care delivery, and effective racial and ethnic minorities reside in neighbor- use of technology (Renders et al. 2001). Health hoods with limited social and public services professional training in empowerment is associ- and facilities with high prevalence of violence ated with better acceptance, implementation, and and poverty. Residents suffer from chronic effectiveness of patient self-management pro- stress of everyday life that impacts their level of grams (Lawn and Schoo 2010). motivation and belief in achieving a healthy life (Williams et al. 2012). Racial and language con- 27.3.3.3 Empowerment of Racially/ cordance can promote trusting relationship Ethnically Diverse Patients between patients and providers (Vargas- Patient engagement levels differ by race and eth- Bustamante and Chen 2011). Culturally tailored nicity. African Americans and Latinos have lower community-based patient education (Alegría level of engagement than Whites (Cunningham et al. 2009) and programs reducing language et al. 2011) which impact engagement in well- barriers can effectively engage minorities in ness and prevention (IOM 2002). Compared to their care (Flores 2006). Whites, racial and ethnic minorities assume a relatively passive role in healthcare and are less willing to participate in care decisions (Sandman 27.3.4 Studies on Community et al. 2012). Empowerment Racial and ethnic minorities are more likely to experience stress from unemployment, pov- Wallerstein (2006) cites outcomes of global ini- erty, limited healthcare access, or single parent- tiatives of WHO on empowerment in some coun- hood (Macartney et al. 2013). Latinos’ lower tries in Latin America, Africa, and Asia. Youth activation and empowerment may reflect their empowerment has strengthened self and collec- limited access to healthcare (Cunningham et al. tive efficacy and improved mental health and 2011) and type of health insurance (Hibbard school performance. In addition, there is stronger et al. 2008). Out-of-pocket cost sharing with group bonding, formation of suitable youth health insurance can influence a patient’s will- groups, and increased youth participation in ingness to seek treatment and adhere to the plan structured activities for social action and policy of care (Carman et al. 2013; Korda and Eldridge changes. Empowerment of HIV/AIDS-affected 2012). In addition to adequate insurance cover- populations has addressed disease prevention and age (Vargas-Bustamante and Chen 2011), the improved capacity of women and their families feeling of being valued in the interaction (James to manage the illness. Women empowerment has 2013) can increase patients’ confidence and created movement toward gender equality and empowerment (Cunningham et al. 2011). initiatives integrating economic, educational, and 27 Advocacy and Empowerment of Individuals, Families and Communities 247 political empowerment for environmental and tural taboos, etc. Externalization allows the dis- policy changes. covery of the root cause of the problem outside of Souliotis et al. (2016) examined participation one’s biology and behaviors. by patient associations in Cyprus and found that The second principle, empowerment, encour- they had greater involvement in consultations ages individuals to identify a range of possible with health-related organizations and policy solutions to the problem. Contradictory solutions reforms and the Ministry of Health. However, are likely to emerge and healthcare workers they were much less involved with health institu- should welcome them as a problem can have dif- tions such as hospitals, ethics committees, clini- ferent solutions. Social problems generally have cal trials, and health technology assessment. no permanent solutions (Rappaport 1981). The role of the healthcare provider is to engage them to critically examine these remedies to determine 27.4 Culturally Competent the benefits, likelihood of success, and other Empowerment resources needed to achieve them. Healthcare providers should validate individuals’ identity by Healthcare reforms and health promotion require affirming their ideas, strengths, and abilities. transformation of individuals and society. The third principle, collectivity, focuses on Empowered individuals are key to transforming defining the sociocultural basis of individuals’ populations and communities (Freire 2000); sus- identity and experiences to reduce feelings of tainable institutionalized reforms require broad fear, isolation, powerlessness, and hopeless- efforts through multisectoral and multilevel col- ness. Social networks are developed by con- laboration among different sectors of government, necting individuals with support groups in the organizations, individuals, and communities community. Socialization with others who (WHO 1986). According to Leininger, culturally have similar experiences can lead to identifica- congruent and competent care is a culturally tion of more effective solutions and group-ori- meaningful way to support, facilitate, or enable ented actions for change. The role of healthcare patients to regain health or help them face disabil- providers is to foster horizontal interdepen- ity or death (McFarland and Wehbe-Alamah dence focused on concrete needs such as hous- 2015). Human beings are social beings; hence, ing, food, medical care, and emotional support empowerment should be informed by the social and encourage individuals to critically reflect and cultural contexts of people’s lives. on common and contrasting experiences. Rose and Black (1985) described the process Collectivity fosters social development that of empowerment based on three principles. The can bring about social change and transforma- principles are apropos to understanding the pro- tion (Rose and Black 1985). cess of culturally competent empowerment. The first principle, contextualization, aims to understand the individual’s reality by unraveling per- 27.4.1 Culturally Competent ceptions, feelings, and interpretations of their Advocacy and Empowerment experiences. The role of health workers is to Strategies engage them to describe their experiences within the context of their interactions, relationships, Table 27.1 presents selected strategies using the and other events. Through empathic listening and principles outlined by Rose and Black (1985). keen observations, individuals are supported in Selected strategies are organized according to the externalizing their problem by linking their different levels of advocacy and empowerment, experiences with factors such as poverty, which include individual/family, organizational/ discrimination, environmental deprivation, cul- institutional, and community levels. 248 D. Pacquiao Identify community leaders and for potential partnership and gatekeepers collaboration. community leaders and Engage in identifying health-related stakeholders issues. representation of population Ensure fair groups in health assessment. Collaborate with scientific and academic community to identify impact of local, and federal policies/programs on regional, population health. of social and cultural Promote awareness issues that influence population health. of community Increase awareness common health issues and factors to the problems. contributing of how Promote community awareness decisions are made in the community and the people responsible for services they collection, need (senior housing, garbage recreation, police, schools, hospitals, etc.). Seek experts to provide information and to provide Seek experts talking points to be presented policy makers. of possible training on a variety Provide specific causes. actions targeting information on specific persons, Provide offices, and leaders to present proposals for change. Seek funding from community and public private stakeholders organizations. Organize community collaboratives and community collaboratives Organize on specific initiatives. partnerships to work Identify potential leaders who will for change. and coordinate efforts organize • • • • • • • • • • • • • Community level Increase staff awareness of social and awareness Increase staff that hamper healthcare cultural factors and health promotion for the delivery population. training for multidisciplinary staff Provide and leadership on culturally competent care, social determinants of health, and vulnerable population health. Restructure services to enhance access and utilization of services by disadvantaged populations (language services, dietary menus, etc.). for culturally Establish incentives competent care delivery. champions to assist other Create staff personnel in culturally competent care. Ensure representation of disadvantaged governance. populations in organizational Promote employee awareness of the awareness Promote employee population and community being served and SES, and cultural values (ethnohistory, to health and caring). practices relevant Assess organizational capacity for Assess organizational addressing needs of the population (religious, language, signage, telephone answering system, educational materials, social services, gender and age specific, visiting policies, schedule of dietary, services, community outreach, navigators, etc.). advocates, of representation Assess degree community and population groups in decisions. organizational of Assess accessibility and affordability groups. services to disadvantaged • • • • • • • • • • Organizational level Organizational Demonstrate respect and genuineness in interactions (not rushing, listening, using appropriate distance, etc.). communicating empathy, on individual family social hierarchy influence of Observe decision-making and behaviors. of the problem using culturally and Promote awareness linguistically appropriate communication and learning strategies. assessment of social and individual/family Facilitate to the problem (income, that contribute cultural factors kinship, literacy, education, housing, environment, age, ethnohistory, religion, gender, language, race, ethnicity, etc.). of existing and family assessment by individual Facilitate resources and support systems. Use culturally and linguistically appropriate ( congruent congruent ) includes appropriate but appropriate be not may and skills of the to promote knowledge teaching strategies and family. individual technology and teaching materials at the level Use available of understanding and capacity the individual/family. with resources and support and family Link individual systems in the community (ethnic associations, ethnic social services, advocates, grocery stores, churches, legal support groups, ethnic health practitioners etc.). Introduce yourself and the purpose of interaction, emphasizing the importance of individual/family’s participation in the entire process. Engage in dialogue to determine the individual/family’s in dialogue to determine the individual/family’s Engage goals, perceptions, and shared meanings about the problems. to ensure that individual Use cultural mediation/negotiation members’ ideas and aspirations are considered by the group. Work with established family hierarchy in developing in developing hierarchy with established family Work priority goals and plan of action. • • • • • • • • • • Individual/family level Individual/family • • Culturally competent advocacy and empowerment strategies and empowerment Culturally competent advocacy Principle Empowerment Contextualization Table 27.1 Table 27 Advocacy and Empowerment of Individuals, Families and Communities 249 Develop a schedule of events, activities, activities, a schedule of events, Develop of community and media coverage initiatives. Seek multisectoral and multilevel Seek multisectoral and multilevel representation of public and private along with community organization members in health promotion. Promote sustained commitment by maintaining communication with the leaders, partners, and community, collaborators. and ethnic Use community gatekeepers leaders to maintain enthusiasm of their members. Disseminate progress and outcomes of through local and ethnic media initiatives as well places frequently visited by community members. Create a systematic and permanent from structure for coordinating activities start to finish. • • • • • • Establish systems for evaluating outcomes Establish systems for evaluating of culturally competent care delivery. Establish a dedicated structure/personnel of and empowerment for advocacy vulnerable patients and families. Establish incentives for employee for employee Establish incentives in community health engagement promotion. for health promotion in initiatives Develop vulnerable communities such as health mobile clinics, health education in fairs, community settings, etc. Restructure services to maximize access by vulnerable populations to outpatient clinics using more user-friendly scheduling. Recruit and train potential interpreters translators from the community. of language support at Ensure availability all times. partnerships with local Develop on health community groups working initiatives. • • • • • • • • Seek community members with similar background to the healthcare in navigating and family assist the individual system. access to community resources by the individual Facilitate (carpooling, senior transport, handicap transport and family and train schedule, etc.). services, bus capacity to individual/family training to improve Provide access services in the community (using phones, internet, EHRs, etc.). Connect individuals and family with community groups and family Connect individuals in seeking solutions to with similar interests and engaged workers’ similar problems (churches, ethnic organization, interested in union, and local politicians bureaucrats their cause). contact information of community members with Provide expertise and resources for dealing with certain specific problems. contact information of specific service providers Provide in the community. and organizations in reaching and families capacity of individuals Improve out to community members and services (police, emergency hospitals, etc.). services, local media, medical providers, • • • • • • • Collectivity Source: Rose SM, Black BL (1985) Advocacy and empowerment: Mental health care in the community. London: Routledge & Kegan Paul Ltd. Paul London: Routledge & Kegan Mental health care in the community. and empowerment: Advocacy Source: Rose SM, Black BL (1985) 250 D. Pacquiao

Conclusion ness cultural diversity to strengthen bonds and Advocacy and empowerment are used together interdependence among people, and compre- in this chapter. Both are processes aimed to hend the broader social and cultural contexts amplify the voices of individuals, families, and in which we live and work. Advocacy and communities into the health process in order to empowerment require a set of skills communi- assure their participation and engagement in cation, problem-solving, motivating others, their health and well-being. While empower- leadership, change process, coalition building, ment is an outcome of advocacy, empower- maintaining sustainable collaborations, policy ment is both a process and an outcome. Among making, etc. Most significantly is nurturing an vulnerable populations, it is critical that advo- attitude of empathy, other centeredness, care, cacy and empowerment for individuals and and respect for others. families are linked with social reforms. Social determinants of poor health are addressed at the macrosocial level through policies. References Advocacy for health in every policy will more effectively minimize health inequity. Alegría M, Scribney W, Perez D et al (2009) The role of The challenge for culturally competent patient activation on patient provider communication advocacy and empowerment is bridging the and quality of care for US and foreign born Latino patients. J Intern Med 24:534–541 gap in between individuals and society. The ANA (2010) Scope and standards of practice. In: Code of disadvantaged and most vulnerable popula- ethics for nurses with interpretive statements, 2nd edn. tions in society tend to be those who belong to Author, Silver Spring subcultures or minority groups. Empowerment ANA (2015) Code of ethics for nurses with interpretive statements. Nursesbooks.org, Silver Spring starts with increasing awareness of the close Anderson RM, Funnell MM (2010) Patient empower- links between individual level vulnerability ment: myths and misconceptions. Patient Educ Couns and societal arrangements of power and distri- 79(3):277–282. https://doi.org/10.1016/j.pec.2009.07.025 bution of resources. When power is limited at Aujoulat I, d’Hoore W, Deccache A (2006) Patient empowerment in theory and practice: polysemy the individual, family, and community levels, or cacophony? Patient Educ Couns. https://doi. advocacy and empowerment must occur org/10.1016/j.pec.2006.09.008 through broad-based coalitions and commit- Barr PJ, Scholl I, Bravo P et al (2015) Assessment ments for the same cause. While diversity is a of patient empowerment – a systematic review of measures. PLoS One 10(5):e0126553. https://doi. virtue, coalitions are founded on the finding a org/10.1371/journal.pone.0126553 common ground, common understanding, and Bennett O (1999) Advocacy in nursing. Nurs Stand commitment to the cause. Externalization and 14(11):40–41 contextualization of the individual’s experi- Bettes BA, Coleman VH, Zinberg S et al (2007) Cesarean delivery on maternal request: obstetrician- ences can foster a common understanding of gynecologists’ knowledge, perception, and practice the root cause of vulnerability across different patterns. Obstet Gynecol 109(1):57–66 groups. Right to health and access to quality Bodenheimer T, Lorig K, Holman H et al (2002) Patient care for all can only occur when sustained self-management of chronic disease in primary care. JAMA 288(19):2469–2475 empowerment and mutual respect for human Carlisle S (2000) Health promotion, advocacy and health dignity can generate health and social reforms. inequalities: a conceptual framework. Health Promot Advocacy and empowerment are built on Int 15(4):369–376 an emotional attachment to the moral obliga- Carman KL, Dardess P, Maurer M et al (2013) Patient and family engagement: a framework for understanding tion of justice and fairness. We need to build the elements and developing interventions and poli- knowledge of the similarities and differences cies. Health Aff 32:223–231. [PubMed: 23381514] between ourselves and others. Knowing the Carroll J, Minkler M (2000) Freire’s message for social other more fully allows us to uncover the path- workers: looking back, looking ahead. J Commun Pract 8(1):21–36 way between social inequality and health Chen J, Mortensen K, Bloodworth R (2014) Exploring inequity, and to understand how we can har- contextual factors and patient activation: evidence 27 Advocacy and Empowerment of Individuals, Families and Communities 251

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Carol Sue Holtz

Sofia is a 35-year-old, married Zapotec Indian testing for all pregnant women receiving prenatal woman living in a remote small mountainous care and encourages women’s sex partners to be village, approximately 8 hours away from the tested as well. Because Sofia tested positive for capital city of Oaxaca in Mexico. Sofia lives with HIV, the public health nurse requested that she her 43-year-old husband, Jose, and four children, bring Jose to the clinic for testing; he was found ages 5, 6, 10, and 12. She had two other children to be HIV positive. who died prior to their first birthday. She finished The couple is shocked, frightened, and con- the third grade but is unable to read very well in cerned for themselves and their children. In their Zapoteca or in Spanish and has minimum writing small community, they are concerned about the skills. Unable to find employment at home, Jose stigma and fear that they and their children will worked as a farm laborer in the United States for be ostracized in the community if others learn the past 4.5 years to support his family. Separated about their diagnosis. They know very little about from his family for a long time, Jose dealt with the disease, the available treatments, and their his loneliness by socializing at the local bar near costs. Sofia is angry and feels hurt by her hus- his work where other Mexicans congregated. He band’s infidelity and blames him for bringing the often engaged in casual sexual relations with disease to her and her pregnancy. She is worried some of the prostitutes who frequented this bar. about the future of their young children if she and Five months ago Jose returned home and Sofia her husband die from HIV. became pregnant again. After visiting the local health department clinic, Sofia became aware that she was not only pregnant but also HIV posi- 28.1 Cultural Issues tive. Before her diagnosis, Sofia and her husband did not know much about HIV and how a person Compared to other states in Mexico, the state of can contract the disease. (Note: the name and Oaxaca in the southern part of the country is location of this woman and her family are home to a greater number of indigenous Indians, fictitious.) including Zapotecs. The majority of Zapotecs are According to Holtz and Sowell (2012), the Catholic, with some Protestants. Roman Oaxaca Health Department now requires HIV Catholicism was introduced by the Spaniards, but many remain resentful of the Spaniards’ destruc- C. S. Holtz, Ph.D., R.N. tion of their original places of worship and con- School of Nursing, Kennesaw State University, tinue to distrust outsiders. Zapotec families live Kennesaw, GA, USA mostly in small isolated areas with village e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 255 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_28 256 C. S. Holtz

members acting as extended family with very consist mainly of tortillas, beans, and corn with strong traditional family and friendship ties. little fruits and vegetables. Some rural areas have Zapotec women live within a male-dominant up to a 75% infant mortality rate. In fact, Zapotec society with specific gender roles. The traditional women believe that they must have large num- roles of women include childbearing and child- bers of children in order to have a few survive to rearing, homemaking, and assisting in farming adulthood (Joyce 2010; Servicios de Salud 2007; and craft making that are considered primary Stephen 2005). male roles. Women are expected to exhibit defer- The majority of women have less than a third ence to males including the father, husband, and/ grade education, speaking mainly a non-Spanish or older brother in decision-making as well as indigenous language. Zapotec women in particu- demonstrate respect for all family and commu- lar are often educated informally in only their nity elders. All family members are expected to traditional Zapoteca language and have minimal contribute to household chores and income or no Spanish language skills. Language barriers (Central Intelligence Agency 2013; Joyce 2010; pose a challenge in obtaining healthcare for Stephen 2005). Zapotec people (Joyce 2010; Sowell et al. 2013; Women, although often knowing what their Murphy and Stepick 1991; Stephen 2005). husbands are actually doing, frequently do not Because Zapotec men lack employment have the traditional role of questioning their hus- opportunities in their areas of residence, they band’s infidelity or demanding the use of con- often leave their families behind for extended doms during sexual relations; women cannot periods of time and go to other parts of Mexico or challenge their husbands about their outside sex- the United States for a period of 6 months to 5 ual activities nor can they force them to get tested years, working in agriculture, construction, res- or treated for HIV (Joyce 2010; Sowell et al. taurants, or factories. They send money back to 2013; Murphy and Stepick 1991; Stephen 2005). their families. While working far away from their families, they encounter women in bars and frequently engage in unprotected sex with them. 28.2 Social Structural Issues The men have little or no background on sex education, sexually transmitted infections, and The Zapotecs live mainly in an agrarian society HIV. They frequently bring home sexually trans- with lower levels of technology, and common mitted infections and give them to their wives, occupations which include farming, manual labor, who often have these infections during their sub- and labor-intensive craft making. Some commu- sequent pregnancies (Hirsch et al. 2007; Holtz nity members refuse to work with the local, state, and Sowell 2012; Sowell et al. 2013). and/or the federal government because of their per- Residents within their small villages (pueblos) ceived lack of recognition and acceptance of their do not fully understand the nature and transmis- specific cultural lifeways and needs. Many demon- sion of HIV and refuse to have anything to do strate against the local government in hopes of with a diagnosed person once the disease is pub- receiving greater respect, tolerance, and assistance licly known. Hence, it is imperative that the diag- (Central Intelligence Agency 2013; Joyce 2010). nosis is kept confidential or they risk being Because of low educational achievement, the ostracized by their community. Being ostracized Zapotecs are often employed in subsistence farm- means exclusion from other family members or ing with minimal wages. Most have extremely friends, not being able to be employed, and not low incomes, necessitating all family members to being accepted into any community gatherings. assist in pooling resources to generate an ade- HIV-infected individuals need to take a 3- to quate family income. Most households have very 16-hour bus ride from their local village to the low income with a minimal health literacy level main HIV clinic (COESIDA) in the metropolitan and many also have malnutrition. Their diets capital city of Oaxaca. In order to maintain their 28 Case Study: Zapotec Woman with HIV in Oaxaca, Mexico 257 privacy, they inform their families and friends • Promote women’s empowerment by showing that they are going to seek treatment for TB or respect and empathy and encouraging their other infections which are more socially accept- participation in their care. able. The state of Oaxaca charges patients on a • Facilitate women’s ability to seek adequate sliding scale for all public health clinic visits, but healthcare, food, and shelter for themselves those who have no ability to pay receive free care and their children as needed. (Holtz and Sowell 2012; Sowell et al. 2013). • Promote health literacy by using pictures/ posters for health education and disease management. 28.3 Culturally Competent • Obtain support from social services for appro- Strategies Recommended priate financial, housing, job, and community services. The following assessment, intervention, and evaluation strategies are recommended in advocacy and empowerment of the Zapotec individual, fam- 28.3.2 Organizational-Level ily, and/or community. Healthcare providers need Interventions to have knowledge of the Zapotec culture including gender roles, geographical and societal factors • Establish policies and structures to promote that impact the population’s health, the culture of healthcare access by the population. the Zapotec people in Oaxaca, and the role of • Allocate funding for affordable and compre- women within the culture. hensive HIV health services, including disease management, health education, social services, and mental health support/counsel- 28.3.1 Individual-/Family-Level ing services. Interventions • Secure funding for transportation of individuals and families to and from the special HIV • Advocate for maintaining privacy and confi- clinic (COESIDA). dentiality of records and interactions with • Implement training of health providers on patients. cultural and social issues that influence care • During the initial clinic visit, perform a com- of HIV-affected individuals and families. plete health and cultural assessment, obtaining Emphasize the need for privacy and information regarding sociodemographic confidentiality. data, health history, cultural background, • Collaborate with other community stakehold- vocation, individual/family income, language ers and leaders to implement a culturally skills, highest level of completed education, appropriate education for school children and knowledge about HIV, and a self-evaluation of adults on HIV disease prevention and treat- their own healthcare situation and needs, ment and ways to combat stigma. including stigma of the HIV illness. • Use culturally and linguistically appropriate communication. If the patient speaks a 28.3.3 Community-/Societal-Level Zapotec dialect that the healthcare provider Interventions cannot understand and speak, obtain a professional interpreter. • Use the leadership role of the State of Oaxaca • Advocate for gender-congruent care. Health Department and its branch of the • Encourage the wife’s participation in decisions COESIDA clinic (HIV care) in promoting while accommodating the traditional role of the culturally appropriate, accessible, and afford- husband as the family decision-maker. able HIV care services. Priority consideration 258 C. S. Holtz

should be given to the financial and geographic Zapotec women should include assuring their limitations to accessing these services. participation in decisions about their health, • Promote community-wide awareness of HIV facilitating appropriate access to resources disease diagnosis, prevention, treatment, and and services, and providing financial support. supportive services (Hirsch et al. 2007; Holtz • Zapotec society’s gender-defined roles and and Sowell 2012; Murphy and Stepick 1991; social infrastructure create the necessity for Servicios de Salud 2007; Smallman 2007; men to leave their communities and families Sowell et al. 2013). to seek employment in distant places for long • Integrate the unique cultural, environmental, periods of time. Prolonged separation from and socioeconomic history and conditions of their loved ones and lack of awareness of HIV the people in combating stigma and preven- predispose these men to engage in unprotected tion of HIV. Incorporate the impact of gender- casual sex. Often, HIV is undiagnosed until differentiated roles in HIV prevention, stigma, their wives back home get pregnant and and care. acquire the infection from their husbands • Collaborate with local communities and their when they return home. Because of their tradi- leaders to assess and plan prevention strategies tional subservience to the male, compounded in schools, health clinics, places of worship, by low literacy and lack of knowledge of HIV, and other public venues within the community. women are unable to question their men on • Utilize community leaders and healthcare pro- their sexual activities or demand that they use viders to promote widespread “buy in” of ini- condoms; they expose themselves and their tiative planning and implementation. fetus to HIV. HIV is preventable, but initia- • Engage in a community-wide effort to pro- tives should be planned and implemented mote education of girls and women and within the cultural and social structural reali- increasing local employment opportunities. ties of the population. The task of promoting widespread community awareness of the Conclusion infection, its diagnosis, prevention, and man- Advocacy and empowerment strategies must agement requires culturally competent strate- be included in the social and cultural context gies targeting individuals, families, and of the Zapotec Indians. Being a female, communities by individual healthcare provid- Zapotec Indian with HIV/AIDS heightens the ers, organizations, and society in general vulnerability of women within a male-domi- (Hirsch et al. 2007; Holtz and Sowell 2012; nated society. The stigma of HIV is com- Murphy and Stepick 1991; Servicios de Salud pounded by the difficulty of keeping the 2007; Smallman 2007; Sowell et al. 2013). diagnosis a secret from extended close-knit The state of Oaxaca Department of Health, relationships in small villages. Zapotec particularly COESIDA, needs to take the lead- women are often proud and strong, who strive ership in transforming HIV care and preven- to live each day caring for themselves and tion at the micro and macro levels of their their families. Their culture provides a vibrant society. Advocacy and empowerment of work ethic and strong religious background, Zapotec women affected with HIV require not and many are talented in wood carving, weav- only individual-level strategies but, more sig- ing, sewing, and ceramic making. However, nificantly, institutional and community leader- once they are affected by HIV, they face the ship in eradicating the stigma associated with added challenges from their geographic isola- HIV, educating men on the disease and its tion, lack of education, poor nutrition, and transmission, and strengthening protection of poverty. Advocacy and empowerment of the women from unprotected sex. 28 Case Study: Zapotec Woman with HIV in Oaxaca, Mexico 259

References Joyce A (2010) Mixtecs, Zapotecs, and Chatinos. Wiley- Blackwell, West Sussex, pp 1–42 Murphy A, Stepick A (1991) Social inequality in Oaxaca. Central Intelligence Agency (CIA) (2013) Adult HIV/ Temple University Press, Philadelphia AIDS prevalence in Mexico. Available at: http://www. Servicios de Salud (2007) Health prevention and pro- indexmundi.com/mexico/hiv_aids_adult_prevalence_ motion: panoramic epidemiology of HIV/AIDS rate.html in the State of Oaxaca 1986-2007. Department of Hirsch J, Meneses S, Thompson B et al (2007) The inevi- Epidemiology of the Centro de Salud de Oaxaca tability of infidelity: sexual reputation, social geog- Smallman S (2007) The AIDS epidemic in Latin America. raphies, and marital HIV risk in rural Mexico. Am J The University of North Carolina Press, Chapel Hill Public Health 9(6):986–996. https://doi.org/10.2105/ Sowell RL, Holtz C, VanBrackle L et al (2013) Depression AJPH.2006.088492 in HIV-infected women: implications for mental Holtz C, Sowell RL (2012) Oaxacan women with HIV/ health services. Online J Med Med Sci Res 2(1):6–12 AIDS: resiliency in the face of poverty, stigma, and Stephen L (2005) Zapotec women: gender, class and eth- social isolation. Women Health 52(6):517–535. nicity in globalized Oaxaca, 2nd edn. Duke University https://doi.org/10.1080/03630242.2012.690839 Press, Durham Case Study: Maternal and Child Health Promotion Issues 29 for a Poor, Migrant Haitian Mother

Joyce Hyatt

Twenty-five-year-old Nathaly migrated to the objected to her migrating and has not been United States from Haiti 5 months ago. She is 38 involved with her current pregnancy. Nathaly was weeks pregnant and experiencing labor pains. hoping to find a job in the United States and help She is brought to the labor and delivery depart- her family in Haiti, but she has been unsuccess- ment of a large urban hospital by her cousin. She ful. She speaks French and Creole and only had one prenatal visit with a midwife in Haiti speaks limited English. about 6 months ago but did not seek healthcare Nathaly, her cousin, and her cousin’s 9-year- since she arrived in the United States. Nathaly old daughter live in a two-bedroom apartment in was examined and found to be in labor. Her a predominantly Caribbean/Haitian community cousin speaks English fluently but was unable to in Northeastern United States, approximately 3 stay with Nathaly throughout labor and childbirth miles from the hospital. There is a West Indian because she needed to pick up her 9-year-old store that sells Haitian food about half a mile daughter from school and stay with her at home away and a supermarket about ten blocks from after. An interpreter from the language line ser- their residence. She describes her neigh- vice was engaged to speak to Nathaly about her borhood as “relatively safe with occasional gun medical history and to obtain her consent for violence.” admission and treatment. Nathaly is in the United States on a temporary Nathaly completed high school and worked as visa and is unsure if she will go back to Haiti a waitress in Port-Au-Prince until the city was after the birth of her baby. She admits that she is devastated by an earthquake in 2010. She moved not adequately prepared for childbirth and has back home to be with her mother in rural Haiti no income nor health insurance. She only has when her father, a carpenter, died in 2012. She minimal amount of cash for some baby supplies was planning to go to college in Haiti but became and depends on her cousin for support (food and pregnant; she left her 3-year-old son with her shelter). Her cousin is employed as a certified mother in Haiti. Her mother sells housewares and nursing assistant (CNA) earning less than farm products in the local market to support $28,000.00 per year. Her cousin admits that it Nathaly’s two younger sisters who are still in has been difficult to manage financially with the school. Nathaly’s husband, a teacher in Haiti, high cost of living in the United States. One in five (20%) Haitians in the United States lives in poverty as compared to 1 in 7 (14%) in the total J. Hyatt, Ph.D., D.N.P., C.N.M. US population (U.S. Central Intelligence Agency Nurse Midwifery Program, School of Nursing, 2017). Nathaly’s cousin is her only family mem- Rutgers University, Newark, NJ, USA e-mail: [email protected] ber in the United States. Her cousin moved to

© Springer International Publishing AG, part of Springer Nature 2018 261 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_29 262 J. Hyatt this community 10 months ago and is not famil- well, and being dependent on her cousin who has iar with the resources available for pregnancy to support her and her own daughter. and childbirth in the area. Nathaly’s fear of spell on her baby is not uncommon in the Haitian culture. Although the majority of Haitians practice Catholicism, some 29.1 Cultural Issues have strong beliefs in the voodoo religion (Alvarado 2011). Understanding and respecting In Haitian culture, pregnancy is considered nor- Nathaly’s beliefs and values are essential to car- mal; hence, many women do not seek prenatal ing for her and her baby and creating a trusting care. Women living in the rural areas of Haiti are patient/provider relationship. Respecting her cul- more likely to be delivered by untrained mid- ture without marginalizing her beliefs promotes wives at home (Colin and Paperwalla 2013). Like trust in the healthcare provider (Colin and most cultures, Haitians tend to maintain tradi- Paperwalla 2013). Health providers need to have tional beliefs and practices pertaining to labor specific knowledge about Haitian cultural prac- and childbirth. According to Colin and tices regarding health and illnesses to facilitate Paperwalla, the women can be very expressive communication and foster culturally competent when having pain by being loud; others may assessment and care (Douglas et al. 2014). groan or become quiet and passive. They are also Migrants experience the stressors stemming known for rubbing their abdomens, walking, from loss of familiar culture and way of life when squatting, or sitting when in pain. exposed to different social milieu, values, and Because of the language barrier, a face pain norms. Adult migrants may experience “child-like scale was used to ascertain Nathaly’s level of dependence” because of the need to cope with a pain. Initially, her pain level was at six out of ten, new way of life, new language, and new behav- but she refused pain medication because she had iors. Nathaly is faced with a new culture, language her first baby without medicine. She opted to barriers, and financial dependence on her cousin. walk around her room, groaning loudly and She is referred to a social worker to assist her in sometimes squatting when in pain. After she was securing health insurance and other available determined to be 6 cm dilated with a pain level of social programs including women, infant, and eight out of ten, Nathaly decided to take the pain children (WIC). She is also referred to a Haitian medication after being assured that the medicine church that has been providing support and food would not affect the baby. She agreed to take the supplies to underserved women and children in intravenous medication but refused epidural the community. analgesia. During the health assessment, Nathaly is comfortable sharing her belief with another nurse 29.2 Social Structural Factors who speaks French. She relates her fear that her mother-in-law (who apparently dislikes her) is Haiti is considered the poorest country in the trying to put “a voodoo/bad spell” on her baby. western hemisphere (U.S. Central Intelligence Her cousin urged her to come to the United States Agency 2017). In 2012, 58.5% of Haitians were to prevent the spell on the baby. In Haiti, it is a living below or at the poverty level (World Bank common belief that if a pregnant woman has an 2016). Lack of adequate infrastructure and enemy, her enemy can cast a bad spell or voodoo resources for healthcare in particular has contrib- on the baby resulting in harm to the pregnancy uted to poor healthcare and subsequent high (Colin and Paperwalla 2013). Nathaly admits that infant and maternal mortality. According to the she feels safer in the United States and does not US Central Intelligence Agency (2017), Haiti’s want to go back to the rural area in Haiti after maternal mortality rate was estimated at 359 having the baby. She is concerned about not deaths/100,000 live births in 2015. In 2016 working, being uninsured, not speaking English Haiti’s infant mortality rate was 48.2 deaths/1000 29 Case Study: Maternal and Child Health Promotion Issues for a Poor, Migrant Haitian Mother 263 live births. These are alarmingly high rates when 29.3.1 Individual-/Family-Level compared to their neighbors, the Dominican Interventions Republic and Jamaica, with 2016 infant mortality rates of 18.1 deaths/1000 and 13.1 deaths/1000 • Empower clients by integrating socioeco- births, respectively. In 2016, about 52.4% of rural nomic, linguistic, and literacy factors during Haiti had inadequate drinking water, while 80.8% interactions, including: had unimproved or poor sanitation facilities –– Promoting awareness of the importance of (U.S. Central Intelligence Agency 2017). prenatal care, postpartum follow-up, and Prior to her migration to the United States, growth and developmental assessment of Nathaly lived and experienced the environmental the baby disadvantages of living in rural Haiti which can –– Selecting interpreters and health education impact her pregnancy outcome. Fortunately for approaches Nathaly, the neighborhood in which she now –– Obtaining comprehensive health history and lives, is considered fairly safe with adequate providing health education and counseling access to transportation and healthy food. –– Providing postpartum education on imme- Because she is unemployed and dependent on her diate and long-term needs including breast- cousin’s income, she has limited ability to pur- feeding and importance of follow-up care chase healthy food. Lack of health insurance, lan- for mother and baby guage difficulty, and unfamiliarity with, or lack • Respect and accommodate client’s prefer- of awareness of community resources are signifi- ences and unique cultural beliefs and practices cant factors that can negatively influence her while promoting safe and supportive care by: access to health services and quality care for her- –– Developing awareness of Haitian cultural self and her baby. It could not be ascertained how beliefs and practices relevant to pregnancy, much weight Nathaly gained during her preg- birthing, and child care nancy, blood type, HIV status, or blood glucose –– Ensuring confidentiality of information level. Laboratory and other diagnostic assess- shared by clients to prevent marginalization ments are usually done during prenatal care, pro- of their traditional beliefs and practices viding significant information about the mother –– Ensuring privacy while conducting exami- and baby’s health status. In Nathaly’s case, these nations and honoring the cultural value of were not available until admission. Lack of base- modesty and preference for gender congru- line and prenatal care puts Nathaly and her baby ent practitioner at risk for labor and birth complications. After • Advocate for client’s access to appropriate 7 h, Nathaly gave birth to a 6-pound baby boy social services and culturally congruent com- who appeared to be grossly normal. munity resources by: –– Facilitating referral to appropriate social services to assist with application for health 29.3 Culturally Competent insurance and nutritional programs for Strategies Recommended mother and baby –– Providing information on English classes for Advocacy and empowerment for Nathaly and her immigrants offered in the local community family must be informed by the social structural –– Providing information on available pro- and cultural factors in Haiti and in their new envi- grams for job training and occupational ronment. In the United States, Haitians are consid- mentorship in the community ered one of the most at-risk populations –– Linking client with Haitian churches and (U.S. Central Intelligence Agency 2017). Based community support networks on the problems identified for Nathaly, the follow- –– Connecting the client with legal advocates ing are the recommended culturally competent to assist legalization of her immigration advocacy and empowerment (Douglas et al. 2014). status in the United States 264 J. Hyatt

29.3.2 Organizational-Level –– Establishing collaborative partnership with Interventions the Haitian church and the Haitian Community Coalition to assist with health • Advocate for organizational responsiveness to education and communication with the healthcare for vulnerable Haitian population by: Haitian population –– Assessing adequacy of organizational –– Collaborating with community leaders and infrastructure of services and care delivery organizations to conduct health fairs pro- –– Training of staff and administrators in cul- viding free health assessment, counseling, turally competent care and treatment referrals –– Ensuring presence of interpretation and –– Collaborating with Haitian community translation services (language line, certi- leaders and organizations to seek partici- fied interpreters) for prominent languages pation in local and statewide policies and of the populations being served programs that impact their community –– Ensuring adequate certified interpreters (in person) when the patient speaks a language Conclusion that is different from the healthcare providers Nathaly is typical of Haitian immigrants who –– Ensuring availability of printed material and are confronted by sociocultural factors that signage with low literacy level and in the can significantly impact their lives. Although major languages of the population served she has a high school education, she is • Recruit and maintain a culturally diverse unemployed, and her capacity for employment workforce by: is limited because of her temporary visa, lack –– Determining presence of culturally congru- of English proficiency, and caretaking ent staff that Haitian patients can commu- responsibilities for her baby. Her lack of nicate and identify with prenatal care and exposure to the limitations –– Integrating cultural competence in staff hir- of her previous rural residence and her current ing, job descriptions, and promotion situation will impact the present and future requirements health of her baby as well as her own. • Promote engagement of the organization with Nathaly needs culturally competent vulnerable communities by: advocacy and empowerment to navigate the –– Conducting free health fairs in the commu- challenges of a new environment and social nity (such as in public housing, local parks, vulnerability. These strategies should not and churches) only focus on her current state of being but –– Establishing partnership with local Haitian should include strategies that will improve community centers and coalitions, churches, her capacity to maintain a healthy life for and radio and television stations to provide her and her baby. Advocacy and information on pregnancy and childbirth in empowerment for vulnerable individuals English, French, and Haitian Creole and families necessitate multisectoral –– Encouraging staff participation in research on approaches addressing individual and the Haitian population to identify significant family needs as well as transformation of health challenges including demographic, services and supports offered by socioeconomic, and epidemiological data organizations and present in the community. The current political climate in the United 29.3.3 Community-/Societal-Level States severely limits the future of Nathaly Interventions and her baby because of her lack of permanent legal status as immigrant. • Empower the Haitian community by: Advocacy and empowerment strategies –– Inviting community participation in plan- must address this issue and not just limited ning of social and health programs that will to maternal and child health. Legal status is benefit the community prerequisite to their survival. 29 Case Study: Maternal and Child Health Promotion Issues for a Poor, Migrant Haitian Mother 265

References Douglas M, Rosenkoetter M, Pacquiao D et al (2014) Guidelines for implementing cultural competent nursing care. J Transcult Nurs 25(2):109–121 Alvarado D (2011) The voodoo hoodoo spellbook. Weiser U.S. Central Intelligence Agency (2017) The world factbook. Books, San Francisco. ISBN 1-57863-513-6 Central America and Haiti 2017. Available at: https:// Colin J, Paperwalla G (2013) People of Haitian heri- www.cia.gov/library/publications/the-world-factbook/ tage. In: Purnell L (ed) Transcultural health care: a geos/ha.html culturally competent approach, 4th edn. F. A. Davis, World Bank (2016) World development indicators. Available Philadelphia, pp 269–287 at: http://data.worldbank.org/country/haiti#cp_wdi Case Study: Caring for a Pakistani Male Who Has Sex with Other Men 30

Rubab I. Qureshi

Fifty-year-old Mr. M, of Pakistani descent, came simple woman from a farming family and does in for a consultation at a local urgent care center. not want to migrate to the United States. Many He states that he is married with no children and men from his village have migrated to Middle that his wife lives in Pakistan. He has no immedi- Eastern countries like Saudi Arabia, Dubai, and ate family members in the United States. He Kuwait, leaving their families in Pakistan and immigrated to the United States 20 years ago and visiting them regularly. He feels lonely and likes drives a taxicab for a living. He is bilingual in his company. He does not like going to other women, native language, Pashto that is spoken in the because it would be cheating on his wife. Khyber Pakhtunkhwa province of Pakistan and As he becomes more comfortable with the fluent in English. Mr. M completed high school health provider, Mr. M says that he had been living before migrating to the United States. He has no with a male Caucasian friend until a year ago. health insurance. He provides financial support They had sex occasionally but were not exclusive for his wife and parents in Pakistan. He tries to of other relationships. He says that sex with other visit Pakistan every year and had recently men is different. He does not use a condom all the returned from a 6-week visit a month ago. He time. Over the years he had multiple sexual part- smokes occasionally but does not drink alcohol. ners but was never in a long-term one-on-one rela- Mr. M complains of urethral discharge with tionship. He just “hooks up with a friend when he some dysuria for a week. He had similar episodes wants to.” He has a circle of nine to ten friends in the past, but he took some antibiotics he had who call on each other when they want to. He had brought back from Pakistan and got better. a casual sex encounter with a couple of men while However, he forgot to bring back some antibiot- in Pakistan. He met them in Karachi, a large bus- ics from his last trip. He is reluctant to talk about tling metropolis, before catching a connecting his sex life. After some probing questions, he flight to his village. He admits doing “all kinds of admits that he is uncomfortable because he has things” without specifying oral or anal sex; no never discussed “this” with anyone. He identifies condoms were used. as heterosexual but has sex with other men When asked about his wife, Mr. M says that (MSM) occasionally. He describes his wife as a “she is fine and would never discuss female problems with me [him].” He had not heard from her. His wife wanted a family, but Allah had not blessed them with children. His family had sug- R. I. Qureshi, M.D., Ph.D. gested that he marry a second time, but he is “fine School of Nursing, Rutgers University, Newark, NJ, USA with things the way they are.” He laughs and e-mail: [email protected] says, “one woman is enough.”

© Springer International Publishing AG, part of Springer Nature 2018 267 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_30 268 R. I. Qureshi

Mr. M is told that he might have a sexually culture it is a rarity for a woman to seek divorce transmitted infection and needs some tests to from her husband. More family resources are confirm the diagnosis. If confirmed, he is advised allocated to raising boys, getting them educated to inform his sexual partners of his diagnosis, so and employed. Very few women are educated and they can get tested and treated if necessary. Mr. even fewer participate in the work force (Qureshi M admits that he may only tell the friends he had 2010). Traditional gendered roles are encouraged, sex with but would not share this with his wife— and contemporary social roles are discouraged, “she does not have to know.” especially for females (Hussain et al. 2015). Internalized gendered behaviors are reflected at the institutional level in gender segregation in 30.1 Social Structural Issues most social spheres.

Pakistan is a predominantly Muslim country comprised of 192 million people (PBS 2016). It is bor- 30.2 Cultural Issues dered by Afghanistan, Iran, China, and India. Pakistan is a developing country with high rates Pakistan is comprised of five major distinct eth- of poverty and unemployment. This has encour- nic groups based on culture and language. These aged a steady stream of emigres with large dias- include Pashtuns/Pakhtuns in Khyber poras of Pakistanis in neighboring Gulf States, the Pakhtunkhwa, Punjabis in Punjab, Sindhis in United Kingdom, Canada, and the United States. Sindh, Baluch and Barhui in Baluchistan (Zaman Social hierarchy and opportunities are gener- 2014). Pakistani culture is a conglomeration of ally structured by male dominance infusing shared cultures bound by a common national and gender-based sociocultural dichotomy in all religious identity. Historically these geographical spheres of life. Gender roles and expectations neighbors share a rich history and identities. define masculine roles. Males act as the family Pakistan and India were part of the Indian sub- link to the external world (providing for the fam- continent ruled by the British until 1947. The ily, shopping, outside interactions, etc.). In con- Pakhtuns are ethnically close to Afghanistan and trast, females’ lives are circumspect and limited share a similar culture, while the Punjabis have to the management of domestic activities cultural similarities with the Indian Punjab. (Hussain et al. 2015). Males are valued and Pakhtuns adhere to a tribal culture, Pashtunwali socialized in an environment emphasizing their (tribal code) and considered the most patriarchal superiority over females. It starts at birth when and most traditional adherents of Islam than other the birth of a male child is celebrated with pomp ethnic groups. and the female child is met with apprehension The family is the cornerstone of ethnic societ- (Qureshi 2010). Gender roles are inculcated early ies in Pakistan (Zaman 2014). It is not uncom- when boys and girls play different games and mon for extended families to live together and boys are encouraged to be tough and chastised if decision-making is shared with deference to the they show weakness (Hussain et al. 2015). Girls older members of the family (Nath 2005; Zaman are socialized to be weak, delicate, sensitive, 2014). Most marriages are arranged and consid- emotional, and dependent, while boys are raised ered a family duty. Family loyalty and honor to be strong, aggressive, brave, and the protectors (izzat in Urdu) are inculcated in child-rearing of the family honor (izzat in Urdu and namus in (Nath 2005; Zaman 2014). Whereas men enjoy Pashto) (Hussain et al. 2015; Qureshi 2010). greater autonomy, women are held to a stricter It is not uncommon for women to be excluded code and closely guarded (Zaman 2014). from property and land inheritence, but are given Men and women have very few opportunities dowries at the time of marriage. Men make key to socialize. Any romantic dalliance is often decisions for the women in their families includ- clandestine because of fear of damaging the fam- ing marriages and even contraception. In Pakhtun ily honor (izzat/namus) if discovered. Such rela- 30 Case Study: Caring for a Pakistani Male Who Has Sex with Other Men 269 tionships can have terrible consequences such as ness with families back in Pakistan. Sexual and honor killing by the women’s family. Single men gender minorities may feel uncomfortable disclos- socialize freely and with greater freedom, but ing their identities orally or in writing in healthcare societal structures and lifestyles are not condu- settings. For Pakistani MSM, disclosure to family cive to developing or maintaining a gay identity. members and co-ethnics is difficult because of Homosexuality is illegal and considered a crime entrenched gendered roles including sexual roles of in Pakistan. Although Islam condemns homosex- males. Failure to disclose adds to their invisibility uality as a sin, in some parts of the country homo- and isolation from social resources and support. sexual relationships are not uncommon (Jaspal and Siraj 2011; Nath 2005). Among the Pashtuns, variant patterns of sexual 30.3.1 Individual Level Interventions identity go against the tenets of Islam and viola- tors may be severely punished (Nath 2005). 1. Advocate for using appropriate literacy level Sexuality cannot interfere with tradition, and as in oral and written communication, signage, long as the institution of marriage is not threat- and teaching materials for foreign-born ened, what men do in their private lives is toler- migrants even if they speak English well. ated. There is no acceptance of a gay identity or 2. Obtain comprehensive health and sociocul- “coming out,” and gay men may be pressured into tural assessment including migration history, marriage to lead “normal” lives (Nath 2005). socioeconomic status, religious beliefs, cul- There are no “gay” rights, and gay men have to be tural traditions, and practices including sexual covert and keep their relationships secret (Nath practices, social support and transnational 2005). Oftentimes erotic love between two males ties, literacy level, language preference, need is reduced to anal penetration and is subject to for interpreter, etc. ridicule in public spheres. In this context, some 3. Promote privacy and confidentiality of inter- men who prefer to have sex with men exclusively actions to allow the client to open up and dis- reported feelings of shame, dissonance, guilt, and cuss his problem freely. Privacy and fear of persecution (Jaspal 2012). confidentiality should be assured when using Within a close-knit family structure, sexuality, medical interpreters. sex education, and preventive care are rarely dis- 4. Advocate for gender-congruent provider if cussed. Consequently overall knowledge about preferred by the client. sexual health is low (Rehan 2002). In addition, 5. Facilitate client referral to social services to there are no reliable data on the prevalence of apply for health insurance and other social sexually transmitted infections (STIs), and not resources. Many immigrants who are self- surprisingly the official rates of STIs are grossly employed or non-naturalized citizens may not underestimated (Maan et al. 2011; Nath 2005). have health insurance. Pakistani immigrant gay men who have strong 6. Promote client empowerment by enhancing transnational ties and second generation gay men his understanding of his condition, diagnosis, are likely to behave like their counterparts in treatment, and prevention and follow up by: Pakistan because their cultural context remains • Providing explanations on the following: the same (Jaspal 2012). (a) need for a battery of tests for STIs including HIV, (b) types of specimens to be collected including urethral discharge, (c) 30.3 Culturally Competent adherence to prescribed treatment regimen Strategies and follow-up to prevent or treat microbial resistance, (d) avoidance of all sexual con- Advocacy and empowerment of Pakistani immi- tact during treatment and for 7 days after grant MSM need to be informed by their cultural treatment, (e) prevention of self-exposure and religious traditions and degree of connected- to STIs and transmission of STIs to others, 270 R. I. Qureshi

(f) need to inform all his sexual partners 30.3.3 Community Level about his condition and how to seek help, Interventions and (g) some states may require the provider to report his case to the health 1. Advocate for research on sexual minority authority. immigrants from South Asian countries • Allowing the client time to ask questions, including Pakistan and inclusion of these clarify ambiguities and express his groups in national databases, e.g., Behavioral feelings. Risk Factor Surveillance System, Centers for • Offering additional support for the client to Medicare and Medicaid Services, etc. reach out for further questions or 2. Disseminate information on organizations concerns. providing care specific for sexual and gender 7. Being aware that MSM may not consider them- minorities. selves as gay or bisexual. This is especially sig- 3. Facilitate development of social networks and nificant for Mr. M who was socialized in an community outreach to SGM members par- environment where private sexual practices are ticularly from South Asian countries using tolerated for as long as these do not interfere with multiple formats. his role as a married man and family provider. Conclusion Sexual minorities have a long, almost univer- 30.3.2 Organizational Level sal history of persecution and discrimination Interventions which makes disclosure difficult. Stigma attached to SGM is widespread in many coun- 1. Ensure language interpretation assistance for tries, and some religions consider variant sex- clients with less English proficiency. uality as sinful and a cultural taboo. These 2. Employ navigators to assist clients in using cultural norms contribute to the invisibility of the various services of the organization as this group which contribute further to their well as resources in the community. health vulnerability. Members of the SGM 3. Foster a sexual and gender minority (SGM) community also experience overt discrimina- friendly environment by: tion and bias from healthcare providers which (a) Participating in the Human Rights deter them from seeking care services. Campaign’s Health Equality Index, an Advocacy and empowerment of SGM clients annual survey that examines hospital poli- must occur at the individual, institutional, and cies toward SGM patients. societal levels. Improving their health is diffi- (b) Implementing regulations and standards cult when they need to hide their sexual iden- for visitation and nondiscrimination from tity and sexual practices. Social and cultural the Department of Health and Human transformation requires legal protection of Services and Joint Commission. SGM individuals. Macrosocial changes are (c) Providing SGM health competency/sensi- needed to combat marginalization and stigma- tivity training to staff and administrators. tization of SGM individuals. Such changes (d) Revising forms used to elicit information begin at the level of the individual but are not appropriate for SGM clients. sustainable unless organizational support and (e) Advertising inclusive philosophy of the community reform occur. Culturally compe- organization. tent advocacy and empowerment of SGM 4. Recruit and maintain a culturally diverse staff groups need to negotiate with the realities of representing the population groups in the the social and cultural contexts of stigma and community. discrimination. 30 Case Study: Caring for a Pakistani Male Who Has Sex with Other Men 271

References Nath S (2005) Pakistani families. In: Ethnicity and family therapy. Guilford, New York, pp 407–420 PBS (2016) Population Census. Available at: http://www. Hussain M, Naz A, Khan W et al (2015) Gender stereo- pbs.gov.pk/content/population-census typing in family: an institutionalized and normative Qureshi RI (2010) Experiences of pregnancy, child- mechanism in Pakhtun society of Pakistan. SAGE birth and post-partum period in urban and suburban Open 5(3):2158244015595258 immigrant Pakistani women. New Jersey Institute Jaspal R (2012) ‘I never faced up to being gay’: sexual, of Technology. Available at: http://archives.njit. religious and ethnic identities among British Indian edu/vol01/etd/2010s/2010/njit-etd2010-102/njit- and British Pakistani gay men. Cult Health Sex etd2010-102.pdf 14(7):767–780 Rehan N (2002) Profile of men suffering from sexually Jaspal R, Siraj A (2011) Perceptions of ‘coming out’ transmitted infections in Pakistan. J Ayub Med Coll among British Muslim gay men. Psychol Sex Abbottabad 15(2):15–19 2(3):183–197 Zaman RM (2014) Parenting in Pakistan: an overview. In: Maan MA, Hussain F, Iqbal J et al (2011) Sexually transmit- Selin H (ed) Parenting across cultures. science across ted infections in Pakistan. Ann Saudi Med 31(3):263– cultures: the history of non-western science, vol 7. 269. https://doi.org/10.4103/0256-4947.81541 Springer, Dordrecht, pp 91–104 Part VIII Guideline: Multicultural Workforce Culturally Competent Multicultural Workforce 31

Dula Pacquiao

Guideline: Nurses shall actively engage in the effort to ensure a multicultural workforce in health care settings. One measure to achieve a multicultural workforce is through strengthening of recruitment and retention efforts in the hospitals, clinics, and academic settings. Douglas et al. (2014: 110)

31.1 Introduction frequently in the workplace (Martin and Nakayama 2010). Workplaces are places where The trend toward increasing diversity in world individuals from diverse cultures convene and populations has been associated with globaliza- collaborate. Recent immigrants comprise more tion supported by advances in technology and than half of the total workforce in the USA internationalization of economy. Technology has (Okoro 2012). Diversity challenges are not lim- allowed easier world travel and movement of ited to businesses and healthcare organizations people, reducing physical distances and height- but also involve academic institutions. ening awareness of cultural diversity. As part of the global economy, people are now living and working in environments exposed to diversity, 31.2 Definition of Multicultural requiring more interactions with people from Workforce diverse backgrounds. The global economy has intensified competition for resources worldwide, Understanding a multicultural workforce moving human and material capital across requires an expanded definition of cultural diver- regions and nations to maximize productivity and sity to encompass differences between people in profitability. Organizations are becoming more an organization including age, generation, diversified to remain competitive. national origin, race, ethnicity, class, gender, Today’s world gradually is becoming more sexual orientation, religion, education, disabil- global in its outlook, and as the marketplace ity, language and communication, and life expe- becomes increasingly global in nature, the need rience (Okoro 2012). Workforce diversity also for multiculturalism in the workplace will con- includes differences in personality, cognitive tinue to grow. For many people, encounters with style, tenure in the organization, organizational people from different racial and ethnic back- role, and work preferences. Diversity requires grounds as well as national origins occur most acknowledging, understanding, accepting, and valuing differences among people; it involves how people perceive themselves and how they D. Pacquiao, Ed.D., R.N., C.T.N.-A., T.N.S. perceive others, which affect their interactions School of Nursing, Rutgers University, Newark, (Mayhew 2017). NJ, USA School of Nursing, University of Hawaii, Hilo, Hilo, HI, USA

© Springer International Publishing AG, part of Springer Nature 2018 275 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_31 276 D. Pacquiao

31.3 Drivers of Workforce recruiting health workers from abroad to fill Diversity in Healthcare their shortages. In contrast to Estonia, Slovakia, and Poland that have little reliance on foreign 31.3.1 Global Healthcare Workforce medical doctors, Switzerland, Slovenia, Ireland, Shortage and the UK have very high reliance on foreign health workers especially medical doctors. A The World Health Organization estimated that study of ten countries in the European Union the worldwide shortage of healthcare workers (EU) found that one third of migrant doctors including doctors, midwives, nurses, and other came from outside EU: 60% in France and Italy healthcare workers rose from 4.3 million to 7.2 and 80% in Ireland and the UK (Dussault et al. million in 2013. This shortage is predicted to 2009). increase to 12.9 million by 2035 (WHO 2013). Worldwide, nurses comprise the largest group The number of countries with health workforces of healthcare workers as well as the largest well below the basic threshold of 23 skilled migrant group among all categories of healthcare health professionals/10,000 people increased workers. In the USA, the number of companies from 75 in 2006 to 83 in 2013. While the largest engaged in international nurse recruitment rose shortages are predicted in parts of Asia, sub- from about 40 in 1990 to 270 in 2009 (Eckenwiler Saharan Africa will be most severely affected. 2009). About 8% of US Registered Nurses (RNs) Internal and international migration of health are foreign-educated with the Philippines as the workers exacerbates regional and global short- major source country accounting for more than ages. The pattern of internal migration flows 30% of US foreign-educated nurses. Nurse immi- from rural to urban areas, while international gration to the USA has tripled since 1994 to migration flows from low- and mid-income about 15,000 annually (Aiken 2007). The USA countries to high-income countries in North employs the most international nurses, but America and Western Europe (Allutis et al. foreign-educated nurses comprise only 4% of its 2014). International migration may occur among nursing workforce, compared to the UK and neighboring countries in the same region or con- Ireland (8%) and Canada (6%). The top six coun- tinent. This is motivated by several factors, tries that export nurses are the Philippines, including better wages and more opportunities Canada, India, Nigeria, Russia, and Ukraine for employment, educational advancement, and (Walker 2010). career mobility. Some health workers migrate to High-income countries have resorted to for- escape poverty, violence, and disease epidemics eign recruitment to address their workforce in their home country (Allutis et al. 2014; shortages instead of developing an adequate plan Kingma 2007). for sustainable workforce development within Many countries in North America, Europe, their own countries. International recruitment the Middle East, and Oceania actively import has created the phenomenon of “brain drain,” a health service labor to sustain their own health- shortage of highly educated and skilled health care system, while African countries workers within the source countries, which has (Zimbabwe, Nigeria, Ghana, Zambia, and catastrophic effects on the quality of care, dis- South Africa) experience a net outflow of health ease burden, and mortality in these countries workers. Seventy percent of health workers (Allutis et al. 2014; Kingma 2007). The “brain from African countries (approximately 65,000 drain” has worsened conditions in source coun- physicians and 70,000 nurses) have migrated to tries that are likely to be low-income, resource high-income countries (Clemens and Petersen poor, and plagued by shortages of manpower 2008). Nearly all European members of the particularly highly skilled professionals and Organization for Economic Cooperation and well-qualified educators; shortages are worse in Development (OECD) increasingly rely on rural areas. 31 Culturally Competent Multicultural Workforce 277

31.3.2 Government Policies USA are the major influence in local nursing enrollment in the Philippines (Jurado and The pattern of migration of Filipino internation- Pacquiao 2015). US immigration policies since ally educated nurses (IENs) illustrates how the after World War II have paved the way for thou- drivers of migration work. Filipino IENs com- sands of Filipino IENs to enter the country prise the largest group of migrants with the USA legally by creating different entry visa categories as the favored destination country. Filipino nurses (temporary and permanent status), extending emigrate because of high unemployment at home their legal residence in the USA after expiration despite a glut of nurses because the local econ- of their temporary work visas and allowing omy could not absorb the large numbers of grad- adjustment of their temporary status to perma- uates, creating tight competition and less nent residents (Jurado 2013). opportunity for advancement. Low wages have The Philippine government has encouraged prompted Filipino physicians to retrain as nurses labor emigration because Filipinos working in for employment abroad. other countries send significant remittances that According to Jurado (2013), both the US and bolster the dollar revenues of the country critical Philippine governments have played a major role to the payment of its foreign debt. Since the time in creating the “push” and “pull” for nurse of President Marcos, the government has encour- migration. The Philippines was colonized by the aged overproduction of nurses for export. Large Americans in 1898 after the Spanish-American numbers of nurses are unemployed due to limited War that ended centuries of Spanish rule since employment opportunities in healthcare. 1521. Except for a brief period of Japanese occu- Healthcare jobs offer low wages, so many nurses pation during World War II, the American occu- seek employment outside of healthcare (Jurado pation finally ended in 1946 when the Philippines 2013). gained its independence. During the occupation, Americans were confronted with health issues in the Philippines from epidemics of typhoid, chol- 31.3.3 Increased Global Demand era, smallpox, and tuberculosis. In addition to for Healthcare Services introducing mass public education, the Americans were instrumental in developing hos- Healthcare workforce shortages have been attrib- pitals, public health programs, and training of uted to high demand for healthcare services doctors and nurses in the Philippines. The because of the increasingly aging population, Americanization of Philippine nursing was population growth, higher prevalence of chronic paved by American teachers and textbooks and and noncommunicable diseases, and expansion further training of nurses in the USA; these of primary care services (WHO 2013). The UN’s nurses subsequently assumed leadership posi- Millennium Development Goals and Alma-Ata’s tions in nursing education and service. The declaration of “healthcare for all” have given American influence in the country’s professional impetus to the global agenda to provide universal nursing and healthcare has remained strong with access to healthcare. Increased recognition of the English as the medium of collegiate instruction social determinants of health has pushed the need (Pacquiao 2003). According to Masselink (2009) for primary care services that promote health countries that were colonized may have been beyond disease-based care (ICN 2006). The introduced to the colonizer’s language and edu- shortage is also attributed to lack of workforce cational systems, facilitating ease of migration planning, inadequate funding for students enter- to the colonizing country. Consequently, Filipino ing the professions, inadequate numbers of fac- nurse graduates are preferred targets of foreign ulty constraining enrollments, and growth of nurse recruitment. In fact, nursing shortages alternative work opportunities for women with corresponding opening of visa entry to the (AACN 2014; ICN 2006). 278 D. Pacquiao

In the USA, there are 6804 geographical areas, By mid-twenty-first century, it is predicted that populations, and facilities with a shortage of pri- the USA will cease to have a majority race. mary medical practitioners, 5598 with a shortage Ethnic and racial minorities will increase from of dental professionals, and 4730 with shortage 37% to nearly 50% of the total population as of mental health professionals (HRSA 2017a). In compared to white Americans who will decrease addition, 4221 areas are designated as medically from 69.4% to 50.1%. Hispanics will experience underserved areas or populations that have too 187% growth and African Americans 71%; few primary care providers, high infant mortality, Hispanics and African Americans will comprise high poverty, or high elderly population (HRSA 24.4% and 14.6% of the population in 2050, 2017b). It is predicted that by 2025, there will be respectively (Colby and Ortman 2015; Okoro a shortage of 23,640 primary care physicians 2012). (general, family, and internal medicine) (HRSA Currently, over 33 million people speak 2016). Buerhaus et al. (2009) have predicted that Spanish in the USA, more than 10 million speak the imbalance in the supply and demand for another European language, and more than 8 mil- nurses will be worsened by the mass retirement lion speak an Asian language (Okoro 2012). of aging American nurses. The RN workforce is However, today’s health professional workforce expected to grow from 2.71 million in 2012 to does not proportionally reflect all racial and eth- 3.24 million in 2022, representing an increase of nic groups; whites comprise more than 80% of 19%. In 2022, 525,000 nurses will be needed to the health professional workforce. While Asian replace those who will retire, bringing a total of Americans are well represented in health careers, 1.05 million job openings to meet the increased the representation of African Americans, demand and replacement (AACN 2015). Hispanics, and Native Americans is much lower. Several studies have indicated that the insuf- When combined, these groups represent over ficient nurse staffing contributes to higher stress 30% of the US population, yet these minorities levels among nurses, which has a negative impact are underrepresented among physicians, regis- on their job satisfaction and retention, as well as tered nurses, dentists, pharmacists, and allied patient safety and survival (AACN 2015). health professionals (Valentine et al. 2016). Adequate nursing staffing was associated with decreased patient hospital stay, rehospitalization, infections, and mortality. Studies in 12 countries 31.3.5 Existence of Health Inequities in Europe, USA, and Canada found fewer patient deaths in intensive care units that were staffed There is mounting evidence of health disparities with higher percentages of nurses with baccalau- in access to health services and health outcomes reate degrees (Aiken et al. 2014). A consensus across population groups within the same region exists among consumers, nurses, physicians, and and across different nations. Worldwide, there is healthcare administrators regarding the signifi- overwhelming evidence demonstrating poorer cant impact of nurse staffing ratios on quality of health among those with lower socioeconomic care and patient outcomes (Aiken et al. 2012). status and groups who experience a history of The Institute of Medicine (2010) has called for systemic discrimination, marginalization, and increasing the numbers of baccalaureate and disempowerment. These groups are likely to live doctorally-prepared nurses to meet this need. in neighborhoods with meager resources and higher health risks as well as encounter prejudice and discrimination when accessing health ser- 31.3.4 Population Diversity vices (see Chap. 1). In the USA, racial and ethnic minorities com- The growing population diversity has highlighted prise the majority of people living in areas desig- the need for greater representation of racial and nated as health professional shortage areas ethnic minorities among healthcare professionals. (Mitchell and Lassiter 2006). According to the 31 Culturally Competent Multicultural Workforce 279

American College of Physicians (2010), minori- curiosity can be stimulated and employees are ties have less access to healthcare than whites motivated to learn more about other cultures. and receive poorer quality of care even when Knowledge of cultural differences can promote access-related factors such as insurance status tolerance in the workplace and implementation and income are controlled. For example, 34% of of work approaches that are informed by this Hispanics are uninsured as compared to 13% knowledge (Green et al. 2015). Exposure to dif- among whites, more minority women avoid doc- ferent viewpoints and cultures can build toler- tors’ visits because of cost, and racial and ethnic ance of different perspectives, which in turn can minority Medicare beneficiaries with dementia foster improved collaboration and cooperation. are 30% less likely than whites to use anti- Employees from diverse backgrounds thrive in an dementia medication. Compared to white organizational climate of inclusion and openness Americans, African Americans are less likely to (Mayhew 2017). The effectiveness of a diverse receive certain treatments, wait longer for kidney workforce depends on a climate of multicultural- transplants, are more likely to die from cancer ism that permeates every aspect of the organiza- from all causes, and have higher infant mortality tion (Greenberg 2004). rates. Hispanic and African Americans are more Organizations can draw from a greater variety likely to die from diabetes complications than of abilities offered by diverse employees, such as, white Americans (AACN 2014). multilingual proficiencies, and work-related Countries with universal access to health expertise and life experiences in other cultures. services have focused on social determinants Companies may benefit from a workforce with a and social inequalities to address health ineq- larger social network than just one ethnic group uity, defining the latter as avoidable and unfair that can generate an interest in providing prod- differences (see Chap. 1). By contrast, the USA ucts and services in many ethnic communities. lacks a universal program for accessing health- An organization providing goods and services care services. Hence, efforts have focused on that appeal to several ethnic groups is more likely increasing representation of racial and ethnic to be successful with workers who can communi- minorities in health professions, training, and cate with these groups. development of health practitioners and stu- Employees with diverse backgrounds can also dents in culturally competent care and changes improve global competitiveness of their organi- in organizational infrastructure and health zations because they are familiar with their own delivery. It should be noted that development country—the customs, traditions, and language of all healthcare practitioners and students in of the people. They can act as cultural brokers culturally competent care has been recom- and facilitate bridging with global customers mended by international and national stake- (Bovee and Thill 2008). Workforce diversity has holders alike. become a powerful tool for recruitment and retention of the best employees in order to sustain an organization’s competitive edge (Cadrain 31.4 Advantages 2008). An effective multicultural workforce can of a Multicultural Workforce increase an organization’s success, competitiveness, and adaptability in a global marketplace. A Multiculturalism in the workplace can create a multicultural workforce offers a greater pool of sense of cultural awareness among workers as talents, ideas, and work ethic that can enhance employees are exposed to different ideas and per- organizational effectiveness. spectives. Encounters with diverse perspectives Healthcare organizations gain these same can stimulate reflection on one’s own ways of benefits from a diverse workforce. A review of thinking and doing. Diverse viewpoints can gen- studies in healthcare by the US Health Resources erate new and innovative solutions (Lewis 2017). and Services Administration (HRSA 2006) As a result of exposure to cultural differences, revealed that patients are more likely to receive 280 D. Pacquiao quality preventive care and treatment when they Performance and productivity of human capital share race, ethnicity, language, and/or religious in the global market depends largely on the effec- experiences with their providers. A diverse tiveness of business communication and employ- workforce and the diverse perspective it provides ees’ competence in interpersonal communication, contribute many benefits, including enhanced intercultural sensitivity, and nonverbal communi- communication, increased healthcare access, cation (Nagourney 2008). By expanding avenues greater patient satisfaction, decreased health dis- for communication and providing ongoing feed- parities, and improved problem-solving for com- back, organizations can establish a culture that plex problems and innovation. Given a choice, values diversity in their employees (Hannay and racial and ethnic minority patients are more Fretwell 2011). likely to select health professionals of the same Another challenge is resistance from employ- racial and ethnic background as themselves. ees to accept and accommodate differences. Patients are more likely to report greater satis- Productive diverse teams require a robust organi- faction with care and higher quality of care zational leadership commitment to allocate received when they share a common racial and resources and create the infrastructure and man- ethnic background as well as language with their agement systems supportive of active participa- providers. Minority providers improve access to tion and success of diverse employees care in underserved areas more than nonminority (Kokemuller 2017). Organizational leaders have providers; they are more likely to practice in the daunting challenge of motivating and promot- underserved communities and care for large ing harmony among diverse employees while numbers of minority patients (HRSA 2006). facing challenges from the community and busi- Diversity in health professional educational ness competitors. environments improves the quality of education There are costs involved in cultivating an and ability to treat patients from different socio- effective multicultural workforce. Ongoing cultural backgrounds by broadening students’ development of managers and future leaders perspectives. Diversity improves learning out- among the diverse pool of employees can facili- comes, thinking and intellectual engagement, tate organizational adaptability to internal and motivation, social and civic skills, and empathy external challenges. There are associated costs to and understanding of racial and cultural differ- global recruitment, training, and development of ences (AACN 2015). diverse employees. There are costs associated with litigation involving internal workforce diversity and community diversity. Managers 31.5 Challenges of a Multicultural need to adapt to changing responsibilities and Workforce social norms by ensuring that practices are aligned with regulatory and legal provisions, e.g., As the workforce becomes increasingly global protection against sexual discrimination and and culturally diverse, organizations are chal- harassment, Equal Employment Opportunity, etc. lenged to communicate more effectively interper- (Greenberg 2004). sonally, interculturally, and in groups (Lauring A diverse workforce poses increased poten- 2011). Internal and external communication is tial for discrimination because when people essential for an organization to maintain its com- with obvious distinguishing traits are placed petitive edge and sustainable growth in a global together, employees with prejudices could use market. Perceptual, cultural, and language barri- them against others. Diversity management is ers need to be overcome for diversity to succeed. so critical to preventing such risks. Communication affects productivity and overall Organizations need to provide cultural aware- business performance, individually and in groups ness and sensitivity training to help create a (Gupta 2008). Ineffective communication results culture of tolerance and acceptance of differ- in confusion, lack of teamwork, and low morale. ences (Kokemuller 2017). 31 Culturally Competent Multicultural Workforce 281

31.6 Strategies for Building professional stakeholders (IOM 2010; Johnson Effective Multicultural and Johnson 2016). Healthcare Workforce To enhance admission of racial and ethnic minorities in medicine, the Sullivan Commission 31.6.1 Workforce Planning (2004), which is comprised of multiple healthcare and Development stakeholders, recommended using quantitative and qualitative criteria for admission to medical Public and private stakeholders worldwide have schools to enhance the competitive edge of racial called for the need for all nations to develop a and minority students who may not do as well in sustainable workforce. Measures are needed traditional measures for admission. To improve through global and multilateral agreement among the quality of pipeline schools in minority neigh- countries to prevent unethical manpower out- borhoods, several initiatives have evolved such as flows that endanger any country’s health. summer enrichment programs to improve Multilateral agreements among governments students’ proficiency in science, math, communi- should address ways to compensate for the loss cation, and critical thinking as well as awareness of financial investment in the education of health- of college-level expectations. Cooperative aftercare professionals and the negative consequences school and summer internship programs between on population health and healthcare services in high schools and local organizations connect stu- source countries. While migration of health pro- dents with mentors in health professions and fessionals has benefited their families and coun- expose them to different healthcare settings. tries through their remittances, these gains are Professional schools have created an infrastruc- hardly used for improviwng overall population ture to provide academic, financial, and psycho- health, healthcare infrastructure, and educational logical support for disadvantaged students. systems. Source countries are also accountable for their lack of policies promoting retention and engagement of health professionals in their own 31.6.2 Training and Development healthcare systems. A significant strategy recommended is Various chapters of this book (Chaps. 1–11) are improving the supply of sufficient numbers of focused in more detail on development of cul- students entering and graduating from health pro- tural competence among healthcare workers. fessions schools, particularly for racial and ethnic This section highlights the process of fostering minority students. Attracting racial and ethnic global citizenship outlook and skills critical to minorities should begin early by increasing culturally competent practices of healthcare awareness of communities of healthcare profes- workers. Developing cultural knowledge and sions and by engaging minority healthcare pro- awareness must emphasize empathic understand- fessionals in recruiting potential students. ing of the social and cultural contexts of people’s Healthcare organizations, including professional lives. Fostering the development of cultural curi- associations and schools, should develop long- osity in learners by communicating enthusiasm standing partnerships with primary and second- about knowing other cultures should be devel- ary schools, the media, and communities to oped early in education. Much influence is promote interest in healthcare professions. exerted by teachers and mentors who are keenly Partnerships among stakeholders in the public interested in cultural phenomena and diversity. and private sectors with health professionals can Curricular integration and selection of learning create sustainable programs and policies on experiences should be carefully planned to pre- recruitment and workforce development, such as vent marginalization of certain groups by build- the partnerships between the Institute of Medicine ing unquestioned superiority of others. Empathic and Robert Wood Johnson Foundation and and compassionate understanding is enhanced by between Johnson and Johnson and nursing using different methods of learning using videos, 282 D. Pacquiao case studies, home visits, travel-learn, etc. personal, social, environmental, and historical Listening to actual narratives by the people pro- factors must be considered in determining the vokes empathy and compassion among listeners. proper course of action. Peer mentors should be The method of instruction must move away trained and made available to facilitate individual from a listing of descriptions of people’s charac- level and unit level cultural competence. teristics and ways of life toward an understanding Development of intercultural communication of how social, environmental, and historical cir- is critical. Health workers deal with different lev- cumstances have shaped people’s life chances els and types of diversity in healthcare. Flexibility and current life situations. Stereotypes and mono- and adaptability are extremely important in inter- lithic generalizations of cultures should be actions. The ability to understand others, work avoided. Actual encounters, observations, and with human and material communication aids, experiences in different social contexts are supe- and reach diverse groups hinges upon one’s rior in promoting appreciation of the holistic con- knowledge of cultural differences, commitment text of people’s lives. Exposure of learners to to diversity and equity and available resources. diversity, disadvantaged communities, and Conflict management skills are essential in inter- diverse groups should be aimed at developing cultural communication as most conflicts are comparative knowledge of cultures and compas- associated with cultural differences. Training and sionate understanding of how and why certain actual practice in advocacy skills to identify, people live differently. Teachers and mentors question, and challenge injustices in the work- should facilitate discovery of hidden forces that place should be provided. Promoting trust and contribute to how people behave and live. For cooperation requires the ability to create bonds example, learning health disparities must not be and attachments emphasizing similarities with limited to morbidity and mortality but should others, recognizing and bridging differences, and promote understanding of why certain groups building mutual capacity by linking with appro- have fewer resources and have greater health lia- priate social networks. Conflict management is a bilities than others; learners must be made aware significant skill to develop as many conflicts arise that poor health is not merely caused by poor from sociocultural differences. Training should genes or unhealthy life choices. be provided in negotiation, cultural brokering, Critical reflection can be facilitated by open and helping others navigate the healthcare sys- and respectful dialogue focusing on critiquing tem. Multilevel and interprofessional communi- and challenging individual opinions. This is built cation skills should emphasize the skills of upon the foundation that each one has value and collaboration, role clarification, and leadership to a positive contribution to the collective wisdom resolve conflicts and enhance patient/family- and decision. Honest and genuine dialogue centered communication (Arain et al. 2017). should be facilitated in order to challenge individual opinions and come up with equitable solutions. The potential impact of recommended 31.6.3 Global Citizenship Values solutions must be examined thoroughly to develop a full understanding of the consequences A critical foundation of culturally competent of each solution on individuals, families, organi- practice is the development of a global outlook zations, and communities. and global citizenship skills. Reysen and Teachers and mentors must model the learn- Katzarska-Miller (2013) define global citizen- er’s role and the value of humility to facilitate ship as “awareness, caring, and embracing cul- growth and mutual respect among learners. This tural diversity while promoting social justice and approach builds trust essential for openness and sustainability, coupled with a sense of responsi- acceptance of differences. While standards for bility to act” (p. 858). As global citizens, indi- practice are essential to follow, these should not viduals have a keen awareness of global trends blindly dictate actions and decisions. Rather, the and issues, appreciate the interconnectedness 31 Culturally Competent Multicultural Workforce 283 among people, and position themselves within a activate the human potentialities in both the larger global context (Cesario 2016). Global citi- advocates and those who are advocated for zens are self-actualized in inherently synergistic (Freire 2000). Empathy allows a deeper apprecia- values such as the desire for relatedness and com- tion of experiences and feelings of others, includ- passion for others (Cooper 2016). Relatedness ing both people who experience oppression and allows for the flourishing of the values of mutual- the oppressors. Compassion allows the practitio- ity and care for others and rejection of oppressive ner to accept another person’s humanity, even or exploitative relationships. when their position as an oppressor or oppressed person is not understandable. Empathy and compassion draw humans together. By helping peo- 31.6.4 Valuing Diversity ple trust, recognize, and articulate their true feelings and experiences along with developing Global citizens have an empathic understanding skills for dialogue and negotiation (Cooper et al. of the feelings and experiences of others, includ- 2012), advocacy for social justice can be informed ing both people who experience oppression and by the context in which injustice occurs and the oppressors (Lemberger and Lemberger- allow best practices for advocacy and empower- Truelove 2016). Empathy and compassion draw ment to occur (Ratts et al. 2016). humans together, building meaningful and transformative connections and social capital. Global citizens have actualized their “wants” that may 31.6.6 Recruitment and Retention be dysergistic in nature such as the quest for individual competence, success, and uniqueness The best recruitment strategy is generated from toward more prosocial values of mutual trust and the positive testimonial from employees and con- reciprocity. Dysergistic wants can be tempered sumers of care. Racial and ethnic groups tend to by the principle of equifinality that accepts the gravitate toward members of their own group and multiple ways by which problems can be solved seek care from organizations that value their cul- and the myriad ways by which individuals can ture and understand their language and commu- achieve (Cooper 2016). Cultural heterogeneity nication. Job promotion and recognition of provides a means whereby each person can actu- minority employees are positive advertisements alize their authentic being as a unique and dis- for recruitment of diverse workforce and con- tinctive person by tapping into their unique sumers. As organizational leaders, they can serve traditions and wisdom to build on the wisdom of as mentors and role models for their group. others. Cultural heterogeneity allows people to Capitalizing on the cultural identity and commu- actualize their desires for competence and sig- nity affiliation of diverse employees can establish nificance without undermining these in others. the link between the community and the organization. By engaging diverse staff, consumers, and communities, the organization can benefit from 31.6.5 Commitment to Social Justice their input in recruiting potential employees, develop interest in health professions in their Social justice is grounded in the principles of community, and improve its services. Partnering human rights and equality, consistent with soci- with local schools (secondary and collegiate) by etal efforts to provide equitable treatment and a offering cooperative work experiences, intern- fair allocation of health resources to all citizens ships, and clinical affiliations can generate long- (Matwick and Woodgate 2017). Understanding, term interest and commitment in students to work respecting, and valuing of existing diversity is the in the organization. foundation that enables global citizens to chal- A diverse workforce flourishes in an organiza- lenge injustice and take action in personally tional climate that values expressions of diversity meaningful ways (Jones 2016). True justice must and using diversity to develop innovative practices 284 D. Pacquiao that others can support. Organizational leaders others. Understanding cultural differences among should develop the structure and management all staff and administrators promotes develop- systems supportive of diversity. Further discussion ment of empathy and compassion for others. In of leadership strategies to promote this organiza- this environment, mutual trust, reciprocity, and tional climate is presented in Chap. 10. engagement with others thrive. Organizational investment in continuing education of employees for advanced degrees nur- Conclusion tures loyalty and commitment of employees to The value of workforce diversity has been doc- stay in the organization. Management systems umented in studies in businesses, healthcare, built on fairness, respect, and appreciation of and education. In healthcare, language and diversity contribute to a sense of value and racial/ethnic concordance between health pro- belonging among diverse staff. Organizational viders and patients have positive impact on leaders, mentors, and preceptors should have patient’s health behaviors, satisfaction with training in advocacy for these values. Orientation care, and access to care. However, the approach of new staff should include not only the technical to increase the proportional representation of aspects of their work but also the culture of the diverse patients among healthcare profession- organization and the community in which it is als is challenged by market forces, globaliza- nested. Concrete explanations with demonstration, and increasing movement of populations tions of policies and protocols of care will mini- across the world. Therefore, training and devel- mize confusion and misinterpretation for opment of all health professionals and students multicultural staff. Soliciting feedback of diverse in culturally competent care must be instituted employees in a non-threatening way will enhance while continuing efforts to recruit and graduate their security and sense of belonging as well as large numbers of diverse health professionals. increase their participation in unit decisions. Culturally competent practice in a diverse Staff retention is enhanced by how employees world with long-standing disparities in health- fit within the organization. Organizational norms care access and outcomes that impact more and cultural nuances are best learned through negatively the disadvantaged and diverse minor- bicultural mentors who can nurture multicultural ities should be grounded in the values of global perspectives within the context of the organiza- citizenship. The model presented in Chap. 1 tion and the community. Training and modeling emphasizes the need for healthcare profession- of professional behaviors (communication, con- als grounded with a compassionate understand- flict management, decision-making, etc.) for ing of social inequities that impact health. It diverse employees require a concerted effort by requires commitment to the principles of social all staff. This is particularly important for nurses justice, equity, and human rights protection. who were socialized in a hierarchical culture and Cultural competence can assist in transforming gender-differentiated behaviors. Training should vulnerable groups when it is grounded in these include both oral and written expression particu- principles. Culturally competent healthcare pro- larly for those who are nonnative speakers of the fessionals have a common grounding in a global mainstream language of the culture. citizenry emphasizing a collective outlook that Advocacy for diverse staff with aggressive respects and treats others as part of oneself and patients and abusive co-workers should be fos- a common humanity. Global citizenship is built tered as well as assist their development of self- on empathy and compassion for others that can advocacy skills. Many cultures across the globe foster common bonds and social connectedness do not value assertiveness and confrontation; for a common good—promote well-being and hence healthcare professionals from these cul- health of everyone. Cultural competence devel- tures need to learn the cognitive, expressive, and opment must be centered on building inherent emotional components of this interactive style. prosocial tendencies to be connected with oth- Effective communication enhances achievement ers in a climate of mutual trust and respect that of desired outcomes and ability to influence transcends cultural differences. 31 Culturally Competent Multicultural Workforce 285

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Louise Racine

Anita is a 21-year-old nurse who recently com- and technology. Following this orientation, Anita pleted her baccalaureate in nursing from a nurs- was matched with a Canadian nurse mentor for 2 ing school in Manila. Anita has aspired to pursue full weeks. Nurses in this tertiary care hospital a nursing career abroad to avail of better working perform 12-h shifts. Anita completed the train- conditions, better pay, and a chance to pursue ing, and the mentor informed the head nurse higher nursing education. She decided to immi- (nurse manager) that Anita was secure enough to grate to Canada and settle in a western Canadian practice without direct supervision by a province. She needed to have her credentials colleague. reviewed and approved by a provincial regulatory Anita seems to perform quite well but has fre- body to determine her eligibility to take the quently been observed by the head nurse to talk Canadian licensure exam (NCLEX) for entry to in her native language, Tagalog, with her Filipino practice as a registered nurse/RN in Canada. colleagues on the unit. Her co-workers and other Anita passed her NCLEX exam. She benefitted nurses have been irritated by this behavior and from the financial support of her Canadian complained to the nurse in charge of the unit. employer. The employer paid Anita’s fees to Anita and her colleagues were reminded to speak write her NCLEX as it did for all recently hired in English during working hours to prevent con- internationally educated nurses. The employer flicts with other nurses. More recently, Anita provided a 6-month allowance to pay Anita’s encountered a problem with a patient. She needed rent. Anita stays in a rented apartment with other to draw a blood sample from a central intrave- Filipino nurses. Anita has very few Canadian nous port line. After the nurse manager received friends outside work. Anita is fluent in English, a complaint from the patient, she asked Anita and and she does not have problems communicating her mentor to come to her office. The nurse man- with her patients in English. ager stated: Anita was hired in an urban hospital to work For instance, let’s say they [Filipino nurses] are on a surgical care unit of 40 beds. Her employer asked to take a sample from a port line. They say, provided her with 1-week orientation training Yes. Yes. I know. I know. Yes. Yes. Then the patient where she and other internationally educated comes to my office and tells me, I do not think Anita knows how to access the port line. Other nurses learned policies, protocols, equipment, nurses do it another way. They [Filipino nurses] will not admit to not knowing how to do the proce- L. Racine, Ph.D.,C.N.M.,F.A.C.N.M., FAAN dure. Instead, the patient comes to tell me. Why College of Nursing, University of Saskatchewan, have you not told me that you were uncomfortable Saskatoon, SK, Canada performing that technique? e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 287 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_32 288 L. Racine

The nurse manager has assumed that interna- problems of cultural incompetency within tionally educated nurses will not disclose prac- health organizations and nursing workplaces tice skills deficit reflecting their lack of (Douglas et al. 2014; Racine 2014). professional accountability. This behavior has been attributed by the nurse manager and other nurses to the internationally educated nurses’ 32.1 Social Structural Factors fear of losing their jobs and being forced to return to their country. If procedures and techniques are Nurse migration is a trend not likely to decrease not adequately followed, this creates risks to in the coming years as migration is a human patient safety and quality of care. While failure to right. Furthermore, some supplying countries disclose lack of practice skills also arises among train their nurses for export to high-income domestic trained nurses, the attribution is only countries for economic purpose. Workplace applied to internationally educated nurses, creat- diversity is becoming increasingly important in ing a major risk of othering internationally edu- healthcare settings in the United States, Canada, cated nurses based on an ethnocentric bias. and other Western nations. As the nursing work- Othering is a process of social stratification by force and demographic patterns change, it is which the color of the skin (race) or other attri- important for nurses to understand cultural butes (speaking English with a foreign accent) diversity in nursing and health workplaces. The are used to marginalize culturally different peo- Sullivan Commission on Diversity in the ples (Racine 2003). Canales (2010) argues that Healthcare Workforce report (2004) underlines othering is both exclusionary and inclusionary three principles for increasing diversity within “often using the power within relationships for health and nursing workforce in the United domination and subordination with the potential States. These principles are designed to: (1) consequences of alienation, marginalization, increase ethnocultural diversity in the health decreased opportunities, internalized oppression, workforce through hiring and retention of minor- and exclusion” (p. 5). ity peoples, (2) facilitate and implement changes The case study reveals how important it is for within health organizations to support ethnocul- nurses to understand the interplay of race, gen- tural diversity, and (3) promote openness to der, and social class within health workplaces in explore new and nontraditional paths to nursing general and nursing workplaces in particular. and allied health professions. O’Brien-Pallas et al. (2007) suggest that inter- Globalization brings increased ethnic and nationally educated nurses experience more cultural diversity within healthcare organiza- physical and emotional abuse in the workplace tions that affects the way nurses deliver care and than Canadian nurses. Issues of “everyday rac- how they interact with nurses coming from other ism” (Essed 1991) have been documented countries. More than ever, nurses must be cultur- within Canadian nursing workplaces (Beaton ally competent and safe in their everyday prac- and Walsh 2010; Calliste 1993; Das Gupta 2009; tice regardless of the health settings in which Newton et al. 2013; Racine 2009; Reimer they work. Cultural competency and cultural Kirkham 2003; Ronquillo et al. 2011; Salami safety are key skills for nurses to acquire and and Nelson 2014). Also, instances of racism and sustain. The International Council of Nurses ethnocentrism have been reported within inter- (2013), Canadian Nurses Association (2015), national nursing work contexts (Bae 2011; Canadian Association of Schools of Nursing Huria et al. 2014; Mapedzahama et al. 2012; (2014), American Nurses Association (1998), McKillop et al. 2013; Puzan 2003; Schroeder American Organization of Nurses Executives and DiAngelo 2010). Racism in nursing does (2015), and the US Department of Health and not represent a new phenomenon per se, yet lit- Human Services (2017) are among the major tle progress has been made in eliminating regulatory nursing bodies and health 32 Case Study: Internationally Educated Nurses Working in a Canadian Healthcare Setting 289 organizations that recognize the moral and ethi- 32.2 Cultural Competency cal duty of nurses to advocate and provide culturally competent care. Cultural competency is a concept that arises Cultural diversity implies the notion of cul- from the seminal work of Madeleine Leininger tural differences which means how individuals who trained as a nurse and an anthropologist and groups vary based on some ethnic, racial, and (McFarland and Wehbe-Alamah 2017). cultural attributes. Andrews and Boyle (2012) Leininger (2002) postulates that “culture is an define diversity as “differences in race, ethnicity, integral and essential aspect of being human, and national origins, religion, gender, sexual orienta- the culture care aspects cannot be overlooked or tion, ability or disability, social and economic neglected” (p. 4). Campinha-Bacote (2002) status or class, education, and related attributes of defines cultural competency as an “ongoing pro- groups of people in society” (p. 5). The notion of cess in which the health care provider continu- diversity creates the need for nurses to become ously strive to achieve the ability to effectively culturally knowledgeable and conscious of their work within the cultural context of the client attitudes toward people from other ethnocultural [individual, family, and community]” (p. 181). groups. The concepts of race and ethnicity are Campinha-Bacote (2002) builds on the assump- often conflated and emerge as problematic issues tion that cultural competency is an ongoing pro- arising from cultural conflicts or misunderstand- cess of being and becoming. She describes five ings between individuals and groups. It is there- interrelated concepts: (1) cultural awareness, (2) fore, important to understand the differences cultural knowledge, (3) cultural skill, (4) cultural between ethnicity and race. encounters, and (5) cultural desire. Campinha- Ethnicity and race constitute different con- Bacote (2002) underlines that to be effective, cepts, although they may overlap. Eriksen (2010) this model “requires health care providers to see defines ethnicity as “the relationships between themselves as becoming culturally competent groups whose members consider themselves dis- rather than already being culturally competent” tinctive” (p. 10). Belonging to an ethnic group (p. 181). may be used to categorize individuals and groups On top of being culturally competent with based on some norms or values that can cause their practice with individuals and groups, nurses prejudice. This phenomenon is called ethnocen- must also become aware of power relations trism. Ethnocentrism refers to a “universal ten- within their workplaces. Becoming aware of dency of human beings to think that their ways of power differentials associated with race, gender, thinking, acting, and believing are the only right and social class represents the first step toward and proper ways” (Purnell 2013: 7). becoming culturally safe. Cultural safety origi- Race refers to “a group of human beings nates from the groundbreaking work of Irihapeti socially defined by physical characteristics. Ramsden, a Maori nurse who described the per- Determining which characteristics constitute a sistent inequities affecting indigenous peoples of particular race, the selection of markers and, New Zealand (Nursing Council of New Zealand therefore, the construction of the racial category 2011; Ramsden 1993). Cultural safety is defined itself, is a choice human beings make” (Cornell as “nursing or midwifery action to protect from and Hartmann 2007: 25). Purnell (2013) argues danger and/or reduce risk to patient/client/com- that “race as a social meaning, assigns status, munity from hazards to health and well-being” limits or increases opportunities, and influences (Papps and Ramsden 1996: 493). While cultural interactions between patients and clinicians” competency helps us to understand other people’s (p. 8). Race can be used as a means of stratifica- attitudes and behaviors, nurses also need to tion through social and cultural othering where understand the limitations of systemic barriers in discrimination arises from the “visibility of one’s maintaining health and social inequities. Cultural Otherness” (Canales 2010: 5). safety requires nurses to be aware of power 290 L. Racine relations in their interactions with individuals, where technology may be limited as compared groups, communities, or colleagues at work. to that of Western countries. The delivery of culturally competent care is a • Document the practice skills and ensure that fundamental standard of ethical practice set by international nurses disclose lack of knowl- international and national nursing regulatory bod- edge or skills to create a culture of patient ies. The International Council of Nursing (2013) safety. mentions that “in providing care, the nurse pro- • Domestic-educated nurses need to receive cul- motes an environment in which the human rights, tural competency training to prevent the harm- values, customs and spiritual beliefs of the indi- ful effects of racism and ethnocentrism in vidual, family, and community are respected” stereotyping ethnocultural groups based on (p. 2). In a position statement on discrimination one individual’s actions. and racism in health care, the American Nurses • International nurses need to know the health- Association (1998) underlines that nurses must care system, the official language, and the cul- strive to eradicate discrimination within health tural norms of the receiving countries. workplaces and guide practice from a social jus- • Provide international nurses the opportunity tice perspective. Similarly, an expert panel for to speak their languages while ensuring that it Global Nursing and Health established by the does not create conflicts at the workplace or American Academy of Nursing and members of interfere with patient care. the Transcultural Nursing Society (2010) report • Pair up international nurses with another inter- the need to apply universal standards of practice national nurse of the same ethnocultural group for culturally competent nursing care in the world. who has successfully integrated in the unit and Arising from that report, Douglas et al. (2014) the healthcare organization. underline the need for nurses to apply Guideline 8 to support a multicultural workforce. The ongoing issue of nurse migration illustrates the need for 32.3.2 Organization Level health agencies to develop strategies to address Interventions cultural conflicts and support internationally educated nurses in their adaptation to their new work- • Develop programs of mentoring for interna- ing environment (Douglas et al. 2014). tionally educated nurses to support their social, cultural, and professional integration. • Develop a policy of zero tolerance of racism 32.3 Culturally Competent and other forms of discrimination based on Strategies Recommended gender, social, class, sexual orientation, disability, religion, language, or ethnicity at Internationally educated nurses from middle- and work. low-income countries need to be mentored and • Develop a charter of rights that apply to all supported in the receiving countries. Based on levels of the organization and staff. Anita’s case study, the following recommenda- • Make cultural competency a shared value of tions are likely to facilitate the creation of a mul- the organization. ticultural workforce and strengthen the • Create activities to support the celebration of recruitment and retention of a culturally diverse cultural diversity. nursing labor force. • Implement professional development activities geared toward developing cultural competency and cultural safety skills within 32.3.1 Individual Interventions the organization. • Facilitate the reporting of discrimination at • Be aware that international nurses may have work and support initiatives to prevent and been educated in different healthcare settings address discrimination in the workplace. 32 Case Study: Internationally Educated Nurses Working in a Canadian Healthcare Setting 291

• Create a positive work environment to avoid http://www.tcns.org/files/Standards_of_Practice_for_ discrimination and bullying that can affect Culturally_Compt_Nsg_Care-Revised_.pdf American Nurses’ Association (1998) Discrimination and international nurses’ job satisfaction and work racism in health care. Position statement. http://www. relations. nursingworld.org/MainMenuCategories/Policy- • Acknowledge that race relations must be man- Advocacy/Positions-and-Resolutions/ANAPosition aged to avoid disrupting the mission of the Statements/Position-Statements-Alphabetically/ Copy-of-prtetdisrac14448.html organization. American Organization of Nurse Executives (2015) AONE • Equip nurses, healthcare practitioners, and Nurse manager competencies. Author, Chicago, IL staff with conflict management training. Andrews MM, Boyle JS (2012) Transcultural concepts • Support policy development and interventions in nursing care, 6th edn. Wolters Kluwer, Lippincott, Williams & Wilkins, Philadelphia, PA to increase cultural competency and safety in Bae SH (2011) Organizational socialization of interna- health care. tional nurses in the New York metropolitan area. Int • Develop collaboration between ethnic com- Nurs Rev 59:81–87 Beaton M, Walsh J (2010) Overseas recruitment: expe- munities, professional organizations, and riences of nurses immigrating to Newfoundland and healthcare regulatory bodies to formulate cul- Labrador. Nurs Inq 17(2):173–183 turally competent care delivery through multi- Calliste A (1993) Women of exceptional merits: immi- cultural workforce. gration of Caribbean nurses to Canada. Can J Women Law 6:85–102 • Organize coalitions to promote recruitment, Campinha-Bacote J (2002) The process of cultural com- graduation, and hiring of multicultural work- petence in the delivery of healthcare services: a model force in health care. of care. J Transcult Nurs 13(3):181–184. Canadian Association of Schools of Nursing (2014) Position statement: education of registered nurses in Conclusion Canada. Author, Ottawa, ON The twenty-first-century context of globaliza- Canadian Nurses Association (2015) Promoting cultural competency in nursing. Position statement. Author, tion, massive displacements of refugees from Ottawa, ON low-income to high-income countries, and Canales MK (2010) Othering: difference understood? A nurse migration compels nurses to apply cul- 10-year analysis and critique of the nursing literature. tural competency knowledge and cultural Adv Nurs Res 33(1):15–34 Cornell S, Hartmann D (2007) Ethnicity and race. Making safety attitudes within health workplaces. identities in a changing world, 2nd edn. Pine Forge Although many efforts to achieve culturally Press, Thousand Oaks, CA competent and safe practices (Racine 2014) Das Gupta T (2009) Real nurses and others. Racism in have been defined, much actions need to be nursing. Fernwood, Halifax, NS Douglas MK, Rosenkoetter M, Pacquiao DF, et al (2014) done as internationally educated nurses still Guidelines for implementing culturally competent face discrimination within Western countries’ nursing care. J Transcult Nurs 25(109). https://doi. healthcare systems (Mortell 2013). Nurses org/10.1177/1043659614520998 have an ethical duty to respect other persons’ Eriksen TH (2010) Ethnicity and nationalism. Anthropological perspectives, 3rd edn. Pluto Press, and groups’ cultural beliefs related to health London and illness. Respect of otherness intersects Essed P (1991) Understanding everyday racism. An inter- with culture and cultural competency to move disciplinary theory. Sage, Newbury Park, CA beyond the boundaries of race and ethnicity to Huria T, Cuddy J, Lacey C et al (2014) Working with racism: a qualitative study of the perspectives of Maori the culturally different other in a humanistic (Indigenous Peoples of Aotearoa New Zealand) regis- and caring way (Andrews and Boyle 2012). tered nurses on a global phenomenon. J Transcult Nurs 25(4):364–372 International Council of Nurses (2013) Position statement of cultural and linguistic competence. http://www.icn. References ch/images/stories/documents/publications/position_ statements/B03_Cultural_Linguistic_Competence.pdf American Academy of Nursing & the Transcultural Leininger M (2002) Culture care theory: a major contribu- Nursing Society (2010) Standards of practice for cul- tion to advance transcultural nursing knowledge and tural competent nursing care. Executive summary. practices. J Transcult Nurs 13(1):189–192 292 L. Racine

Mapedzahama V, Rudge T, West S, et al. (2012) Black Racine L (2003) Implementing a postcolonial feminist nurses in white space? Rethinking the in/visibility of perspective in nursing research related to non-Western race within Australian nursing workplace. Nurs Inq, populations. Nurs Inq 10(2):91–102 19(2): 153–164. Racine L (2009) Haitian-Canadians’ experiences of rac- McFarland MR, Wehbe-Alamah HB (2017) The theory of ism in Quebec; a postcolonial feminist perspective. In: cultural care diversity and universality. In: McFarland Agnew V (ed) Racialized migrant women in Canada. MR, Wehbe-Alamah HB (eds) Leininger’s transcul- Essays on health, violence, and equity. University of tural nursing: concepts, theories, research and prac- Toronto Press, Toronto, ON, pp 265–274 tice, 4th edn. McGraw-Hill, New York, pp 1–35 Racine L (2014) The enduring challenge of cultural safety McKillop A, Sheridan N, Rowe D (2013) New light in nursing. Can J Nurs Res 46(2):6–9 through old windows: nurses, colonists, and indig- Ramsden I (1993) Cultural safety in nursing education in enous survival. Nurs Inq 20(3):265–276 Aotearoa (New Zealand). Nurs Prax N Z 8(3):4–10 Mortell S (2013) Delving into diversity-related conflict. Reimer Kirkham S (2003) The politics of belong- Nurs Manag 44(4):28–33 ing and intercultural health care. West J Nurs Res Newton S, Pillay J, Higginbottom G (2013) The migra- 25(7):762–780 tion and transitioning experiences of internationally Ronquillo C, Boschma G, Wong ST et al (2011) Beyond educated nurses: a global perspective. J Nurs Manag greener pastures: exploring contexts surrounding 20(4):534–550 Filipino nurse migration in Canada through oral his- Nursing Council of New Zealand (2011) Guidelines for tory. Nurs Inq 18(3):262–275 cultural safety, the Treaty of Waitangi and Maori Salami B, Nelson S (2014) The downward occupational health in nursing education and practice. Author, mobility of internationally educated nurses to domes- Wellington, NZ tic workers. Nurs Inq 21(2):153–161 O’Brien-Pallas L, Tomblin Murphy G, Birch S et al (2007) Schroeder C, DiAngelo R (2010) Addressing whiteness Health human resources modelling: challenging the in nursing education. The sociopolitical climate proj- past, creating the future. Canadian Health Services ect at the University of Washington school of nursing. Research Foundation, Ottawa, ON Adv Nurs Sci 33(3):244–255 Papps E, Ramsden I (1996) Cultural safety in nursing: Sullivan Commission on Diversity in the Healthcare the New Zealand experience. Int J Qual Health Care Workforce (2004) Missing persons: minorities in the 8(5):491–497 health professions. The Sullivan Alliance to Transform Purnell LD (2013) Transcultural health care. A culturally the Health Professions, Alexandria, VA competent approach. F.A. Davis, Philadelphia, PA U.S. Department of Health and Human Services (2017) Puzan E (2003) The unbearable whiteness of being in The National CLAS Standards. The Office of Minority nursing. Nurs Inq 10(3):193–200 Health. https://minorityhealth.hhs.gov/omh/ Case Study: Recruitment of Philippine-Educated Nurses 33 to the United States

Leo Felix Jurado

Twelve nurses from the Philippines were grocery shopping. This experience was stressful recruited by an agency for a long-term care facil- as it entailed much expense and the winter ity at a suburban area in the southern region of weather was particularly difficult for newcomers Midwestern United States. The nurses signed a from a tropical country. Some Filipino nurses in contract with the agency in the Philippines stipu- the facility offered them a ride when they worked lating the following: (a) a minimum of 2-year the same schedule. When they inquired from the employment at the facility, (b) advanced payment recruitment agency about the free transportation, by the agency for their airfare with the amount to they were informed that the contract they signed be deducted from their salary over a period of 1 was recently revised. year, (c) free accommodation in a furnished Upon receipt of their first paycheck, the nurses apartment and transportation to and from work discovered that their hourly rate was five dollars for the first 3 months of employment, (d) agency less than what was written in their contract in will facilitate processing of necessary papers for addition to the automatic deduction for their air- employment (social security cards and RN fare. They were not paid differentials for working license), and (e) differential pay for working dur- off shifts and weekends. Half of them worked on ing evenings and night shifts and weekends. evenings, and the other half worked on night The nurses arrived during the winter month of shifts. The nurses also found out that they have to February and were housed in a two-bedroom pay about 200 dollars from each paycheck for unfurnished apartment two miles away from the health coverage. facility. None of them confronted the recruiting The nurses realized that the recruitment agency about their housing. They all started agency reneged on the terms of the contract they working a month upon arrival after obtaining signed in the Philippines. They requested to meet their social security cards and RN licenses except with the agency administrator but were denied for five nurses who agreed to work as nursing each time they called the agency. When the nurses assistants while waiting for their RN licenses that threatened to resign en masse, the administrator took 6–8 weeks. Because they were not provided sent them a letter stating that they will have to assistance with transportation, the nurses used a pay $30,000.00 each to breach the contract. The taxicab or walked in bitter cold to work and for nurses were also concerned that their immigration papers (green cards) were kept by the agency L. F. Jurado, Ph.D., R.N., APN, FAAN as they used the agency’s address to apply for Department of Nursing, William Paterson University, immigration. They had legal documentation to Wayne, NJ, USA enter and work in the United States. e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 293 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_33 294 L. F. Jurado

The nurses also experienced challenges at Kingdom, Australia, New Zealand, and other work. Oftentimes, the staffing was so inadequate Asian countries (Singapore and Japan) (Brush increasing their workload from 15–20 residents and Sochalski 2007; Choy 2003; Jurado and to 30 residents per nurse. Some of the nurses Pacquiao 2015). Emigration is motivated by eco- found some of the nursing assistants to be unco- nomic, social, and political factors. Governmental operative and argumentative. When asked for and private institutions in the Philippines and the assistance, some nursing assistants refused United States have facilitated the emigration of because they were busy or were missing from the Filipino nurses. Immigration policies have helped unit for long periods of time. To avoid conflict, ease the nursing shortages in the United States. the nurses did not report them to the nurse man- The Philippine government has pushed emigra- agers or supervisors. Often, the nurses did not tion by production of nurses primarily for export finish their tasks at the end of the shift and were because of very limited employment opportuni- told that they will not be paid overtime. ties in the local market; dollar remittances from Nevertheless, they continued working beyond overseas workers significantly contribute to the their shift until the tasks were completed. nation’s ability to pay for its foreign debt (Jurado The hardships at work and in their living con- 2013). ditions took a toll on the nurses. Four of them left their employment after only 6 months and lived with their relatives in other states without ever 33.2 Cultural Factors receiving their green cards from the agency. Two nurses reached out to the local chapter of the The family-centered social structure of Filipinos national organization of Filipino nurses plays a major role in the emigration of nurses to (Philippine Nurses Association of America) for developed countries. The family is a major influ- help. The national organization investigated their ence in the career choice of their children and in complaint and referred them to a law firm. After propagating the idea that working abroad is a legal pursuit, all the nurses were able to get out of pathway to help the entire family back home. their contract without paying any fees for breach Filipinos view education as key to economic suc- of contract and received restitution from the cess. The educational achievement of children recruitment agency. enhances the family’s well-being and reputation in the community. Success of the children in finding lucrative employments abroad means support 33.1 Social Structural Factors for the family through remittances sent back home to assist siblings in pursuing their educa- Internationally educated nurses (IENs) will con- tion and the family’s economic well-being tinue to contribute to the multicultural workforce (Jurado 2013). in the United States and globally. They bring At least 81% of Filipinos are Catholics (Pew diversity in the workplace because of their vari- Research Center 2015) who believe in the power ant knowledge, skills, and caring approaches. of God to resolve problems (Fuchs 1967). The According to NCSBN (2017), the Philippines Filipino value of bahala na (bathala or God in tops the list, followed by India, among IENs that Tagalog) is attributed to their strong religious sit for the licensing exams during the past 5 years. belief manifested in the common philosophical Other countries supplying IENs to the United expression used when confronted with problems States include Puerto Rico, South Korea, Jamaica, (Morgan 2013), “come what may; whatever will and Canada. be, will be; or leave it to God.” Filipinos tend to Filipino nurses comprise the largest group of accept what comes their way, appreciate what emigres to the United States and other developed they have, and leave the rest to God, believing countries including the Middle East, the United that God is on their side if they give their all. This 33 Case Study: Recruitment of Philippine-Educated Nurses to the United States 295 belief may be viewed negatively because of the in public or to have an outburst is considered dis- tendency to avoid conflict, accept status quo, or graceful and can result to “loss of face.” In gen- rely on others to solve their problems. On the eral, the emphasis of communication is on other hand, it can be positive because it gives maintaining smooth personal relationships them strength and confidence to endure and be (Jurado 2013; Pacquiao 2003). buoyed by the hope that everything will turn out for the best if God wills it. Filipino culture emphasizes utang na loob 33.3 Culturally Competent (debt of gratitude), a debt of gratitude for those Strategies Recommended who have sacrificed or performed deeds on ones’ behalf. A son or daughter has utang na loob to IENs have been a part of the US multicultural their parents, and it is the child’s obligation to healthcare workforce since the exchange visa return the favor as the parents grow older. Utang program was initiated in 1948 (Choy 2003). na loob has a deeper meaning as it reflects shar- Organizations that embrace diversity find that ing of one’s kapwa (personhood) with others. there are several benefits of a multicultural Failure to reciprocate the kindness and good workforce. Employees from different back- deeds of others is tantamount to losing face or grounds bring a rich array of skills, experiences, hiya, which can bring shame to oneself, one’s and different cultural viewpoints that can be family, or community (Flores 2012; Hays 2015). advantageous to an increasingly diverse popula- Collectivistic societies like the Philippines tion of consumers. Business companies with a often use high-context communication. Filipinos more diverse workforce have noted that when have a particular way of behaving in different diverse employees are more inspired to perform situations. Among insiders (fellow Filipinos or in their highest potential, there is greater pro- in-group), the expectation is to speak in a com- ductivity and return of investment (Greenberg mon language familiar to the group; communica- 2004). tion tends to be implicit and indirect without having to elaborate. Nonverbal communication speaks louder than words. In contrast, individual- 33.3.1 Individual-Level Interventions istic cultures like the Western world, low-context communication is predominant. Direct, explicit, • Support initial adaptation of IENs to the new and more elaborate communication is common. environment (e.g., the University of The goal of high-context cultures is to maintain Pennsylvania Model Transition Program for harmony, while the goal of low-context cultures IENs (Adeniran et al. 2008). The transition is the giving and getting of information (Storti program should include: and Bennhold-Samaan 1997). –– Providing support for relocation (initial Filipinos avoid direct confrontation by keep- housing, heating, telephone, transportation, ing calm and controlling emotions until a crisis appropriate clothing for winter, etc.) develops and the situation becomes intolerable. –– Ensuring safety of IENs who are more This is demonstrated in the case study by the likely to work on off shifts and walking to Filipino nurses’ behavior toward the recruitment work or home agency and nursing assistants they worked with. –– Designating a responsible person with They prefer harmony and conflict avoidance and whom IENs can seek help during rely upon others such as the Philippine Nurses emergencies Association of America to intervene on their –– Connecting IENs with support groups at behalf. Maintaining “face” and upholding an work and in the community (churches, individual’s reputation is a significant cultural ethnic grocery stores, Filipino workers and trait among Filipinos. To disagree with someone organizations, etc.) 296 L. F. Jurado

• Implement comprehensive and adequate ori- 33.3.2 Organizational-Level entation for IENs to develop their understand- Interventions ing of: –– Own cultural values and those of • Develop a job orientation curriculum with co-workers input from other Filipino IENs, organizations, –– American dominant and variant cultural and multidisciplinary staff, and use evidence values and organizational values/ from relevant research including regulatory expectations and accreditation requirements, organizational –– Differences in communication styles, con- policies and procedures, professional and flict management, and professional variant communication patterns (slang, com- communication mon idiomatic expressions, jargon, and collo- –– Differences in care modalities (technology, quial terms), care technology, nutrition, nutrition, drugs, diagnostics, etc.) pharmacology, managing psychiatric patients, –– Caring approaches to multicultural health insurance and payment for care ser- patients vices, delegation, performance evaluation, –– Ways of negotiating with patient and orga- employment benefits and salaries, etc.). nizational hierarchy • Implement a bicultural program for multidis- –– Legal and ethical aspects of professional ciplinary staff, unit staff, educators, and nursing in the state and country (regulatory administrators including: and accreditation requirements) –– Need for IEN recruitment and their poten- –– Individual professional accountability and tial contribution to the organization leadership role expectations –– Awareness of cultural differences between • Implement bicultural mentorship program for IENs and themselves IENs for an extended time period beyond the –– Advocacy for IENs against bias and dis- initial orientation in order to: crimination from staff and patients –– Promote advocacy and empowerment of –– Work and social engagement of staff with IENs at work to build teamwork, confront IENs discrimination, and ensure equitable –– Role modeling for IENs workload • Develop an organizational climate of multi- –– Foster cross-cultural communication, com- culturalism and cultural competence by: municating with people perceived to be in –– Integrating multiculturalism and cultural higher status and authority, conflict man- competence in organizational policies, hir- agement, decision making, and care ing and staffing, staff education, leadership approaches training, staff and leadership performance –– Help identify lingering issues and mea- evaluation, patient surveys, language ser- sures for addressing them vices, social services, etc. –– Promote further understanding of organi- –– Celebrating workforce diversity through zational values and expectations including publications, websites, and organizational evaluations by peers, administrators, and events patients –– Creating a formal structure dedicated to • Encourage dialogue between IENs and admin- promote workforce diversity and organiza- istrators to determine relocation needs, job- tional teamwork related issues, and other challenges by: –– Engaging IENs in establishing policies and –– Visiting their residence procedures promoting equity, accessibility, –– Connecting them with Filipino workers and affordability of patient care services to and community diverse patients –– Facilitating their access to religious, food, –– Creating an office with dedicated person- and other venues. nel to ensure that the above goals are met 33 Case Study: Recruitment of Philippine-Educated Nurses to the United States 297

–– Consulting with diversity experts in pro- –– Distinguish actual employment offers by moting continued development of staff and the organization and other specifications by administrators the recruitment agency. –– Engaging diverse communities in organi- –– Maintain open dialogue with IENs to iden- zational policy development and care tify issues. improvement • Facilitate reporting of unscrupulous practices –– Developing unit champions who can facil- to appropriate agencies by: itate valuing diversity at the grassroots –– Familiarizing with the Voluntary Code of level Ethical Conduct for Recruitment of –– Promoting continuing education and lead- Foreign-Educated Health Professionals to ership development of staff and IENs the United States published by the Alliance for Ethical International Recruitment Practices (2011) which includes legal 33.3.3 Community/Societal-Level adherence, communication, contract, Interventions immigration and labor practices, transition support, working with local authorities, • Develop social network of support for IENs respecting prior agreements, and selecting through collaboration with ethnic professional recruitment countries nursing associations such as the Philippine –– Partnering with ethnic professional organi- Nurses Association of America, Asian zations and consular offices American Pacific Islander Nursing Association, • Engage diverse communities in supporting National Indian Nurses Association, Hispanic adaptation of IENs. Nurses Association, etc. They can provide edu- –– Identify ethnic community leaders and cational programs, consultation, and mentor- stakeholders interested in workforce diver- ship to organizational leaders and staff sity. For example, Filipino church groups including IENs. and physicians have been supportive of ini- • Engage in ethical recruitment of IENs. tiatives for Filipino IENs. –– Develop partnership with reputable recruit- –– Invite participation of ethnic communities ment agencies. in organizational events and develop policy –– Collaborate with the Philippine Nurses initiatives for the community as well as Association of America and its state chap- IENs. ter. PNAA works with the Philippine Commission of Filipinos Overseas (CFO), Conclusion the Migrant Heritage Commission, and the IENs particularly Filipino nurses have con- Philippine consular offices in the United tributed to increasing the multicultural work- States to (1) ensure protection of Filipino force in the United States and other developed IENs, (2) provide comprehensive predepar- countries for more than half of a century. ture orientation, (3) maintain statistics of Culturally competent strategies at the individ- Filipino IENs in different countries, and (d) ual, organizational, and community levels are track and follow up on reported violations recommended to promote ethical recruitment, of contract violations and related abuses. smoother transition, and effective integration –– Develop thorough knowledge of immigra- of IENs in their social and work environments. tion, recruitment, and relocation policies in Comprehensive transitional programs were both the United States and countries sup- found to promote increased job satisfaction plying IENs. and retention of IENs (Adeniran et al. 2008). –– Scrutinize and preapprove all work con- In return, IENs contribute to the provision of tracts offered to IENs by recruitment quality care, patient safety, and positive patient agencies. outcomes (Jurado 2013). 298 L. F. Jurado

References diversity/diversity-in-the-workplace-benefits-challenges-solutions.asp Hays J (2015) Social relations in the Philippines: utang Adeniran RK, Rich VL, Gonzalez E, et al (2008) na loob, bayanihan and pakikisama. Facts and Details. Transitioning internationally educated nurses for suc- http://factsanddetails.com/southeast-asia/Philippines/ cess: a model program. Online J Issues Nurs 13(2). sub5_6c/entry-3868.html#chapter-5 http://www.nursingworld.org/MainMenuCategories/ Jurado L (2013) Social construction of Filipino nurses in ANAMarketplace/ANAPeriodicals/OJIN/ the Philippines and as foreign-educated nurses in the TableofContents/vol132008/No2May08/TIENS. United States. PhD Dissertation, Rutgers, The State html University of New Jersey Alliance for Ethical International Recruitment Practices Jurado L, Pacquiao DF (2015) Historical analysis of (2011) Voluntary Code of Ethical Conduct for the Filipino nurse migration to the US. J Nurs Pract recruitment of foreign educated health professionals Appl Rev Res 5(1):4–18. https://doi.org/10.13178/ to the United States. http://www.cgfnsalliance.org/wp- jnparr.2015.0501.1303 content/uploads/2014/11/THE-CODE11.pdf Morgan R (2013) What is the meaning of BAHALA NA? Brush BL, Sochalski J (2007) International nurse https://rosalindarmorgan.com/ migration: lessons from the Philippines. NCSBN (2017) NCLEX fact sheet. https://www.ncsbn. Policy Polit Nurs Pract 8(1):37–46. https://doi. org/search.htm?q=NCLEX+Fact+Sheet org/10.1177/1527154407301393 Pacquiao DF (2003) People of Filipino heritage. In: Choy CC (2003) Empire of care: nursing and migration Purnell LD (ed) Transcultural health care: a cultur- in Filipino American History. Duke University Press, ally competent approach. F. A. Davis Company, Durham, NC Philadelphia, pp 138–159 Flores R (2012) The typical Filipino family. http://www. Pew Research Center (2015) Facts about Catholicism filipino-heritage.com/filipino-family.html in the Philippines. http://www.pewresearch.org/fact- Fuchs L (1967) Those peculiar Americans. Meredith tank/2015/01/09/5-facts-about-catholicism-in-the- Press, New York philippines/ Greenberg J (2004) Diversity in the workplace: benefits, Storti C, Bennhold-Samaan L (1997) Culture matters: challenges, and solutions. The multicultural advan- the Peace Corps—cultural workbook. Government tage. http://www.multiculturaladvantage.com/recruit/ Printing Office, Washington, DC Case Study: Health Care for the Poor and Underserved 34 Populations in India

Joanna Basuray Maxwell

Ramesh, a 12-year-old male, is brought to a low- correctly diagnose and treat his problem. The cost clinic by his parents in the city of Kochi, in chronic need for medical services for Ramesh to the state of Kerala in South India. Ramesh has treat a correctable condition has further devas- been suffering from severe asthma for several tated the family’s already meager resources. years. He appears younger and underdeveloped for his age. Ramesh’s parents had previously sought several doctors who repeatedly informed 34.1 Cultural and Social Factors them that Ramesh has asthma. Ramesh’s parents had sold all their belongings to pay for his health Gender is a social determinant of health in India care prior to this last visit. The family lives in a (see Chap. 1) placing females in all age groups at thatched-roof hut. His parents are in their early a higher health risk than males. Being a male son, 30s; his father is the sole family breadwinner Ramesh’s health is a priority in the traditional working as a day laborer. Indian culture. An increasing aging population Ramesh’s history indicates that he had been a includes women who are living longer than men normal boy until the age of 10 months when he in worse health than elder men. Indian cities are started waking up during the night with respira- overpopulated as 40% of the population has tory wheezing that has worsened over time. migrated into major cities to improve their eco- Auscultation of his lungs reveals clear breath nomic conditions and access to basic services, sounds, but severe wheezing is heard over his such as health care. The urban poor suffer many right lower lobe. The physician suspected foreign hardships including vulnerability to respiratory body aspiration and referred the family for fol- illnesses such as asthma, cardiovascular disease, low-up at a nearby medical university hospital. and diabetes. At the medical center, a plastic bead was removed Poverty has been defined by the Indian from Ramesh’s lung, immediately relieving his Government as a “multidimensional problem that wheezing. While Ramesh’s condition was includes low access to opportunities for develop- resolved, it took much from his family’s meager ing human capital and to education, health, fam- income to reach a physician who was able to ily planning, and nutrition” (Nolan et al. 2014: 2). Urbanization is seen as a structural determinant of health due to the ill effects of “rapid and J. B. Maxwell, Ph.D., R.N. unplanned” urbanization leading to slums and Department of Nursing, Towson University, 8000 York Road, Towson, MD 21252, USA exposing urbanites to undesirable living condi- e-mail: [email protected] tions and sanitation. Children under 5 years of

© Springer International Publishing AG, part of Springer Nature 2018 299 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_34 300 J. B. Maxwell age experience higher incidence of developmen- eighteenth century. The educational preparation tal delays and stunting as well as higher mortality and professional practice of Indian physicians rates than their nonpoor and non-slum and nurses in India are influenced by the British counterparts. medical model. Although the government My interviews of two Indian health service acknowledges Indian indigenous health systems providers (a social worker and a physician) who based on generic healthcare practices such as have worked in India and in the United States Ayurveda, Unani, and Siddha, professional edu- offered a multiple-layered perspective on the cation and training of healthcare practitioners has social and cultural factors in India. According to been consistently based on the Western biomedi- K. Cunningham (social worker) and D. Suskind, cal model (Basuray 2002). MD (personal communication, August 25, 2017), As the population growth increases, millions physicians in India are confronted by large num- of people will never receive health care as most bers of patients who generally come to the clinic Indians cannot afford health insurance to cover or hospital with severe life-threatening condi- hospitalization cost. Many poor people are unin- tions. Because of these long lines of patients to be formed about health insurance plans (Basuray seen, it is rare to see a physician take the time to 2002). According to the World Bank report do a physical examination, such as assessing lung (2012), about 25% (approximately 300 million) sounds or evaluating findings followed by a plan of India’s population had access to either private of treatment. Poor and illiterate patients are ver- insurers or insurance providers through the gov- bally intimidated and sent home with a prescrip- ernment. However, health insurance in India only tion. For example, parents accompanying a child, covers inpatient hospitalization and hospital- like Ramesh are scolded for not responsibly tak- based treatment but not outpatient visits. As a ing care of the child to prevent the asthma attack. result, 70% of the population have to pay out of A physician’s diagnosis assumes a culturally pocket for these services, increasing the financial biased lens that results in further neglect, oppres- burden on individuals and families (World Bank sion, and alienation of people of lower socioeco- 2012). nomic status (K. Cunningham and D. Suskind, India is experiencing a major workforce crisis personal communication, August 25, 2017). through a shortage of practicing physicians. In Physicians are not compensated adequately 2016, the Medical Council of India reported the for an exhausting workday dealing with a heavy doctor/patient ratio of 1:1681 (Chatterjeel 2016). workload. In order to support their middle-class Despite large enrollment and graduation rates in and upper middle-class lifestyle, many physi- medicine and nursing, India lacks qualified pro- cians work in private practice where they are paid fessional practitioners to provide preventive and per-patient visit generated from self-paying primary care to its people (Nolan et al. 2014). patients (Basuray 2002; Sharma 2015). Doctors According to Sharma (2015), 8% of the 25,300 attempt to exercise control of their work environ- primary centers nationwide had no doctor on the ment by displaying arrogance, rudeness, and premises; 38% lacked lab technicians, and 22% abuse toward other health providers such as lacked pharmacists. Vacancies among healthcare nurses. Nurses’ work is largely subsumed under assistants included 50% females and 61% males. the physician’s plan of treatment. Majority of The shortage of medical specialists included 83% nurses are educated in a 3-year diploma program surgeons, 83% pediatricians, and 76% obstetri- at a teaching hospital setting. Few programs offer cians and gynecologists. There is also a shortage a master’s degree in nursing with specific clinical of healthcare assistants. Sharma also highlighted concentrations (Indian Nursing Council 2017). high absenteeism among physicians compound- The structure and management of clinics and ing the shortage. Physician shortage is critical in hospitals in large cities of India are based on a remote rural areas as many physicians are unwill- Western healthcare delivery system that was ing to work in these areas because of poor infra- originally introduced by the British in the structure (e.g., unpaved roads), limited medical 34 Case Study: Health Care for the Poor and Underserved Populations in India 301 resources, and lack of opportunity for profes- –– Build a strong social service component to sional development that is only accessible in health services. large city hospitals (Sharma 2015). –– Use appropriate interpreters to assist in communicating with illiterate and poor patients. 34.2 Culturally Competent –– Use gender-congruent community advo- Strategies cates to assist patients. • Restructure workplace services and resource 34.2.1 Individual/Family-Level utilization. Interventions –– Evaluate workload of staff and streamline their roles and responsibilities. • Recognize human potential of every citizen to –– Utilize auxiliary personnel to assist with achieve optimum health. nonprofessional tasks and responsibilities. –– Seek health provider volunteers to assist –– Develop team approach to healthcare ser- with managing patient admission and vices by delegating expanded professional assessment. responsibilities to nurses and other health –– Promote integrity of the family by accom- professionals. modating traditional family roles in care of –– Provide training for volunteers or “para- family members. professionals” to manage patient traffic –– Observe and listen to patients with respect and some administrative tasks. and genuine attentiveness. • Design educational programs and ongoing –– Maintain patients’ dignity and their right to training of interprofessional staff in the fol- health care. lowing areas: –– Create an environment that encourages –– Impact of social determinants on popula- open and trusting interaction between tion health, health behaviors, and access, patients and health providers. utilization, and adherence with health • Promote health provider awareness of the services. impact of social determinants on health –– Culturally competent care that is respectful outcomes. of gender, age, religious, language, and –– Increase awareness of the impact of pov- social class differences. Use creative teach- erty, class/caste, illiteracy, gender, religion, ing methods such as simulation and and language proficiency on physical and modeling. Reward culturally competent mental health and access, utilization, and outcomes. adherence with health care. –– Indigenous health practices, practitioners, –– Promote self-reflection on the impact of values, and beliefs of individuals and workload and work environment on one’s communities. own behavior toward vulnerable patients. • Collaborate with private, business, faith-based –– Promote critical reflection on the influence organizations and the community to promote of personal and cultural bias on one’s access by underserved populations to preven- behavior toward vulnerable patients. tive and primary healthcare services. –– Seek funding and participation in community-based initiatives for the 34.2.2 Organizational-Level underserved. Interventions (Clinic and City –– Promote community empowerment by Hospitals) opening health education classes for patients, families, and communities on pre- • Develop systems for addressing multifaceted ventive measures for healthy living, health problems of the poor and underserved. promotion, and illness prevention 302 J. B. Maxwell

(including pregnancy, child-rearing, and Conclusion adult health behaviors). Offer information Ramesh and his parents provide a classic profile on health promotion and illness of a family in India that is from a lower socio- prevention. economic level with a male child who is ill. This –– Collaborate with indigenous health practi- family reflects the interplay between gender, tioners in the community in promoting socioeconomic status, and healthcare infrastruc- access to primary healthcare services. tural variables that influence healthcare decisions, access, and utilization of services and 34.2.2.1 Community/Societal-Level health outcomes of the Indian population. The Interventions cultural factors compounded by lack of access • Collaborate with schools of nursing and medi- to health care are based on the parents’ level of cal colleges to integrate social determinants of income and a healthcare system that is inade- health in the curriculum. quate for the underserved population. –– Increase emphasis on managing the care of Healthcare professional shortage particu- patients and communities from lower larly of physicians has reached a crisis level. socioeconomic levels and culturally diverse Reorganization of the public healthcare system populations. is critical to promote access of populations to –– Increase the focus on health promotion and primary care services and improve their living prevention of illness. conditions. The role of professional nurses –– Strengthen educational training of nurses should be expanded to increase their leader- for leadership roles in health promotion ship and participation in health promotion and and illness prevention. disease prevention. Changes in the educational • Promote partnerships among academic insti- preparation of healthcare professionals are tutions, businesses, health organizations, and imperative to emphasize population health local communities to improve the living con- promotion by addressing social determinants ditions of the people by expanding access to of health vulnerability. Genuine collaboration health screening especially for children, between indigenous and allopathic health females, and the elderly. practitioners can help address the multiple and • Develop multisectoral collaboration among complex health needs of the population. public and private entities, professionals, and academicians to improve living conditions of slum dwellers and those living in poverty to promote their access to potable water and References sanitation, enhance safety inside and outside Basuray J (1997) Nurse Miss Sahib: colonial culture- their homes, and control environmental bound education in India and transcultural nursing. pollution. J Transcult Nurs 9(1):14–19 • Develop sustainable partnerships and multi- Basuray J (2002) India: transcultural nursing and sectoral collaboration to influence public healthcare. In: Leininger MM, McFarland MR (eds) Transcultural nursing: concepts, theories, research policies impacting health such as retention and practice, 3rd edn. McGraw-Hill, New York, of healthcare professionals, universal access pp 477–491 to quality health care, and combating Chatterjeel S (2016) India has just 1 doctor for every unequal treatment of the poor, women and 1,681 persons: MCI. http://timesofindia.indiatimes. com/life-style/health-fitness/health-news/India-has- children, the elderly, and other disadvan- just-1-doctor-for-every-1681-persons-MCI/article- taged groups. show/52102964.cms –– Explore indigenous health systems in the Dixit U (2011) Development of nursing education in community as a point of referral when India: post-independence. http://hinsar.hitkarini.com/ wp/?p=479 appropriate and in agreement with patients’ Indian Nursing Council (2017) Nursing programs. http:// health beliefs. www.indiannursingcouncil.org/nursing-programs 34 Case Study: Health Care for the Poor and Underserved Populations in India 303

Nolan LB, Balasubramaniam P, Muralidharan A (2014) The World Bank (2012) Government-sponsored health Urban poverty and health inequality in India. http:// insurance in India: are you covered? http://documents. paa2014.princeton.edu/papers/140103 worldbank.org/curated/en/644241468042840697/pdf/ Sharma DC (2015) India still struggles with rural doctor 722380PUB0EPI008029020120Box367926B.pdf shortages. Lancet 386(10011):2381–2382. https://doi. org/10.1016/S0140-6736(15)01231-3 Part IX Guideline: Cross Cultural Leadership Attributes of Cross-Cultural Leadership 35

Dula Pacquiao

Guideline: Nurses shall have the ability to influence individuals, groups, and systems to achieve outcomes of culturally competent care for diverse populations. Nurses shall have the knowledge and skills to work with public and private organizations, professional associations, and communities to establish policies and guidelines for comprehensive implementation and evaluation of culturally competent care. Douglas et al. (2014: 110)

35.1 Global Context and health on the world stage. It is a process for Leadership resulting from a combination of forces that is increasing the flow of information, goods, capi- According to Friedman (2007), international sys- tal, and people across political and geographic tems have arisen from dramatic changes in the boundaries. It has its own rules, logic, pressures, global economy and global landscape making and incentives that can affect directly or indi- historical and geographic divisions increasingly rectly countries, businesses, and communities, irrelevant. Markets, technology, information sys- worldwide (Cohen 2010). An overarching feature tems, and telecommunication systems are inter- of globalization is integration as threats and weaving globally, thus shrinking the world and opportunities flow among those who are inter- enabling humans to connect farther, faster, connected. Centers of economic activity are deeper, and cheaper. On the other hand, global- shifting profoundly regionally and globally. A ization and modernization have created a new demographic trend pushing this macroeconomic world order—a “runaway world” that is out of shift is the aging population particularly in the control and filled with risks and cultural com- developed world with profound impact on the plexity (Giddens 2003). Modern society is growth of the workforce, economic productivity, becoming a risk society that is increasingly pre- and innovations in technology and services. Mass occupied with its future and safety and in control- retirement and aging of the nursing workforce in ling the risks associated with modernization and the United States is predicted to create acute human activity. According to Giddens, risk needs nursing shortages and increased burden and to be controlled, but active risk-taking is central demands on healthcare and social services (see to a dynamic economy and an innovative Chap. 31). The demands of an aging population society. will need realignment of economic activity and Globalization is associated with major trends priority in both private and public sectors. that place businesses, politics, popular culture, Geographic and social environments have been transformed by technology and enhanced connectivity, changing the way people and orga- D. Pacquiao, Ed.D., R.N., C.T.N.-A., T.N.S. nizations interact, operate, and thrive (Aggarwa School of Nursing, Rutgers University, Newark, NJ, 2011). Growth of foreign-owned and affiliated USA companies has become a worldwide trend as School of Nursing, University of Hawaii, Hilo, local markets open to meet growing local demand Hilo, HI, USA

© Springer International Publishing AG, part of Springer Nature 2018 307 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_35 308 D. Pacquiao for economic growth and survival. Ongoing shifts wealth, and social resources (WHO 2008). For in labor and talent are prompted by migration of example, polluting industries are usually sited in jobs to low-wage countries. Demand for well- poorer countries and in underprivileged neigh- trained workers in knowledge-intensive indus- borhoods. Globalization initiatives must be tries has precipitated a global search for talented examined along with other issues as social and workers (Cohen 2010). Nontraditional business economic development of global populations, models and blurring of corporate borders have health equity, and environmental justice (WHO prompted the growth of large, complex organiza- 2006). tions that require innovative decision techniques and management strategies to compete in a highly complex and unpredictable market. An interna- 35.2 Global Leadership tional labor market is facilitated by shifting population demographics, technological connectivity, Leadership is the process of influencing, facilitat- global migration, international sourcing of labor, ing, and organizing a group with an aim of and local workforce shortages. accomplishing a vision, purpose, or significant Indeed, globalization, technological innova- goal (Pierce and Newstrom 2011). Leadership is tion, and demographic changes have transformed substantially distinct in global and domestic or human life. Technology has a significant role in local leadership. The global context significantly shaping global policies, economies, culture, and increases the valence, intensity, and complexity systems (Fritsch 2011). Globalization also cre- of the structure and processes involved ates problems with distance and disconnection on (Lokkesmoe 2009). Global leaders inspire a human relations and leadership. The trend toward group of people to willingly pursue a positive globalized communities is accompanied by dis- vision in an effectively organized fashion while solution of local identity and cultural distinctive- fostering individual and collective growth in a ness. In fact, this transformative aspect of context characterized by significant levels of globalization has fueled the movement toward complexity and relationships across different national entrenchment (Giddens 2003). The rise spatiotemporal dimensions (Mendenhall et al. of nationalistic populism in the United States and 2012). Europe is evidence of the counterreaction to glo- Global leaders face higher degrees of com- balization. Hofstede and Hofstede (2005) believe plexity and uncertainty as there is need for adapt- that a new world order is inevitable necessitating ing to different cultures and leadership style attention to national identities in cross-cultural preferences based on different cultural norms and interactions. values. They need to simultaneously create global While globalization is generally considered in integration and local responsiveness and balance economic terms, it has broader effects in other commercial and cultural concerns (Cohen 2010). areas such as health and social structures. Uncertainty is a consequence of lack of unifor- Globalization has changed the dynamics of health mity in customer preferences, competitive cir- across populations. International trade of goods cumstances, economic conditions, employee and services can negatively impact social deter- relations, or governmental regulations across the minants of health such as access to employment, various countries and cultures. Although the education, and social support as well as increase world is increasingly becoming borderless, there health risks. By contrast, sharing of knowledge are linguistic, cultural, political, temporal, eco- and resources through enhanced technology can nomic, and social boundaries that exist (Bingham, have positive effects (Canadian Nurses Felin, and Black 2000). Association 2009). Inequities in health and envi- Global leaders face greater complexity inher- ronmental degradation result from social norms, ent in the multiplicity of stakeholders, competi- policies, and practices that promote economic tors, cultures, and governments involved. The exploitation and unfair distribution of power, rapid movement of capital, information, and 35 Attributes of Cross-Cultural Leadership 309

people necessitates complex and interdependent internationally educated healthcare professionals arrangements across different units and sites of to wealthier (receiving) countries has depleted operations. Complexity results from ambiguity available manpower in poorer (sending) coun- presented by massive information, lack of cer- tries impacting their population morbidity and tainty, nonlinear and equivocal events, and out- mortality. Conversely, the mass influx of interna- comes. Lack of certainty from rapidly changing tionally educated workers in organizations has systems creates a state of flux and complexity consequent changes in interpersonal relation- (Lane et al. 2006). ships, communication, role performance, leader- In healthcare, globalization has resulted in ship behaviors, and systems. increased cultural diversity in both workforce and clientele posing a challenge for leaders while addressing global trends and domestic realities. 35.3 Attributes of Cross-Cultural Organizations need to be concerned with the Leadership dominant social and cultural norms of society in which they are nested (Hofstede and Hofstede 35.3.1 Global/World Citizenship 2005). Organizations are comprised of multicultural groups including racial, ethnic, gender, sex- A global citizen is someone who identifies with ual identity, language, religious, generational, being part of an emerging world community and work roles, education, immigration status, socio- whose actions contribute to building this commu- economic and educational status, physical and nity’s values and practices (Israel 2017). Gillis Jr mental health status, etc. Healthcare leaders also (2011) contends that there is a shortage of devel- deal with different governmental and regulatory oped and prepared leaders with global leadership bodies and private entities, different cultures of competency that includes a body of knowledge, affiliate organizations, and different geographic skill, or ability to motivate, influence, and enable communities. While technology has produced individuals across national boundaries and cul- great innovations in healthcare, it has posed tural diversity to contribute to the accomplish- issues regarding unequal access to technology, ment of an organization’s goal. Nussbaum (2013) privacy, and quality of life. Technology and identifies a global crisis because we have become growth of large healthcare organizations have “nations of technically trained people who are shaped the way people work and interact within useful profit makers” but lack the ability to chal- and across organizations. lenge authority, think in terms of the good of the The changing context of society significantly world, and concern for the lives of others. impacts leadership. Leaders need to adapt to the Nussbaum proposes development of world citi- evolving social and cultural milieu of the envi- zenship that allows one not only to view oneself ronments outside and within the organization. within one’s own customs and beliefs but as Leaders need to grasp the interconnectivity someone belonging to the world—citizens in an between local events and global trends. Aging of interlocking world (Gorman and Womack 2017; the local population promotes outsourcing and Teshima 2010). importation of goods, services, and workers. According to Nussbaum (2003), world citi- Catastrophic events in other countries can lead to zens have three abilities: (1) to criticize one’s mass migration of refugees and vulnerable popu- own traditions and engage in discourse based on lations to the country and local community with mutual respect for reason; (2) think as a citizen of intense need for access to comprehensive ser- the whole world, not just some local region or vices. Leaders need to recognize the impact of group; and (3) imagine what it would be like to local and national policies and initiatives on both be in the position of someone very different from local and global populations. Preferential immi- oneself. Education for world citizenship needs to gration policies of one country can deplete be multicultural emphasizing awareness, knowl- resources in another. Mass migration of edge, and respect of cultural differences. 310 D. Pacquiao

Education for world citizenship is grounded in in different countries worldwide revealed the the humanities and liberal education as the foun- need for adaptation of leadership style to the dation for fostering compassionate understand- dominant national culture. Values, ideas, and ing of others, developing habits of critical beliefs of a culture or culture clusters determine thinking and reflection and the value of social its conception of effective leadership. History justice. and culture shape leadership practices and fol- lower expectations (House and Javidan 2004; Dorfman et al. 2004). 35.3.2 Cultural Intelligence

A significant attribute of cultural competence is 35.3.3 Compassion and Empathy critical reflection. Cultural intelligence is a system of cognitive structures and processes and Nussbaum (1997) identifies compassion as a psy- multiple types of cultural knowledge and skills chological link between our own self-interest and linked by cultural metacognition that promote the reality of another person’s good or ill. effective patterns of intercultural interactions and Compassion however is purely emotional and behaviors (Thomas et al. 2012). Cultural knowl- without thought. She emphasizes development of edge is the foundation for comprehending and empathy—an imaginative and emotional under- decoding one’s behavior and those of others. It standing of what it might be like to be in the includes content knowledge (culture, social inter- shoes of a person different from oneself actions, and history), procedural knowledge (Nussbaum 1997; Teshima 2010). Empathy is a (effect of cultural knowledge on one’s nature), deep understanding of another’s point of view and knowledge of cross-cultural encounters and experiences that may be different from their (reflective learning of culture-specific and own. Empathy and compassion foster values of culture-general aspects). Knowledge allows one mutuality, interconnections and reciprocal social to grasp the internal logic and model behavior of obligation (Story 2011). another culture and negotiate between similarities and differences across cultures (Lane et al. 2000). 35.3.4 Social Justice Identity Cultural skills in a variety of domains include information gathering or perceptual, interper- Social justice identity is the attainment of perva- sonal, action, and analytical skills. Cultural skills sive internalization of the values of social justice are related to emotional intelligence that includes in one’s life as demonstrated by a consistent and important traits as world mindedness and open- profound commitment to foster social equity ness (Caligiuri 2000). Cultural metacognition is (Singh et al. 2010). The goals of social justice are the knowledge of and control over one’s thinking beneficence, justice, and respect for people’s and learning activities in the cultural domain rights and dignity (APA 2010). Social justice involving core mental processes that transcend requires multicultural competence (Kaplan et al. environmental context. Metacognition allows the 2014). Leadership practices that reflect social ability to consciously and deliberately monitor, justice promote the agency and empowerment of regulate, and orchestrate one’s knowledge pro- individuals and groups and systemic change in cesses and cognitive and affective states to order to promote equity and fairness for the accomplish cognitive tasks or goal (Thomas et al. oppressed and marginalized members of society 2012). (Ratts 2009). Leaders engage in ongoing self- What constitutes intelligent behavior may dif- examination, sharing power, giving voice to the fer from one cultural environment to another weak, facilitating consciousness raising, building (Johnson et al. 2006). The GLOBE study of for- strengths, and leaving others with the tools for eign business executives and managers working social change (Dollarhide et al. 2016). 35 Attributes of Cross-Cultural Leadership 311

Leaders engage in advocacy to empower indi- self-awareness that in turn develops the ability to viduals, groups, and organizations to promote have self-confidence, self-reliance, and self- social and systemic change. Leaders interact with insight, as well as social and cultural awareness. structures, organizations, or institutions that are Cultural self-awareness and self-reliance pro- perceived as oppressive by marginalized groups mote the courage to take a stand, openness, self- (Constantine et al. 2007). Leaders initiate inter- confidence and self-insight, and valuing diversity ventions at both individual and societal levels to (Peterson 2004). It involves self-regulation and promote greater levels of social justice and the ability to control impulses, maintain integrity, respond to institutional, systemic, and cultural and remain flexible as one adapts to new situa- barriers impeding well-being (Crethar et al. tions. In other words, self-regulation is thinking 2008). Promoting social justice and sustainability before acting and capacity for behavioral flexibil- along with a responsibility to act on behalf of ity and adaptability (Mumford et al. 2000). Self- others is inherent in global citizenship (Reysen transformed leaders are excellent coaches and and Katzarska-Miller 2013). Becoming aware of mentors to others. the larger global context, understanding one’s interconnectedness with the world and valuing existing diversity are the foundation for challeng- 35.3.6 Community Engagement ing injustice and taking action in personally meaningful ways (Jones 2016) based on the prin- Leaders with social justice orientation have the ciple of human rights and equality (Cesario right and responsibility to recognize and raise 2017). awareness of the root causes of inequity in global health and participate in finding solutions. They are aware that individuals and communities have 35.3.5 Capacity a right to be informed of their rights as citizens of for Self-Transformation a particular state and participate fully in defining their healthcare needs and deciding on approaches Engagement in personal transformation requires to address those needs (Dollarhide et al. 2016). motivation to learn and commitment to ongoing Leaders in healthcare should engage in development of personal knowledge and skills addressing social determinants of health in vul- (Caligiuru and Tarique 2009). Personal transfor- nerable populations. Social determinants are best mation requires critical reflection – a meaning- addressed at the community level to create making process that helps one set goals, use what broader impact on populations through systemic was learned to inform future action, and consider change. Leaders can promote engagement of the real-life implications of one’s thinking. It is their organizations in building social capital for the link between thinking and doing and can be health in vulnerable communities. Social capital transformative (Rodgers 2002). Engaging in crit- are resources that become available for use or ical reflection helps articulate questions, confront exchange based on social connections, mutual bias, examine causality, contrast theory with acquaintance, and/or social recognition gained practice, and identify systemic issues which help through associations in a stable network of mutu- foster critical evaluation and knowledge transfer ally established relationships. Resources may be (Ash and Clayton 2009: 27). Critical reflection is actual or potential in the form of material, infor- learned through practice and feedback (Rodgers mation, psychological support, and/or social rela- 2002). tionships (Eriksson 2011; Walther 2014). Personal transformation is built on developing Culturally competent leaders can foster trust social judgment skills built on a big picture and between communities and their organization and long-term orientation (cause-effect, interdepen- among other communities and organizations. dencies, consequences) considering multiple Leaders can determine informal and formal constituents’ perspectives. It also involves social groups in the communities where people 312 D. Pacquiao are engaged on a steady basis. Fostering trust and that are presented through formal training, social cohesion can be enhanced by promoting developmental activities, and self-help activi- the structure and process for people to engage ties (Yukl 2002). High-contact training activi- with each other. Trust is the foundation for build- ties are more likely to change behaviors of ing mutual respect, reciprocity, and social norms. trainees (Caligiuru and Tarique 2009; Gillis Jr Trust among close-knit groups that regularly 2011). High-contact activities include experi- meet each other such as families, local churches, ence working in other countries, global teams, and social groups has the structure and process experiential learning, and coaching. By con- for developing bonding capital. Bonded groups trast, low-contact activities include intercul- can develop networks with outside groups tural training, assessment, and reflection (Bridging capital) to gain greater potential for exercises. Direct experience with diversity can sharing information and resources through hori- be facilitated within an organization and zontal collaboration and cooperation. through engagement with diverse teams, Connections among various church groups and patients, and communities. It is extremely social groups in different communities demon- important to promote encounters with diver- strate bridging capital. Linking capital involves sity in different contexts to gain multiple per- vertical ties between people in different formal or spectives, compassionate empathy, and institutional groups (Eriksson 2011). Engagement reflexivity. Coaching and feedback are impor- of healthcare organizations and public schools tant to promote cultural metacognition and with the community to decrease obesity in young critical reflection. children is an example of linking capital. Bonding, bridging, and linking strategies Leaders need to have strong networking skills should be modeled and fostered to expose pro- for establishing and maintaining relationships spective leaders to diversity. Incentives and within an organization and across a range of recognition of community engagement by stakeholder groups to build social networks and workers can promote transformation of indi- mutual capacity. Networking should involve viduals and communities. Leaders must men- domestic and global connections that can be tor advocacy and empowerment of called upon to facilitate changes. Leaders should disadvantaged individuals and communities to maintain a high degree of engagement with their help develop social justice identity in others. professional, work, and community organiza- Compassion, empathy, critical reflexivity, tions. They can model volunteerism and commu- social justice, and global mind-set are best nity engagement for others. Involvement in developed through direct experience and policy making is valuable in developing multiple exposure to diversity and vulnerability. perspectives on issues and in critically reflecting Innovative training must incorporate direct on the best course of action. Leaders should experiences with diverse patients and peers design systems within their organizations to and community engagement with ample feed- facilitate active participation of communities and back and coaching provided. Leaders as men- stakeholders in decision making. They should tors and coaches can facilitate opportunities strengthen participation of management and staff for others to observe demonstration of desired in policy and program development and evalua- leadership attributes. tion. High impact assessment of policies and pro- Effective leadership is evident in how orga- grams on the population particularly the nizations and groups are influenced to achieve vulnerable groups should be standard practice. personal transformation of individuals and social change for vulnerable communities. Conclusion Cross-cultural leadership aims to create high The capacity for cross-cultural leadership can impact solutions to population health through be learned (Northouse 2004). Training and organizational initiatives. Cross-cultural lead- development should focus on the attributes ers are effective because they maintain active 35 Attributes of Cross-Cultural Leadership 313

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Susan W. Salmond

As a nation, the United States is facing a health- access to health care is unequally influenced by care crisis; our current system of care is unsus- ethnicity, income, education, and where they live. tainable. The United States’ national health Despite successful national efforts to increase the expenditure (i.e., the annual health spending) number of Americans with health insurance grew 5.8% in a single year to $3.2 trillion in (through the Affordable Care Act), at the end of 2015. This amounted to $9990 per person, and 2015 there were still 28.5 million Americans the number is projected to continue to grow 1.3% without health insurance. People of color are at faster than gross domestic product (GDP) per higher risk of being uninsured (Kaiser Family year from 2015 to 2025 (Salmond and Echevarria Foundation 2016). Although health insurance 2017). Despite outspending all other comparable isn’t the only factor in access to health care, it is high-income nations, our health-care system an important one. In the United States, ethnic ranks last or near last on measures of health, minorities including African Americans, Asian quality, access, and cost. The United States has Americans, Native Americans, and Latinos expe- higher infant mortality rates; higher mortality rience well-known health disparities, i.e., a rates for deaths amenable to health care (mortal- higher relative burden of illness, injury, disability that results from medical conditions for which ity, or mortality. there are recognized health-care interventions These groups have a higher prevalence of that would be expected to prevent death); higher chronic conditions along with higher rates of lower-extremity amputations due to diabetes; mortality and poorer health outcomes, when higher rates of medical, medication, and lab compared with the white population. For exam- errors; and higher incidence of chronic illness ple, the incident rate of cancer among African and disease burden than comparable countries Americans is 10% higher than among whites. (Peterson-Kaiser Health Tracker System 2015). African Americans, Native Americans, and Our country is more racially and ethnically Latinos are also approximately twice as likely to diverse, and it is projected that by 2044, no one develop diabetes as white people are, and Asians racial group will make up a majority of the coun- are 1.6 times as likely. We are a nation facing an try’s population. Yet, Americans’ health and epidemic of chronic disease. In fact, chronic disease accounts for three-quarters of America’s S. W. Salmond, Ed.D., R.N., A.N.E.F., FAAN direct health expenditures. As of 2012, about half School of Nursing, Rutgers University, of all adults—117 million people—had one or Newark, NJ, USA more chronic health conditions. One of four e-mail: [email protected]; adults had two or more chronic health conditions. [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 315 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_36 316 S. W. Salmond

Many chronic diseases can be prevented. Health dealing with faculty turnover; changing demo- risk behaviors are unhealthy behaviors which graphics of faculty, staff, and students; as well as lead to chronic disease. Four of these health risk changes in the broader community and political behaviors—lack of exercise or physical activity, backdrop. The leadership of the School recog- poor nutrition, tobacco use, and drinking too nized that there were deficits among faculty in much alcohol—cause much of the illness, suffer- cultural awareness and knowledge. Students ing, and early death related to chronic diseases raised concerns that the learning environment and conditions (Centers for Disease Control and was not inclusive and that to some degree subtle Prevention 2017). discrimination was occurring. This sense of These patterns cannot be denied. Improvement alienation was not conducive to student personal of health outcomes requires greater emphasis on and academic development and the problem keeping people well and preventing and manag- needed to be addressed. Additionally, there was ing chronic illness. Care across the continuum little involvement of the School in the larger must be better coordinated necessitating cross community. Clinical practicums were predomi- professional teams partnering not only with nantly hospital-based, and the School and most patients and family but with community groups of its faculty were not vested in ongoing activities contributing to improving health and well-being to promote improvement in clinical care in the of its members. A culturally competent health local clinical agencies or in improving the health care and health professional education system of those in the community outside of periodic and a shift toward population health are a prereq- health education programs. It was a clear priority uisite to improving health outcomes and quality to address this issue. of care and contributing to the reduction of racial and ethnic health disparities. 36.2 Developing the Structure to Address Cultural 36.1 Changing Nursing Education Competence Issues to Respond to Changing Health-Care Needs Early efforts focused on examining the School’s mission and vision and commitment to diversity. This case study presents the journey of one At a faculty and staff retreat, the intention to School of Nursing’s efforts to prepare its students address issues surrounding diversity and commu- to be culturally competent nursing leaders pre- nity involvement was raised by the Dean and pared to address the challenges of improving actively discussed by faculty. Although not uni- population health and quality care in tomorrow’s versal, most agreed with the focus and believed health-care industry. The School of Nursing at that student learning would be improved if the the center of this case study is based in the north- School and faculty would actively work to create eastern United States; it is a well-established, an inclusive, culturally competent student and sizeable School of Nursing that is part of a much work environment. The School mission was dis- larger state university. The School is grounded in cussed and adapted to affirm a commitment to an urban, economically challenged, highly clinical practice, scholarship, and advocacy for diverse city and serves a diverse student body underserved populations and the diverse commu- with approximately 50% of students belonging to nities served by the wider university. Goals were a minority ethnic group. established to look at curriculum (inclusive of The process of reenvisioning the School and clinical experiences) and the teaching-learning curriculum to enhance cultural competence, to environment. promote cultural diversity, and later to move The Dean assumed responsibility for imple- toward population health has been a journey—a menting and overseeing this process. Resources journey that will continue as the School is always were allocated across a 5-year period. The goals 36 Case Study: Integrating Cultural Competence and Health Equity in Nursing Education 317 were added to her own self-evaluation plan so 36.2.2 Initial Findings that the larger university was aware of the School’s plans and efforts and consequently Cultural competence was one of eight organizing would hold her accountable for achieving the constructs for the curriculum. There was one goals. Additionally, these goals were reported to course on health promotion and community the School’s advisory board and examined on an health that had a strong focus on culture, cultural ongoing basis. beliefs, and explanatory models for what causes A diversity task force was charged with per- illness, beliefs about approaches for curing or forming an overall assessment and making rec- treating illness, and who should be involved in ommendations specific to the goal areas. This the process. Across the rest of the curriculum, task force ultimately was voted on by faculty to there were course objectives highlighting cultural become a standing committee—further attesting competence, but in discussion with faculty and to our commitment to cultural competence. students, it emerged that this content was “pres- Members of the committee in collaboration with ent but hidden” with significant variation across a faculty leader in community and cultural com- faculty, little incorporation of cultural compe- petence updated the School’s philosophy with tency as a main theme in case studies and simula- greater emphasis on health across the life course tion, and virtually no test questions specific to and in respecting and valuing cultural differences cultural competence other than in the one health and right of choice regarding health-care issues. promotion and community health course. The philosophy and mission were discussed with All identified that it was through clinical expe- all incoming students at orientation and within riences that culture came alive, but in many cases, relevant courses. It was also discussed at faculty this was a “casual” learning in that students were orientations and revisited in ongoing forums for caring for people from different cultural and reflection as to whether it was being actualized in socioeconomic backgrounds but sometimes with our approach. little discussion as to how this impacts assessment, planning, and delivery of care at either the individual or the population level. Almost all 36.2.1 Assessment clinical experiences were found to be hospital- based and students had little experience with care A three-prong approach to assessment was taken. across the continuum. First, course syllabi were reviewed, examining Assessment of the work environment showed course objectives and content, and curricular a lack of diversity at the faculty level but not at mapping was completed. Second, faculty were the staff level, sterile hallways that did not reflect interviewed to understand their perceptions and the diversity of the School, some evidence of to explore whether teaching within each course strained relations across dominant and non- reflected culture or cultural competence, their dominant groups, and a general discomfort with perceptions on teaching diverse student groups, how to handle these situations. the overall valuing of diversity within the School, and any recommendations they had for change. The third focus was on students. Students from 36.3 The Approach different levels (year group within the program) and cultures participated in focus groups to The first priority was training. Over a span of examine their experiences of inclusion, valuing 5 years, there were multiple faculty and staff diversity within the School; experiences during development programs to increase awareness of which they had gained insight about cultural issues surrounding cultural competence and to competency and what these experiences were; build knowledge and skills—both in cultural and recommendations they had for change within competence itself and how to teach it. Approaches the School. ranged from skits depicting common classroom 318 S. W. Salmond scenarios to a series of workshops examining cul- examine how to integrate upstream (e.g., social, ture and social determinants of health. These pro- economic, and environmental factors), mid- grams often incorporated self-assessments so that stream (e.g., working conditions and housing), each individual was forced to reflect on their own and downstream (e.g., behavioral and biological values, beliefs, implicit biases, and ways of inter- determinants of disease) factors contributing to acting with others. Issues of power differentials exposure within key clinical didactic courses, between faculty and student as well as confront- rather than waiting until the final community ing issues of stereotyping and racism were nursing clinical. included. Although this was challenging, it was felt to be fundamental to changing the culture. Curricular changes were implemented to 36.3.1 Diverse Faculty and Students make the teaching of cultural competence more explicit. Case studies and simulations were In addition to updating the curriculum, the School developed to elicit culturally appropriate health of Nursing leadership recognized that the nursing assessment inclusive of social determinants. workforce of the future must reflect—in terms of Teams of faculty worked on examining class- ethnicity, race, and religious and cultural back- specific scenarios (i.e., the patient with heart fail- ground—the patients they will be serving. The ure or the patient with diabetes) and integrating School of Nursing has been successful in recruit- different cultural concepts, so the case study was ing a diverse student body to meet the needs for more about the whole person than simply the dis- diversity in our field with over half of the stu- ease. A review of the revised cases showed that dents describing themselves as racial or ethnic we had targeted the major cultural groups in our minorities. demographic region as well as common sub- We have not been as successful in ensuring groups. Not only were ethnic groups examined faculty diversity. Cultural competence includes but also diversity in religion, sexual orientation, ensuring that the School is a safe zone for anyone gender identification, and generation. who considers themselves a minority—whether a As these cases were being implemented, sexual, racial, or religious minority—and actively School leadership began discussing the impor- working to create this environment. We recog- tance of ensuring that the curriculum truly pre- nized the challenge of having a diverse student pared the nursing student for a future in nursing, body without the diversity in faculty and recog- a future very different from that faced by the nized that students looking for academic role nursing student just a few decades ago. We recog- models to encourage and enrich their learning nized that our focus on cultural competence may be frustrated in their attempts to find men- needed to be integrated within other demands for tors and a community of support. change in nursing student preparation. We knew The School is implementing approaches to it was particularly important that our students be recruit and retain minority faculty. As part of a ready to contribute to the National Health and Robert Wood Johnson grant, we were able to sup- Human Services goals of improving health-care port minority students in obtaining graduate quality, emphasizing primary and preventive degrees which had an added curricula component care, reducing the growth of health-care costs, inclusive of the faculty role, teaching/learning, ensuring access to culturally competent care for and curriculum development. Participating stu- vulnerable populations, and improving health dents had mentors to guide them through the care and population health through meaningful graduate program as well as into the role of fac- use of health information technology. Resources ulty and the different faculty committees, includ- were allocated to training for population health— ing the diversity committee. Several of these understanding vulnerable and high-risk popula- graduates continued on as full-time or adjunct tions and the contextual conditions that increase faculty. To continue to support these faculty and risk exposure. Curriculum groups began to aim for retention, resources were allocated during 36 Case Study: Integrating Cultural Competence and Health Equity in Nursing Education 319 the first year of employment for participation in a The revised curriculum stresses that even “new faculty” development program and in the when a diagnosis takes place in a health facility, second year a scholarly writing development getting well happens in the community, probably program. the same community where that individual Attempting to draw from the pipeline of became unwell. Didactic presentations move diverse students, the Dean developed an aspiring from the population to the individual level. First faculty scholarship program for ethnic minority we present the epidemiology, contributing fac- undergraduate students and later for doctoral stu- tors, and comparisons of disease statistics across dents. Within these programs, students were geographic counties/states and across population exposed to graduate education opportunities and groups; then we discuss the manifestations of ill- different faculty research and worked alongside ness at the individual level, contrasting that with experienced faculty in the classroom and clinical a discussion at the group and population level for area. how to manage and prevent the illness across the Although the outcomes demonstrate that the continuum of care. More of our clinical practi- School of Nursing has the most faculty diversity cums are set to be community-based, not only in of other health professions schools and programs primary care and post-acute care facilities but in the university, the reality is that that is not also in patients’ homes and within community- enough—we continue not to reflect the diversity based organizations where the nurse can gain a of the students or the community we serve. We better understanding of the context in which the continue to actively recruit using a variety of patient lives and the social determinants of health methods including one-to-one contacts, advertis- the patient faces. ing in a range of sources, and negotiating for competitive salary and development packages. 36.3.3 Legacy Clinical Experiences

36.3.2 Curriculum Updates As the faculty addressed curricular change to enhance cultural competence and develop curri- We recognized the need for curricular adaptation cula to integrate population health, a supportive moving from a curriculum which was strongly School goal was to “build community service grounded in a systems (disease), developmental, capacity” by engaging in collaborative and evidence-based practice approach to one community-based service with the goal of devel- with a greater focus on supporting clients with oping community capacity for health. If we were health promotion and prevention. We were pre- to provide meaningful population health clinical paring nurses with the skills to assist clients and experiences, we needed to be a partner with the their families with self- and disease management, community, actively addressing their priority coordinating care across the continuum, and health concerns. working with the community to address health One such undertaking was the development needs from the perspective not only of clinical and ultimately expansion of a nursing commu- care but also of the physical environment, health nity health center serving four public housing behaviors, and social and economic factors such facilities. A lead faculty and the School Dean as family and social support and community developed a business plan for how the School safety. We aimed to provide our students with a could develop and lead an interprofessional, col- range of experiences to better understand the laborative, community-based population health social, cultural, and environmental factors that initiative to improve health outcomes and well- can enhance wellness or increase vulnerability to being. We had our foot in the door as the lead illness, i.e., the social determinants of health faculty member had already built a connection (SDOH), and how to provide care that is cultur- with the communities by offering weekly health ally competent in ever-diverse settings. screenings and follow-ups with residents. 320 S. W. Salmond

Demonstrating our commitment to the commu- level. Taking such a population-focused approach nity, we expanded our efforts to include active has been a win-win proposition. For the commu- partnership with the tenant association to define nity, there is a committed school partner and priority needs and allocated School resources to improved health outcomes. For the School, we offer screening and health promotion programs have a wealth of clinical experiences for pediat- and to have an RN hired to coordinate some of rics, maternal-child, adult health, and psych men- the efforts. The RN served in a dual capacity— tal health that are grounded in the community working with the community and working with demonstrating nursing’s strong role in health pro- students for active participation in case finding, motion and care management within the context care coordinating and navigating, as well as of real life. designing and implementing health promotion programs. Students work alongside community Conclusion members to develop culturally appropriate pro- The current state of health care in the United grams and services. They gain firsthand experi- States is unsustainable: costs are spiraling out ence in making complex medical issues of control despite a health-care system that understandable for patients—being guided by ranks last or near last on measures of health, community members in how to do this. They wit- quality, access, and cost. This cost is, in part, ness the reality of not being able to simply say driven by America’s epidemic of chronic dis- “eat fresh fruits and vegetables” when people live ease: nearly half of American adults had one in food deserts or saying “get 30 minutes of exer- or more chronic health conditions, many of cise a week” where people feel unsafe walking which can be prevented through lifestyle outdoors. An outcome of some of these connec- changes. The health-care system is particu- tions has been students partnering with commu- larly poor at meeting the needs of America’s nity agencies to start a community garden, ethnic minority populations who have dispro- implementation of Tai Chi programs for the portionately borne the burden of illness and elderly, using Wii fitness with pre-teens and yoga chronic disease. programs for youth, and parenting and child The School of Nursing at the center of this wellness programs. As a legacy partnership, these case study recognized the role of nursing in programs are ongoing, and students orient new leading change not only within the School groups of students to the community and to the institution itself but in the wider health-care specific projects so there is continuation of efforts system it serves. The School of Nursing rec- and commitment. ognized that it needed to make structural and In addition to the health promotion activities, curricular changes to ensure its graduates the project expanded to provide primary health were ready to serve in the health-care system care “on wheels”—a mobile health van that of the future. The Dean took the lead in work- moved from site to site. Nurse practitioner (NP) ing with faculty to address the School’s mis- and NP students would see patients, and follow- sion and vision. Once the overall philosophy up was done by the community registered nurse was agreed, she then worked with a faculty (RN) and baccalaureate students. Working with task force to establish goals to look at curricu- the medical school, we partnered with the com- lum, the teaching-learning environment, and munity board to develop a community health the work environment. Initiatives included worker (CHW) program. Now, CHWs, residents training of faculty and updating the curricu- of the community and supervised by an RN, are lum. Key themes woven into all initiatives part of the team for health outreach and educa- were a greater emphasis on cultural compe- tion. Interprofessional teams of students work tence; reorienting the curriculum to train stu- with a CHW, and the CHW serves a culture bro- dents to provide preventive, acute, and chronic ker, guiding the students on culturally appropri- care in the community; and recruiting faculty ate ways to intervene at the group and individual and students that better represent the patient 36 Case Study: Integrating Cultural Competence and Health Equity in Nursing Education 321

populations they (will) serve. Driving these Kaiser Family Foundation (2016) Analysis of the changes was the Dean, who ensured that she 2016 ASEC supplement to the CPS. http://www. kff.org/uninsured/report/the-uninsured-a-primer- consulted with faculty and students at every key-facts-about-health-insurance-and-the-unin- step—from development of a new framework sured-in-the-wake-of-national-health-reform/view/ for change to the implementation of concrete footnotes/ initiatives. On a big picture level, the School Peterson Center on healthcare, Kaiser Family Foundation (2015) Health of the healthcare sys- of Nursing is training the nurse leaders of tem: an overview. Peterson-Kaiser Health Tracker tomorrow to drive the needed changes within System. http://www.healthsystemtracker.org/chart- our wider health-care system. collection/health-of-the-healthcare-system-an- overview Salmond SW, Echevarria M (2017) Healthcare transformation and changing roles for nursing. Orthop Nurs References 36(1):12

Centers for Disease Control and Prevention (2017) Chronic disease overview. https://www.cdc.gov/ chronicdisease/overview/index.htm Case Study: Cross-Cultural Leadership for Maternal and Child 37 Health Promotion in Sierra Leone

Florence M. Dorwie

I was born in Sierra Leone, in Jimmi Bagbo, a After the brutal civil conflict in Sierra Leone headquarter of Bargo Chiefdom. Jimmi can be (1991–2002) that devastated the healthcare infra- accessed by 36 miles of dirt road from the nearest structure, I felt a sense of urgency and responsi- town of Bo. I grew up in a polygamous family bility to assume a role that would be both and my mother was the last wife of my father. My professionally rewarding and challenging. After I mother is a homemaker who worked as a tradi- completed my MSN, I established a nongovern- tional birth attendant/TBA in our village. I was mental organization, Sa Leone Health Pride Inc., delivered by a TBA. I came to the USA in 1983 in partnership with five international colleagues. after my father allowed me to leave and pursue I am the Founder and Chairperson of its Board. In further education despite the cultural belief that a 2005, the NGO was registered as a tax-exempt girl’s role is to bear children and prepare a home organization in the USA and recognized as an for her family. Previously, my father only sent his affiliate of the UN. The goal of the organization sons to school. I was the first of his daughters to is to reduce infant and maternal mortality in go to school who finished high school. I was not Sierra Leone primarily through education. In born in wealth but was spared from poverty and order to accomplish this goal, the organization risk of early marriage like many girls in my com- conducts annual fund raising dinners, individual munity. I emigrated alone and stayed initially solicitations, grant writing, and presentations to with a family friend who looked after her chil- potential donors. I developed collaboration with dren. Later, I worked as a nurse’s aide in a long- schools of nursing and pharmacy, hospitals, and term care facility that provided tuition support for healthcare practitioners in the USA to participate my BSN degree. I subsequently completed my in the NGO’s projects in Sierra Leone. Our initia- MSN and DNP and have been practicing as a pri- tives and projects are published in the organiza- mary care provider in the ambulatory clinic of a tion’s website, www.saleonehealth.org. large urban hospital in a metropolitan area in the Sa Leone Health Pride is registered as an northeast. NGO under the Ministry of Social Welfare and has two part-time personnel in Sierra Leone (Liaison and Coordinator). The liaison facilitates approval for project implementation and meet- F. M. Dorwie, D.N.P., R.N.C., A.P.N.-B.C. ings between the NGO Chairperson with vital Sa Leone Health Pride, Inc., North Bergen, NJ, USA stakeholders (Ministry of Health, Chief Medical New York Presbyterian Columbia University Medical Health Officer for Clinical Services, Ministry of Center, New York, NY, USA Education, and the Vice-Chancellor of the

© Springer International Publishing AG, part of Springer Nature 2018 323 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_37 324 F. M. Dorwie

University of Sierra Leone). The Coordinator is child development, etc. The NGO has provided in charge of all program implementations in kits for TBAs to prevent infection through hand- Sierra Leone. The NGO is affiliated with the washing, asepsis, and barrier techniques. It has national nursing organization in Sierra Leone and conducted one-on-one clinical supervision of collaborates with local nurses to identify needs to participants, providing valuable critique of their be addressed. Annual programs are planned practice. It has developed a train-the-trainer cur- based on identified needs from program partici- riculum to facilitate sustainable training of mater- pants and observations by program facilitators. nal and child health workers. In keeping with the Programs are jointly planned and coordinated by recommendation from WHO, in 2010 the the Chair and in-country Liaison and Coordinator. Ministry of Health has mandated that all women As Chairperson, I am involved in all project should be delivered in a healthcare facility and implementation and evaluation that entail 1–2 attended by trained health workers, not TBAs. visits annually in Sierra Leone. TBAs have been incentivized to bring the women Jimmi is comprised of about 15 villages. The to the clinic or hospital for prenatal, delivery, and nearest hospital is 36 miles away in Bo Town. It postnatal follow-up. MCHAs supervise the care has 1 birthing clinic staffed by 5–7 maternal and given by TBAs at home. Sa Leone Health Pride, child health aides (MCHAs) under the supervi- along with other NGOs, helped with the imple- sion of 1 registered nurse (RN). MCHAs undergo mentation of the government’s mandate by help- a formal training of about 6 months conducted by ing TBAs adapt to their new role. Women who the RN and subsequently work as an apprentice seek their care are encouraged and accompanied of the RN in prenatal, birthing, postnatal, and by TBAs to go to the clinic for delivery as well as newborn care at the clinic. They also make home for their scheduled prenatal, postnatal, and new- visits and supervise TBAs. born care follow-up. Sa Leone Health Pride has The NGO has partnered with local community maintained its policy to provide health education leaders such as the village chiefs, government to anyone including TBAs. and religious leaders, clinical health officials, In one of the annual national conferences nurses, and TBAs to build a “holding area” sponsored by Sa Leone Health Pride in Freetown, attached to the clinic for mothers who are sick or a foreign white male presenter cited the research close to delivery as many of them live very far that “female circumcision increases susceptibil- from the local clinic. This need was identified ity of women to HIV infection.” The audience during our dialogue with community leaders and erupted and a local reporter confronted the stakeholders in Jimmi. The leaders met with the speaker: “We don’t do that in this country; men community and asked each adult member to don’t talk about female circumcision.” The audi- bring stone or sand for the building structure ence was offended and became disruptive, pre- when they come to seek healthcare. Sa Leone venting the speaker from continuing his Health Pride provided monetary assistance. presentation. The incident required immediate Today, the clinic and its “holding area” is intervention. I had to intervene by apologizing to equipped with solar-powered electricity and run- the audience. The audience responded that “I did ning water from a well. It has expanded services not offend them” but continued their objection to for minor surgery and has hired one additional hearing the speaker further. RN. I met with the presenter, advising him to mod- Since 2004, Sa Leone Health Pride has been ify his presentation for the next round in another collaborating with Sierra Leone’s Ministry of venue. I explained to him that this is a cultural Health and Sanitation in providing health educa- taboo prohibiting men from openly discussing tion and training of women in the community, about women’s sexuality, pregnancy, and female TBAs, MCHAs, and RNs on prenatal care, circumcision. Female circumcision is not dis- healthy nutrition, safe delivery, prevention of cussed in public especially by a male to a female newborn and postpartal infection, umbilical care, audience or by females to other females who are 37 Case Study: Cross-Cultural Leadership for Maternal and Child Health Promotion in Sierra Leone 325 nonmembers of the Sande society. While the particularly among the youth. In 2010, Sierra speaker was warned about the danger of talking Leone has the fifth highest maternal mortality about this topic the day before the conference, he rate in the world with 890/100,000 live births was very adamant in presenting relevant research (CIA 2017a) which rose to 1360/100,000 live evidence. births in 2015 (WHO 2015). In 2016, the country I met with the reporters right after the incident ranked 11th among countries with the highest to explain that the presenter was merely present- infant mortality rate with 70/1000 live births ing a research finding which may not be specific (CIA 2017b). In 2015, the country’s under 5 mor- to Sierra Leone. They informed me that they tality rate was 120/1000 live births (WHO 2015). were offended by an outsider—a white male The country’s total population in 2015 was unfamiliar with their culture, telling them about 7,076,641 with a ratio of 1 doctor per 100,000 something that should not be discussed in public people (WHO 2017). In 2009, there were 685 by a male, particularly a non-native. registered nurses, 95 midwives, and 825 health Cross-cultural leadership requires awareness aides (UNICEF 2009). of social and cultural issues in the context of the In 2013, 54.4% of deliveries occurred in people and communities. Cultural awareness and healthcare facilities despite the government man- sensitivity to others mandate adaptation of date that all women deliver in healthcare facilities knowledge and decisions to prevent transgres- in 2010 (WHO 2015). The study by Dorwie and sions of taboos. Presentation of evidence-based Pacquiao (2014) found that most women were practices and scientific facts may be offensive delivered by traditional birth attendants/TBAs without thorough consideration of the sociocul- who were valued by mothers, health profession- tural context. My role as the conference sponsor als, and the community because they provided was to guide the presenter beforehand and pre- accessible and affordable care to mothers who vent alienation of the people we were trying to may otherwise have no access to health services. reach. It was apparent that because of my long- TBAs needed training, supervision, and resources term engagement in the community and the work for effective referral of mothers. Systemic prob- that the NGO has done, mutual trust protected me lems in the healthcare system created enormous from the audience’s anger. In fact, they made it barriers to effective care for mothers and children clear that I was not the object of their scorn. independent of TBA practices that may have con- Confronting a cultural taboo requires mutual tributed to high maternal and infant mortality trust and being accepted by the people. rates (Dorwie and Pacquiao 2014).

37.1 Social Structural Issues 37.2 Cultural Issues

Sierra Leone is a country in West Africa that suf- According to Dorwie and Pacquiao (2014), the fered a civil war in 2002 that lasted 11 years. In majority of women belong to the Mende tribe addition, the Ebola outbreak has killed close to and speak Mende. Adolescent girls are trained in 4000 of its people between 2014 and 2016 (BBC child care, homemaking, and sexual matters. News 2016). These events had dramatic conse- The value of hard work and respect for hus- quences on its economy and healthcare infra- bands, elders, and authorities are emphasized. structure. According to UNDP (2016), Sierra Most women are active members of the Sande, a Leone remains among the world’s poorest coun- society that teaches practical knowledge about tries, ranking 180th out of 187 countries in the birthing, healing, and wisdom that evolved over Human Development Index in 2011. Poverty is centuries and generations. Adolescent females widespread with more than 60% of the popula- undergo initiation rites to become members of tion living on less than US$ 1.25 a day. the Sande society marking their transition to Unemployment and illiteracy remain high, womanhood. The Sande society is recognized as 326 F. M. Dorwie the guardian and protector of women and influ- 3. Respect valued cultural traditions of the peo- ences all aspects of a woman’s life. The society ple by: forbids women from divulging its secrets such • Assuring gender-congruent care services as the birthing process; violations are consid- for women ered a major infraction (Dorwie and Pacquiao • Accommodating desired level of privacy 2014). and secrecy by pregnant women Men and nonmembers are not involved in the • Promoting confidentiality of information process of childbirth, and issues surrounding shared by women about their pregnancy deliveries by TBAs are not discussed with out- • Accommodating preference for oral siders (Lori and Boyle 2011). Women of child- consent bearing age are the backbone of the community • Including family in care decisions and and viewed as capable of becoming leaders or encounters holding political office. High officials in the 4. Promote trusting relationship by: society are generally skilled in midwifery. The • Demonstrating hospitality and generosity Sowie is the leader of the Sande society who is through sharing of food and offering finan- accepted as a role model, enforcer of proper cial support social relationships, and protector of women in • Demonstrating continued commitment and the community (Dorwie and Pacquiao 2014). long-term engagement in the community Sowies and members of the Sande society have • Accommodating established social and control over sacred knowledge essential to the family hierarchy success and happiness of Mende women and 5. Integrate appropriate cultural, linguistic, and their families. Most TBAs are either Sande soci- literacy factors in communication by: ety members or Sowies. Sowies are experts in the • Developing programs and teaching materi- Sande culture and believed to have access to als using appropriate language and level of spirits. In the Mende culture, childbearing sym- literacy bolizes a woman’s strength and capacity to par- • Consulting with local community mem- ticipate actively in society. Marriage and having bers regarding appropriateness of health a baby are rites of passage to higher status. The education materials and content more children a woman bears, the higher is her status and influence. A woman’s role is primarily devoted to her family’s needs, especially among 37.3.2 Organizational Level families of low literacy where girls are encouraged to stay at home to work and supplement the 1. Establish a formal structure and systems for family income and care for younger siblings goal implementation locally and worldwide. instead of pursuing secondary education (Kallon 2. Seek approval and participation in decision and Dundes 2010). making by community stakeholders including village chiefs and elders, government officials, and healthcare administrators. 37.3 Cross-Cultural Leadership 3. Use culturally appropriate brokers and media- Strategies tors to negotiate with established community social hierarchy. 37.3.1 Individual Level 4. Develop multisectoral social network in the community through vertical and horizontal 1. Develop self-awareness of own strengths and collaboration. limitations. 5. Demonstrate trustworthiness through long- 2. Develop in-depth awareness of the communi- term engagement and continued commitment ty’s social and cultural characteristics, history, to the community. and current health-related issues. 37 Case Study: Cross-Cultural Leadership for Maternal and Child Health Promotion in Sierra Leone 327

6. Disseminate programs and initiatives once change. Cross-cultural leadership flourishes in approved. a climate of mutual trust and involvement that 7. Collaborate with community members and can foster expansion of local and global con- stakeholders in needs assessment, selection of nections and networks of support for effective priorities, program implementation, and solutions to problems. Sustainable solutions evaluation. are the outcomes of culturally competent 8. Maintain close communication with stake- engagement with multisectoral stakeholders holders regarding progress of initiatives and and community members in identifying prob- future plans. lems, priorities, and solutions.

37.3.3 Global Community Levels References

1. Develop sustainable multisectoral partner- BBC News (2016) Ebola: mapping the outbreak. http:// ships in the local community, nationwide and bbc.com/news/world-africa 28755033 CIA (2017a) The world fact book. https://www.cia. globally. gov/library/publications/the-world-factbook/ 2. Develop global partnerships and affiliations rankorder/2223rank.html such as with the UN, healthcare organizations, CIA (2017b). The world fact book. https://www. religious groups/churches, nursing organiza- cia.gov/library/publications/the-world-factbook/ rankorder/2091rank.html tions, academic institutions, multidisciplinary Dorwie FM, Pacquiao DF (2014) Practices of traditional health professionals, etc. birth attendants in Sierra Leone and perceptions 3. Seek avenues for funding of initiatives. by mothers and health professionals familiar with 4. Engage experts in collaborative implementa- their care. J Transcult Nurs 25(1):33–41. https://doi. org/10.1177/1043659613503874 tion and research on outcomes of Kallon L, Dundes L (2010) The cultural context of the initiatives. Sierra Leone Mende women as patients. J Transcult 5. Disseminate program initiatives and outcomes Nurs 21:228–236 to worldwide audience and stakeholders. Lori JR, Boyle JS (2011) Cultural childbirth practices, beliefs and traditions in post conflict Liberia. Health Care Women Int 32:454–473 Conclusion UNDP (2016) About Sierra Leone. http://www.sl.undp. Cross-cultural and global leadership requires org/content/sierraleone/en/home/countryinfo.html in-depth knowledge of the cultural and social UNICEF (2009) Free healthcare services for pregnant and lactating women and young children in Sierra context of communities/countries where lead- Leone. Accessed from. https://www.unicef.org/wcaro/ ership transpires. In global contexts, leaders wcaro_SL_freehealthcareservices_2010.pdf on 16 should facilitate evidence-based health pro- March 2018 motion strategies that are adapted to the local WHO (2015) Sierra Leone: country health profile. http:// www.afro.who.int/en/sierra-leone/country-health- context. Compassionate and culturally com- profile.html petent leadership builds mutual trust and reci- WHO (2017) Sierra Leone. http://www.who.int/countrire/ procity and social network supportive of sle/en/ Case Study: Nursing Organizational Approaches 38 to Population and Workforce Diversity

Lucille A. Joel, Dula Pacquiao, and Victoria Navarro

A group of Filipino internationally educated affiliates. One of its goals is to foster the positive nurses (IENs), who entered the USA as legal image and welfare of its constituent members immigrants to join their families, applied to take (PNAA 2016). PNAA facilitated a face-to-face the registered nurse licensure examination. After meeting between the president of the Philippine evaluation of their school transcripts, the state Association of Deans of Colleges of Nursing and Board of Nursing rejected their application the state Board of Nursing. According to Dr. because the clinical laboratory component of Divinagracia (president of the Philippine deans), their nursing courses was not taken concurrently concurrency between classroom and clinical with the theory portion of the course. They were components is also a standard in the Philippines. deemed ineligible and mandated by the Board of However, during the mass recruitment of Filipino Nursing to retake these nursing courses in an IENs by foreign employers, proliferation of accredited program of nursing. It should be noted hospital-based schools of nursing and large nurs- that the additional requirement of concurrency of ing enrollment created overcrowding and short- theory and clinical courses was a problem in this ages of clinical sites. Consequently, some schools state, which is in keeping with states’ rights. allowed students to take the theory portion prior In this instance, some of the nurses sought to clinical practice to manage student progression assistance from the state chapter of the Philippine in the curriculum. At the height of the last nurs- Nurses Association of America (PNAA). PNAA ing shortage in the USA and other rich countries, is the national organization representing Filipino nursing enrollment in the Philippines grew expo- nurses in the USA with several statewide chapter nentially as entrepreneurs (physicians and hospital owners) established several schools of nursing. Organized nursing leadership was powerless in controlling the growth of these schools due to the L. A. Joel, Ed.D., R.N., A.P.N., FAAN School of Nursing, Rutgers University, support by the Philippine government eager to Newark, NJ, USA bolster its dollar reserve from overseas employ- e-mail: [email protected] ment of nurses (Jurado 2013). D. Pacquiao, Ed.D., R.N., C.T.N.-A., T.N.S. (*) PNAA collaborated with a local community School of Nursing, Rutgers University, college to develop a program to remedy the defi- Newark, NJ, USA cits in the nursing curricula of these nurses. It School of Nursing, University of Hawaii, Hilo, provided initial funding for tuition support of the Hilo, HI, USA first cohort of 40 students. This program is con- V. Navarro, M.S.N., R.N. tinuing as hundreds of Filipino IENs were Joint Commission International, Oakbrook, IL, USA

© Springer International Publishing AG, part of Springer Nature 2018 329 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_38 330 L. A. Joel et al. affected. PNAA developed a position statement recruitment practices that exploit and mislead on nursing education standards which was shared nurses to accept working conditions incompati- with the Association of Deans of Colleges of ble with their qualifications and experience. In Nursing in the Philippines emphasizing the need addition, ICN condemns recruitment of nurses to for concurrent theory and clinical practice in the countries where the authorities have failed to nursing curricula. Many of these questionable implement sound resource planning and work- nursing programs have since closed when foreign force development and retention. It has called for demands for nurses dwindled. its member national nurses associations to engage Thousands of nurses, the vast majority of in promoting ethical recruitment by guiding them women, migrate each year in search of bet- informed decision-making and reinforcing sound ter pay and working conditions, career mobility, employment policies on the part of governments, professional development, and sometimes just employers, and nurses, as well as supporting fair novelty and adventure (Kingma 2006). and cost-effective recruitment and retention prac- Worldwide, nurses comprise the largest group of tices. According to ICN, governments and nurs- healthcare workers as well as the largest migrant ing leaders of member nations should develop group among all categories of healthcare work- strategic plans for workforce development, ers. About 8% of registered nurses/RNs in the employment, and retention in order to build an USA are foreign-educated with the Philippines as adequate and sustainable healthcare workforce. the major source country accounting for more In response to the worldwide human and work- than 30% of US foreign-educated nurses. Nurse force diversity, ICN (2013) has developed a posi- immigration to the USA has tripled since 1994 to tion statement emphasizing the need for culturally about 15,000 annually (Aiken 2007). The USA competent nursing and healthcare for populations employs the most international nurses, but worldwide. foreign-educated nurses comprise only 4% of its nursing workforce, compared to the UK and Ireland (8%) and Canada (6%). The top six coun- 38.1 Social and Cultural Issues tries that export nurses are the Philippines, Canada, India, Nigeria, Russia, and Ukraine In the USA, the government monitors the safety (Walker 2010). of consumers and qualifications of individuals The flow of migration of healthcare workforce seeking to practice as registered nurses through has consistently followed a pattern from low- the State Boards of Nursing and a system of income to high-income countries. A paradox licensure, but the development of the profession exists in the Philippines with as much as 300,000 is chiefly through the private sector. Organized unemployed nurses while healthcare facilities nursing such as the American Nurses Association particularly in rural areas are critically under- (ANA), the National League for Nursing (NLN), staffed. Many nurses seek employment outside of and the American Association of Colleges of nursing, but nursing school enrollment is greatly Nursing (AACN) has fought for many years to influenced by employment opportunities abroad. move entry into practice for nursing to the level A shortage of highly educated and skilled health of the baccalaureate degree (BSN) with no suc- workers within the source countries (“brain cess. Efforts included requiring the baccalaureate drain”) has had catastrophic effects on the quality degree for licensure and later requiring, through of care, disease burden, and mortality in these legislation, that this degree be completed within countries (Allutis et al. 2014; Kingma 2008). 10 years of initial entry into practice. It should be The International Council for Nurses (ICN noted that ANA’s 1965 position statement 2007) recognizes the right of individual nurses to (Donley and Flaherty 2008) for BSN as entry to migrate and the benefits of multicultural practice practice was the impetus for the implementation and learning opportunities supported by migra- of BSN as the sole entry to practice in the tion. However, it denounces unethical Philippines in 1983 (Republic Act 877). This was 38 Case Study: Nursing Organizational Approaches to Population and Workforce Diversity 331 achieved through leadership by the Philippine IENs need to adapt their clinical practice and Association of Deans of Colleges of Nursing, the communication skills to that of their new envi- Board of Nursing, and the Philippine Nurses ronment in order to successfully deliver safe, Association. quality care to patients. They need to be aware of While efforts to push the BSN in the USA as cultural differences between their own home entry to practice failed, the Magnet Program and country and that of the USA and negotiate with the Institute for Medicine Report (2011), both these differences to enhance care effectiveness. private sector initiatives, have revolutionized the For instance, the individual right of confidential- workplace and moved the BSN into new promi- ity and autonomy may be contrary to the ethic of nence through their demands for a more educated many IENs and doctors. Another example is the nurse, given the growing complexity of health- alleviation of pain. Pain has long been labeled as care. These demands were evidence-based, draw- the fifth vital sign in the USA. Depending on the ing directly on research done by Aiken and other preference of the patient, no one needs to suffer scholars (Aiken et al. 2014; Kutney-Lee et al. pain and pain need not be the natural by-product 2013; Stimpfel et al. 2016). In a partnership of illness (Department of Veterans Affairs 2000). referred to as “twinning,” Magnet hospitals in the As a vital sign, pain should be routinely assessed, USA have become mentors to institutions in and nurses have the responsibility to advocate for developing countries to enhance care. the patient’s optimal alleviation of pain, some- Increasing diversity of populations brings a times in the face of strident medical or family unique challenge in care provision because of opposition. These opposing viewpoints can cultural and linguistic differences. The Office of intrude on clinical care. Some of these attributes Minority Health (2017) has identified the need of caring are guaranteed legally, others are moni- for culturally competent healthcare services. tored through accreditation, but they all draw This directive has been fully adopted by private from the US culture. Earlier, there was little organizations such as the accrediting bodies for appreciation that IENs may bring a different phi- hospitals and other care settings as well as edu- losophy of care. There is much that can be learned cators in various health professions. Some of the from these new colleagues, while remaining vigi- issues that emerged in healthcare have stemmed lant over one’s own context of care. from cultural differences between patients and Cultural competence is inextricably linked to health system norms. The need for translation linguistic competence. The essence of nursing is and interpretation has posed conflict between communication—the ability to engage patients as patients and practitioners. While some families true partners in their care and establish the trust may prefer their own family members for lan- relationship that is essential to building that part- guage interpretation, this has resulted in some nership require linguistic competence. Every legal problems for practitioners and healthcare aspect of nursing practice, from initial assess- organizations. The individual patient’s right to ment to teaching, counseling, and support, confidentiality demands that the patient deter- depends on linguistic competence. Linguistic mines who has access to his/her medical infor- competence is the capacity to communicate mation. Many cultures assume the sick should effectively with persons who have limited lan- not be burdened with information about their guage proficiency, who are to some degree illiter- prognosis or that medical information should ate or have a disability inhibiting hearing and/or only be shared with specific family members understanding (National Center for Cultural such as the oldest son. Care should be taken to Competence (NCCC) 2017). This becomes a reconcile these choices with the legal require- problem in any culture where the provider or the ments of a hosting country. Often the expecta- patient is not proficient in the local language and tions of confidentiality and autonomy require the appropriate nonverbal communication. educating patients to their rights and then docu- This patient-centric model within the context menting their preference. of nationally established standards and ethics is 332 L. A. Joel et al. an expectation of nursing graduates. Respect for is a member of ICN that represents the interests multiculturalism is fostered in nursing education of 3.6 million registered nurses in the USA (ANA and in in-service programs. Private and public 2017). In response to the influx of IENs and other sector endorsement of culturally and linguisti- foreign-educated health professionals to the cally competent healthcare services has been pro- USA, ANA and NLN established the Commission moted by the Office of Minority Health (2017), on Graduates of Foreign Nursing Schools The Joint Commission, and the Institute of (CGFNS) in 1977. CGFNS has evolved to be a Medicine (2010). The NLN and AACN have federal and national authority for credentials developed and promulgated standards for inte- evaluation and verification pertaining to the edu- gration of cultural competence in nursing educa- cation, registration, and licensure of nurses and tion. Diversity/multiculturalism in education other healthcare professionals across the world promises to improve the quality of even the best (CGFNS 2016). of programs. AACN (2014) has emphasized that IENs experienced a high failure rate in the diversity among the student body and faculty RN licensure exams and were consequently improves “learning outcomes, thinking and intel- employed in roles below their educational prepa- lectual engagement, motivation, social and civic ration in order to survive in the USA. Many skills, and empathy…”. employers and co-workers also noted their diffi- Evidence-based practice has become the rai- culty with English communication. CGFNS son d’etre of nursing which needs to be rein- developed the test of English proficiency and forced in every nurse, regardless of country of nursing knowledge for IENs that has demon- origin or date of completion of their entry educa- strated the ability to predict success in the RN tional program. Increasing diversity in the US licensure exams. These exams were mandated by population necessitates evidence-based practices most states for visa qualification and RN licen- to reflect the demographics of the patient popu- sure eligibility. Since the RN licensure exams lation as well as practitioners. Institutional have been offered in countries outside the USA, review board approval should be contingent on the requirement for CGFNS exam has been abol- this factor. If the major portion of the clinical ished by many states. population is of an immigrant population, risk Funded by the Kellogg Foundation, CGFNS management, utilization review, quality assur- (2016) has developed coalitions with nursing ance, and clinical research models should reflect leaders in Canada and Mexico to identify and this demographic makeup. Indeed, a review of examine the challenges and opportunities pre- studies in healthcare by the US Health Resources sented by the North American Free Trade. One of and Services Administration (HRSA 2006) its divisions, the Alliance for International Ethical revealed that patients are more likely to receive Recruitment Practices (CGFNS 2016), has quality preventive care and treatment when they recently partnered with the Philippine Labor share race, ethnicity, language, and/or religious Organization, the Philippine Overseas experiences with their providers. This observa- Employment Agency, and the Philippine Nurses tion holds challenges for both education and Association of America to establish standards for practice. employment contracts offered to Filipino IENs by US employers. As the national organization of Filipino nurses 38.2 Approaches by Professional in the USA, the PNAA represents the profes- Nursing Organizations sional interests of its members. PNAA has strived to align itself with the official position of ANA ICN (2017) is a federation of more than 130 and has maintained a collaborative relationship national nurses’ associations (NNAs), represent- with ANA’s state affiliates. Filipino nurses coming more than 20 million nurses worldwide. ANA prise the largest group of IENs in the USA. At the 38 Case Study: Nursing Organizational Approaches to Population and Workforce Diversity 333 height of the nursing recruitment in the 1980s, 38.3 Cross-Cultural Leadership state chapters of PNAA partnered with local Strategies healthcare employers and nursing schools to develop an acculturation program for newly 38.3.1 Individual Level recruited nurses which included hospital educators, managers, and staff. Using feedback from • Design mentoring programs for diverse stu- IENs, their employers, and co-workers, these dents and nurses to promote academic and programs have evolved to include cultural differ- professional success. ences, communication, critical thinking, • Provide consultation to healthcare organiza- decision-making, legal-ethical issues, leadership, tions and professionals on culturally compe- teamwork, etc. State chapters of PNAA also part- tent leadership strategies. nered with local schools of nursing and health- • Promote development of professional and care employers in preparing IENs for CGFNS leadership network for diverse students and and RN licensure exams. nurses. The Philippine government views labor export • Promote active membership of diverse stu- especially of healthcare manpower as a big dents and nurses in professional nursing source of dollar revenue. This governmental push organizations. has limited the capacity of local nursing leaders • Model leadership behaviors for racial and eth- to address the nationwide depletion of skilled nic minority students and professionals. educators and practitioners and large nursing • Participate in education and training of health- vacancies in healthcare facilities because of lack care professionals in culturally competent of government funding and proliferation of low- care. quality nursing programs during periods of mass foreign recruitment. PNAA has instituted the annual educational exchange program (“Balik- 38.3.2 Organizational Level Turo”) to facilitate dissemination of academic and clinical practices to nurses in the Philippines. • Design organizational systems and structure This annual program is offered in different to promote delivery of culturally competent regions of the Philippines to reach different sec- healthcare services. tors of practitioners. PNAA has also partnered • Promote engagement of organizations and its with the Department of Health in the Philippines leaders in vulnerable and underserved to establish the first nurse anesthesia program to communities. address the shortage of anesthesiologists in rural • Implement systems and structure to reward areas. culturally competent practices and prevent PNAA has worked with the Philippine discrimination and inequity in healthcare. Overseas Employment Agency to promote ethi- • Enhance recruitment, retention, and success cal recruitment practices based on the experi- of diverse students and nurses. ences of nurses in the USA. PNAA has referred • Participate in developing position statements nurses to the Philippine Human Rights Committee and public dissemination of healthcare agenda for legal assistance with fraudulent recruitment supportive of culturally competent care and and contract violations with their employers. The health equity. Philippine Commission on Overseas Filipinos has partnered with PNAA to offer a global summit in the Philippines every 2 years to promote 38.3.3 Community Level understanding of trends and requirements for international nursing employment among local • Engage in multisectoral and multidisciplinary stakeholders, nurses, and students. collaboration to influence laws, policies, and 334 L. A. Joel et al.

regulations to enhance population health in the organization’s budget (The Joint equity. Commission 2010). • Maintain active involvement in professional Nursing leaders need to engage with racial organizational committees to improve health and ethnic communities and other stakehold- equity. ers to implement a strategic plan to build a • Participate in local, national, and global initia- multicultural student body or the multicultural tives to improve workforce development and workforce. This creates a vibrant community retention. for learning and practice, a ready laboratory to • Participate in local, national, and global initia- advance the science and improve health inter- tives to promote healthcare equity worldwide. nationally. This will be one way to provide • Expand social and professional networks to staff with the resources for culturally compe- advance initiatives for health equity. tent practice. It is also the way to create a wel- • Participate in research and evaluation of pro- coming bridge between the agency and the grams and policies relevant to population community it serves. health. Engagement with racial and ethnic nursing organizations and communities can promote Conclusion recruitment of diverse students to nursing and Preparation for culturally competent/profi- the professions. They serve as a vital social cient organizations/communities must start support network for students. These systems with the individual. Cultural competence and their leaders can provide the link to requirements should be included in job enhance awareness of culture-specific best descriptions, performance appraisals, and pro- practices in education and practice. motion criteria. Organizational policies should Cross-cultural leaders not only transform reflect the characteristics of the workforce and their organizations toward cultural compe- the community served. The healthcare organi- tence but also engage in regional, national, zation is situated in a community and is depen- and international collaborations to promote dent on the community for its sustenance. The safe and equitable healthcare globally. Cross- hospital, long-term care facility, home care, or cultural leaders should be mindful of the posi- ambulatory care setting should begin to take tions of global experts in healthcare. They can on the characteristics of the population it engage their national organizations to collabo- serves. It is best to educate healthcare workers rate with governmental agencies in their coun- to the values and traditions of the people and tries to influence policies on workforce listen to their community leaders. Know the development and deployment. Cross-cultural community, ask their indulgence for one’s leaders should collaborate with professional ignorance, and invite them to speak to staff or nursing organizations globally to create a uni- provide “friendly” visits to patients. Bring ser- fied strategy to influence governmental poli- vices to the local ethnic population, breaking cies to promote local employment and down barriers and establishing familiarity. Let retention of healthcare professionals, alloca- patient satisfaction data speak for itself and tion of adequate healthcare manpower for determine the receptiveness of services to local needs, and universal access of local pop- diverse populations. Track programs with the ulations to basic care services. International volume of services being provided, and deter- collaboration should promote dissemination mine how this impacts on the organization’s of knowledge and best practices in nursing bottom line. Be aware that resources cost education and care delivery. money, so cultural competence deserves a Agreements among governments should budget line of its own. The costs of consulta- address ways to compensate for the loss of the tion, interpretation, printed material and trans- financial investment in the education of lation services, and more, deserve to be visible healthcare professionals and the negative 38 Case Study: Nursing Organizational Approaches to Population and Workforce Diversity 335

consequences on population health when they ICN (2007) Position statement: ethical recruitment of decide to leave for more opportunities and nurses. http://www.icn.ch/images/stories/documents/ publications/position_statements/C03_Ethical_ better salaries and working conditions. While Nurse_Recruitment.pdf migration of health professionals might bene- ICN (2013) Position: cultural and linguistic competence. fit individual families and even countries http://www.icn.ch/images/stories/documents/publica- through their remittances, these gains are tions/position_statements/B03_Cultural_Linguistic_ Competence.pdf rarely used to improve the social agenda of the ICN (2017) Who we are. http://www.icn.ch/who-we-are/ sending country. who-we-are/ Institute of Medicine (2010) The future of nursing: leading change, advancing health. National Academies Press, Washington, DC References Jurado L (2013) Social construction of Filipino nurses in the Philippines and as foreign-educated nurses in the AACN (2014) Fact sheet. The need for diver- United States. PhD Dissertation, Rutgers, The State sity in healthcare workforce. http://www.aap- University of New Jersey cho.org/wp/wp-content/uploads/2012/11/Need Kingma M (2006) Nurses on the move: migration and the ForDiversityHealthCareWorkforce.pdf global health care economy. Cornell University Press, Aiken LH (2007) U.S. nurse labor market dynam- Ithaca ics are key to global nurse sufficiency. Health Kingma M (2008) Nurses on the move: historical per- Serv Res 42(3 Pt 2):1299–1320. https://doi. spective and current issues. Online J Nurs 13(2). org/10.1111/j.1475-6773.2007.00714.x http://www.nursingworld.org/MainMenuCategories/ Aiken LH, Sloane DM, Bruyneel L et al (2014) Nurse ANAMarketplace/ANAPeriodicals/OJIN/ staffing and education and hospital mortality in TableofContents/vol132008/No2May08/Nurseson nine European countries: a retrospective obser- theMove.html vational study. Lancet 383:1824–1830. PMCID: Kutney-Lee AM, Sloane DM, Aiken LH (2013) An PMC4035380 increase in the number of nurses with baccalaureate Allutis C, Bishaw T, Frank MW (2014) The workforce for degrees is linked to lower rates of postsurgery mor- health in a globalized context – global shortages and tality. Health Aff 32:579–586. PMCID: PMC3711087 international migration. Glob Health Action 7:23611. National Center for Cultural Competence (NCCC) (2017) https://doi.org/10.3402/gha.v7.23611 Self-assessment: an essential element of cultural ANA (2017) Members and affiliates. http://www.nurs- competence. http://nccc.georgetown.edu/foundations/ ingworld.org/FunctionalMenuCategories/AboutANA/ frameworks.html. Accessed 13 May 2017 WhoWeAre Office of Minority Health (OMH), US DHHS (2017) CGFNS (2016) Milestones. http://www.cgfns.org/about/ The national standards for culturally and lin- history/ guistically appropriate services in health and Department of Veterans Affairs (2000) Pain as the health care. minorityhealth.hhs.gov/omh/browse. 5th vital sign toolkit. Geriatrics and Extended aspx?lvl=2&lvlid=53. Accessed 10 May 2017 Care Strategic Healthcare Group National Pain PNAA (2016) Mission. http://mypnaa.org/About-Us Management Coordinating Committee Veterans Stimpfel AW, Sloane DM, McHugh MD et al (2016) Health Administration, Washington, DC Hospitals known for nursing excellence associated Donley R, Flaherty J (2008) Revisiting the American with better hospital experiences for patients. Health Nurses Association’s first position on education for Serv Res 51(3):1120–1134 nurses. http://www.nursingworld.org/MainMenu The Joint Commission (2010) Advancing effective com- Categories/ANAMarketplace/ANAPeriodicals/ munication, cultural competence, and patient- and OJIN/TableofContents/Volume72002/No2May2002/ family-centered care: a roadmap for hospitals. The RevisingPostiononEducation.html Joint Commission, Oakbrook Terrace, IL HRSA (2006) The rationale for diversity in the health Walker J (2010) Migration, brain drain, and going for- professions: a review of evidence. http://bhpr-hrsa- ward. Johns Hopkins Nursing. http://magazine.nurs- healthworkforce-reports-diversityreviewevidence ing.jhu.edu/2010/08/the-global-nursing-shortage/ Part X Guideline: Evidence Based Practice and Research Designing Culturally Competent Interventions Based on Evidence 39 and Research

Marilyn “Marty” Douglas

Guideline: Nurses shall base their practice on interventions that have been systematically tested and shown to be the most effective for the culturally diverse populations that they serve. In areas where there is a lack of evidence of efficacy, nurse researchers shall investigate and test interventions that may be the most effective in reducing the disparities in health outcomes. Douglas et al. (2014: 115)

39.1 Introduction Council of Nurses 2012; Munten et al. 2010; Saunders and Vehviläinen-Julkunen 2017; Cheng According to a World Health Organization report et al. 2017). of more than a decade ago (WHO 2004), more than half of the world’s deaths are preventable with cost-effective interventions that are known 39.2 Evidence-Based Practice and evidence-based. Yet, we neither know how to (EBP) make these interventions more available to those who need them nor do we adequately direct our As the costs of delivering healthcare rise, solu- efforts and resources toward closing the gap tions to aligning quality, improved patient out- between what is known and what we practice. comes, and costs have become more urgent. Consequently, the disparities in healthcare deliv- Increasingly, healthcare delivery systems are ery, health inequities, and health outcomes using standardized practices that are based on the remain a significant challenge worldwide, and best research findings as a means to improve one that does not seem to be diminishing even as patient outcomes while at the same time reducing science makes significant advances in curing costs. Almost 10 years ago, the US Institute of human diseases. In an effort to address these Medicine set the following goal: “By the year challenges, evidence-based practice is now a 2020, 90 percent of clinical decisions will be sup- well-established global priority of nursing, rec- ported by accurate, timely, and up-to-date clini- ognizing that nursing practice must be based on cal information, and will reflect the best available findings from the best evidence derived from evidence (Institute of Medicine 2008: 189).” well-designed research studies (International Furthermore, EBP has been strongly endorsed by several international nursing organizations as a foundation of nursing practice (International M. Douglas, Ph.D., R.N., FAAN Council of Nurses 2013; Sigma Theta Tau School of Nursing, University of California, International 2017; Royal College of Nursing San Francisco, San Francisco, CA, USA e-mail: [email protected]; 2014; American Academy of Nursing 2017; [email protected] American Nursing Credentialing Center 2015).

© Springer International Publishing AG, part of Springer Nature 2018 339 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_39 340 M. Douglas

39.2.1 Definition and Goals change practice. Organizational lack of support, lack of essential knowledge of the EBP process, Evidence-based practice is a method used to and unavailability of electronic and library incorporate the best evidence into the clinical resources were also cited as barriers. decision-making process. It uses a problem- Studies of European nurses have shown simi- solving approach to combine three major lar barriers. Investigators in Spain (Pericas- elements: the best evidence from research, Beltran et al. 2014) reported nurses’ lack of patient’s preferences and values, and the clini- autonomy, perceived lack of inclusion in clinical cian’s expertise (Melnyk et al. 2014). EBP is a decision-making, and insufficient leadership sup- complex process involving clinical nurses, port as well as physician resistance as impedi- advance practice nurses, and administrative staff. ments to implementing EBP. Patelarou et al. Its goal is to improve patient outcomes as well as (2013) confirmed these findings in an investiga- staff satisfaction and retention, which ultimately tion of European community settings. reduces costs in both areas. Since standardizing evidence-based practices across large hospital systems is one suggestion for improving patient outcomes and reducing 39.2.2 Barriers to EBP costs, Warren et al. (2016) surveyed 1608 nurses in one large 9-hospital system spread out along Despite the overwhelming support for EBP, many the mid-Atlantic area of the USA. These investi- barriers to its implementation remain. In an gators used questionnaires developed by Melnyk attempt to identify global barriers to implement- et al. (2008) to describe not only the nurses’ atti- ing EBP, Ubbink et al. (2013) conducted a sys- tudes, beliefs, and perceptions about EBP tematic review of 31 studies with 10,798 (Evidence-Based Practice Belief scale (EBPB)) respondents in 17 countries representing all con- but also their readiness to implement EBP tinents. Surprisingly they found that the barriers (Evidence-Based Practice Implementation scale at both the individual and organizational levels (EBPI)). A third questionnaire used was the were similar across settings, except for the lan- Organizational Culture and Readiness for guage barrier in non-English-speaking countries System-Wide Integration of EBP Scale and limited access to electronic databases in (OCRSIEP) developed by Fineout-Overholt and some countries. Both nurses and physicians Melnyk (2006). This questionnaire asked the par- found similar barriers, such as lack of time to ticipants to rate the availability of EBP resources access research findings and implement the evi- and mentoring staff at their organization, identify dence in their own settings, lack of training in the key leadership roles in decision-making, and rate process of implementation, lack of facility the readiness of their organization to implement resources, and lack of administrative and staff EBP. support for EBP. In addition, nurses cited their Overall, less than half of the nurses in this lack of authority to change practice, limited study reported having access to resources to understanding of statistics and the research pro- implement EBP, while almost 80% had not cess in general, and their inability to translate the accessed national guidelines to evaluate a change research findings into implications for practice as in their clinical practice within the past 2 months. impeding implementation of EBP. Almost 2/3 of RNs reported a lack of organiza- These findings are consistent with many other tional readiness for EBP, especially in the areas studies. Khammarnia et al. (2015) surveyed 280 of human and financial resources. And nearly nurses in Iran to determine barriers to implement- 80% perceived their involvement in clinical ing evidence-based practice in six teaching hos- decision-making as “None” to “Somewhat.” pitals. Besides the language barriers, they found However, notable demographic and educational similar issues related to time, that is, insufficient differences were found. The nurses who were time to access then read the literature, as well as younger, who worked in Magnet® hospitals, and work overload precluding time to evaluate and those with less work experience had a much more 39 Designing Culturally Competent Interventions Based on Evidence and Research 341 positive attitude toward EBP, similar to those with advanced EBP training, working side by with graduate nursing degrees. These differences side with clinical nurses, is essential if the best can be attributed to newer curricula in nursing evidence is going to be integrated into estab- programs and that Magnet® designated hospitals lished practice. These EBP mentors are needed place a strong emphasis on EBP (American to help interpret statistics, select well-designed Nursing Credentialing Center 2013). studies, and identify which findings can be tested Viewed from a global perspective, the barriers in their own settings. Unless organizations allo- are remarkably similar among nurses around the cate funds to hire these EBP mentors, staff nurses world. Although more nurses are becoming will be ill equipped to interpret and integrate increasingly aware of the need for EBP, many EBP. still report lack of time, resources, and leadership Nursing leadership at the executive, depart- in order to provide care based on the best evi- mental, and unit levels is required to facilitate dence available. the implementation of EBP (Melnyk et al. 2016). Nurse leaders endorse the essential ingredient of time to be spent by the nurses to 39.2.3 Facilitators of EBP study a problem, gather the necessary evidence, and then evaluate its relevance to their current Despite the obstacles faced by clinicians to imple- practice. Nurse leaders foster a positive attitude ment evidence-based care, a number of facilitators toward EBP by encouraging staff to partake in have been identified. The essential characteristics EBP classes and projects and by providing the of an environment that facilitates EBP include necessary time and resources to accomplish nurses with a positive attitude toward EBP and these activities. Nursing leadership legitimizes access to the necessary resources to search current this commitment by incorporating participation research. First and foremost, the healthcare deliv- in EBP in job descriptions and clinical ladders ery system must embrace a philosophy and culture and as a competency in the functional state- and mentorship to guide nurses in the interpreta- ments and performance evaluations of nursing tion, critical appraisal, and translation of evidence staff at all levels. into their practice (Davidson and Brown 2014) Besides time, mentors, and leadership sup- that supports EBP and then provide financial, digi- port, material, digital, and human resources also tal, and human resources to support this culture are needed to enable nurses to participate in EBP (Melnyk 2017). A belief in the value of EBP to activities. Access to electronic databases contain- improve patient outcomes, reduce costs, and ing relevant research studies is a prerequisite, in increase nurse satisfaction is crucial at the execu- whatever form, whether it is at the point of care tive level. Without this conviction, organizational or accessible through a university. In addition, goals will not be created, and fiscal resources will librarians who can assist the staff with accessing not be allocated to support EBP. these databases are crucial. These librarians can For nurses to have a positive attitude toward contribute through instruction in continuing edu- EBP, they need knowledge of its process and ben- cation classes for the staff at the point of care, as efits. Since younger nurses and those more well as assisting with identifying and searching recently graduated from nursing programs have the appropriate library resources and databases already been introduced to EBP, more experi- (Melnyk and Fineout-Overholt 2015). enced nurses are more critically in need of continuing education programs in these concepts. Integrating EBP and research content into staff 39.2.4 Strategies for Implementing orientation, continuing education, and leadership Evidence-Based Practice development programs demonstrate one aspect of organizational support and preparation for EBP. A number of models have been developed to Knowledge alone about EBP does not guar- address the barriers to EBP and to emphasize antee its implementation. Mentorship by nurses those elements that facilitate the transfer of 342 M. Douglas research findings into clinical practice. Four such –– Identifying the clinical practice issues in models will be discussed: the Iowa model, the their division or on their units that require Johns Hopkins model, the Advancing Research exploration of research-based validation and Clinical Practice Through Close –– Critiquing the appropriate research with Collaboration (ARCC ©) model, and the Joanna the help of EBP mentors and support of Briggs Institute (JBI) model of evidence-based divisional nursing administrators healthcare, a model reconsidered. –– Developing strategies for pilot testing evidence-based practices in their own set- 39.2.4.1 Iowa Model of Research tings and evaluating the effect of the and Practice changes on patient outcomes The team of Titler et al. (1994, 2001) was a pio- –– Coordinating any changes needed in prac- neer in developing a coherent framework for tice protocols with the appropriate infusing nursing research findings into clinical committees. practice. They developed the Iowa Model of –– Presenting projects developed at the unit or Research and Practice©, which was an outgrowth division level at the Professional Nursing of the Quality Assurance Model Using Research Council, which serves as a platform for (QAMUR) (Watson et al. 1987). The Iowa model sharing and discussing how their experi- was developed by nursing leaders within the ences and findings have applicability to the University of Iowa Hospitals and Clinic (UIHC) work in other divisions and units system, a multi-division healthcare system in the Central USA. The steps in the process of integrat- In this model, the process of problem identifi- ing research into practice are illustrated in cation, evaluation, and implementation is accom- Fig. 39.1. plished by point-of-care providers, thus providing Although knowledge of the process is essen- some assurance that the research-based changes tial, it is insufficient without an adequate struc- will be integrated into standard practice. ture in which to implement EBP. Nursing administration at UIHC constructed such an envi- 39.2.4.2 Johns Hopkins Nursing EBP ronment in the following way: Model A second model for implementing EBP, the Johns • Department of Nursing Research Committee Hopkins Nursing Evidence-Based Practice provides the organizational structure for coor- Model, is one of the easiest to use by the practic- dinating all the department’s research activi- ing nurse (Dearholt and Dang 2012). It uses a ties, such as the following: three-step problem-solving approach named –– Strategic planning for nursing research, PET: (1) practice question, (2) evidence, and (3) including prioritizing topics to be translation. A diagram of the model plus nine investigated user-friendly tools is available on the Internet at –– Consultants to divisional and unit-based http://www.hopkinsmedicine.org/evidence- nursing research committees based-practice/jhn.html. –– Reviewing research protocols –– Presenting classes and papers on clinical 39.2.4.3 Advancing Research research topics and Clinical Practice –– Disseminating research findings to divi- Through Close Collaboration sional committees (ARCC) Model • Divisional and Unit-Based Nursing Research A third model was designed to be implemented Committees are composed of front-line care on a system-wide basis. The Advancing Research providers such as staff nurses, clinical nurse and Clinical Practice Through Close specialists, and nurse managers. Their activi- Collaboration (ARCC©) model was designed and ties include as follows: tested by the team of Melnyk et al. (2017). It 39 Designing Culturally Competent Interventions Based on Evidence and Research 343

The Iowa Model of Research-Based Practice to Promote Quality Care

Tr iggers to Improve Practice Through Research

Problem Focused Triggers Knowledge Focused Triggers 1. Risk Management Data 1. National Agencies or Organizational 2. QA/QI* Data Standards & Guidelines 3. Identification of Clinical Problem 2. Philosophies of Care 4. TQM/CQI** 3. Questions from Institutional Standards Committee 4. New Information in the Literature

Assemble Relevant Research Literature

Critique & Evaluate for Use in Practice

YesNo Is There a Sufficient Research Base?

Research Base is Sufficiently Developed to Research Base Not Sufficiently Guide Practice Developed to Guide Practice 1. Select Outcomes to be Achieved 2. Design Nursing/Multidisciplinary Practice 3. Implement Practice Changes on a Pilot Unit 4. Evaluate Process & Outcomes Determine Conduct Consult with 5. Modify Intervention as Needed Scientific Research Experts Principles

Is the Change Appropriate for Adoption in Practice?

Change Practice

Monitor Outcomes

Patient & Staff Fiscal Family

**TQM/CQI=Total Quality Management/Continuous Quality Improvement *QA/QI=Quality Assessment/Quality Improvement

Fig. 39.1 The Iowa model of research-based practice to K (1994) Infusing research into practice to promote qual- promote quality. Source: Titler MG, Kleiber C, Steelman ity care. Nursing Research, 43: pg. 309. Reproduced with VJ, Good C, Rakel B, Barry-Walker J, Small S, Buckwalter permission 344 M. Douglas incorporates an organizational assessment as a (Melnyk et al. 2014). Each of these steps can be first step in identifying the barriers and strengths further expanded into separate courses. within the specific healthcare system. Based on Finally, in order to integrate and sustain EBP the findings from this tool, the Organizational within the organizational culture, competencies Culture and Readiness for System-Wide were developed for both registered nurses and Integration of EBP Scale (OCRSIEP) (Fineout- advanced practice nurses, as outlined in Overholt and Melnyk 2006), system-specific Table 39.2 (Melnyk et al. 2014). These compe- strategies are developed to address the identified tencies provide clear expectations of the staff that strengths and barriers. For example, some poten- EBP is part of the organizational culture. tial strengths may be that the organization as a If the clinical problem of interest involves a whole places a strong value on EBP, has adminis- racially or ethnically diverse or vulnerable pop- trative support, and has potential EBP mentors. ulation, then added criteria need to be applied Barriers may include inadequate knowledge and to defining the problem (PICOT question) and skills about EBP among the staff and their per- evaluating the research for applicability. For ceived lack of value in the benefits of EBP. example, additional questions to ask are as fol- After organizational assessment, an evalua- lows: Was the population of interest included in tion of the point-of-care clinicians is the next the study? Were different cultural groups stud- step. Findings from two tools administered to ied and compared? Was the intervention appro- staff, the Evidence-Based Practice Belief scale priate and feasible for or adapted to the (EBPB) and the Evidence-Based Practice population of interest? Were the outcomes of a Implementation scale (EBPI) (Melnyk et al. culturally specific intervention clinically sig- 2008) are used to build a curriculum for orienta- nificant? Was the effectiveness of a particular tion and continuing education workshops in EBP intervention studied across several cultural and research. Central to these workshops is the groups? seven-step process of EBP outlined in Table 39.1 39.2.4.4 The Joanna Briggs Institute Model Table 39.1 The seven steps of evidence-based practice (Melnyk et al. 2014) This final model, the JBI Model of Evidence- Based Healthcare, a model reconsidered (Jordan Step 0. Cultivate a spirit of inquiry along with an EBP culture and environment et al. 2016), is the most recent revision of the Step 1. Ask the PICO(T)a question model first published in 2005 by Pearson et al. Step 2. Search for the best evidence Evidence-based practice is defined as “clinical Step 3. Critically appraise the evidence decision-making that considers the best evidence; Step 4. Integrate the evidence with clinical experience the context in which care is delivered; client pref- and patient preferences to make the best clinical erence; and the professional judgement of the decision health professional” (Pearson et al. 2005: 209). Step 5. Evaluate the outcome(s) of the EBP practice change Its major components are broader than the other Step 6. Disseminate the outcome(s) (Melnyk and models in that it includes evidence generation, Fineout-Overholt 2015) evidence synthesis, evidence transfer, and evi- aPICO(T): P = patient population, I = intervention or issue dence utilization, with its newest component of of interest, C = comparison intervention or issue, O = out- global health. come, T = time for intervention to achieve outcome (if rel- Its emphasis on the context in which care is evant) (Melnyk 2017) Source: Melnyk BM, Gallager-Ford, L, Long LE, Fineout- delivered and client preferences makes this model Overholt E. (2014). The establishment of evidence-based particularly relevant and useful with vulnerable practice competencies for practicing registered nurses and populations. At the core of the model are four cri- advanced practice nurses in real-world clinical settings: teria, which can be applied when evaluating proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence- whether the evidence is applicable to diverse based Nursing. 11: page 6. Reproduced with permission populations: 39 Designing Culturally Competent Interventions Based on Evidence and Research 345

Table 39.2 Evidence-based practice competencies (Melnyk et al. 2014) Evidence-based practice competencies for practicing registered professional nurses 1. Questions clinical practices for the purpose of improving the quality of care 2. Describes clinical problems using internal evidence (internal evidence=evidence generated internally within a clinical setting, such as patient assessment data, outcomes management, and quality improvement data) 3. Participates in the formulation of clinical questions using PICOT format (P=patient population, I=intervention or area of interest, C=comparison intervention or group, O=outcome, T=time) 4. Searches for external evidence to answer focused clinical questions (external evidence = evidence generated from research) 5. Participates in clinical appraisal of pre-appraised evidence (such as clinical practice guidelines, evidence-based policies and procedures, and evidence synthesis) 6. Participates in the critical appraisal of published research studies to determine the strength and applicability to clinical practice 7. Participates in the evaluation and synthesis of a body of evidence gathered to determine its strength and applicability to clinical practice 8. Collects practice data (e.g., individual patient data, quality improvement data) systematically as internal evidence for clinical decision-making in the care of individuals, groups, or populations 9. Integrates evidence gathered from external and internal sources in order to plan evidence-based practice changes 10. Implements practice changes based on evidence and clinical expertise and patient preferences to improve care processes and patient outcomes 11. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations to determine best practices 12. Disseminates best practices supported by evidence to improve quality of care and patient outcomes 13. Participates in strategies to sustain an evidence-based practice culture Evidence-based practice competencies for practicing advanced practice nurses All competencies of practicing registered professional nurses plus: 14. Systematically conducts an exhaustive search for external evidence to answer clinical questions (external evidence = evidence generated from research) 15. Critically appraises relevant pre-appraised evidence (i.e., clinical guidelines, summaries, synthesis of relevant external evidence) and primary studies, including evaluation and synthesis 16. Integrates a body of external evidence from nursing and related fields with internal evidence in making decisions about patient care (internal evidence = evidence generated internally within a clinical setting, such as patient assessment data, outcomes management, and quality improvement data) 17. Leads transdisciplinary teams in applying synthesized evidence to initiate clinical decisions and practice changes to improve the health of individuals, groups, and populations 18. Generates internal evidence through outcomes management and EBP implementation projects for the purpose of integrating best practices 19. Measures processes and outcomes of evidence-based clinical decisions 20. Formulates evidence-based policies and procedures 21. Participates in the generation of external evidence with other healthcare professionals 22. Mentors others in evidence-based decision-making and the EBP process 23. Implements strategies to sustain an EBP culture 24. Communicates best evidence to individuals, groups, colleagues, and policy makers Source: Melnyk BM, Gallager-Ford, L, Long LE, Fineout-Overholt E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-based Nursing. 11:5–15, pg. 11. Reprinted with permission 346 M. Douglas

• Feasibility: Would this intervention be work- practitioners with scientifically tested, evidence- able, practical, and sustainable in the cultural based strategies and practices designed for spe- context of interest? Would the population be cific groups, nurse researchers play an important able to integrate the intervention into their role in deceasing global racial and ethnic dispari- daily life? ties in health outcomes. An overview of a few, • Appropriateness: How well does the interven- more frequently used research methods are pre- tion align with the cultural beliefs and prac- sented below. tices of the cultural group? • Meaningfulness: Would the racial, ethnic, or vulnerable population of study respond posi- 39.3.1 Qualitative Methods tively to the intervention? Would they endorse the intervention? Most of the early research in transcultural nurs- • Effectiveness: Does the intervention achieve ing used a variety of qualitative methodologies to the desired outcome for this group? explore cultural phenomenon and culturally specific health beliefs and practices. Qualitative Finally, four overarching principles complete research aims to examine the meanings of a phe- the model: culture, capacity, communication, and nomenon and to analyze observations in order to collaboration. Further elaboration of the model discover patterns of behaviors and relationships. and the resources provided by the institute can be These methods continue to be useful to nurse found at: http://joannabriggs.org. researchers investigating culturally specific care In summary, knowledge and skills in inte- issues. The choice of the qualitative method used grating EBP, human resources in the form of depends heavily on the research question being mentors, and a positive attitude within the orga- asked. nization are necessary but insufficient for EBP to be sustainable. Additional administration 39.3.1.1 Ethnography support is required in the form of clinical release Ethnography is rooted in techniques developed time to participate in research activities, such as by anthropologists who spent extended periods library searches, journal clubs, collecting data, of time living among a group of people. funding for attendance at research courses and Ethnographic research investigates the customs, presentations at research conferences, and men- beliefs, practices, and worldview of a group of toring in writing research abstracts and papers. people. The researchers using this method con- All of these elements are crucial to providing an struct a comprehensive view of the social frame- environment that encourages nurses to seek sci- work of the society, not just about health and entific evidence to underpin their nursing illness. practice. Ethnography forms the bases for other research methods as well, such as grounded theory and, more recently, community-based partici- 39.3 Research patory research (CBPR) and mixed-method designs (Morse 2016). Nurse researchers can use Nurse researchers have the opportunity to reduce some of ethnography’s methods to focus on a racial and ethnic disparities in health outcomes specific health issue or nursing problem observed by exploring cultural phenomena and testing in a small group of vulnerable culturally diverse interventions that have been specifically targeted persons. The key elements of ethnographic meth- to the health needs and life ways of specific cul- ods that have proven useful to nurse researchers tural groups. Both qualitative and quantitative include the following: research methodologies are available to those nurse researchers investigating questions related • Participant observation. It involves active to culturally appropriate care. By providing involvement in activities of the group, study- 39 Designing Culturally Competent Interventions Based on Evidence and Research 347

ing these activities as they appear in their nat- involves breaking up the raw data from field ural settings. The amount of engagement can notes and interviews into themes and patterns. range from observer only to total participa- Computer software programs are available to tion. The goal is to identify the emic (insid- assist the researcher with managing and cod- er’s) view and interpretation of the events as ing what usually involves massive amounts of well as their meaning and significance in rela- data. tion to health problems. The researcher then applies the etic (outsider’s) perspective to elu- Examples of how clinical issues can be exam- cidate patterns of behaviors. ined using these methods are provided by several • Field notes. These are the notations the authors. Ge et al. (2016) explore beliefs about researcher makes to document the observa- health and illness and health-related behaviors tions. They include what the ethnographer among urban women with gestational diabetes saw, heard, thought, or experienced (Speziale mellitus in Southern China using semi-structured and Carpernter 2007). interviews. Their research questions were as fol- • Selection of key informants. Identifying com- lows: “What are the health and illness beliefs munity leaders and those knowledgeable among women in this group?” “Are these beliefs about the topic of investigation is crucial not influenced by Chinese culture, and if so, in which only for entry into the community of study but way?” (Ge et al. 2016: 595). Another example is also for their broader knowledge and perspec- illustrated in the study by Choi et al. (2017) who tive of the culture in general and the health used participant observation and qualitative inter- issue in particular. views to culturally tailor a diabetes education • Interviews. Ethnographic interviews are gen- program for Chinese patients. Morse (2015) erally done face-to-face and use semi- describes how qualitative methods can be used to structured, open-ended, broad questions like assess the pain experience. On the other hand, “What is it like to have emphysema?” there are challenges to using these methods in the Depending on the response, the researcher clinical setting. Bloomer et al. (2012) outline proceeds to more specific prodding questions, these challenges during their study of end-of-life such as “What has been the most difficult part care using nonparticipant observations. Being of your treatment?” Other types of interviews even more sensitive to the needs of the patient, used in qualitative research contain more families, and staff and strict adherence to the eth- structured questionnaires or are done with ical issues are essential when using these meth- focus groups, via telephone or Internet, among ods in the clinical setting. others. • Review of pertinent documents. In order to 39.3.1.2 Community-Based supplement field notes, the researcher may Participatory Research search for other documents that may be rele- (CBPR) vant to the clinical issue of interest. These As qualitative methods have evolved to explore may include a patient’s medical history, prog- cross-cultural issues, the CBPR method has ress notes of clinical events, written proce- gained increasing favor with public health dures and protocols, photographs, and researchers and practitioners. CBPR approaches newspaper accounts of community events. research from a partnership perspective. It views • Content analysis. Analysis of ethnographic all partners, such as the community members, data usually begins while the data are being researchers, and organizational representatives, collected, which allows the investigator to as equals in all aspects of the research process. redirect avenues of inquiry according to Decision-making, expertise, and final owner- responses from the participants or observa- ship are contributed and shared by all members. tions of events. Formal analysis begins after This involvement by the community helps the completion of data collection. The process assure that the interventions developed by the 348 M. Douglas researchers are responsive to the needs of the for nurse researchers working with vulnerable community. minority groups. A third example of CBPR illus- As described by the National Institute of trates the process of involving the community in Minority Health and Health Disparities (2017), a the translation and back translation of a question- CBPR program usually has three phases. The naire and subsequent testing of an intervention planning stage is used to conduct a needs assess- among a population of Navajo women. Yost et al. ment, identify the community’s priorities of these (2017) describe their procedure for translating a needs, and then design and pilot an intervention questionnaire and subsequent intervention to aimed at addressing the prioritized need. During have good content validity and to be culturally the second stage, the intervention is refined and linguistically appropriate for this population. according to the findings of the pilot study, meth- They used a rigorous translation process ods are developed to evaluate the effectiveness of described by Squires et al. (2013), which included the intervention in the community, and finally, community participation in a translatability full-scale intervention is implemented. The third review, forward and backward translations, phase entails the analysis, publication, and dis- expert panel review, and qualitative feedback semination of the results. The researchers and from potential respondents. Involving commu- community partners share their findings and nity members is especially important at these implications with the targeted CBPR community beginning stages of a project in order to increase as well as with other organizations and the validity and applicability of the findings from researchers. any subsequent interventions. The use of the CBPR design is exemplified in the following articles. In a study conducted in a 39.3.1.3 Phenomenology Canadian urban center (Boucher et al. 2017), A third type of qualitative method used by nurse investigators combined interviews with the use of researchers is phenomenology. This research a “Life Story Board” to co-construct a “life approach is used to study the meaning of the scape” with people who inject drugs. Together lived experience. Phenomenology is concerned the collaborative group of investigators and par- with the study of experiences from the perspec- ticipants identified barriers and facilitators to tive of the individual, which makes it particularly using harm-reducing strategies as well as offer- useful when examining cultural issues. It empha- ing suggestions for improving services and sup- sizes the person’s perspective, interpretation of port for people who use drugs. the phenomena, and their motivations for actions Another example of the use of CBPR is pro- taken. Data collection methods for this approach vided by Nypaver and Shambley-Ebron (2016). can include participant observation, interviews, In their investigation of meaningful prenatal care conversation focus groups, and analysis of dia- among African-American women, the research- ries, among others. Minimum structure and max- ers enlisted their participant to take photos of imum depth are guiding principles. Diekelmann people, places, or things that were either barriers et al. (1989) and Groenewald (2004) provide or facilitators to meaningful prenatal care in their detailed descriptions of the stages for analyzing community. The photos were then discussed in data from phenomenological research. group meetings, eliciting significance of the This phenomenological approach and the use items and suggestions for improvement of their of the analysis plan of Diekelmann et al. (1989) care during pregnancy. Although this study did are illustrated by Nikfarid et al. (2017) in a study not include the design and testing of an interven- of chronic sorrow in eight Iranian mothers of tion, the findings provide the basis for designing children with cancer. Semi-structured, in-depth a culturally appropriate prenatal intervention for interviews were used to ask questions such as: this population. “What is it like to have a child with cancer?” Translations of instruments and cultural adap- “How did you feel when they told you that your tations of interventions are common challenges child had cancer?” “Explain to me the complete 39 Designing Culturally Competent Interventions Based on Evidence and Research 349 daily routine for you and your child (from the in the study. The caregivers were both profes- time you wake up until the time you go to sleep).” sional and nonprofessional support staff, such as These probing questions were meant to elicit the personal care workers and home support work- lived experience of these Iranian mothers. Data ers. A series of ten focus group discussions were were analyzed using the Diekelmann’s seven- held at four locations within the Jewish commu- step process, as outlined by Nikfarid et al. (2017: nity, with each session lasting 90 min. The care- 101). These included the following: givers were asked to share both their positive and negative experiences with caring for the Jewish • Transcription of data, reading and re-reading Holocaust survivors and their families. All ses- text to understand the interview as a whole sions were audiotaped and transcribed verbatim. • Preparation of interpretative summaries of In addition, in-depth interviews were conducted each interview, i.e., abstracting, coding, and with six professionals with extensive experience identifying themes, subthemes, and working with this population. Thematic analysis categories of the data first involved explicating participants’ • Discussions with team members to build con- statements that reflected the phenomena being sensus on the themes studied. Then similar statements were clustered • Resolution of disagreements among research into themes and subthemes and explored how team members as to coding and themes these themes contributed to overall story of the • Comparing and contrasting interviews to lived experience of caring for this population. identify recurring themes with similar Peer debriefing was used to help ensure the cred- meanings for the same experience for all ibility of their findings. In this case, two addi- participants tional colleagues, who were not part of the core • Identifying relationships between themes research team, were called in to examine the data • Construction of a pattern that best describes and evaluate the links between the data and the the lived experience based on the concepts themes identified. extracted from the interviews In the final analysis, three major themes emerged. First, knowledge about the survivor’s From this analytical process, the authors were past helps the caregiver better understand the sur- able to identify 3 major themes and 13 sub- vivor and those “triggers” that may evoke adverse themes. Their results revealed that the Iranian emotional and behavioral reactions. The second mothers’ lived experiences of having a child with theme described the extra level of understanding cancer were similar to mothers of other cultures and empathy that is needed when caring for sur- in the same situation but also had themes specific vivors. Their care is more complex than caring to the Persian culture. for other elderly. In providing an example of car- Teshuva et al. (2017) use the phenomenologi- ing for a survivor of extreme starvation, the nurse cal approach to investigate the lived experience said, “If they want to take a whole loaf of bread, of providing care for aging Jewish Holocaust sur- just let them. It will get cleaned up later. You have vivors in Australia. They illustrate how this to respect that” (Teshuva et al. 2017: 1109). approach could be applicable to studying other Caregivers also need to devote more efforts than vulnerable populations that are survivors of usual to building trust and assuring safety for sur- severe traumas, such as wars, rape, life-long vivors of such traumas. The third theme involved racial discrimination, or being refugee from a the caregivers themselves. Caring for elderly sur- conflict zone. In this study, investigators ask vivors of trauma has an emotional impact on the “How do aged-care workers describe the lived care providers as well. Caregivers need to be experience of caring for Holocaust survivors?” aware of and use self-care strategies frequently in (Teshuva et al. 2017: 1105). Seventy paid care- order to defuse the stresses of this type of work. givers of Jewish Holocaust survivors residing in In addition, their supervisors need to acknowl- residential homes or in their homes participated edge the extra amount of time, effort, and 350 M. Douglas sensitivity the staff need to care for these persons from this type of study can be used as a basis by providing sufficient numbers of staff and for planning and funding of future care or for amount of relief time to support these further research. caregivers. Correlational studies explore the relationship Qualitative methods have been and continue among variables. Again, the variables are identi- to be very useful in exploring research questions fied but not controlled. The research inquiry cen- regarding cultural issues, especially in the area of ters on identifying solely the relationship, among healthcare. They are particularly valuable when the variable, and does not infer cause and effect. studying issues previously unexplored, with little This type of design is particularly helpful in or no knowledge on which to base care decisions. model testing. Typically, a cross section of the Findings from qualitative studies can help in the population is given a structured questionnaire designing of interventions, recruitment of appro- that has been validated in its original language priate research participants, and testing and sub- and, if relevant, also validated in its translated sequent implementation of culturally appropriate language. Responses are analyzed using care. Pearson’s correlations, multiple regression, and factor analysis. Excellent examples of this type of study are provided by Musa et al. (2016) in 39.3.2 Quantitative Methods their description of the impact of spiritual well- being and religiosity on the self-rated health of Whereas qualitative methods use a subjective Jordanian Arab Christians and by Kara and inductive approach to explore the cultural Tenekeci (2017) in their investigation of the sleep meanings of beliefs and practices, quantitative quality of older Turkish adults with hypertension methods take an objective deductive approach to and the factors that influence the quality of sleep describe and test relationships, examine the cause in this population. and effect of relationships and test hypotheses. Scale validation studies are another type of Quantitative research methods are characterized quantitative descriptive design that is particu- by objective measurement of variables and statis- larly useful for nurse researchers attempting to tical analysis of data, which are usually collected use questionnaires developed in one language by surveys, questionnaires, or other structured but administered to a population speaking research instruments. These quantitative methods another language. A simple translation of an are used to test hypotheses and make predictions instrument is a necessary but insufficient pro- with the hope of generalizing the findings to a cess to ensure validity in a context that is dif- larger population. They are particularly useful in ferent from which it was designed. evaluating and testing interventions that have Herrero-Hahn et al. (2017) outline the process been developed for a specific culturalof adapting and validating a scale of cultural population. self-efficacy for a population of Colombian nursing professionals. The investigators tested 39.3.2.1 Descriptive Observational their instrument for validity, reliability sensi- and Correlational designs tivity, and feasibility using a process outlined In descriptive observational studies, variables by Carvajal et al. (2011). This cultural adapta- of interest are identified but not controlled. tion process included the following steps: (1) They typically describe “What is/are…,” for translation from English to Spanish, (2) seman- example, “What are the health characteristics tic analysis review by a committee of experts to of older refugee populations?” (Miner et al. determine linguistic validation, (3) pilot test- 2017: 128). In this case, a retrospective chart ing the instrument, (4) back translation from review was performed, and health outcomes Spanish to English, (5) comparison of back- were analyzed using descriptive statistics, fre- translated version with the original version, (6) quency distributions, and percentages. Findings analyzing the psychometric characteristics of 39 Designing Culturally Competent Interventions Based on Evidence and Research 351

Cronbach’s alpha of both versions, and (7) fac- between the two groups are analyzed tor analysis with varimax rotation for internal statistically. consistency. Using this process, the investiga- Joseph et al. (2016) describe an intervention tors were confident that the cultural self-effi- study in which a pretest/posttest design was used. cacy tool was valid and adequately adapted to The aim of their study was to decrease sedentary the cultural group that they wish to test in behavior and increase moderate activity in a future research. group of young African-American women with a Another good example of a scale validation body mass index (BMI) >25 kg/m2 (overweight study is described by Santos Prudencio et al. and obese). As the intervention, the investigators (2016: 512). These investigators provide a highly designed a culturally relevant website that con- detailed explanation and illustration of the pro- tained exercise demonstration videos; blogs cess of cultural and linguistic validation of an about physical exercise, nutrition, and wellness; instrument into Brazilian Portuguese. In this online recipes; tools for tracking dietary intake case, the Patient Expectations and Satisfaction and daily physical exercise (PA); a diary; and a with Prenatal Care scale was analyzed using a message board. The study participants logged homogeneous group of Brazilian women seeking into the website with a username and password. publicly funded prenatal care in one urban area. Participants were encouraged to engage in But because of the sociocultural heterogeneity of 30–60 min of exercise four times per week for 3 the Brazilian population, the investigators recom- months. Two of the weekly sessions were held at mended further assessment of this instrument a local indoor track, with research assistants with a wider, more diverse sample. This is a poi- monitoring the participants while they walked. gnant observation as caution is warranted when For the other two weekly sessions, participants attempting to use a translated instrument for a could choose either to walk alone or join a group population different from the one used for the exercise class. The dependent variables of BMI, original validation, despite the similarity of self-efficacy for PA, social support for PA, enjoy- languages. ment of PA, and weekly amount of physical activity and sedentary screen time (e.g., TV, 39.3.2.2 Experimental and Quasi- DVD, computer games) were measured both experimental Designs before the intervention began (pretest) and after 3 Experimental designs seek to establish a cause- months of the intervention (posttest). This study effect relationship between two or more vari- illustrates how complex, resource intensive, and ables. The major differences between time consuming these designs can be, particu- quasi-experimental and true experimental larly if the intervention needs to be tailored to designs are that in quasi-experimental designs cultural sensitivities. However, these efforts are the groups being tested are not randomly necessary to determine efficacy of our interven- selected and the independent variable is not tions, especially when we are evaluating pro- manipulated. Common quasi-experimental grams and testing interventions in racial, ethnic, designs include pre- and posttest designs, post- and vulnerable populations. test-only designs, and interrupted time-series A major benefit of using quantitative research designs. designs is that the findings may be generalizable In true experimental designs, participants are to a broader population. These techniques enable randomly assigned to control and experimental the researchers to gather information from a rela- groups, and the researchers attempt to control tively large number of participants, allowing for for all variables except for the one being manip- comparisons. And with the use of numerical rat- ulated, i.e., the independent variable or inter- ing information, statistical analysis can be used vention. The intervention is administered only to determine relationships between variables and to the experimental group. Outcome or depen- examine probable cause and effect of this dent variables are measured, and comparisons relationship. 352 M. Douglas

39.3.3 Mixed Method Designs different perspectives of the respondents’ healthcare experiences. On the other hand, a modified In the past decade, mixed method research qualitative mixed-method (QUAL-qual) design designs have become more widely accepted. But is described by Phillips et al. (2014). To study as they evolved and gained recognition, their def- Australian nurses in small healthcare organiza- inition became more blurred. Traditionally, tions, these authors used a number of qualitative mixed methods are characterized by using statis- methods, including semi-structured interviews, tical trends (quantitative data) combined with the structured and unstructured observations, photo- stories (qualitative data). A leading expert in graphs, floor plans, and social scanning data. mixed methods research has delineated six differ- Their design did not adhere strictly to Morse’s ent strategies to guide the combination and analy- requirement for a core method with others being sis of both types of data. These include sequential supplemental. Instead, the investigators used two explanatory design, sequential exploratory standard qualitative methods as core compo- design, sequential transformative design, concur- nents, in-depth interviews and structured obser- rent triangulation design, concurrent nested vations, and the other four methods as (embedded) design, and concurrent transforma- supplemental. The combination of these meth- tive design (Creswell 2013). More recently, qual- ods rendered a more complete and complex por- itative researchers such as Morse (2010) and trayal of the research problem than if only one Morse and Cheek (2015) contend that mixed method was used. method designs can also apply to the use of two or more methods of the qualitative nature (QUAL-qual), such as in-depth interviews as the 39.4 Evidence-Based Research: core component of a research study and Selecting the Most participant observation as a second, supplemental Appropriate Evidence data source. Mixed method research takes advantage of One of the most crucial stages in the EBP process using several ways to explore a research problem is searching the literature for the best evidence to and gives a more complete understanding of our address the clinical practice issue and target the research problem than by using just one method. individual person or group. But not all evidence The choice of the appropriate combination of is equal. The quality of the evidence is usually methods cannot be arbitrary. Rather, the described as a hierarchy, with level one produc- researcher selects qualitative and quantitative ing the greatest degree of current scientific evi- methods that have complementary strengths and dence available, as outlined in Table 39.3 do not have overlapping weaknesses. Data are (Stillwell et al. 2010). not just collected and analyzed separately, but, instead, qualitative and quantitative data are integrated and analyzed according to a specific 39.4.1 The “5S” Model mixed-method design, such as one described by Creswell (2013). The University of Michigan Library website Two studies provide examples of mixed meth- (2017) provides a wealth of information regard- ods designs. De Gagne et al. (2015) explore the ing evidence-based research, including a pyra- healthcare experiences of Asian Indians in the mid further delineating the levels of evidence Southeastern United States by using surveys, (Fig. 39.2). This model aligns the hierarchy which provided quantitative data, plus focus described in Table 39.3 with a second hierarchy groups, which, through content analysis of the of evidence strength (Haynes 2006; Townsend transcripts, provided qualitative data. The find- et al. 2015). For example, studies, which most ings from the combination of qualitative and often examine a single aspect of care, are fol- quantitative data provided both overlapping and lowed by syntheses, such as systematic reviews 39 Designing Culturally Competent Interventions Based on Evidence and Research 353

Table 39.3 Hierarchy of evidence for intervention studies Level of Type of evidence evidence Description Systematic review or I A synthesis of evidence from all relevant randomized, controlled trials meta-analysis Randomized, controlled II An experiment in which subjects are randomized to a treatment group or control trials group Controlled trials without III An experiment in which subjects are nonrandomly assigned to a treatment group randomization Case-control or cohort IV Case-control study: a comparison of subjects with a condition (case) with those study who do not have the condition (control) to determine characteristics that might predict the condition Cohort study: an observation of a group (s) (cohort[s]) to determine the development of an outcome(s) such as a disease Systematic review of V A synthesis of evidence from qualitative or descriptive studies to answer a qualitative or descriptive clinical question studies Qualitative or VI Qualitative study: gathers data on human behavior to understand why and how descriptive study decisions are made Descriptive study: provides background information on the what, where, and when of a topic of interest Opinion or consensus VII Authoritative opinion of expert committee Source: Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. (2010). Searching for the Evidence: Strategies to help you conduct a successful search. AJN. 110 (5). p.43. Reprinted with permission

Computerized Decision Support Software Systems Electronic Healtn Records (Future)

Evidence-based Textbooks, Practice Guidelines Dynamed, Essential Evidence Summaries National Guideline Clearinghouse, UMHS Practice Guidelines

Pre-appraised Abstracts of Studies & Syntheses Synopses DARE, ACP Journal Club

el of Evidence v Meta- Le Systematic Reviews analyses Syntheses Cochrane DSR, PubMed Clinical Systematic Queries (Systematic Reviews) Reviews Secondary/Pre-appraised RCTs Primary/Original Primary Research Cohort Studies Studies PubMed Clinical Case Control Studies Queries (Studies) Case reports/Case series Foundational Resources Background Resources Integrated Clinical Tools Textbooks, Expert Opinion, Narrative Reviews Drug Resources, Clinical Calculators, etc.

Clinical Key, AccessMedicine, STAT!Ref, UptoDate, Micromedex, Facts & Comparisons, ePocrates, PubMed (Review limit) MedCalc 3000, Diagnosasurus, Mobile Apps

Fig. 39.2 Sources for evidence-based research: inte- org/licenses/by/4.0/. Adapted from: Haynes RB. Of stud- grated “5S” levels of organization of evidence pyramid. ies, syntheses, synopses, summaries and systems: the Source: Townsend W; Donovan K; Ginier E; MacEachern “5S” evolution of services for evidence-based health care M; Mani N. “Integrated “5S” Levels of Organization of decisions. ACP J Club. 2006 Nov–Dec;145(3): A8–9. Evidence Pyramid.” September 2015. (http://hdl.handle. Reprinted with permission net/2027.42/138965). CCBY 4.0 https://creativecommons. 354 M. Douglas like Cochrane Reviews (Rew 2011). Integrative life has shifted clinical decision-making toward reviews also fall in the category of syntheses but value-based care (Marzorati and Pravettoni are the only approach that combines studies 2017). using both nonexperimental and experimental But value can be defined differently by each of research methods to address a research question the stakeholders, depending on their perspective. (Whittemore and Knafl 2005). Synopses are Patients, healthcare providers, healthcare sys- concise, abstract-like descriptions of the systems, economists, health insurance companies, tematic reviews. Summaries compile and inte- and employers all can assess value differently. grate the best evidence from the three lower Hence, to date, there is no consensus on what levels in order to extract the full range of evi- constitutes value. For example, healthcare pro- dence for a particular care problem. Finally, sys- viders assess value according to clinical effec- tems, such as a computerized decision support tiveness and evidence-based interventions. On system (DSS) within the electronic health the other hand, health economists define value in record, link the individual patient with the best terms of clinical benefit achieved for the money evidence for his or her specific problem. spent. Obviously, this highest system level is ideal and Value, from the individual’s perspective, is would be very useful for racial and culturally very personal and incorporates unique prefer- diverse populations, specifically in the case of ences and expectations that can be culturally pharmacological efficacy. However, these DSS derived. Value encompasses the person’s health- systems are very expensive and consequently related quality of life and goals related to all rare; yet they remain the goal. This “5S” pyra- aspects of life, including levels of functional mid also lists services and resources compiling impairment, pain management, spiritual well- the evidence at each level. being, and social and cognitive functioning. Mohammed et al. (2016) conducted a systematic review of 36 studies assessing patients’ percep- 39.5 Evolution from Evidence- tion of high-quality healthcare. A majority of the Based to Value-Based studies were published after 2005; the designs Practice included quantitative, qualitative, and combined methods and were conducted in ten countries, After decades of work dedicated to developing although 63% of the studies were in the models for implementing evidence-based inter- USA. Most of the study settings were in primary/ ventions, there is increasing attention over the ambulatory care, but in-patient and emergency past 10 years being given to patient centeredness services also were studied. Both a longitudinal and the “value” of the treatment as viewed by the comprehensive measure of quality of care and a patient as well as the healthcare provider and the single encounter with the healthcare system were healthcare system. Brown et al. (2005) first evaluated. Of the ten dimensions of quality care coined the term by defining value-based care as identified, the top three were communication, “…incorporating the highest level of evidence- access, and shared decision-making. based data with the patient perceived value con- Incorporating cultural competency principles ferred by health care interventions for the within value-based practice can be easily resources expended.” Although the original defi- achieved because of the shared goals of adapting nition of EBP included patient values and prefer- care to the person’s unique values, preferences, ences, those components were overshadowed by and aspirations, which in the case of vulnerable the search for the best evidence. Now the renewed and racially and ethnically diverse populations emphasis on patient satisfaction and quality of can be culturally defined. 39 Designing Culturally Competent Interventions Based on Evidence and Research 355

39.6 Implications for Practice, For those clinicians working in low to middle Education, and Research income countries, where financial and digital resources are limited, quality assurance projects 39.6.1 Individual Level may be the optimal level achievable. However, the same seven-step process described in For healthcare professionals at the point of care, Table 39.1 applies. Enlisting the assistance of the most important contributions are the identifi- university librarians and faculty members to aid cation of researchable care problems and the in the literature searches may be helpful, if such implementation of evidence-based process and alternatives are feasible. solutions. Unit-based journal clubs to review transcultural health literature can serve as entry points for new nurses and well as those with more 39.6.2 Organizational Level work experience but less preparation in EBP and research from their training curricula. Attendance As described above, without an organizational at staff development programs on EBP lays the climate that supports EBP and research, the foundation for participation in the EBP process. financial, digital, and human resources will not Participation on unit-based and system-wide be allocated. Staff development programs and committees that collect data on patient satisfac- time allotted for the staff to attend need to be pro- tion, especially from patients of diverse cultural vided. APNs and medical librarians are needed to heritages, helps elucidate potential cross-cultural guide the staff in searching the literature. Unit- challenges and areas for further exploration. based computers with Internet access to univer- Ultimately, it will be the primary providers of sity medical libraries are necessary if an adequate care who will be responsible for implementing literature search is to be conducted. The job any policy changes made as a result of the descriptions and performance evaluations of research process. APNs must include EBP mentoring and research Advanced practice nurses (APN) have the to validate those functions as totally integrated additional responsibilities of mentoring staff in into their practice, rather than as “extras” that the EBP process and conducting continuing edu- somehow never are addressed for lack of time. cation programs on EBP and the research pro- The organization is also responsible for col- cess. In addition, the APNs can serve as leaders lection of health data for all its citizens within its of interdisciplinary research teams investigating “encatchment” or service. This is particularly cross-cultural problems, seeking funding for important where large numbers of vulnerable or such projects, and collaborating with profes- racial and ethnically diverse populations reside. sional colleagues and faculties. They can evalu- These statistics can serve as the basis for investi- ate research tools and services provided for gating cultural applicability and appropriateness cultural applicability, specifically for the popula- of the services for these populations. tions they serve. By collaborating with their international colleagues, they can test research instruments with diverse populations around the 39.6.3 Community Level world, investigate common cross-cultural problems, and consult with and mentor their global Collaboration between clinicians and faculty colleagues. Finally, the APNs can coordinate and researchers in the community can be mutually host conferences to disseminate evidence on beneficial. The clinicians gain from the research effective approaches to culturally congruent expertise of the faculty in designing EBP projects practice. and research studies. And the faculty benefit from 356 M. Douglas the access to clinical settings for data collection provide the most meaningful (valued) inter- for their own research and can identify first-hand vention based on the best available evidence. clinically relevant and significant researchable Practice based on evidence has been shown problems for their future search. to increase both patient and nurse satisfaction, By expanding this collaboration to include reduce costs, and improve patient outcomes. interdisciplinary networks of clinicians and Therefore, improving health outcomes, espe- researchers, studies can be designed to include cially among the vulnerable and racially and higher proportions of patients from diverse popu- ethnically diverse populations, may help lations than if only conducted in one healthcare decrease the racial disparities in health seen system. Findings from these network studies today. have the potential for greater generalizability of results. 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Gülbu Tanriverdi

Fatma is a 67-year-old Kurdish Muslim woman husband had 17 siblings, but none of them was who practices in the Shafi’i Muslim sect. She is living in or near them in their new location. They married with three children and literate and did not adapt well to this different culture, but the works as a housewife. Fatma’s husband is working conditions compelled them to stay. 70 years old, Kurdish, and also practices in the Fatma’s husband was spending long days work- Shafi’i Muslim sect. He completed his primary ing in construction with other workers, who came school education. Fatma and her husband were from a culture that was similar to his. Fatma, on both born and raised in a village located in the the other hand, was spending time alone at home easternmost part of Turkey. This is also where with the children. they married and had their children. Forty-five She did not like this city at first. Residents of years ago, Fatma and her husband and children the city were not friendly. She thought they did migrated to an urban area in western Turkey due not like her and looked down on her. No one who to financial reasons. Fatma’s husband was a con- lived close by had more than two children, and struction foreman. Because the weather in east- she felt that everybody was avoiding her and her ern Turkey is cold and snowy in winters, it was children. Fatma remembered an elderly woman impossible for construction workers to find a per- who said hello to her once, and this woman was manent job year-round. However, the climate the first person she talked to. When she saw the conditions were appropriate for construction in elderly woman again, she became happy and felt almost every season when they moved to their as if she had seen a member of her own family. new location in western Turkey. Fatma and her husband were worried about When they moved, their children were 1, 2, their children. They thought that they could not and 3 years of age. Fatma and her husband raise their children in this city according to their encountered a culture that was very different own cultural values. In their opinion, young peo- from their own when they first migrated to the ple in this big city were too free. Their clothing city in western Turkey. They did not have any and lifestyles did not conform to the standards of social support. Fatma had 6 siblings, and her the culture of Fatma and her husband. They did not approve of the relationships between young women and men. This was not in accordance G. Tanriverdi, Ph.D. with the culture of Fatma and her family. They Canakkale School of Health, Terzioglu Campus, feared that their children could grow up to be like Canakkale Onsekiz Mart University, these young people, and this was unacceptable in Canakkale, Turkey their culture. There were some migrant families e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2018 361 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_40 362 G. Tanriverdi that went back to their hometown for these rea- view the surveillance tape recorded by the hospi- sons alone. tal cameras. However, her husband told her that On the one hand, Fatma and her husband he could not accept her explanation. were making efforts to raise their children in Thus, Fatma began having horrible days, with accordance with their own cultural beliefs. On her husband becoming violent toward her almost the other hand, they did not make any effort to every day. At first, she believed that she deserved accommodate themselves to this new culture to this. Her husband insulted her and used physical which they had migrated. They socialized with violence against her, and they had sexual inter- other migrant families whose culture was simi- course rarely, only when he wished. But there lar to their own. One study found that families was no emotional expression of fondness or love. who migrated to another city in Turkey created Sexual violence then was added to what first various solidarity networks with other migrants began as physical and emotional violence. She living in their city. Through these social net- continued to believe that she deserved this vio- works, they coped with the difficulties of living lence. Fatma could not say no to the sexual desire in a city that was strange to them (Canatan and of her husband despite everything she experi- Yıldırım 2009). enced. Eventually she experienced a psychologi- In her new life in western Turkey, Fatma was cal breakdown, for which she blamed herself. conducting herself and behaving in ways that She felt ashamed, desperate, scared, and worried were specific to her own culture. She tried to because she was subjected to violence. She solve the problems she faced within these pat- prayed for this violence to stop and awaited terns because she was aware of the consequences God’s help. she would face if she did not behave in accor- Fatma did not tell anyone about these epi- dance with her culture. sodes of violence, but instead she remained However, 6 months ago, Fatma behaved unin- silent. While her husband was committing physi- tentionally in a way that was inappropriate to her cal violence against her, she tried to protect her culture. It occurred when Fatma went to see a face, and she did not make a sound. She did not doctor. She had entered the examination room of want anyone outside to hear her screams. Fatma a male doctor, unaccompanied by her husband, believed that no one should know about the vio- even though she knew this would make her hus- lence that she was subjected to by her husband. band angry. Her husband had brought her to the She should resist this violence by herself as hospital, but he left to do a short errand just much as she could. In this way, she would stay before Fatma’s turn came to see the doctor. Fatma married, and her husband would not be pun- did not know how to behave when her turn came ished. She wanted to prevent any damage to the to see the doctor, because her husband was not reputation of her family. She believed that if there to accompany her to the examination room. their neighbors reported the violent acts to a gov- She felt uncomfortable with the strange looks the ernment agency, such as the police, gendarmerie, others in the waiting room gave her, but she nev- health institutions, or prosecutor’s office, there ertheless entered the examination room with the would be irreversible negative consequences. male doctor, without her husband. When her hus- Although their home was only a few minutes band returned, he could not find Fatma where he from the Family Health Center, Fatma did not had left her. report the violence to her family doctor or nurse. After she had seen the doctor, Fatma told her With the continuing violence, Fatma felt desper- husband that she was not alone in the examina- ate at times. She even thought of committing sui- tion room. She told him that she had merely cide, but this was against her religious beliefs. showed her medical analysis results to the doctor She believed that if she committed suicide, she and was not examined, but she could not con- would go to hell. Another way to stop the vio- vince him of this explanation. Fatma swore on lence would be to get a divorce, but she felt the Qur’an and suggested to her husband that he ashamed to even consider this. In her culture, it 40 Case Study: Domestic Violence of an Elderly Migrant Woman in Turkey 363 is unacceptable for a woman, particularly an culture, proverbs such as “men both love and elderly one, to get divorced. The same belief beat,” “no one can come between husband and statements were observed in a qualitative wife,” and “beating is heaven-sent” are used to research conducted in Turkey (Yalcin Gursoy normalize violence, while other proverbs such as and Tanriverdi 2017). “you can leave the house where you have come with your wedding dress only with your shroud” are used to make divorce seem impossible 40.1 Cultural Issues (Yüksek Oktay 2015). A nationwide study conducted in Turkey According to Fatma’s beliefs, when a woman reported that among women, 14% think that it is needs to visit a male doctor, a man or a woman acceptable, in some cases, for men to commit must accompany her. Their culture requires this. physical violence against them, while 48.5% do A study found that, in some cultures in Turkey, it not talk about the physical and emotional vio- is important that the doctor who examines a lence they experience. Also, 92% do not seek woman is female and that if the doctor is not help from any institution because of violence; female, the woman does not get examined and of the women who are exposed to physical (Özçelik Adak 2002; Tanriverdi et al. 2011; and sexual violence, 55% do not want to receive Yalcin Gursoy and Tanriverdi 2017). any kind of support, and 91.8% do not want to Defining violence is difficult in Turkish cul- receive support from government agencies (The ture. Because the family is regarded as sacred and General Directorate on the Status of Women private, it is not acceptable for other people to 2009). Another study conducted in Turkey interfere in one’s family life. This issue comes reported that 39.3% of the women surveyed into question more in traditional societies. approved of this type of violence. In the same Elderly people may not accept that their families study, approximately one in five women stated have a problem regarding violence. The elderly that the cause of violence is cultural (Kocacık may feel ashamed of their family members’ and Çağlayandereli 2009). behaviors. They may be worried about how their relatives would react and believe that their relatives might mistreat them when they report the 40.2 Social Structural Factors violence. Many of the older generations think that they have caused the problems they face, and In Turkey, life expectancy at birth is 75.3 years they may not want to tell anyone else about their for males, 80.7 years for females, and 78 years on problems (Yeşil et al. 2016). average. There are approximately 6.6 million The cultural structure forces women to give persons 65 years or older, comprising 8.3% of the into difficulties, to continue their marriages in all Turkish population. A higher percentage of circumstances, and to question what they have elderly (13.5%) live in the city to which Fatma done to deserve the violence. Moreover, women migrated. Nearly half of the elderly people in accept violence for reasons such as fear of being Turkey only have a primary school education of lonely, feeling ashamed, fear of having to appear five grades. in court, fear of losing financial support, and wor- One of the common social problems in Turkey rying about their children (Ibiloglu 2012). Many is violence against women (Guvenc et al. 2014; elderly people in Turkey do not want to disclose Lök 2015). Studies conducted on the elderly in to anyone out side of their families that they are Turkey found that the incidence of physical vio- experiencing violence. They prefer to remain lence varies between 2 and 10% (Artan 2016) silent about who is committing violent acts, and the people who commit violent acts are gen- believing that their relatives will be punished if erally the relatives of the victims (Artan 1996). the violence is reported to governmental agencies Studies found that being female and having a low (Kalaycı and Şenkaynağı 2015). In Turkish educational level are the factors that increase 364 G. Tanriverdi violence (Kissal and Beşer 2011; Tanriverdi and Council that is binding and which has a monitor- Şipkin 2008; Fadıloğlu and Şenuzun 2012). ing mechanism. Moreover, not being submissive was regarded as On the other hand, the Act of Family Protection a risk factor for violence directed against women and Prevention of Violence Against Women of (Ali et al. 2015). March 8, 2012 was passed after long meetings For several decades violence against women and spirited debates between members of the in Turkey was interpreted and understood to be Ministry of Family and Social Policies and the a domestic issue. This viewpoint changed Stop Violence Platform, which consisted of more because of the influence of the women’s move- than 250 women organizations. This law aims to ment in the 1980s, which upheld that domestic protect women who are married, divorced, and violence is a crime and therefore local law engaged and whether in a relationship or single. enforcement should protect women against such It also protects children and family members who violence based on enforceability of the law. As a have already been victims of violence or who live result, it became a matter of public discussion in under the threat of violence as well as all indi- the society as opposed to being a private per- viduals who are victims of “persistent pursuit.” sonal matter. The first legal dictate preventing According to the Stop Violence Platform, the law violence against women under Turkish law was was based on the Istanbul Convention, and the Family Protection Law No. 4320, known as despite the Act’s shortcomings when compared the Act No. 4320, which came into effect on to the Convention itself, it has been a significant January 17, 1998. Subsequently, Act No. 4320 achievement in terms of advocacy. It provides was inadequate, and it became evident that two main measure injunctions as protective mea- either the law needed to be enforced or amend- sures and preventive measures. Protective mea- ments were required to the existing Act. Finally, sures cover injunctions for the woman who is the two new laws were passed: the Act of Family victim of violence, such as access to shelter, legal Protection and Prevention of Violence Against assistance, and psychological support. Preventive Women was passed on March 8, 2012, and then measures cover injunctions for the author of the on January 18, 2013, the Regulation on the Act violent act, such as suspension. Those injunc- of Family Protection and Prevention of Violence tions can be handed down by family court judges Against Women was approved and enforced and in urgent cases enforced by the police (Ayhan (Ozturk 2017). 2017). Furthermore, international treaties were However, the rights acquired may not always signed, such as the Convention on the Elimination be put into practice and used to protect women of all Forms of Discrimination Against Women because of cultural reasons. Discussions about (CEDAW) and the Council of Europe Convention the fact that this topic is a specific problem that (2011) on preventing and combating violence needs to be solved within the family are still against women and domestic violence (Istanbul ongoing (Salacin 2016). Convention https://rm.coe.int/168046031c). The Istanbul Convention brings several obligations to signatory states, from prevention of all kinds of 40.3 Culturally Competent discriminations related to gender, sexual orienta- Strategies Recommended tion, and gender identity and prevention of male violence to taking necessary measures against 40.3.1 Individual-/Family-Level violence, providing compensations for women Interventions who were victims of violence, and inflicting penalties for perpetrators that are commensurate • In the cases of migrants, the reasons for migra- with the severity of the violent act. The treaty, tion, the migration process of the family, and which Turkey was one of the first to sign in 2011, their post-migration experiences should be is the first international Convention for European examined. Some of these issues include 40 Case Study: Domestic Violence of an Elderly Migrant Woman in Turkey 365

cultural conflict, cultural shock, cultural pain, 40.3.2 Organizational-Level and cultural lag that Fatma and her husband Interventions have experienced. • The cultural differences of the family should • Strategies should be developed for combat- be examined. For example, the native lan- ing domestic violence that are in accordance guage of the family was Kurdish, and the sect with the various cultures. Pamphlets and leaf- of the family was Shafi’i. Because women do lets in the language and literary level of the not actively take part in the decision-making patients should be prepared and educational process, they could not make individual programs arranged. Concerns about privacy decisions. and fear of stigmatization related to domestic • The family’s perception of violence and the violence should be eliminated. Awareness cultural reasons for violence should be exam- among the staff and the patients should be ined. Explore how Fatma and her husband raised about ways to combat domestic perceive violence against women or domestic violence. violence. Do women deserve violence? • Long-term solutions that do not ignore the Should the occurrence of violence be kept cultural consequences of violence should secret within the family? Is committing vio- be planned in combating domestic violence. lence against women a right granted to men? Women should not be encouraged to get etc. divorced before the consequences of • Employ culturally preferred means to combat divorce in their cultures are clearly domestic violence. These may include remain- identified. ing silent, not revealing anything about the • The support of religious leaders should be violence, denying the violence, consulting a sought for combating domestic violence. traditional healer, etc. • The cultural obstacles to combating domestic violence should be examined, such as wishing 40.3.3 Community- and Societal- to remain in the marriage and worrying that Level Interventions reporting violence can damage the reputation of the family. • Strategies and interventions should be planned • Women who are victims of violence should that prevent victims of violence and perpetra- be evaluated within the framework of their tors of violence from being socially own cultures, and they should not be forced stigmatized. to exhibit any behavior that is deemed inap- • Community events should be planned to help propriate within their cultures. The ways to remove the cultural obstacles to combating combat domestic violence should be domestic violence. For example, women who explained to women with patience. Strategies come to a new region through migration could appropriate to their culture should be devel- be invited to participate in social activities that oped, and women should be persuaded to are not contrary to their own cultures; this can adopt these strategies. Female victims of vio- help to raise their awareness. lence should be assured that the violent acts • Support mechanisms should be developed that are not reported to any government agencies are appropriate to the cultures of women who such as police or gendarmerie without their are victims of violence. Communication lines consent. organized and advisory hotlines appropriate to • The cultural obstacles that hinder victims of the various cultures can be established for vic- violence and/or perpetrators of violence from tims of domestic violence. seeking help from institutions, such as stigma- • Public awareness of ways to combat domestic tization and fear of exclusion, should be violence in a way that is appropriate to the explored. various cultures should be raised, and help and 366 G. Tanriverdi

support should be provided by governmental 40.4.3 Culture Care Repatterning/ as well as nongovernmental organizations. Restructuring Such assistance can be obtained from foundations, social life centers, or violence preven- Fatma agreed to tell her doctor and son about the tion centers that are founded in accordance episodes of domestic violence. Her family doctor with the various cultures. spoke with Fatma’s husband and told him that she needed to see a psychiatrist. Fatma went to a private psychiatric clinic with her son and hus- 40.4 Conclusions: Case Study band. Her husband was also included in the pro- Follow-Up cess of the treatment, and after the second interview he began to receive treatment. Fatma’s 40.4.1 Culture Care Preservation/ husband had difficulty in accepting treatment. At Maintenance times, her husband did not want to take his medication. Fatma took her doctor’s advice and gave Although Fatma was a victim of violence, she did her husband his medication by dissolving it in not reveal this situation to anyone and did not fruit juice. Except for their children, no one else seek a way of combating it because of cultural knew about the episodes of violence or about reasons. On follow-up visits, Fatma was not mar- their visits to a psychiatric clinic. The violence ginalized or judged by her healthcare providers ended after a course of 4 weeks of treatment. because of her decision, and her decision to Fatma’s son began to visit his parents with his maintain privacy was accepted with respect. wife and children more often. Their grandchil- Assurance was given in helping her feel cultur- dren sometimes spent weekends with them. ally safe. Fatma’s husband began to work at his son’s workplace during the day. All these changes were good for Fatma. Fatma was invited to a neighbor- 40.4.2 Culture Care Accommodation/ hood social life center in order to mix with her Negotiation peers and have an enjoyable time. However, her husband did not allow her to go. Fatma continued At first, Fatma was interviewed without her hus- to spend most of her day performing domestic band present. During these interviews, her chores associated with her role as a woman, healthcare provider spoke with Fatma using a according to her culture and religious practices. nonjudgemental tone and with cultural sensitiv- A life without violence became the major source ity. She was asked how she perceives violence, of happiness for Fatma. why she did not use effective ways of combating Except for her children, no one was told that violence, why she preferred to remain silent, Fatma had been a victim of violence. She was not and why she did not report the violence to any- forced to do anything against her will or her one. Fatma was assured that she would not be desires. She was sent to the psychiatrist in strict forced to do anything against her will. The nega- confidence through the referral of her family doc- tive health effects of violence and ways of com- tor, and the response to treatment was positive. bating violence were explained to Fatma. She stated that she would not accept any approach that would harm her husband. It was suggested References to Fatma that she share this situation with her family doctor and her children. It was also rec- Ali PA, Naylor PB, Croot E, O’Cathain A (2015) Intimate ommended that she consult a psychiatrist along partner violence in Pakistan: a systematic review. Trauma Violence Abuse 16(3):299–315 with her husband, without telling anyone out- Artan T (1996) Domestic physical Elder Abuse. side of the family. Unpublished Master Thesis. Istanbul University 40 Case Study: Domestic Violence of an Elderly Migrant Woman in Turkey 367

Department of Social Sciences Institute of Forensic Özçelik Adak N (2002) Health sociology women and Medicine, Istanbul urbanization, 1st edn. Birey Publishing, İstanbul, p 319 Artan T (2016) Financial abuse as a type of elderly abuse Ozturk N (2017) Ailenin korunmasi ve kadina karşi among elderly people residing in senior centers. HSP şiddetin önlenmesine dair kanunun getirdiği bazi yeni- 3(1):48–56 likler ve öneriler. Inonu Univ Law Revew 8(1):1–32 Ayhan T (2017) Protecting the woman or the family? Salacin S (2016) Hollistic approches to the combat- Contradiction between the law and its practice in vio- ing violence against women and expectations from lence against woman cases in Turkey. Marmara Univ J İstanbul convention. Turkiye Klinikleri J Foren Med- Polit Sci 5(1):137–162 Special Topics 2(2):6–18 Canatan K, Yıldırım E (2009) Family sociology. Acilim Tanriverdi G, Şipkin S (2008) Effect of educational level Book. 1st edn. İstanbul of women on the domestic violence at Primary Health Fadıloğlu Ç, Şenuzun AF (2012) Approach to abuse and Care Unities in Canakkale. Fırat Med J 13(3):183–187 neglect in the elderly. Ege J Med 51(Suppl):69–77 Tanriverdi G, Bayat M, Seviğ Ü, Birkök C (2011) Guvenc G, Akyuz A, Cesario SK (2014) Intimate partner Evaluation of the effect of cultural characteristics violence against women in Turkey: a synthesis of the on use of health care services using the Giger And literature. J Fam Violence 29(3):333–341 Davidhizar’s Transcultural Assessment Model: a Ibiloglu AO (2012) Domestic violence. Curr Approaches sample from a village in Eastern Turkey. Dokuz Eylül Psychiatry 4(2):204–222 Univ School Nurs Electron J 4:19–24 Kalaycı I, Şenkaynağı A (2015) Violence perception The General Directorate on the Status of Women (2009) of the old people’s attendants: sample of Suleyman Domestic violence against women in Turkey. Elma Demirel University Hospital. Elderly Issues Res J Technical Printing, Ankara, Turkey 8(1):22–33 Yalcin Gursoy M, Tanriverdi G (2017) Comparison of Kissal A, Beşer A (2011) Elder abuse and neglect in a violence against the elderly in different cultures living population offering care by a primary health care in Canakkale: a qualitative research. In: 3nd interna- center in Izmir, Turkey. Soc Work Health Care 50(2): tional congress on violence and gender, 21–22 April 158–175 2017, Kocaeli-Turkey Kocacık F, Çağlayandereli M (2009) Domestic violence Yeşil P, Taşci S, Öztunç G (2016) Elder abuse and neglect. towards women: Denizli case study. Int J Hum Sci J DU Health Sci Inst 6(2):128–134 6(2):25–43 Yüksek Oktay E (2015) The common problem of Turkey Lök N (2015) Elder abuse and neglect in turkey: a system- and the world: violence against women. J Acad Stud atic review. Curr Approach Psychiatry 7(29):149–156 16(64):57–118 Case Study: Sources of Psychological Stress 41 for a Japanese Immigrant Wife

Noriko Kuwano

Miho is a 32-year-old married Japanese woman to ask advice. As a result, she was very anxious at who accompanied her husband on his posting the time of her examination. overseas, together with their 2-year-old child. After the initial examination, she made several Before marriage, Miho worked for 2 years as a more appointments to undergo all of the neces- contract employee at a trading company after sary tests. Finally, she received a diagnosis of graduating from junior college. Six months ago, uterine fibroids. To complicate matters even fur- they relocated from a large metropolitan area in ther, she was also looking for a pediatrician who Japan to a suburban area near a big city on the could administer the necessary vaccinations to east coast of the USA. In Japan, she had been a her child. In addition, even though she wanted full-time homemaker who provided support for to properly support her husband, who continued her busy husband and cared for their child. By to be busy after the move, she was unable to do so contrast, moving with a young child to another because of her illness, causing more stress. country in which she was not fluent in the lan- Owing to the time it took her to receive a diagno- guage meant that she started her life in the USA sis, the unfamiliar American healthcare system with a great deal of anxiety. and lifestyle, and the stress of parenting, her Last month, her menstruation persisted for stress began to accumulate. With no one to turn to 3 weeks. At first, she thought this was due to the for advice, she became depressed. stress of the move and thus just decided to moni- In order to visit hospitals and grocery stores, tor the situation. However, the bleeding contin- she needed to visit an area of the city that was not ued for several more days, so she decided to visit very safe. Crime rates, especially for robberies, the hospital. Although she had health insurance were above the national average, and there had that could be used in the USA, finding a hospital previously been shootings in that area. Because that actually accepted it took longer than she had she lacked confidence in being able to communi- expected, leading to further increases in stress cate with taxi drivers, she relied on the subway to before her appointment. Moreover, her child was get around when she was not with her husband. still small and needed constant attention. Her Taking her child with her on the subway in a dan- busy husband could not provide much support, gerous part of town was another substantial and she did not know anyone in the neighborhood source of stress for Miho. In Japan, her husband had led a work-centered lifestyle, leaving all domestic matters to Miho. N. Kuwano, Ph.D., R.N., M.W., P.H.N. These responsibilities had not changed after they International Nursing Department, Oita University of came to the USA. If anything, she carried more of Nursing and Health Sciences, Oita, Japan e-mail: [email protected] the domestic duties because her husband was

© Springer International Publishing AG, part of Springer Nature 2018 369 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_41 370 N. Kuwano working even harder every day to adapt to the 41.1 Cultural Issues new environment. Although he had noticed that Miho was becoming depressed, he felt helpless Although traditional Japanese culture and values because he did not know how to support her. have been influenced greatly by the West, per- Miho also felt very guilty about the burden she sonal perspectives and communication styles was putting on her husband. remain the basis of Japanese behavior and thought After receiving her diagnosis, Miho was given (Takemura 2005). In Japanese culture, a strong several options regarding further treatment and emphasis is placed on family bonds, harmonious was provided explanations about the effects and interpersonal relationships between group mem- side effects of each. However, her English was bers, emotional restraint, and the avoidance of not adequate to understand most of what she was stigma or shame (Cheung et al. 2013). told, so she just kept saying, “yes, yes” repeat- Some studies have found that traditional gender edly. It soon became apparent to the nurse that roles—males working outside the home to provide she did not understand what was being said, so for the family while females manage the halfway through the explanations, the nurse hur- household—remain dominant in Japan (Kozuki riedly arranged for a volunteer medical inter- et al. 2006; Gunderman and Hua 2014). A central preter to attend. With the assistance of the medical role of married Japanese women, one that takes interpreter, Miho was able to grasp the essential precedence even over their own needs, is to content of the conversation. But when she was maintain harmony within the family (Makabe and asked to decide between either continuing to Hull 2000). Excessive self-sacrifice sometimes monitor her condition or to begin treatment adversely affects the mental and physical health of immediately, she became confused and was married women, especially in new immigrants or silent. She only managed to say, “Let me talk to those who are socially isolated. my husband.” The nurse recommended that for Communication among Japanese people is her next visit, Miho should be accompanied by known to be more indirect than that among her husband. Miho then scheduled her next Westerners. Effective nonverbal communication, appointment and went home. including subtle gestures such as pausing between The nurse subsequently arranged for a profes- words, nodding the head, and silently smiling, is sional Japanese-American medical interpreter to very important to the Japanese because it conveys attend Miho’s next appointment. In addition, the important content of a message (Makabe and because Miho appeared to be emotionally dis- Hull 2000). In terms of interaction, Japanese peo- tressed, Miho’s healthcare team decided that it ple rely on context, shared experience, and non- would be beneficial to introduce her to a therapist. verbal clues (Gunderman and Hua 2014). In Therefore, a list of mental health clinics in her area contrast to communication in Western culture, was prepared for her next visit. which is based on the spontaneous feelings and On the day of the next appointment, Miho thoughts of the parties involved, communication came with her husband. With the assistance of the in Japan is based on how accurately the person interpreter, they were able to discuss the treat- who initiates communication responds to the ment options and make a decision. She and her recipient’s nonverbal needs and thoughts, which husband agreed that she would first undergo drug are defined by numerous social roles and norms treatment under continued observation. (Kozuki et al. 2006). In Japan, people tend to Thereafter, her physician would evaluate the situ- regard tacit understanding as being a natural form ation to determine whether she would need to of communication and might demand others temporarily return to Japan for an operation. understand what they have in mind without being They received information on mental health clin- told (Masaki et al. 2014). Furthermore, asking ics in her area but politely declined after offering others about their feelings or disclosing one’s their thanks. They seemed reluctant to have Miho feelings to another without being asked are both undergo a psychological evaluation at a clinic. considered impolite (Kozuki et al. 2006). 41 Case Study: Sources of Psychological Stress for a Japanese Immigrant Wife 371

In Japanese culture, non-verbalization and cally share decision-making with their relatives guessing (tacit understanding) in interpersonal (Takemura 2005). relationships can sometimes lead to excessive Although historically, Japan is a homoge- hypersensitivity and in turn, psychological dis- neous society, it has been progressively transi- tress (Kozuki and Kennedy 2004). In addition, tioning into one that is more culturally diverse. Japanese people rarely touch each other or main- However, as of 2016, foreign residents only tain eye contact in communication (Yamashita accounted for 1.82% of the population (Statistics and Doutrich 2013). One exception would be Japan 2016), indicating that Japanese people still Japanese nurses, who sometimes utilize touching have few chances to communicate with culturally and eye contact to demonstrate special concern and linguistically diverse residents in daily life. for their patients (Takada and Nagae 2012). Some Japanese therefore remain unaware of their Some reports in the literature note that unique communication style and underlying cul- Japanese people prefer to seek informal rather tural values, as well as those of other countries. than formal help when they have psychological distress because of the shame and social stigma associated with such mental illnesses as depres- 41.3 Culturally Competent sion (Cheung et al. 2013). Whether deliberate or Strategies Recommended instinctual, patients sometimes present their depressive symptoms as a physical health issue, In 2015, a total of 419,610 Japanese citizens since expressing emotional distress as a manifes- resided in the USA, an increase of 5.4% within tation of physical illness may be seen as more the last 5 years and with more females than males appropriate in Japanese culture. For Japanese (Ministry of Foreign Affairs of Japan 2015). Even persons, physical symptoms are understood to be though the Japanese population in the USA is a a possible indication of emotional distress very small proportion of the entire population, (Makabe and Hull 2000). because of the uniqueness of Japanese culture, the following recommendations might be useful to improving culturally appropriate care for this 41.2 Social Structure Factors population.

The healthcare delivery system in the USA is different from that in Japan. Consequently, Japanese 41.3.1 Individual-/Family-Level patients may find it confusing and considerably Intervention stressful when attempting to access it. Japan has a universal “free access” health insurance system • Listen carefully to clients’ somatic complaints through which anyone can receive a medical because the disclosure of physical symptoms examination at any institution (Ministry of Health, can sometimes serve as a means for reporting Labor and Welfare 2013), and no scheduled psychological distress. appointment is required for the first visit. • Provide educational information about psy- In the healthcare setting, Japanese patients chological distress, and reframe the negative often prefer to wait rather than decide on a treat- concept of seeking mental help. ment plan on their own, even though healthcare • Respect clients’ help-seeking behavior, and providers try to provide sufficient information to suggest finding support to release tension. patients and encourage them to make decisions • Maintain constant openness to cultural differ- with respect to their rights and quality of life. ences in the caring process. Japanese patients, especially those of the older • Contact family members and try to involve generations, tend to trust healthcare providers as them in the individual’s treatment plan. the authority and often consider it impolite to ask • Consider differences in communication patterns, questions. Furthermore, Japanese patients typi- and be aware of the reliance on nonverbal 372 N. Kuwano

communication patterns; for example, saying • Establish a partnership with the Japanese “yes” does not mean affirmation or that I community coalition to assist with mental understand but rather “Yes, I hear you.” health education, such as during health fairs. • Show strong interest in the person, and encourage them to talk about his or her feelings in a Conclusion place where their privacy is protected. Various forms of cultural issues and social structural factors influenced Miho’s physical and mental health status. Because of the 41.3.2 Organizational-Level traditional gender roles, Miho assumed that Intervention she should devote herself to her family, focusing on her function as full-time • Establish organization-wide committees to homemaker even under the pressures of address the promotion of culturally competent moving to another country. As a consequence care delivery to all individuals. of limited exposure to the new environment, • Provide printed materials on multiple condi- her acculturation process may have been tions in the major languages of the population delayed, and she was becoming socially served. isolated. The cumulative stressors, such as the • Provide a certified interpreter when the patient disturbing symptoms, problems dealing with a has limited language proficiency in the lan- health delivery system different from her guage that is different from the healthcare original country, and her limited English providers. proficiency, all led to her depressive symptoms. • Provide easy-to-express environment for Furthermore, because of the stigma of mental patients when they have difficulty in express- illness in her culture, she may have failed to ing opposition to the decision made by the share her emotions and thus gain advice about physician and/or family (Takemura 2005) and assistance with mental health problems. • Collaborate with the mental health therapist In order to improve her health, an approach and psychologists/psychiatrists who under- involving families and community is needed stand Japanese culture and the unique in order to be effective. It is important to try to characteristics of the Japanese to foster effective reframe the negative concept of help-seeking care. for mental health problems through providing educational information both for clients and their families. A constant openness to cultural 41.3.3 Community-Level differences and challenges and efforts to Intervention understand a person’s ways of preserving health and coping behavior in the care setting • Establish a partnership with the Japanese are indispensable. community in your area or coalitions, such as an association of people from the same prefecture of Japan, to foster mutual support for References healthy lifestyles both physically and mentally. Cheung M, Leung P, Tsui V (2013) Japanese Americans’ • Collaborate with the Japanese community in health concerns and depressive symptoms: implications for disaster counseling. Soc Work 58(3):201–211 your area or coalitions such as an association Gunderman R, Hua C (2014) Education in cultural com- of people from the same prefecture of Japan to petency in Japan. Acad Radiol 21(5):691–693 bring isolated Japanese persons together Kozuki Y, Kennedy MG, Tsai JH (2006) Relational expe- within the community. riences of partnered Japanese immigrant women with affect disorders. J Adv Nurs 53(5):513–523. https:// doi.org/10.1111/j.1365-2648.2006.03753.x 41 Case Study: Sources of Psychological Stress for a Japanese Immigrant Wife 373

Kozuki Y, Kennedy MG (2004) Cultural incommensura- Statistics Japan (2016) The number of registered foreign bility in psychodynamic psychotherapy in Western and nationals in Japan. http://www.moj.go.jp/nyuukoku- Japanese traditions. J Nurs Scholarsh 36(1):30–38. kanri/kouhou/Nyuukokukanri04_00060.html http://dx.doi.org/10.1111/j.1547-5069.2004.04008.x Takada M, Nagae M (2012) Hisesshokubunka dearu Makabe R, Hull MM (2000) Components of social sup- nihon no kango rinsho genba ni oite touching ga yuko port among Japanese women with breast cancer. ni hataraku yoin: togoteki bunkenkenkyu (Factors for Oncol Nurs Forum 27(9):1381–1390 effectiveness of touching in clinical ward in Japan Masaki S, Ishimoto I, Asai A (2014) Contemporary where has contactless culture: literature review) (in issues concerning informed consent in Japan based Japanese). Bull Jpn Red Cross Toyota Coll Nurs on a review of court decisions and characteristics of 7(1):121–131 Japanese culture. BMC Med Ethics 15:8. https://doi. Takemura Y (2005) Cultural traits and nursing care par- org/10.1186/1472-6939-15-8 ticular to Japan. In: de Chesnay M (ed) Caring for the Ministry of Foreign Affairs of Japan (2015) Annual vulnerable: perspectives in nursing theory, practice, Report of Statistics on Japanese Nationals Overseas. and research. Jones and Bartlett Publishers, Sudbury, http://www.mofa.go.jp/mofaj/files/000162700.pdf MA, pp 235–243 Ministry of Health, Labor, and Welfare (2013) Health Yamashita CY, Doutrich DL (2013) Japanese Americans. insurance: general overview. http://www.mhlw.go.jp/ In: Giger JN (ed) Transcultural nursing: assessment english/policy/healthmedical/healthinsurance/dl/ & intervention, 6th edn. Elsevier, St. Louis, MO, health_insurance_bureau.pdf pp 309–339 Case Study: Early Childbearing and Contraceptive Use Among 42 Rural Egyptian Teens

Azza H. Ahmed

Hala is a 19-year-old Egyptian immigrant woman green card he received because of an application who came to the emergency room (ER) with submitted 2 years earlier, in which he cited finan- heavy bleeding after miscarriage. Hala was cial limitations. He traveled alone to the east 8 weeks pregnant with her second baby. The coast of the USA and found minimum wage work obstetrician performed a D&C, and blood testing as an accountant and worker in a small business revealed that her hemoglobin was 9.5. Iron sup- company. Hala joined her husband about plements were ordered for her. 7 months ago. Hala did not have any prenatal visits for this Hala is a member of a large Muslim family recent pregnancy. She and her husband had with ten household members, including seven looked for a prenatal care clinic in their area, and siblings who are younger than herself. She did when they ultimately found such a clinic, they not complete her high school education because scheduled an appointment. However, the miscar- she was always busy helping her mother with riage occurred before the appointment. Hala’s raising her younger siblings. When she married, older baby is an 11-month-old boy who was born she dropped out of school completely. Her father in Egypt. Hala mentioned that she had made two is a religious conservative man who does not visits to the health center during this pregnancy believe in contraceptive use. Hala’s husband in Egypt, but she gave birth at home with the Othman has four siblings. He received his bach- assistance of a traditional birth attendant (daya) elor’s degree in commerce from a state university despite the risk of having premature birth. in northern Egypt. After serving his 1-year Hala and her 26-year-old husband Othman requirement of military service, he worked for were born and raised in a rural county in northern the Egyptian government as an accountant for Egypt. When Hala was 17 1/2 years old, they 2 years before immigrating to the USA. married in an Egyptian traditional marriage Hala and her husband are currently living in a arranged through their families. Hala became small apartment in a predominantly Arab com- pregnant immediately after the wedding, and her munity. They have very few fiends as Othman is first child was born at 35 weeks gestational age. working most of the time and Hala just recently After the birth of their son, Othman was permit- arrived from Egypt. They visit their local mosque ted to immigrate to the USA with the lottery for prayer during the month of Ramadan and whenever there is a special event or celebration. Because of her limited English language ability, A. H. Ahmed, DNSc, RN, IBCLC, CPNP Hala does not like to interact with non-Arab School of Nursing, Purdue University, neighbors. Consequently, she only shops when West Lafayette, IN, USA e-mail: [email protected] accompanied by her husband and only on the

© Springer International Publishing AG, part of Springer Nature 2018 375 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_42 376 A. H. Ahmed weekends when he is free of work responsibili- dren, mostly out of shyness. Therefore, as part of ties. She does not have a driving license. Since their prenuptial counseling, mothers do not teach she did not drive in Egypt, she first needs to learn their daughters and sons about the need to use driving skills as well as learn enough English to contraception during marriage. Not only do the obtain a driver’s license in her new country of parents avoid this topic, but schools in Egypt also residence. do not provide needed information about success- In the emergency department, during post- ful use of contraceptive methods. Studies by miscarriage counseling, the couple was asked Eltomy et al. (2013) and Awadalla (2012) found about contraceptive use. Othman said that they that lack of knowledge and cultural issues were never discussed this topic before or after getting the main barriers to contraceptive use and family married and they were not aware of the different planning among Egyptian women. This phenom- options or types of contraception that they could enon is more common and predominant in rural use. Hala said that she and her mother never talked areas where families consider discussing sex edu- about using any contraceptive methods and that cation and contraceptive use to be totally inappro- her mother-in-law told her that she would not get priate and shameful. This phenomenon in rural pregnant while she is breastfeeding. areas is also combined with marriage at an early Although the recent pregnancy was not age, which leads to high rates of pregnancy, con- planned, Hala and her husband were very sad traception nonuse, abortions, and other conse- about the loss of their baby. They started to dis- quences, such as prematurity and maternal and cuss the need to visit a health provider and ask infants’ mortality and morbidities (WHO 2014; about contraceptive alternatives they could use. Awadalla 2012). In addition, married couples Othman said that he would love to have another rarely discuss contraceptive use and family plan- baby, but not until Hala’s condition stabilizes and ning before marriage out of shyness and may dis- their son gets older, as she doesn’t have family to cuss it only with precaution after getting married. help her in the USA. In the Egyptian tradition, A qualitative study was conducted by Farrag the women who had had a miscarriage stay home and Hayter (2014) to examine Egyptian school with family, and friends visit her to provide sup- nurses’ knowledge and perception about sex edu- port and cook for the family until the mother’s cation. The study highlighted several barriers to condition is improved. Family and friends also sex education: these include parents’ concerns provide help with taking care of the children dur- about discussing this topic with their children, ing this time. Based on Islamic ruling, if the fetus saying that it a Western topic that is not appropri- of the miscarriage is around 12 weeks of gesta- ate for their children; cultural and religious issues tion or the body of the fetus is complete, the fam- that do not allow discussing the topic with chil- ily should ask that the fetus be named. In addition, dren; and the nurses’ concerns about their ability, they need to follow the rules for any dead child, skills and self-confidence to teach sex education. such washing the body in the Islamic way, laying Therefore, the main source of information about it in a coffin (three layers of fabric), praying for intimate relations and contraceptive use is from the deceased person in the Mosque, and, finally, the women’s peers who often provide inaccurate burying the body. In Hala’s case, this process was information. Women even feel shy to discuss this not required as she was 8 weeks pregnant and the topic if they have male healthcare providers. body of the fetus was not complete. Some aspects of sex education have been described in Islamic oral teachings. It is documented by the companions of Prophet 42.1 Cultural Issues Muhammad (peace be upon him) that He practiced coitus disruption as a method to prevent In the Egyptian culture sex education and intimate pregnancy. The following Hadiths (the Prophet’s sexual relationships, including contraceptive use, Sunnah) explains: “As Jaabir ibn Abdullah (may are not topics that parents discuss with their chil- Allah be pleased with) said: ‘We used to practice 42 Case Study: Early Childbearing and Contraceptive Use Among Rural Egyptian Teens 377 azl (coitus interruptus) while our Qur’an was tus, and income. In addition, adolescent fertility being revealed. Jabir added ‘We used to practice adversely affects not only young women’s health, coitus interruptus during the lifetime of Allah’s education, and employment prospects but also messenger (blessings and peace of Allah be upon that of their children. Births to women aged him)’” (al-Bukhari, 5208). Imam Muslim al- 15–19 years old have the highest risk of infant Naysaburi (1440) added: “This (the news of this and child mortality as well as a higher risk of practice) reached Allah’s Apostle (blessings and morbidity and mortality for the young mother peace of Allah be upon him) and he did not forbid (WHO 2014). it. Currently in Egypt, IUDs are the most com- According to WHO (2014), in the Arab monly used contraceptive method (36%), fol- Republic of Egypt, there are over 15.6 million lowed by the pill (12%) (Family Planning 2020 adolescents aged 10–19 years, which is 18.4% of 2016; The world Bank 2016). the country’s total population. More than 50% of A study by Darmstadt et al. (2008) found that adolescents live in rural areas, 55.8% of adoles- mothers usually received antenatal care from cent girls and 47.8% of adolescent boys. By age physicians in healthcare centers but traditional 19, the mean number of years of school attended birth attendants (dayas) conducted most deliver- by married adolescent girls is 9.2. Among mar- ies. They found that dayas attended roughly half ried adolescent girls who become parents before of deliveries and were more common birth atten- age 20, the average age at which they have their dants than physicians, nurses, or relatives. More first baby is 17.9 years. recent statistics found that slightly more than 9% The WHO report also reported that most of total births in rural areas in Egypt are done by women who reported using contraceptive meth- traditional birth attendants, as compared to 3% in ods were 30–39 years old, were employed, were the urban areas (Egypt 2014). Despite the efforts rich, were educated, and lived in urban gover- of the Ministry of Health and WHO projects to norates. According to the Egypt Demographic ensure facility delivery and decrease maternal and Health Survey (EDHS) conducted by the morbidity and mortality, traditional birth atten- Ministry of Health and Population (MOHP dance still exist in rural and urban areas in Egypt, 2015), 79.5% of married adolescent girls aged and dayas are still prominent and widely accepted 15–19 are not using a method of contraception. care providers for the large share of births at However, while 38.3% of married adolescent home in rural Egypt, suggesting that expanding girls reported that they did not want a child in their skills to provide intrapartum care and ante- the next 2 years, only 23.4% of these are cur- natal and postnatal advice to recognize and rently using any method to prevent pregnancy. encourage care-seeking for complications could The main reasons these adolescents report for improve neonatal outcome. not using a contraceptive method include men- Another cultural aspect in HaIa’s case relates ses has not returned after giving birth (41.8%), to the fact that in Egyptian culture, the oldest infrequent sex (28.5%), and breastfeeding daughter has the responsibility of helping her (10.0%). When contraceptives are used, IUDs, mother and family in taking care of younger sib- one of the most effective methods, and pills are lings. This cultural aspect combined with early the most common modern methods used (9.8% marriage played a role in Hala’s case of not being and 7.1% of these adolescent girls, respec- able to complete her high school education. tively). Injectable contraceptives are used by 0.9%, and lactational amenorrhea (LAM) is used by 1.6% (WHO 2016). 42.2 Social Structural Factors In Egypt, while early childbearing is more prevalent among the poor compared to rich coun- Several sociodemographic factors are associated terparts, the rich-poor gap in prevalence of early with the early childbearing and contraceptive childbearing is similar across cohorts. Findings use, including age, education, employment sta- from a study conducted in a rural area in northern 378 A. H. Ahmed

Egypt by El-Shazly et al. (2015) found that most preterm birth, anemia, inadequate prenatal care, of the women in the study were not aware of and ultimate miscarriage. physiological, surgical, and emergency contraceptive methods. The most common contraceptive method used by this cohort of women was 42.3 Culturally Competent contraceptive pills. Strategies Recommended In Egypt, the literacy rate among females aged 15 and above is 58%. Fewer girls are enrolled in Gender equality and women’s empowerment are primary schools compared to boys, with a ratio of important for improving reproductive health, female to male primary enrollment of 95%. The especially in developing countries. Higher levels World Bank Report (2011) acknowledged that eco- of women’s autonomy, education, wages, and nomic progress and greater investment in human labor market participation are associated with capital of women will not translate into better improved reproductive health outcomes (Shaikh reproductive outcomes if women lack access to et al. 2013). reproductive health services. It is thus important to ensure that health systems provide a basic package of reproductive health education and services, 42.3.1 Individual-/Family-Level including family planning (The World Bank 2016). Interventions In order to improve maternal health including positive pregnancy outcomes, mothers should • Consider cultural assessment in all aspects have access to prenatal care and family planning including language, care preferences, reli- services. In Egypt, only about one quarter of gious beliefs, education, and socioeconomic pregnant women receive antenatal care from status. skilled medical personnel (physician, nurse, or • Consider asking about parents and parents’ midwife) with merely 66% of these having the in-law involvement in the family’s recommended four or more antenatal visits. decision-making. Nationally, 79% of pregnant women deliver their • Be sensitive when addressing intimate partner babies with the assistance of skilled medical per- relationships. sonnel. But while 97% of women in the wealthi- • Consider privacy and discuss the topic with est quintile delivered with skilled health each partner separately and then both together. personnel, only 55% of women in the poorest • Encourage sexual awareness and early intro- quintile obtained such assistance. Furthermore, duction of contraceptive use and its benefits 86% of urban women as compared to 59% of for families and their children. rural women delivered their babies with assis- • Provide premarital information sessions for tance from skilled health personnel. Moreover, couples about important topics for marriage, 45% of all pregnant women are anemic (defined including contraceptive use in collaboration as hemoglobin <110 g/L), increasing their risk of with the local Egyptian community. preterm delivery, low birth weight babies, still- • Teach the couples decision-making skills, birth, and newborn death. Among all women including family planning. Awadalla (2012) aged 15–49 years who had given birth, 34% had reported that whatever the level of education, no postnatal care within 6 weeks of delivery, the majority of women thought that family while only 0.1% received postnatal checkup from planning decisions should be made by both a traditional birth attendant (Ministry of Health partners. It is better to discuss contraceptive and Population (MOHP) 2015). These data are use with both partners together and help them highly related to Hala’s situation in terms of to take an informed decision by educating being a young mother who came from rural them about different types of contraception Egypt and experienced early childbearing with available. 42 Case Study: Early Childbearing and Contraceptive Use Among Rural Egyptian Teens 379

• Introduce Hala to the Special Supplemental students in Muslim community schools if they Nutrition Program for Women, Infants, and have private Islamic schools. Farrag and Hayter Children (WIC) for her child and herself. WIC (2014) reported that school nurses had con- provides healthy nutrition that could help with cerns about their ability and self-confidence to her low hemoglobin level and breastfeeding, discuss the topic with middle and high school and she could receive correct information students. about lactation amenorrhea. • Connect Hala with community resources to • Introduce Hala to community resources to complete her education. learn life skills and be an active member in her community. Conclusion Hala is a typical case of an Egyptian teenager in rural Egypt who did not complete her high 42.3.2 Organizational-Level school education because of family and Interventions marriage responsibilities, got married early, and did not use any contraceptive methods to • Provide a licensed, culturally competent, and plan her family. Several factors played a role in proficient interpreter to assist with communi- Hala’s case. Lack of knowledge, low cation between healthcare providers and Hala educational level, and cultural and family issues and her husband, especially with the discus- all contributed to Hala’s situation. Hala married sion of types of contraceptives and selecting when she was 17 1/2 years old, did not complete the appropriate method. her basic education, had no information about • Provide translated information in Arabic about contraceptive use and its benefits, and the different types of contraception and writ- experienced a preterm birth with her first baby ten in educationally appropriate terminology. and a miscarriage with heavy bleeding in her Partner with the local Egyptian community to second pregnancy. All these factors not only raise awareness about the availability of con- affect Hala’s health but also her whole family traceptive service available in the community and their future. Strategies to address Hala’s and their correct uses. situation should be discussed by culturally • Provide English conversation classes to competent providers who should consider all empower women like Hala to improve her social, cultural, religious, and familial aspects. English so she could be able to engage in more social relationships and understand her right to information and education. References

al-Bukhari M. The Sunnah of Muhammad. Book 67 42.3.3 Community-/Societal-Level Wedlock and Marriage, Hadith 142, hadith # 5208– 5209. https://sunnah.com/bukhari/67 Interventions Awadalla HI (2012) Contraception use among Egyptian women: results from egypt demographic and health • Collaborate with local community mosques, survey in 2005. J Reprod Infertil 13(3):167–173 and involve religious leaders in family plan- Darmstadt G et al (2008) Practices of rural Egyptian birth attendants during the antenatal, intrapartum and early ning programs. Shaikh et al. (2013) reported neonatal periods. J Health Popul Nutr 26(1):36–45 that the involvement of religious leaders in El-Shazly H, Elkilani O, Nashat N, Elshishiny R (2015) family planning programs had a positive influ- Evaluation of family planning services in a rural area in ence on rural women. Al-Shohdaa district, Menoufiya governorate. Menoufia Med J 28(3):650–656. http://www.mmj.eg.net/article. • Discuss the importance of school nurses’ and asp?issn=1110-2098;year=2015;volume=28;issue=3;s teachers’ training sessions on how to discuss page=650;epage=656;aulast=Anwar contraceptive use with middle and high school Eltomy EM, Saboula NE, Hussein AA (2013) Barriers affecting utilization of family planning services 380 A. H. Ahmed

among rural Egyptian women. Eastern Mediterr Shaikh B, Azmat S, Mazhar A (2013) Family planning Health J 19(4):400–408 and contraception in Islamic countries: a critical Family Planning 2020 (2016) Egypt: Family Planning review of the literature. J Pak Med Assoc 63(4 Suppl 2020 Core Indicator Summary Sheet 2016. http:// 3):S67–S72 www.track20.org/download/pdf/2016%20FP2020%20 The World Bank (2016) Reproductive health at a CI%20Handouts/english/Egypt%202016%20 GLANCE, Egypt. http://documents.worldbank.org/ FP2020%20CoreIndicators.pdf. Accessed August 2017 curated/en/575751468233940262/pdf/629610BRIEF Farrag S, Hayter M (2014) A qualitative study of Egyptian 0Eg0BOX0361514B00PUBLIC0.pdf. Accessed June school nurses’ attitudes and experiences toward sex 2017 and relationship education. J School Nurs 30(1):49–56 World Health Organization (2014) Arab Republic of Egypt: Ministry of Health and Population (MOHP) [Egypt], adolescent contraceptive use. WHO Publications. El-Zanaty and Associates [Egypt], and ICF International http://apps.who.int/iris/bitstream/10665/252445/1/ (2015) Egypt demographic and health survey 2014. WHO-RHR-16.69-eng.pdf?ua=1 Ministry of Health and Population and ICF International, World Health Organization (WHO) (2016) Adolescent Cairo, Egypt. https://dhsprogram.com/pubs/pdf/fr302 contraceptive use: data from the Egypt demographic Imam Muslim. The Sunnah of Muhammad. Book 16. The and health survey 2014 (EDHS). http://apps.who.int/ book of marriage. Hadith 164, hadith # 1440. https:// iris/bitstream/10665/252445/1/WHO-RHR-16.69- sunna.com/muslim/16 eng.pdf. Accessed 24 July 2017 Case Study: A Chinese Immigrant Seeks Health Care in Australia 43

Patricia M. Davidson, Adam Beaman, and Michelle DiGiacomo

The forces of globalization and migration have about health, challenge Chinese Australians’ enriched diversity across the globe as well as access to health care. It is also impossible to deny intensified certain migration corridors (Czaika that many Australians are not accepting of the ris- and Haas 2014). Australia is a diverse and ing Chinese influence (Grigg and Manderson culturally pluralistic society with people from a 2016). Living in this environment can be chal- range of cultural, ethnic, linguistic, and religious lenging for individuals experiencing such dis- backgrounds (Radermacher and Feldman 2017). crimination and may affect their level of trust Aboriginal and Torres Strait Islander people have when interacting with their health team. inhabited Australia for tens of thousands of years Therefore, it compels health-care professionals and are the traditional owners of the land (Brown to explore their own knowledge, attitudes, and 2009). Most Australians are immigrants or the beliefs about other cultural groups. Every day, descendants of immigrants who arrived over the millions of individuals fail to receive optimal last two centuries from more than 200 countries. care and are either exposed to medical errors or Mainland China continues to remain the biggest lack access to care. Ethnicity, culture, and country from which immigrants come to sociodemographic factors are important consid- Australia, and in recent years, it has overtaken the erations influencing these challenges (Vincent United Kingdom to become its largest source of and Amalberti 2016). The antecedent and moder- immigrants. ating factors for this situation are complex and Differences between the Australian and multifaceted and require innovative and collab- Chinese health-care systems are evident and orative solutions. The story provided below is not beyond language. Many factors, including an unusual one. It underscores the importance of differences in knowledge, values, and beliefs ensuring there is both understanding of the health information provided to the client and its follow- up, particularly in individuals with limited P. M. Davidson, Ph.D., MEd., R.N., FAAN (*) A. Beaman, M.P.H. English language proficiency and health literacy. School of Nursing, Johns Hopkins University, It is a busy Wednesday in the cardiology clinic Baltimore, MD, USA when the clinical trial nurse looks up at Mr. e-mail: [email protected]; [email protected]; Wang’s face. She sees a 54-year-old Chinese man [email protected] who migrated to Australia from Mainland China M. DiGiacomo, Ph.D. 3 years ago. He was recently admitted to the hos- University of Technology Sydney, Faculty of Health, Sydney, NSW, Australia pital with a diagnosis of chronic heart failure and e-mail: [email protected] was eager to engage in conversation with the

© Springer International Publishing AG, part of Springer Nature 2018 381 M. Douglas et al. (eds.), Global Applications of Culturally Competent Health Care: Guidelines for Practice, https://doi.org/10.1007/978-3-319-69332-3_43 382 P. M. Davidson et al. nurse. He is smiling, and the nurse and Mr. Wang confronting attitude had likely led the clinical are engaging in social chatter before the staff to assume he could both read and under- interpreter arrives to explain a clinical trial that stand the written discharge instructions. A lack Mr. Wang has agreed to consider. Mr. Wang has of systematic follow-up as well as exploring the working knowledge of English, and he is reasons for not presenting for his surgical proce- employed as a painter in a local company. He dures was a missed opportunity. Mr. Wang confesses that he is very tired, and it is harder to seemed to still hold onto many of his traditional do his job. beliefs about health and wellness, and it did not While assessing eligibility to participate in the appear that he understood the seriousness of clinical trial, the nurse is perplexed to see that Mr. receiving a diagnosis of chronic heart failure, Wang had been scheduled for coronary bypass nor the importance of managing his coronary surgery 3 months earlier, but it appeared that the artery disease and engaging in secondary pre- surgery was not done—at least not at this hospital. vention strategies. These factors should have She makes a note that this is an important issue to been considered in his discharge planning and in explore when the health-care interpreter arrives. developing a follow-up plan. His belief and faith During a discussion with the health-care in traditional Chinese medicine was also an interpreter, it was clear that the surgery was not important flag to ensure that drug interactions performed and that Mr. Wang was not aware of are explored (Daly et al. 2002; Davidson et al. the severity of his condition. In addition, he had 2003). It is important for health-care profession- not followed up with his primary care provider als to promote a culture that enables individuals following the hospitalization. What evolved was and their families to discuss their traditional this serendipitous visit to consider a clinical trial beliefs and explore how they align with recom- that might save Mr. Wang’s life. Through the mended treatment strategies. By openly discuss- direct intervention of the clinical trial nurse, who ing and asking about home remedies used, worked with the interpreter to assure that Mr. health-care providers can project a receptive atti- Wang understood his condition and the need for tude toward traditional health-care beliefs and surgery and follow-up medications, treatment for practices. his chronic heart failure, finally started. The surgery for his triple-vessel coronary artery disease was scheduled, and therapy for his 43.1 Social and Structural Factors chronic heart failure was initiated. Underling the Vulnerability Mr. Wang also told the nurse and interpreter of This Population that he goes to the traditional Chinese medicine and Influencing the Problem doctor in Chinatown for his health problems and does not see the primary care physician listed in Although migrants often have a “healthy immi- his medical record. This is an important grant effect,” this effect diminishes over time observation in ensuring adherence with (Gushulak 2007). The process of migration, recommended medications and avoiding drug whether forced or voluntary, is a stressful event. interactions. The nurse and interpreter Immigrants are commonly identified as emphasized to Mr. Wang the importance of vulnerable populations. But there is, in fact, engaging in regular contact with his primary care heterogeneity in the exposure to these physician and carefully disclosing all of his susceptibilities, which are largely moderated by medications, including herbal preparations. social determinants of health and access to It was evident from this encounter that Mr. resources. Derose et al. (2007) consider factors Wang had “slipped through the cracks” in the such as socioeconomic circumstances, system. His “working” English had led to many immigration status, language proficiency, access assumptions by the health-care providers regard- to publicly funded health care, residential ing his literacy. Plus, his agreeable and non- location, stigma, and marginalization that can 43 Case Study: A Chinese Immigrant Seeks Health Care in Australia 383 have an impact on health-care outcomes. Sadly, ensure individuals like Mr. Wang obtain optimal global nationalistic forces can amplify the care: alienation and marginalization of many migrant groups, particularly those who visibly appear • Effective cultural communication demon- different from the mainstream population or hold strates respect, dignity, and appreciation of specific religious and cultural beliefs (Gostin and differences and, like any other skill, requires Friedman 2017). training and practice. It is difficult for health-care professionals to • As part of the admission process, there should address issues such as residential location and be an assessment of the person’s cultural self- stigma. Yet, with thought, preparation, and identity, health-seeking behaviors, home training, health-care professionals can address remedies used, language preferences, and health literacy and improve communication and environmental, occupational, socioeconomic, coordination of care through tailored and tar- and educational status. geted strategies. Nurses are in an excellent posi- • Engagement with certified health-care inter- tion to activate these important strategies, preters is crucial in ensuring that individuals including addressing health literacy. Health lit- understand their condition and treatment eracy is the degree to which individuals have the strategies. capacity to obtain, process, and understand • Translation deals with written communica- basic health information and services needed to tion, while interpretation involves the spoken make appropriate health decisions. Health liter- word, both of which are important in achiev- acy can often be a stronger predictor of health ing a level of shared understanding. outcomes than social and economic status, edu- • Understanding traditional health beliefs is cation, gender, and age (DeWalt et al. 2004; important in developing plans of care. Mr. Nutbeam 2008). Providing health information Wang’s use of traditional medicines may and addressing language, literacy, and numer- cause interactions with other medications. acy are important to addressing the needs of • Promotion of a culture that enables the indi- individuals and populations (Batterham et al. vidual to feel comfortable with disclosure is 2016). important. • There are many websites and resources available to assist in providing culturally appropri- 43.2 Culturally Competent ate and translated material. Reliable sources Strategies Recommended are provided by the Centers for Disease Control and Prevention (National Center for 43.2.1 Individual-/Family-Level Health Statistics 2016). Interventions • Many lesbian, gay, bisexual, transsexual, and queer persons may have great difficulty in Achieving familiarity with a cultural and envi- obtaining high-quality health care, and this ronmental context is essential for nurses to pro- experience is often amplified for those persons vide culturally competent communication. if they are members of minority populations Culturally relevant guidelines provide a useful (Wilson and Yoshikawa 2007). backdrop and contextual information. However, it is always important to avoid stereotyping of cultural issues and take steps to identify and dis- 43.2.2 Organizational Level cuss each individual’s own knowledge, attitudes, and beliefs about their health situation Ideally, our health-care institutions should be (Davidson et al. 2007). The following factors seen as part of our communities, and the staff should be considered within a comprehensive working in these institutions should reflect the clinical, cultural, and social assessment to sociodemographic and cultural profile of the 384 P. M. Davidson et al. local community. The following factors are cial status and no health insurance. Many immi- useful in promoting cultural competence and grants to Australia are not covered by reciprocal optimal patient outcomes at the level of the health-care agreements, and the cost of private organization and community: health insurance can be prohibitive. Just and civil societies provide a safety net for all individuals • Engagement with core community organiza- regardless of immigration status. Globally, more tions is crucial in increasing alignment of insti- and more individuals are displaced by geopoliti- tutional programs and resources with the cal instability, climate change, and environmental community’s goals. disasters. A study from the United Nations • The use of community health workers and Refugee Agency found a total of 65.3 million liaison staff can be useful additions to the people were displaced at the end of 2015, and this health-care team within the organization. number continues to grow, challenging health- • Implementation of system-wide interdisciplinary care systems across the globe (Langlois et al. programs for cultural competence development 2016). It is critical that health-care providers are should be a priority of the organization. prepared for the associated changes and chal- • The health-care system should ensure that its lenges that lie ahead, particularly in relation to budget includes human and financial resources patient populations. for both health-care interpreters and translation of materials. Conclusion • Interpreters via telephone and video-based Achieving cultural competency requires a conferencing can be useful in emergency multilevel approach. Realizing equity, social situations. justice, and optimal outcomes requires inter- • Health-care interpreters must ensure confiden- ventions at the level of the individual, organi- tiality, be knowledgeable about health-care zation, and society. Social ecological language, and conduct all sessions in an ethi- frameworks have been widely adopted, recog- cal manner. nizing that no single factor can explain or pre- • Policies and systems should be available to dict a particular phenomenon (Baron et al. monitor health outcomes and ensure quality 2014; Fleury and Lee 2006). Given the com- improvement and progress in addressing the plexity of the environments in which nurses care needs of diverse patients and communities. serve the health of others, an understanding of the dynamic interplay between the dimensions influencing culture, work environments, and 43.2.3 Societal Level practice is necessary. Addressing health disparities at the local, national, and global level Programs and policies that address social determi- requires making fundamental changes in nants of health are crucial. For societies to be engag- health-care delivery. Much of this can be ing and welcoming to migrants, policies should be achieved by interventions at the policy level enabling and appreciative of differences. The and requires data-driven approaches to advo- Australian Bureau of Statistics (2016) estimated cacy. Viewing health care within a social eco- that as of 30 June 2016, 28.5% of the Australian logical context is important for considering population was born overseas, equal to 6.9 million this complex interaction (Davidson et al. people, underscoring the importance of this issue. 2016). Policies have the power to have an Immigrants often face disproportionate barri- impact on changing systems and the health of ers to accessing health coverage and care (Artiga populations. We can see the impact of the et al. 2016). Challenges can be the lack of knowl- Affordable Care Act in the United States on edge in how to enter the health-care system as improving access to care and, as a conse- well as discrimination and stigmatization. It is quence, health outcomes (McManus et al. particularly challenging for those with nonoffi- 2016). 43 Case Study: A Chinese Immigrant Seeks Health Care in Australia 385

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