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Health Promotion and Wellness.
Cultural Diversity.
Environmental Health.
Discuss various theories of health promotion, including Pender’s Health Promotion Model, the Health Belief Model, the Transtheoretical Theory, and the Theory of Reasoned Action.
Discuss at least two definitions of health.
Critically analyze racial and cultural diversity in the United States.
Chapter 13
Cultural Diversity and Community Health
Nursing
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Cultural Competence
Cultural competence is respecting and
understanding the values and beliefs of a certain
cultural group so that one can function effectively in
caring for members of that cultural group.
Culturally competent community health nursing
requires that the nurse understand…
➢
➢
➢
Lifestyle
Value system
Health and illness behaviors of diverse individuals, families,
groups, and communities
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2
Standards of Practice for Culturally
Competent Nursing Care
1.
2.
3.
4.
Social Justice
Critical Reflection
Knowledge of Cultures
Culturally Competent
Practice
5. Cultural Competence in
Health Care Systems
and Organizations
6. Patient Advocacy and
Empowerment
7. Multicultural Workforce
8. Education and Training
in Culturally
Competent Care
9. Cross-Cultural
Communication
10. Cross-Cultural
Leadership
11. Policy Development
12. Evidence-Based
Practice and Research
From: Expert Panel on Global
Nursing and Health (2010)
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Population Trends
In 1970
➢
By 2010
➢
Minority groups increased to 36% of population
By 2025
➢
Minority groups were 16% of population
More than half of all children will be minorities
By 2050
➢
➢
More than 54% of total population will be minorities
First time in U.S. history that minorities will make up a
majority of the population
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Population Trends (Cont.)
By 2060, projected demographic trends:
➢
White 44%
➢ Hispanic 30%
➢ African American 15%
➢ Asian 9%
➢ American Indians & Alaska Natives 2%
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Immigration to the United States
Since 1991, more than 13 million legal
immigrants
In 2010, almost 40 million foreign-born
individuals in the United States (12.9% of
population) from:
➢
➢
➢
➢
Latin America 53.1%
Asia 28.2%
Europe 12.1%
Other regions 9%
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Diversity Among Nurses
Minorities are generally
underrepresented by nursing workforce
(HRSA, 2009):
➢
➢
➢
➢
➢
White/non-Hispanic 81.8%
African American 4.2%
Hispanic 1.7%
Asian and Pacific Islander 3.1%
Native American and Alaska Native 0.3%
Minority groups tend to be geographically
distributed in the United States.
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Cultural Perspectives and Healthy
People 2020
Developed a set of national health
targets…eliminating racial and ethnic
disparities in health
Embraced and focused on ways to
close the gaps in health outcomes
Focused on disparities among racial
and ethnic minorities, women, youth,
older adults, people of low income and
education, and people with disabilities
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Health Disparities
AHCRQ (2005) reveals that:
Cancer mortality rates are 35% higher in
African Americans than in whites.
African Americans with diabetes are seven
times more likely to have amputations and
develop renal failure than are whites with
diabetes.
30% of Hispanics and 20% of African
Americans lack a usual source of health care
(compared with less than 16% of whites).
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Health Disparities (Cont.)
AHCRQ (2005) reveals that:
Hispanic children are nearly three times as
likely as non-Hispanic white children to have
no usual source of health care.
African Americans (16%) and Hispanic
Americans (13%) are more likely to rely on
hospitals or clinics for health care than are
whites (8%).
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10
Addressing Racial and Ethnic
Disparities in Health Care
Disparities can be reduced or
eliminated when adults have:
➢
➢
Health insurance and
A medical home
– Commonwealth Fund, 2007
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Transcultural Nursing
“…a formal area of study and practice
focused on a comparative analysis of different
cultures and subcultures in the world with
respect to cultural care, health and illness
beliefs, values, and practices with the goal of
using this knowledge to provide culturespecific and culture-universal nursing care to
people.”
– Leininger (1978)
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12
Transcultural Nursing Terminology
Culture specific refers to the
“particularistic values, beliefs,
and patterning of behavior
that tend to be special, ‘local,’
or unique to a designated
culture and which do not tend
to be shared with members of
other cultures”
– Leininger (1991)
Culture universal refers to
the “commonalties of values,
norms of behavior, and life
patterns that are similarly
held among cultures about
human behavior and
lifestyles and form the bases
for formulating theories for
developing cross-cultural
laws of human behavior”
– Leininger (1978)
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Transcultural Nursing Terminology
(Cont.)
Ethnocentrism is a
person’s tendency to
view his or her own way
of life as the most
desirable, acceptable, or
best, and to act in a
superior manner toward
another culture.
Cultural imposition is
a person’s tendency to
impose his or her own
beliefs, values, and
patterns of behavior on
individuals from another
culture.
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Leininger’s Theory of Culture Care
Diversity and Universality
Describes, explains, and projects nursing
similarities and differences focused primarily
on human care and caring in human cultures.
Uses world view, social structure, language,
ethnohistory, environmental context, and the
generic or folk and professional systems to
provide a comprehensive and holistic view of
influences in cultural care and well-being.
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Leininger’s Sunrise
Model depicting the
theory of cultural
care diversity and
universality
Figure 13-1
From Leininger MM: Culture, care,
diversity, and universality: a theory of
nursing, New York, 1991, National
League for Nursing Press.
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Overview of Culture
Culture refers to the complex whole, including
knowledge, beliefs, art, morals, law, customs,
and any other capabilities and habits
acquired by virtue of the fact that one is a
member of a particular society (Tylor, 1871).
Culture represents a person’s way of
perceiving, evaluating, and behaving within
his or her world, and it provides the blueprint
for determining his or her values, beliefs, and
practices.
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Overview of Culture (Cont.)
Four basic characteristics of culture—it is:
1. Learned from birth through the processes of
language acquisition and socialization
2. Shared by members of the same cultural
group
3. Adapted to specific conditions related to
environmental and technical factors and to
the availability of natural resources
4. Dynamic
– Sir Edward Tylor, 1871
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Subculture
A fairly large aggregate of people who share
characteristics that are not common to all
members of the culture
Enables them to be a distinguishable
subgroup
May be based on ethnicity, religions,
occupation, health-related characteristics,
age, gender, sexual preferences, or
geographic location
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Culture and Formation of Values
Common human problems related to values and
norms:
➢
➢
➢
➢
➢
What is the character of innate human nature (human nature
orientation)?
What is the relationship of the human to nature (personnature orientation)?
What is the temporal focus of human life (time orientation)?
What is the mode of human activity (activity orientation)?
What is the mode of human relationships (social
orientation)?
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Human-Nature Orientation
Innate human nature may be good, evil, or a
combination of good and evil.
The dominant U.S. cultural group chooses to
believe the best about a person until that
person proves otherwise.
– Kohls (1984)
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Person-Nature Orientation
Destiny, in which people are
subjugated to nature in a
fatalistic, inevitable manner.
Harmony, in which people and
nature exist together as a single
entity.
Mastery, in which people are
intended to overcome natural
forces and put them to use for the
benefit of humankind.
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Time Orientation
The focus may be on the past, with traditions
and ancestors playing an important role in the
client’s life.
The focus may be on the present, with little
attention paid to the past or the future.
The focus may be on the future, with progress
and change highly valued.
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Activity Orientation
Being, in which a spontaneous
expression of impulses and desires is
largely nondevelopmental in nature.
Growing, in which the person is selfcontained and has inner control,
including the ability to self-actualize.
Doing, in which the person actively
strives to achieve and accomplish
something that is regarded highly.
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Social Orientation
Lineal relationships: Exist by virtue
of heredity and kinship ties. Follow an
ordered succession and have
continuity through time.
Collateral relationships: Focus
primarily on group goals—and family
orientation is important.
Individual relationships: Personal
autonomy and independence
dominate; group goals become
secondary.
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Culture and the Family
Cross-cultural differences may exist in:
➢
Structural differences
➢ Functional diversity
➢ Socialization context
➢ Sex roles and parenting values
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Culture and Socioeconomic Factors
Socioeconomic status (SES) is a composite
of the economic status of a family or
unrelated individuals based on:
➢
Income
➢ Wealth
➢ Occupation
➢ Educational attainment
➢ Power
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Culture and Socioeconomic Factors
(Cont.)
Poverty guidelines
➢
Determined by comparing pretax cash income
with the poverty threshold adjusted for family size
and composition issued annually by USDHHS.
➢ The U.S. Census Bureau (2012) reported that the
poverty rate in 2011 was 15%
• African American population—27.6%
• Asian population—12.3%
• Hispanic population—25.3%
• Children under 6 years—24.5%
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Culture and Socioeconomic Factors
(Cont.)
Distribution of resources
➢
Upper, middle, and lower classes
• Total family income, occupation, and educational level
• Age, sex, material possessions, health status, family
name, location of residence, family composition, amount
of land owned, religion, race, and ethnicity
➢
➢
A disproportionate number of individuals from the
racially and ethnically diverse subgroups are
members of the lower socioeconomic class
Outcome of social stratification is social inequality
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Culture and Socioeconomic Factors
(Cont.)
Education
➢
➢
Perhaps the single most important factor in SES.
Child’s educational development affected more by
differences in levels of formal schooling than by
cultural differences or economic indices.
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Culture and Nutrition
Culturally competent nutrition assessment:
➢
➢
➢
➢
➢
➢
Cultural definition of food
Frequency and number of meals eaten away from home
Form and content of ceremonial meals
Amount and types of food eaten
Regularity of food consumption
Social contacts during meals
Beware of cultural stereotyping.
Cultural food preferences are often interrelated with
religious dietary beliefs and practices.
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Culture and Religion
Culturally competent nursing care and religious
factors:
➢
➢
Gain a general understanding of religious calendars.
• Know the customary days of religious worship.
• Learn about special days of observance or celebration.
Ask clients what religious practices they follow.
Religious beliefs may influence a client’s belief about
the cause of illness, perception of its severity, choice
of healer, and source of consolation.
Assess spiritual needs of clients.
Know the difference between religion and spirituality.
Remember that various religions have shared beliefs.
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Culture and Aging
Different cultures view older adults
in very different ways.
Tasks of older adults
➢
➢
To achieve a sense of integrity in accepting
responsibility for their own lives
To have a sense of accomplishment
Older adults develop their own means of
coping with illness through self-care,
assistance from others, and social support
groups.
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33
Cross-Cultural (Intercultural)
Communication …
… between a nurse and client attempts to
understand the other’s point of view from a
cultural perspective.
➢
Nurse-client relationship
➢ Space, distance, and intimacy
➢ Overcoming communication barriers
➢ Nonverbal communication
➢ Language
➢ Touch
➢ Gender
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Health-Related Beliefs and Practices
Understand personal culturally based values,
beliefs, attitudes, and practices.
Include the client’s beliefs about the cause of
illness:
➢
➢
➢
Biomedical perspective
Naturalistic perspective
Magicoreligious perspective
Understand the role and value of folk or
religious healers.
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Health-Related Beliefs and Practices
(Cont.)
Cultural variations exist in how symptoms and
disease conditions are perceived, diagnosed,
labeled, and treated.
Expression of pain is culturally determined.
Some conditions are culturally defined—a
culture-bound syndrome.
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Management of Health Problems:
A Cultural Perspective
First effort at treatment is often self-care.
➢
➢
Mobilizes client’s social support network
Provides a caring environment
Cultural negotiation is used when conceptual
differences exist between client and nurse.
➢
Same words but different meanings
➢ Same phenomenon; different notions of causation
➢ Different memories or emotions associated with
the term and its use
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Cornerstones of Public Health
Nursing
Focus on health of entire population
Reflect communities’ priorities and needs
Establish caring relationships
Remain grounded in social justice
Provide care for the whole person
Promote health based on epidemiological
evidence (evidence-based practice)
Collaborate with community resources
– Keller, Strohschein, & Schaffer, 2011
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Management of Health Problems in
Culturally Diverse Populations
Providing health information and education
Delivering and financing health services
Developing health professionals from minority
groups
Enhancing cooperative efforts with the
nonfederal sector
Promoting a research agenda on minority
health issues
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Providing Health Information and
Education
Developing programs to increase public
awareness about health problems.
➢
Plan health information campaigns:
• Be sensitive to cultural factors.
• Involve community leaders.
• Acknowledge existing cultural beliefs and practices.
• Involve families, churches, employers, and community
organizations as support systems.
• Use lay volunteers to organize community support
networks.
➢
Client education should be interpersonal; carefully
use credible printed materials and audiovisuals.
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Role of the Community Health Nurse
Conduct a “culturological” assessment.
Conduct a cultural self-assessment.
Seek knowledge about local cultures.
Recognize political issues of culturally diverse
groups.
Provide culturally competent care.
Recognize culturally based health problems.
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Culturological Assessment
Brief history of ethnic and racial origins of the
cultural group with which the client identifies
Values orientation
Cultural sanctions and restrictions
Communication
Health-related beliefs and practices
Nutrition
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Culturological Assessment (Cont.)
Socioeconomic considerations
Organizations providing cultural support
Educational background
Religious affiliation
Cultural aspects of disease incidence
Biocultural variations
Developmental considerations
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43
Resources for Minority Health
U.S. Department of Health and Human
Services and Public Health Service
➢
Office of Minority Health
• Disadvantaged Minority Health Improvement Act of 1990
➢ Indian Health Service
• Indian Self-Determination Act of 1975
National Institutes of Health
➢
National Center on Minority Health and Health
Disparities (NCMHD)
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Federally Sponsored Initiatives to
Improve Health of Minority Groups
HRSA Health Disparity Collaboratives (HDC)
Racial and Ethnic Approaches to Community
Health (REACH 2010)
National Breast and Cervical Cancer Early
Detection Program (NBCCEDP)
Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act B
National Center on Minority Health and
Health Disparities (NCMHD)
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45
Chapter 14
Environmental Health
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Environmental Health Is …
… all the physical, chemical, and biological
factors external to a person and all the
related factors impacting behaviors.
… encompasses the assessment and control
of those environmental factors that can
potentially affect health.
… targeted toward preventing disease and
creating health-supportive environments.
– WHO (2013)
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Environmental Health
The purpose of environmental health is to
ensure the conditions of human health and
provide healthy environments for people to
live, work, and play.
Accomplished through…
➢
➢
➢
Risk assessment
Prevention
Intervention
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3
Using a Critical Theory Approach
Uses “thinking upstream” framework.
Raises questions about oppressive situations.
Involves community members in the definition
and solution of problems.
Facilitates interventions that reduce healthdamaging effects of environments.
Asks critical questions about clients’ work and
home environments to help discern the
contributions of specific hazards to health.
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4
Benefits of an Environmental Health
History
Increased awareness of environmental/
occupational factors
Improved timelines and accuracy of diagnosis
Prevents disease and aggravation of
conditions
Identifies potential work-related
environmental hazards and/or environmental
hazards in and around clients’ homes
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5
I PREPARE
Environmental Exposure History
●
●
●
●
●
●
●
●
I – Investigate potential exposures
P – Present work
R – Residence
E – Environmental concerns
P – Past work
A – Activities
R – Referrals and Resources
E – Educate
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6
Figure 14-1
From U.S. Department of Health and Human Services: Healthy People 2010, ed 2,
Washington, DC, U.S. Government Printing Office, 2000.
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Areas of Environmental Health
Built environment
Work-related
exposures
Outdoor air quality
Healthy homes
Water quality
Food, safety, and
waste management
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8
Built Environment
The connection between
people, communities,
and their surrounding
environments that
affects health behaviors
and habits,
interpersonal
relationships, cultural
values, and customs
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9
Built Environment: Examples
Drunk driving
Second-hand smoke
Noise exposure
Urban crowding
Technological hazards
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10
Work-Related Exposure
Poor working conditions that result in
potential injury or illness
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11
Work-Related Exposure: Examples
Asbestosis
Asthma
Lung cancer
Agricultural accidents
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12
Outdoor Air Quality
The purity of the air
and the presence of
air pollution
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13
Outdoor Air Quality: Examples
Gaseous pollutants
Greenhouse effect
Destruction of the
ozone layer
Aerial spraying of
herbicides and
pesticides
Acid rain
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14
Healthy Home
The availability, safety, structural strength,
cleanliness, and location of shelter, and
indoor air quality
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15
Healthy Home: Examples
Homelessness
Rodent and insect infestation
Poisoning from lead-based paint
Sick building syndrome
Unsafe neighborhoods
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Water Quality
The availability, volume,
mineral content levels,
toxic chemical pollution,
and pathogenic
microorganism levels
The balance between
water contaminants and
existing capabilities to
purify water for human use
and plant and wildlife
sustenance
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17
Water Quality: Examples
Contamination of drinking supply
by human waste
Oil spills in the world’s
waterways
Pesticide or herbicide infiltration
of ground water
Aquifer contamination by
industrial pollutants
Heavy metal poisoning of fish
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18
Food Safety
Availability,
accessibility, and
relative costs of healthy
food free from
contamination of
harmful herbicides,
pesticides, and
bacteria
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Food Safety: Examples
Malnutrition
Bacterial food
poisoning
Food adulteration
Disrupted food chains
by ecosystem
destruction
Carcinogenic chemical
food additives
FDA food safety campaign:
http://www.fightbac.org/safe-food-handling
http://www.foodsafety.gov/
Figure 14-5
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20
Waste Management
The handling of waste
materials resulting from
industry, municipal
processes, and human
consumption as well as
efforts to minimize waste
production
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Waste Management: Examples
Use of nonbiodegradable
plastics
Poorly designed solid waste
dumps
Inadequate sewage systems
Transport and storage of
hazardous waste
Illegal industrial dumping
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22
Waste Management: Examples
(Cont.)
Nuclear facility emissions
Radioactive hazardous wastes
Radon gas seepage in homes
and schools
Nuclear testing
Excessive exposure to x-rays
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23
Effects of Environmental Hazards
Figure 14-6 From Environmental Protection Agency: Air Pollution and Health Risk.
http://www.epa.gov/ttnatw01/3_90_022.html. Retrieved March 27, 2013.
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24
Emerging Issues in Environmental
Health
Environmental public health infrastructure
Natural disasters
Global climate change
Ozone depletion
Fossil fuel burning
Marine dumping
Active land mine abandonment in war-torn
areas
Destruction of tropical rain forests
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25
Critical Community Health Nursing
Practice
Approach environmental health at the
population level
Take a stand; advocate for change
Ask critical questions
Facilitate community involvement
Form coalitions
Using collective strategies
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26
Chapter 4
Health Promotion and Risk Reduction
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Health Promotion Is…
…any combination of health education and
related organizational, economic, and
environmental supports for behavior of
individuals, groups, or communities
conducive to health (Green & Kreuter, 1991)
…that which is motivated by the desire to
increase well-being and to reach the best
possible health potential (Parse, 1990)
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2
Health Protection Is …(Cont.)
… those behaviors in which one engages
with the specific intent to prevent disease,
detect disease in the early stages, or
maximize health within the constraints of
disease (Parse, 1990)
… an important step in maintaining health
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3
Defining Health
The way health is defined has shifted from a
focus on the curative model, to a focus on
multidimensional aspects such as the social,
cultural, and environmental facets of life and
health (Benson, 1996)
Health is viewed not only as an important
goal, but as a resource for living (WHO, 1986)
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4
Healthy People 2020 …
… is the health promotion initiative for the
nation.
… challenges individuals, communities, and
professionals … to take specific steps to
ensure that good health, as well as long life,
are enjoyed by all.
– U.S. Department of Health and
Human Services, 2012
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5
Healthy People 2020 …
(Cont.)
Broad goals
➢
➢
➢
➢
Attain high-quality, longer lives free of preventable
disease, disability, injury, and premature death.
Achieve high equity, eliminate disparities, and
improve the health of all groups.
Create social and physical environments that
promote good health for all.
Promote quality of life, healthy development, and
healthy behaviors across all life stages.
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6
Determinants of Health
Biology
Behaviors
Social environment
Physical environment
Policies and
interventions
Access to high-quality
health care
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7
Figure 4-1
From U.S. Department of Health
and Human Services.
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8
Theories in Health Promotion
Pender’s Health Promotion Model (HPM)
Health Belief Model (HBM)
Transtheoretical Model (TTM)
Theory of Reasoned Action (TRA)
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9
Risk and Health
Risk is “the probability that a specific event
will occur in a given time frame” (Oleckno,
2002).
A risk factor is an exposure that is associated
with a disease (Friis & Sellers, 2004).
Risk Assessment is a systematic way of
distinguishing the risks posed by potentially
harmful exposures.
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10
Steps in Risk Assessment
Hazard identification
Risk description
Exposure assessment
Risk estimation
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11
Risk Assessment
Modifiable risks
➢
➢
Individual has control
Examples: smoking, lifestyle,
eating habits, activities
Nonmodifiable risks
➢
➢
Individual has little or no control
Examples: genetics, gender,
age, environmental exposure
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12
Risk Reduction …
➢
➢
… is a proactive process
… enables individuals to react to
actual or potential threats to their
health
Risk communication …
➢
➢
… is the process of informing the
public regarding threats
… is affected by perceptions,
process, and actions
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13
Tobacco and Health Risk
Leading cause of preventable death
Most common in less educated populations
and those living below poverty level
Most common form of chemical dependency
Tobacco in all forms is harmful.
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14
Health Promotion Activities
Look for teachable moments
Assess client’s tobacco use
Explore willingness to quit
Refer to cessation programs
Encourage attempts to quit
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15
Alcohol Consumption and Health
Third leading lifestyle-related
cause of death for the nation
Short-term use causes acute
risks
Long-term effects have major
impact on health and social
issues
Influenced by legal drinking age
➢
# 1 used and abused drug among
U.S. youth
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16
Health Promotion Activities (Cont.)
Prevent underage drinking
Assist with enforcement of legal drinking age
Identify individuals and groups at risk of
abuse and dependence
Educate adults and youth on dangers of
alcohol
Requires a community-wide effort to address
the problem on several fronts
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17
Diet and Health
Diet—one of most modifiable risk
factors
Imbalance of caloric intake and
physical activity
Complex interplay among
metabolism, genetics, behavior,
environment, culture, and
socioeconomic status
Geographic areas, age, ethnicity all
influence weight
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18
Health Promotion Activities (Cont.)
Special populations have different nutritional
needs
For individualized plans, see
http://myplate.gov/
Educate clients about:
➢
Balancing caloric intake and physical activity
➢ Servings vs. portion control
➢ Eating away from home affects “portion distortion”
➢ Using social media and mobile applications to help
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19
Physical Activity and Health
Physical activity serves both
health promotion and
disease prevention
purposes
Leisure activities are
influenced by level of
education, gender, age,
economic level, geography
One’s environment plays a
significant role in activity
level
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20
Health Promotion Activities (Cont.)
Support and develop
“walkable” neighborhoods and
cities
Determine recommended
exercise levels for individuals
Visit
http://www.cdc.gov/physicalacti
vity/data/facts.html
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21
Sleep and Health
Sleep is an essential component of
chronic disease prevention and
health promotion
Requirements change with age and
life circumstances
Regulated by waking time and
circadian rhythms
Hormones during sleep affect
memory, blood pressure, and kidney
function.
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22
Health Promotion Activities (Cont.)
Sleep assessment is important
➢
➢
Identify disorders that may affect
daily activities
Keep sleep log
Practice sleep hygiene
➢
➢
Establish environment that
promotes sleep
Avoid food and activities that
interfere with sleep
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23
Chapter 13
Cultural Diversity and Community Health
Nursing
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Cultural Competence
Cultural competence is respecting and
understanding the values and beliefs of a certain
cultural group so that one can function effectively in
caring for members of that cultural group.
Culturally competent community health nursing
requires that the nurse understand…
➢
➢
➢
Lifestyle
Value system
Health and illness behaviors of diverse individuals, families,
groups, and communities
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2
Standards of Practice for Culturally
Competent Nursing Care
1.
2.
3.
4.
Social Justice
Critical Reflection
Knowledge of Cultures
Culturally Competent
Practice
5. Cultural Competence in
Health Care Systems
and Organizations
6. Patient Advocacy and
Empowerment
7. Multicultural Workforce
8. Education and Training
in Culturally
Competent Care
9. Cross-Cultural
Communication
10. Cross-Cultural
Leadership
11. Policy Development
12. Evidence-Based
Practice and Research
From: Expert Panel on Global
Nursing and Health (2010)
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3
Population Trends
In 1970
➢
By 2010
➢
Minority groups increased to 36% of population
By 2025
➢
Minority groups were 16% of population
More than half of all children will be minorities
By 2050
➢
➢
More than 54% of total population will be minorities
First time in U.S. history that minorities will make up a
majority of the population
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4
Population Trends (Cont.)
By 2060, projected demographic trends:
➢
White 44%
➢ Hispanic 30%
➢ African American 15%
➢ Asian 9%
➢ American Indians & Alaska Natives 2%
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5
Immigration to the United States
Since 1991, more than 13 million legal
immigrants
In 2010, almost 40 million foreign-born
individuals in the United States (12.9% of
population) from:
➢
➢
➢
➢
Latin America 53.1%
Asia 28.2%
Europe 12.1%
Other regions 9%
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6
Diversity Among Nurses
Minorities are generally
underrepresented by nursing workforce
(HRSA, 2009):
➢
➢
➢
➢
➢
White/non-Hispanic 81.8%
African American 4.2%
Hispanic 1.7%
Asian and Pacific Islander 3.1%
Native American and Alaska Native 0.3%
Minority groups tend to be geographically
distributed in the United States.
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7
Cultural Perspectives and Healthy
People 2020
Developed a set of national health
targets…eliminating racial and ethnic
disparities in health
Embraced and focused on ways to
close the gaps in health outcomes
Focused on disparities among racial
and ethnic minorities, women, youth,
older adults, people of low income and
education, and people with disabilities
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8
Health Disparities
AHCRQ (2005) reveals that:
Cancer mortality rates are 35% higher in
African Americans than in whites.
African Americans with diabetes are seven
times more likely to have amputations and
develop renal failure than are whites with
diabetes.
30% of Hispanics and 20% of African
Americans lack a usual source of health care
(compared with less than 16% of whites).
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
9
Health Disparities (Cont.)
AHCRQ (2005) reveals that:
Hispanic children are nearly three times as
likely as non-Hispanic white children to have
no usual source of health care.
African Americans (16%) and Hispanic
Americans (13%) are more likely to rely on
hospitals or clinics for health care than are
whites (8%).
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10
Addressing Racial and Ethnic
Disparities in Health Care
Disparities can be reduced or
eliminated when adults have:
➢
➢
Health insurance and
A medical home
– Commonwealth Fund, 2007
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11
Transcultural Nursing
“…a formal area of study and practice
focused on a comparative analysis of different
cultures and subcultures in the world with
respect to cultural care, health and illness
beliefs, values, and practices with the goal of
using this knowledge to provide culturespecific and culture-universal nursing care to
people.”
– Leininger (1978)
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12
Transcultural Nursing Terminology
Culture specific refers to the
“particularistic values, beliefs,
and patterning of behavior
that tend to be special, ‘local,’
or unique to a designated
culture and which do not tend
to be shared with members of
other cultures”
– Leininger (1991)
Culture universal refers to
the “commonalties of values,
norms of behavior, and life
patterns that are similarly
held among cultures about
human behavior and
lifestyles and form the bases
for formulating theories for
developing cross-cultural
laws of human behavior”
– Leininger (1978)
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13
Transcultural Nursing Terminology
(Cont.)
Ethnocentrism is a
person’s tendency to
view his or her own way
of life as the most
desirable, acceptable, or
best, and to act in a
superior manner toward
another culture.
Cultural imposition is
a person’s tendency to
impose his or her own
beliefs, values, and
patterns of behavior on
individuals from another
culture.
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14
Leininger’s Theory of Culture Care
Diversity and Universality
Describes, explains, and projects nursing
similarities and differences focused primarily
on human care and caring in human cultures.
Uses world view, social structure, language,
ethnohistory, environmental context, and the
generic or folk and professional systems to
provide a comprehensive and holistic view of
influences in cultural care and well-being.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
15
Leininger’s Sunrise
Model depicting the
theory of cultural
care diversity and
universality
Figure 13-1
From Leininger MM: Culture, care,
diversity, and universality: a theory of
nursing, New York, 1991, National
League for Nursing Press.
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16
Overview of Culture
Culture refers to the complex whole, including
knowledge, beliefs, art, morals, law, customs,
and any other capabilities and habits
acquired by virtue of the fact that one is a
member of a particular society (Tylor, 1871).
Culture represents a person’s way of
perceiving, evaluating, and behaving within
his or her world, and it provides the blueprint
for determining his or her values, beliefs, and
practices.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
17
Overview of Culture (Cont.)
Four basic characteristics of culture—it is:
1. Learned from birth through the processes of
language acquisition and socialization
2. Shared by members of the same cultural
group
3. Adapted to specific conditions related to
environmental and technical factors and to
the availability of natural resources
4. Dynamic
– Sir Edward Tylor, 1871
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18
Subculture
A fairly large aggregate of people who share
characteristics that are not common to all
members of the culture
Enables them to be a distinguishable
subgroup
May be based on ethnicity, religions,
occupation, health-related characteristics,
age, gender, sexual preferences, or
geographic location
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19
Culture and Formation of Values
Common human problems related to values and
norms:
➢
➢
➢
➢
➢
What is the character of innate human nature (human nature
orientation)?
What is the relationship of the human to nature (personnature orientation)?
What is the temporal focus of human life (time orientation)?
What is the mode of human activity (activity orientation)?
What is the mode of human relationships (social
orientation)?
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20
Human-Nature Orientation
Innate human nature may be good, evil, or a
combination of good and evil.
The dominant U.S. cultural group chooses to
believe the best about a person until that
person proves otherwise.
– Kohls (1984)
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21
Person-Nature Orientation
Destiny, in which people are
subjugated to nature in a
fatalistic, inevitable manner.
Harmony, in which people and
nature exist together as a single
entity.
Mastery, in which people are
intended to overcome natural
forces and put them to use for the
benefit of humankind.
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22
Time Orientation
The focus may be on the past, with traditions
and ancestors playing an important role in the
client’s life.
The focus may be on the present, with little
attention paid to the past or the future.
The focus may be on the future, with progress
and change highly valued.
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23
Activity Orientation
Being, in which a spontaneous
expression of impulses and desires is
largely nondevelopmental in nature.
Growing, in which the person is selfcontained and has inner control,
including the ability to self-actualize.
Doing, in which the person actively
strives to achieve and accomplish
something that is regarded highly.
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24
Social Orientation
Lineal relationships: Exist by virtue
of heredity and kinship ties. Follow an
ordered succession and have
continuity through time.
Collateral relationships: Focus
primarily on group goals—and family
orientation is important.
Individual relationships: Personal
autonomy and independence
dominate; group goals become
secondary.
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25
Culture and the Family
Cross-cultural differences may exist in:
➢
Structural differences
➢ Functional diversity
➢ Socialization context
➢ Sex roles and parenting values
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26
Culture and Socioeconomic Factors
Socioeconomic status (SES) is a composite
of the economic status of a family or
unrelated individuals based on:
➢
Income
➢ Wealth
➢ Occupation
➢ Educational attainment
➢ Power
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
27
Culture and Socioeconomic Factors
(Cont.)
Poverty guidelines
➢
Determined by comparing pretax cash income
with the poverty threshold adjusted for family size
and composition issued annually by USDHHS.
➢ The U.S. Census Bureau (2012) reported that the
poverty rate in 2011 was 15%
• African American population—27.6%
• Asian population—12.3%
• Hispanic population—25.3%
• Children under 6 years—24.5%
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28
Culture and Socioeconomic Factors
(Cont.)
Distribution of resources
➢
Upper, middle, and lower classes
• Total family income, occupation, and educational level
• Age, sex, material possessions, health status, family
name, location of residence, family composition, amount
of land owned, religion, race, and ethnicity
➢
➢
A disproportionate number of individuals from the
racially and ethnically diverse subgroups are
members of the lower socioeconomic class
Outcome of social stratification is social inequality
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
29
Culture and Socioeconomic Factors
(Cont.)
Education
➢
➢
Perhaps the single most important factor in SES.
Child’s educational development affected more by
differences in levels of formal schooling than by
cultural differences or economic indices.
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30
Culture and Nutrition
Culturally competent nutrition assessment:
➢
➢
➢
➢
➢
➢
Cultural definition of food
Frequency and number of meals eaten away from home
Form and content of ceremonial meals
Amount and types of food eaten
Regularity of food consumption
Social contacts during meals
Beware of cultural stereotyping.
Cultural food preferences are often interrelated with
religious dietary beliefs and practices.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
31
Culture and Religion
Culturally competent nursing care and religious
factors:
➢
➢
Gain a general understanding of religious calendars.
• Know the customary days of religious worship.
• Learn about special days of observance or celebration.
Ask clients what religious practices they follow.
Religious beliefs may influence a client’s belief about
the cause of illness, perception of its severity, choice
of healer, and source of consolation.
Assess spiritual needs of clients.
Know the difference between religion and spirituality.
Remember that various religions have shared beliefs.
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32
Culture and Aging
Different cultures view older adults
in very different ways.
Tasks of older adults
➢
➢
To achieve a sense of integrity in accepting
responsibility for their own lives
To have a sense of accomplishment
Older adults develop their own means of
coping with illness through self-care,
assistance from others, and social support
groups.
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33
Cross-Cultural (Intercultural)
Communication …
… between a nurse and client attempts to
understand the other’s point of view from a
cultural perspective.
➢
Nurse-client relationship
➢ Space, distance, and intimacy
➢ Overcoming communication barriers
➢ Nonverbal communication
➢ Language
➢ Touch
➢ Gender
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34
Health-Related Beliefs and Practices
Understand personal culturally based values,
beliefs, attitudes, and practices.
Include the client’s beliefs about the cause of
illness:
➢
➢
➢
Biomedical perspective
Naturalistic perspective
Magicoreligious perspective
Understand the role and value of folk or
religious healers.
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35
Health-Related Beliefs and Practices
(Cont.)
Cultural variations exist in how symptoms and
disease conditions are perceived, diagnosed,
labeled, and treated.
Expression of pain is culturally determined.
Some conditions are culturally defined—a
culture-bound syndrome.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
36
Management of Health Problems:
A Cultural Perspective
First effort at treatment is often self-care.
➢
➢
Mobilizes client’s social support network
Provides a caring environment
Cultural negotiation is used when conceptual
differences exist between client and nurse.
➢
Same words but different meanings
➢ Same phenomenon; different notions of causation
➢ Different memories or emotions associated with
the term and its use
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37
Cornerstones of Public Health
Nursing
Focus on health of entire population
Reflect communities’ priorities and needs
Establish caring relationships
Remain grounded in social justice
Provide care for the whole person
Promote health based on epidemiological
evidence (evidence-based practice)
Collaborate with community resources
– Keller, Strohschein, & Schaffer, 2011
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38
Management of Health Problems in
Culturally Diverse Populations
Providing health information and education
Delivering and financing health services
Developing health professionals from minority
groups
Enhancing cooperative efforts with the
nonfederal sector
Promoting a research agenda on minority
health issues
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
39
Providing Health Information and
Education
Developing programs to increase public
awareness about health problems.
➢
Plan health information campaigns:
• Be sensitive to cultural factors.
• Involve community leaders.
• Acknowledge existing cultural beliefs and practices.
• Involve families, churches, employers, and community
organizations as support systems.
• Use lay volunteers to organize community support
networks.
➢
Client education should be interpersonal; carefully
use credible printed materials and audiovisuals.
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40
Role of the Community Health Nurse
Conduct a “culturological” assessment.
Conduct a cultural self-assessment.
Seek knowledge about local cultures.
Recognize political issues of culturally diverse
groups.
Provide culturally competent care.
Recognize culturally based health problems.
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41
Culturological Assessment
Brief history of ethnic and racial origins of the
cultural group with which the client identifies
Values orientation
Cultural sanctions and restrictions
Communication
Health-related beliefs and practices
Nutrition
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42
Culturological Assessment (Cont.)
Socioeconomic considerations
Organizations providing cultural support
Educational background
Religious affiliation
Cultural aspects of disease incidence
Biocultural variations
Developmental considerations
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
43
Resources for Minority Health
U.S. Department of Health and Human
Services and Public Health Service
➢
Office of Minority Health
• Disadvantaged Minority Health Improvement Act of 1990
➢ Indian Health Service
• Indian Self-Determination Act of 1975
National Institutes of Health
➢
National Center on Minority Health and Health
Disparities (NCMHD)
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44
Federally Sponsored Initiatives to
Improve Health of Minority Groups
HRSA Health Disparity Collaboratives (HDC)
Racial and Ethnic Approaches to Community
Health (REACH 2010)
National Breast and Cervical Cancer Early
Detection Program (NBCCEDP)
Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act B
National Center on Minority Health and
Health Disparities (NCMHD)
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45
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