Culture, Family, and Community

Margaret M. Andrews and Joyceen S. Boyle

An understanding of culture and cultural concepts enhances the nurse’s knowledge and facilitates culturally competent nursing care in community-based settings. Currently, many nurses practice in community settings with clients from a wide variety of cultural backgrounds, and this trend is expected to increase with more nurses moving from acute care institutions to community settings. The care of clients in the community can be extremely complex, calling for a high level of nursing skill. In addition, it is predicted that cultural diversity will increase in the United States. Trends in the health care delivery system as well as an increased emphasis on health promotion and disease prevention have influenced nurses to make changes in their practice as well as the setting in which care is delivered. Concepts such as partnership, collaboration, empowerment, and facilitation now form the basis for community-based nursing practice with individuals, families, and aggregates in the community. For some time, national nursing associations, including the National Institute of Nursing Research (NINR), have urged a community focus in both nursing research and practice. For example, NINR defines community- based services as those services requiring “active involvement of clients and communities in assessing the needs for care, designing service programs, implementing interventions, and evaluating outcomes” (NINR, 1995, p. 2).

Although it is possible to provide community-based nursing services to individuals and families in communities as well as to provide community-oriented nursing care to either the community or groups within the community, for culturally competent care to be provided, clients and populations must be involved in all aspects of the care or services. Indeed, it is this focus—involving clients in planning for and providing nursing services that is the foundation of culturally competent care.

Specialized community interventions that are culturally relevant to the people served are built on collaboration and partnerships between community leaders, health consumers, and health care providers. When community residents or health consumers are involved as partners, community-based services are more likely to be responsive to locally defined needs, are better used, and are sustained through local action. The NINR has stated that “until recently…research tended primarily to address the needs of the majority population, with little examination of cultural or gender-based influences on disease incidence or health outcomes often seen among diverse communities” (NINR, Specialized Community Interventions, p. 1, September 2007).

Specialized community interventions are complex and often fragile. They require a high level of nursing knowledge and skill in working with and relating to different individuals and groups. In many instances, the complexity is increased when clients and their families come from diverse cultures. Nurses must understand how to help persons from various cultures work with community leaders and health care providers to form partnerships that are responsive and can structure nursing care in ways that are culturally sensitive and appropriate. It is often the cultural factors that determine whether a particular population or group will choose to participate in community-based health services. There is always a need for continuing communication among health care providers and community residents that is characterized by mutual understanding and respect. It is this understanding and respect that forms the basis for culturally relevant and competent nursing care.

In this chapter, the terms community nursing, community-based nursing, and community health nursing are used interchangeably, even though they have different meanings in some settings and in different contexts (Clark, 2008). Whether the nurse is employed as a community health nurse in a health department or practices in a community-based setting, he or she needs the knowledge and skills to provide culturally competent care. The practice of nursing in a community setting requires that nurses be comfortable with clients from diverse cultures and the broader socioeconomic context in which they live. As the U.S. population continues to grow in diversity, health disparities have become more apparent in diverse populations and are now a vital area of focus for researchers and practitioners alike. Care that is not congruent with the client’s value system is likely to increase the cost of care because it compromises quality and inhibits access to services. Furthermore, members of diverse cultural groups, such as the officially designated minority groups in the United States, tend to experience greater health disparities than do members of the general population. This was the impetus for targeting the four ethnic minority groups in Healthy People 2000 (U.S. Department of Health and Human Services, 1990) and Healthy People 2010 (U.S. Department of Health and Human Services, 2000) because cultural diversity must be respected and taken into account by health care professionals. Equally important, we must address the stark disparities that exist in health status between minority groups and the wider American society.

Overview of Culturally Competent Nursing Care in Community Settings

Nurses practice in many settings within the community, including work sites, schools, physicians’ offices, health care program sites, churches, and the community itself .

The use of cultural knowledge in community-based nursing practice begins with a careful assessment of clients and families in their own environments. Cultural data that have implications for nursing care are selected from clients, families, and the environment during the assessment phase and are discussed with the client and family to develop mutually shared goals.

Community nurses are particularly challenged when they frequently encounter clients and families who must change behaviors and living patterns to maintain health or promote wellness. Nursing interventions based on cultural knowledge help clients and families to adjust more easily and assist nurses to work effectively and comfortably with all clients, especially those from different cultural backgrounds. Cultural data are important in the care of all clients; however, in community nursing, they are a prerequisite to successful nursing interventions.

Community nursing is practiced in a community setting, often in the home of the client, and frequently requires more active participation by the client and family. Usually, the client and family must make basic changes in lifestyle, such as changes in diet and exercise patterns. Cultural competence requires that the nurse understand the family lifestyle and value system, as well as those cultural forces that are powerful determinants of health-related behaviors. Nurses often work closely with clients with chronic diseases or those who have other health problems and nursing interventions must include aspects of counseling and education as well as anticipatory guidance directed toward helping clients and families adjust to what may be lifelong conditions. Nursing care must take account of the diverse cultural factors that will motivate clients to make successful changes in behavior because improvement in health status requires lifestyle and behavioral modifications.

Transcultural nursing practice has the potential to improve the health of the community as well as the health of individual clients and families. An additional consideration of the nurse who is involved in community focused planning is the health needs of populations at risk.

Special at-risk groups can be found in all communities: the homeless, the poor, persons with HIV/AIDS and/or tuberculosis, refugees, prison populations, and even the elderly are groups at risk for decreased health status. From a community standpoint, an understanding of culture and cultural concepts will increase the skill and abilities of the nurse to work with diverse groups within the community. Identification of high-risk groups and appropriate community-based strategies to reduce health risks requires considerable knowledge about cultural and ethnic groups and their place in the community.

Consider if you will, what problems might arise if one were to design a health program for a community composed primarily of Somali refugees who recently arrived in the United States. They may have spent years in refugee camps in other countries and lost many family members, or their family members may be still in Somalia and they are now making a life for themselves in a strange country.

Certainly language would be a major problem, but so could many other cultural differences, from nuances in communication to differences in beliefs of what constitutes health and illness, as well as treatment and cure. A failure to understand and deal with these differences would have serious implications for the success of any health or nursing intervention. Nurses, who have knowledge of, and an ability to work with, diverse cultures are able to devise effective community interventions to reduce risks that are consistent with the community and group, as well as individual values and beliefs of community members.

A Transcultural Framework

A distinguishing and important aspect of community-based nursing practice is the nursing focus on the community as the client (Nies & McEwen, 2007; Stanhope & Lancaster, 2006). Effective community nursing practice must reflect accurate knowledge of the causes and distribution of health problems and of effective interventions that are congruent with the values and goals of the community. An epidemiologic model can be used by the community nurse to collect, organize, and analyze information about high-risk groups that are encountered in community practice. An epidemiologic model emphasizes human biology, environment, lifestyle, and the health care system; however, with modifications, the nurse can use this model to collect cultural data that influence the health of the community (Clark, 2008). The epidemiologic model focuses on the community or on aggregate groups rather than on individuals or families. Using a cultural overlay with the epidemiologic model enhances nurse– community interactions in numerous ways.

Identifying Subcultures and Devising Specialized Community-Based Intervention s

A transcultural framework for nursing care helps the nurse to identify subcultures within the larger community and to devise community-based interventions that are specific to community health and nursing goals. For example, in the multicultural societies of the United States, it is common to speak of “the Black community,” “the Hispanic community,” or “the Francophone community.” We might also speak more broadly of “the immigrant community” or the “refugee community” or of other unique groups within or near a local community. A cultural focus allows this variety and facilitates data collection about specific groups based on their health risks. A cultural/epidemiologic framework facilitates a view of the community as a complex collective yet allows for diversity within the whole. Interventions that are successful in one subgroup may fail with another subgroup of the same community, and often the failure can be attributed to cultural differences or barriers that arise because of these differences.

Identifying and Analyzing Various Components of the Community

Transcultural concepts often are useful in identifying and analyzing various components of the community, such as social structure and religious and political systems. A cultural approach allows the nurse to identify cultural health care systems, which are made up of individuals who experience illness as well as those who provide care for them. Anderson and McFarlane (2008) suggest that each cultural health care system can have as many as three recognized sectors, most commonly referred to as popular, folk, and professional. We often forget that alternative health systems as well as alternative therapies exist side by side with the professional system. How individuals organize themselves to meet group and individual needs within cultural health care systems is important information for community and transcultural nurses. An assessment of whether social institutions such as churches and schools meet the health, social, and emotional needs of their members, and whether the health and political systems are responsive to the needs of all residents, can sometimes pinpoint critical needs and identify gaps in care. Cultural traditions within a community often determine the structure of community support systems as well as how resources are organized and distributed.

Identifying the Values and Cultural Norms of a Community

A transcultural framework is essential to the community nurse’s identification of the values and cultural norms of a community. Although values are universal features of all cultures, their types and expressions vary widely, even within the same community. Values often serve as the foundation for a community’s acceptance and use of health resources or a group’s participation in community-based intervention programs to promote health and wellness. Just as nurses share data and collaborate with clients and families to establish mutually acceptable goals for nursing care, the community-based nurse works with the community or aggregates within the community to plan community-focused health programs. In addition to forming partnerships with communities, the community nurse considers the influences of social, economic, ecologic, and political issues. Larger policy issues directly and profoundly affect many, if not all, community health issues. These larger policy issues are, in turn, influenced by the wider national and/or international culture. An example of this can be seen in the recent emphasis on bioterrorism, now a focus and concern of local and state health departments as well as at the national level.

Cultural Issues in Community Nursing Practice The need for nurses to be sensitive to clients who are culturally different is increasing as we become more aware of the complex interactions between health care providers and clients and how these interactions might affect the client’s health. Diverse client groups who have limited access to health services, along with barriers resulting from language and cultural differences often suffer a variety of health disparities (NINR, Specialized Community Interventions, September, 2007). The material in this chapter will assist nurses to be aware of cultural factors that affect health, illness, and the practice of nursing in community settings. Several cultural assessment tools or guides are available that provide comprehensive frameworks to guide the nurse in the assessment of cultural factors in the care of individuals, families, and groups.

The Andrews/Boyle Transcultural Nursing Assessment Guides (see Appendices A and B) provide outlines for the nurse to collect and assess cultural data relevant to individuals, families, and communities.

The majority of cultural assessment guides are oriented to individuals and occasionally to families. Only a few have the comprehensive view necessary for assessing cultural factors for intervention at the community level. Because individual clients and their families constitute larger communities, nurses who work in community settings must understand cultural issues as they relate to individuals and families as well as communities. We shall begin with a discussion of cultural influences on individuals and families before moving to a discussion of cultural factors within communities.

Cultural Influences on Individuals and Families Cultural influences —those values, norms, beliefs, and behaviors—have a profound effect on health. When assessing individuals and families, the community health nurse should carefully examine the following:

1. Family roles, typical family households and structure, and dynamics in the family, particularly communication patterns and decision making

2. Health beliefs and practices related to disease causation, treatment of illness, and the use of indigenous healers or folk practitioners and other alternative/complementary therapies

3. Patterns of daily living, including work, school, and leisure activities

4. Social networks, including friends, neighbors, kin, and significant others, and how they influence health and illness

5. Ethnic, cultural, or national identity of client and family, for example, identification with a particular group, including language

6. Nutritional practices and how they relate to cultural factors and health

7. Religious preferences and influences on well-being, health maintenance, and illness, as well as the impact religion might have on daily living and taboos or restrictions arising from religious beliefs that might influence health status or care

8. Culturally appropriate behavior styles, including what is manifested during anger, competition, and cooperation, as well as relationships with health care professionals, relationships between genders, and relations with other groups in the community.

A cultural assessment of individuals and families includes all the preceding factors. This list is by no means exhaustive; rather, it is presented as a guide for community nurses as they assess cultural aspects of individuals and families. Cultural values shape human health behaviors and determine what individuals and families will do to maintain their health status, how they will care for themselves and others who become ill, and where and from whom they will seek health care. Most importantly family members are often the ones who decide on the course of treatment. Families have an important role in the transmission of cultural values and learned behaviors that relate to both health and illness. It is in the familycontext that individuals learn basic ways to stay healthy and to ensure the well-being of themselves and their family members. One commonality shared by members of functioning families is a concern for the health and wellness of each individual within the family because the family has the primary responsibility for meeting the health needs of its members. The nurse not only must assess the health of each family member, but also define how well the family can meet family health needs. Just how well families function in relation to this will determine how, when, and where interventions will take place; by whom; and what the specific approach to the family will be.

A cultural orientation assists the nurse in understanding cultural values and interactions, the roles that family members assume, as well as the support system available to the family to help them when health problems are identified. The family is usually an individual’s most important social unit and provides the social context within which illness occurs and is resolved and within which health promotion and maintenance occur.

Most traditional health beliefs and practices promote the health of the family because they are generally family and socially oriented. Frequently, traditional beliefs and practices reinforce family cohesion. Some values are more central and influential than others; given a competing set of demands, these central values will typically determine a family’s priorities. In families that adhere to traditional cultural values, the families’ (or tribe’s and/or community’s) needs and goals often will take precedence over an individual’s needs and goals.

The culturally competent nurse can recognize and use the family’s role in promoting and maintaining health. This requires an appreciation of the family context in health and illness and how this varies among diverse cultures.

Cultural Factors Within Communities

In addition to identifying and meeting the cultural needs of clients and families, the community health nurse must consider social and cultural factors on a community level to respect cultural values, mobilize local resources, and develop culturally appropriate health programs and services. Important cultural factors include demographics in the United States, with detailed data on specific states and cities; cultural diversity in communities; subpopulations in the United States; refugee and immigrant populations, with special consideration given to newly arrived refugee communities; maintenance of traditional cultural values and practices; and access to health and nursing care for diverse cultural groups.

Demographics and Health Care During the 21st century, the United States and many other countries will face enormous demographic, social, and culture change. North America is becoming more diverse, not less so, and thus it is incumbent on nurses to be prepared to respond appropriately. Since the 1990s and 2000s, there has been a steady growth in cultural diversity in the United States. The health status of individuals in the United States differs dramatically across cultural groups and social classes. Certain population groups in the United States face greater challenges than the general population in accessing timely and needed health care services, and national goals have been adopted in Healthy People 2010 to address these health disparities (U.S. Department of Health and Human Services, 2000). Major indicators such as morbidity and mortality rates for adults and infants show that the health status of minority Americans in the United States is substantially worse than that of White Americans. Health status is worse among those who are medically underserved. Medically underserved populations are defined as those who have inadequate access to quality health care. These include low-literacy, low-income, rural, tribal, isolated and non-English-speaking groups (NINR, Specialized Community Interventions, September 2007). Thus, community nurses must assess groups within the community in a very sensitive manner; often those characteristics that we assume are related to the group’s culture may be caused by other factors instead.

Developing Cultural Competence to Promote Health in Diverse Cultural Groups

• Learn about the history of the cultural group or diverse population with which you are working. For example, an understanding of African American culture would not be complete without considering the effect of slavery on this group of Americans.

• Make an effort to understand the African American cultural values beliefs and ways of life of the community. Read some of the works of noted African American authors such as James Baldwin, Malcolm X, Langston Hughes, Maya Angelou, and so on.

• Incorporate as many of the traditional values, beliefs, and ways of life into the design and use of any educational materials. Whereas Chinese American teenagers might prefer a comic book or video in English, their grandparents might prefer a health magazine or a news article in the Chinese language.

• Become familiar with the appropriate verbal and nonverbal communication patterns within the group as well as many of the communication nuances that are contextual in nature. An example might be that a traditional Afghan woman would never speak to a strange man outside of her own kinship circle.

• Become familiar with beliefs and practices related to religion, gender, food preferences, and other related cultural differences that might lead to the quick success or failure of a health program. Be aware that the most effective health programs are those that foster community ownership and involvement. This implies that they must be planned and implemented with community input.

• Spend as much time as possible within the community, attending local events. Examples might be churches, school programs, fairs, and meetings with leaders. Taking an intervention into the community rather than having the community come to the intervention might be more effective over time.

• Seek the community’s input and feedback for any health program that is planned for the community. Be aware that the use of peer educators, such as promotoras or the Native American community health workers (CHRs) from within the community, have been found to be effective in delivering health promotion programs and other health services to diverse communities.

Cultural Diversity Within Communities

The United States has many diverse cultures as a result of the history of immigration to this country by a variety of cultural and ethnic groups and because of the indigenous populations of Native Americans, Native Alaskans, and Native Hawaiians. If current trends continue, the United States will consist of an even greater variety of cultural groups. In 2007, minority groups accounted for 33% of the population (U.S. Census Bureau, May 17, 2007). Although most people in this country share broad cultural values, a rich diversity of cultural orientations does exist, including those with considerable variations in health and illness practices.

Subcultures in the United States

Subcultures are aggregates of people that establish certain rules of behavior, values, and living patterns that are different from mainstream culture. Leininger described subcultures as having “distinctive patterns of living with sets of rules, special values and practices that are different from the dominant culture” (1995, p. 60). Obviously, there can also be diversity within each subculture. Hispanic culture as a group is very broad and includes Mexican Americans, Puerto Ricans, Cubans, and Central and South Americans, as well as undocumented individuals. There is diversity within each of these groups as well. Certain geographic areas of the country, such as Appalachia, can be singled out as containing subcultures. Persons born and reared in the southern states or in New York City can often be identified by their language and mannerisms as members of a distinct subculture. We used to believe that the United States had a “melting pot” culture in which new arrivals gave up their former languages, customs, and values to become Americans. It is now agreed that the “melting pot” or “blending” concept may not be appropriate, at least not for everyone. A more accurate metaphor would be to view the U.S. population as a rich and complex tapestry of colors, backgrounds, and interests (Figure 11-2).

Refugee and Immigrant Populations

Immigrants are persons who voluntarily and legally immigrate to the United States to live. Immigrants come of their own choice, and most plan to eventually become citizens of their new host country. Of course, many persons also come to the United States, Canada, and Western Europe illegally or without the proper documentation. Although terms differ for these persons, in the United States they usually are referred to as “undocumented” or, perhaps in a more pejorative sense, “illegal immigrants.” Under international law, refugee is a special term that describes a person who is outside of his or her country of nationality or habitual residence and who has a well-founded fear of persecution if he or she returns to his or her own country. By definition then, refugees are persons escaping persecution based on race, religion, nationality, or political stance (United Nations High Commissioner for Refugees [UNHCR], 1966.

Evidence-Based Practice 11-1 presents a study about the barriers to human rights that women encountered in southern Sudan. Violence against women is considered the most pervasive human rights violation in the world. Violence against women is exacerbated in war-torn countries with a high incidence of rape and other physical/sexual abuse during armed conflicts. Women and girls, often unaccompanied by family members, are particularly at high risk. Many refugee women who come to the United States have experienced these human rights violations.

EVIDENCE-BASED PRACTICE 11-1 Human Rights Barriers for Displaced Persons in Southern Sudan This is a community-based research study that explores community perspectives on barriers to human rights that women encounter in a post conflict setting of southern Sudan. Violence against women is considered the most pervasive human rights violation in the world. Violence against women is exacerbated in war-torn countries with high incidence of rape and other physical/sexual abuse during armed conflicts; women and girls are particularly at high risk. Violence against women is often rooted in social values and mores and potential success of change depends on learning more about local priorities regarding gender relationships, practices, and rights. The region of southern Sudan is the site of a 40-year civil war that has had a horrific effect on the population as well as the social, economic, and physical infrastructures and health care services. Focus groups and key informant interviews provided the data for this ethnographic study. Themes found in human rights structures and barriers are described in this article. Most human rights situations are dealt with by the traditional clan system and then go on to the more formal court and police system. Customary behavior often prevails and often women are disadvantaged because of their social positions and power differentials. Although some police officials receive procedural training in law enforcement and occasionally informal training in human rights, key informants reported that the police might actually perpetuate human rights abuses. The formal court system is still “developing” and do not always offer protection to women. Numerous barriers exist to extending human rights and protection to women.

These barriers include :

(1) shifting legal frameworks that create a lack of knowledge about what constitutes a human rights violation

(2) mistrust and doubt about human right

(3) weak government infrastructure

(4) poverty.

Clinical Application

1. Nurses should be aware of the everyday struggle for justice and human dignity that refugees from the Sudan have experienced. Similarly, nurses must consider the broader historical and cultural factors that contribute to human rights abuses when working with displaced or refugee communities.

2. Given their advocacy role and direct contact with communities, nurses can help educate community members regarding the health effects of human rights violations. Furthermore, by questioning social practices (domestic violence, for example) that violate women’s rights, nurses can create opportunities for social change.

3. Research results also indicated that enacting human rights was frequently associated with a sense of connectedness and community responsibility, suggesting that nurses can work with local residents and service providers in addressing violence against women and promoting human rights.

4. Nurses are in a key position to help refugee communities analyze and address human rights barriers thus advancing women’s health and wellbeing.

Barnes, Harrison, and Heneghan (2004) suggested that there is a need for research about refugees that is distinct from other categories of immigrants. The circumstances that lead to forced migration of refugees are very different from those that influence an immigrant to relocate and these differences can have distinct health implications. Currently, immigration of undocumented individuals, or those who do not have the appropriate documentation to immigrate, can be a contentious issue in the industrialized nations of the world. Many of the key issues in the debate on immigration policy are economic (U.S. Chamber of Commerce, n.d.). One well-known group of refugees was made up of persons who came to the United States from Southeast Asia after the Vietnam War. Primarily, these refugees came from Vietnam, Laos, and Cambodia. In more recent times, refugees have come to the United States from countries in Africa, including Sudan and Somalia, Eastern Europe, Afghanistan, the Middle East, and other countries undergoing violent transitions; refugees are fleeing war, famine, and other social upheavals. They are fleeing for their lives and safety rather than personally choosing to leave their homeland. The term refugee and the status of an individual who is a refugee have

legal meanings and designations that differ from those of ordinary immigrants. Another classification of newcomers is that of asylees— persons who come to a particular country seeking political asylum from some sort of persecution in their home country. These various types of classification—immigrant, refugee, asylee, or undocumented or illegal immigrant—often determine the rights of individuals (e.g., the granting of work permits or residency status, or the types of social and health services that newcomers may obtain). In addition, those who are undocumented, or without appropriate residency status may face arrest and deportation to their country of origin. The United States has grown and achieved its success as a nation of immigrants and foreigners. Immigration is a continuing phenomenon in this country. Many recent immigrants and refugees are not acculturated to prevailing Western norms of health beliefs or behaviors. Many arrive with scant economic resources and must learn English and become economically self-sufficient as quickly as possible. Certain factors such as settlement patterns or living near friends or family, communication networks, social class, and education have helped many immigrants maintain their cultural traditions. Immigrant or refugee communities provide support for newcomers and opportunities for cultural continuity because these ethnic communities reflect the identities of the home countries. At the same time, belonging to such a community tends to set immigrants and refugees apart and isolate them from the larger community. For example, newcomers from Mexico realize that they need to learn English to get better jobs, but they often join expanding Latino communities where most residents speak Spanish. Learning English well enough to obtain employment in the English-speaking world is difficult, and it is to their credit that most immigrants and refugees do learn English and make significant contributions to their new country. Nevertheless, where immigrants live and how they participate should remain individual choices and privileges rather than prescribed options.

Special Considerations: A New Refugee Community—The Dinka of Southern Sudan.

Sudan is one of the largest refugee-producing countries in Africa and the world today (UNHCR, 2006). Forced migration and displacement have been occurring in Sudan for decades, as Sudan’s civil war began in 1955 and is now the longest lasting civil war in the world. This civil war is the result of religious and ethnic conflict between the predominantly Muslim north and the minority indigenous, and Christian south. It is estimated that some 2 million people have died and 4 million others have been displaced as a result of the civil war (Adar, 2000). For some time now, Sudan has gained worldwide attention for documentation of human rights violations, including genocide and slave trade (UNHCR, 2006). Both sides of the conflict are thought to be involved in these violations, although it is evident for some time that the government-backed northern militia has targeted the minority south. It is estimated that over 80% of the southern Sudanese population are either internally displaced or refugees in other countries and one of every five southern Sudanese has died as a result of the civil war (Adar, 2000, p. 18). Most Sudanese are displaced in neighboring African countries such as Ethiopia, Kenya, Uganda, and Egypt. In particular, Sudanese refugees have undergone stressful, traumatic, and even catastrophic experiences such as war, torture, refugee camps, death of family members, and loss of homeland. Many of the health problems experienced by the Sudanese refugees are the result of prolonged civil war, and the lack of nutrition and basic medical care. Refugees arriving from Sudan may suffer a variety of problems including severe malnutrition and diseases endemic to Sudan, including gastrointestinal diseases, tuberculosis, schistosomiasis, sleeping sickness, and HIV/AIDS (Brown, 2004; Pinto et al., 2005). Given the horrendous scale of human rights abuses that Sudanese refugees have experienced, many of them suffer PTSD. Studies have indicated that many refugees experience PTSD, which follows a psychologically traumatic event outside of the range of usual human experiences. The symptoms may include nightmares, depression, withdrawal, hopelessness, sleep disorders, and other somatic complaints (American Psychiatric Association, 1987). The Sudanese refugees were forced out of their communities and often traveled many miles, some on foot, adapting to temporary environments,and often harsh conditions. Many have lost close family members in the conflicts as well as all that is familiar to them, thus losing a sense of identify and community. Many others have witnessed and/or experienced the worst kind of human atrocities, including forced slavery, torture, rape, and genocide. Refugee Sudanese women were especially vulnerable during migration when they did not have the protection and support of their families and communities. However, trying to make a new life in a new host country has also been very stressful for Sudanese refugees. Factors such as unemployment, decreased family income, changes in lifestyle, lack of ability to speak English, cultural conflict, and separation from family and loved ones continue to add to stress and decrease the quality of life for many Sudanese refugees. The Dinka tribe is one of the largest tribes in southern Sudan and its members are some of the most persecuted. Their Christian faith and practices have made them a target of ethnic persecution by the Islamic northern militia. Many Dinka have come to the United States as refugees and large communities can be found in Georgia, Florida, and Kansas. The Dinka refer to themselves as Monyjang, which means “The lord of all people” (Deng, 1984, p. 2). In general, the Dinka have a tall, thin, and graceful appearance. This following section will discuss the traditional Dinka culture, health care for Dinka communities, as well as presenting a Dinka family health case study. Although the focus is on Dinka refugees, many of the issues, challenges, and topics identified here have relevance to other refugee groups as well.

Traditional Dinka Culture Traditional Dinka culture is very community-oriented, and kinship and family ties extend beyond blood relatives. A husband may have more than one wife, and the wives and their children exist as one extended family. Although Dinka women are traditionally subservient to men, it is not uncommon for jealousy and competition to arise between a Dinka man’s wives. Cattle hold special significance in Dinka culture and traditions as well as providing a livelihood for the tribe. In addition, cattle are also considered an important aspect of Dinka marriage rituals. Bridewealth (or a bride’s value) depends on the amount of cattle her union will bring to her family (Deng, 1984). The Dinka are considered very religious and spirituality is an integral part of Dinka life. They have a belief in an inseparable connection between the natural and supernatural world. Even as refugees in the United States, the Dinka have established a strong Christian church presence within their communities. Health and illness are closely linked to spirituality and supernatural forces. Illness is considered a community affair and family and friends often gather at the bedside of a sick member to pray or to sit in watchful silence. Dinka women have been the center of family life and responsible for the transmission of the cultural values and beliefs to the children. There is still tremendous social pressure from family members and the Dinka community to continue these cultural traditions after resettlement to the United States. This sometimes causes problems as Dinka women are also coping with tremendous role changes as we shall see in the case study. Although marriage and childbearing have traditionally been the only acceptable roles for women, now there are considerable variations, given that Dinka family life here in the United States is in transition. Many Dinka women now work to help support their children; they have learned to drive cars, speak English and to provide for their families. Dinka traditions such as patriarchy, bridewealth, and polygamy, which have perpetuated the family clan system in Sudan for centuries, have created conflict for some Dinka women who resettle in the United States. When Dinka women come to the United States, they are encouraged to find employment and learn English; they begin to experience the freedoms and autonomy that benefit American women and this sometimes causes difficulties within the extended family as roles and expectations change very rapidly.

Polygamy, a long-standing Dinka tradition, which has served to extend family lineage and promote large families, creates problems for both Dinka women and men when they come to the United States as refugees. The practice of polygamy conflicts with the cultural values and laws in the United States and when polygamous Dinka families are resettled to the United States, the husband must choose only one wife and their children. This obviously leads to dissolution and separation of families. Dinka refugees living in the United States remain very close to their family members back in Sudan, particularly now with the availability of cell phones. Frequent phone calls enable the resettled Dinka to keep in touch with their extended families back in Sudan and this contact sometimes reinforces traditional practices and values. As an example, Dinka women learn very quickly that domestic abuse is against the law in the United States. When a Dinka woman experiences domestic violence, she can call the police and threaten divorce. Divorce is simply not an acceptable option for traditional Dinka and the husband’s family back in Sudan might arrange for him to take another wife to replace the one who they believe is causing all of the marital problems. If the wife actually pursues a divorce, the husband’s family back in Sudan may ask for the bridewealth to be returned. This could place a considerable financial hardship on the woman’s family. Thus, although some traditional practices can be deterrents to the well-being of women and disrupt the family system, it is very important to remember that traditional customs also serve as a form of protection and they buffer the stress of being a refugee in a new country.

Characteristics of a Dinka Refugee Community

A community assessment of a Dinka community within the United States requires that the nurse assess cultural factors such as kinship, religious practices, family roles and patterns, language use, and cultural health beliefs and practices. Obviously, other parameters of a community assessment such as population trends, environment, industry, education, employment opportunities, recreation, and health care services are important to assess also. However, the composition of refugee and other immigrant communities requires that nurses study and interpret cultural data and understand how these data influence health and wellness. Several years ago, DeSantis observed “that interventions that are not built on an understanding of the concept of culture will always limit the effectiveness of nursing” (1997, p. 184). This is certainly true now more than ever in our multiethnic/ multicultural and pluralistic society. There is no “one” Dinka refugee community in the United States; however, several cities have significant communities of Dinka refugees who have settled there. Traditionally, the Dinka are basically a tribal society and are very community-oriented. A tribal society simply refers to a social group, often with a territorial affiliation, which has a strong cultural and ethnic identity. Traditional Dinka society was further divided along gender and generational lines. The experiences of men, women, and children who have grown up outside of Sudan may be strikingly different from their elders. Many Dinka adults, as well as their children, have spent years in refugee campus or countries of transit before arriving in the United States. It is also quite possible that they have experienced traumatic events prior to relocation and such factors may have a profound experience on transition to life in the United States. In essence, any attempt to bring health care services to the community or to address the community’s health problems must take into account the tremendous diversity within the whole community. This obviously requires flexibility and ingenuity on the part of health care professionals. Further complicating this situation is language. Some Dinka may have learned English in their homeland due to postcolonial British occupation. Most Dinka speak the tribal language, named after their ethnic clan, the Dinka, and many speak Arabic, although few are literate in either. It goes without saying that as Dinka are resettled in the United States, they are learning English as they seek employment, interact with Americans, and send their children to school during the resettlement process. Many of the Dinka families live in apartment complexes with large concentrations of Dinka and other African refugees. Although this practice may isolate newly arrived refugees from other Americans, close association with persons from their own culture and tribe can form a supportive network for new arrivals.

Refugee communities that facilitate healthy transitions include support from family, friends, and health care professionals. Social support has been identified in the resettlement process as one of the most critical factors that promotes health and well-being. The cultural values and traditions that refugees maintain after resettlement such as a sense of communality, hope, and religious practices are resources that enable them to develop healthy strategies to cope with resettlement experiences.

The Dinka Family

The Dinka are very proud of their traditional tribal culture and their identification of being “Dinka.” The traditions of communality, the bonds of family kinship, respect for elders, and a strong Christian lifestyle are some of the important traditions that the Dinka women strive to maintain and pass on to their children. Both men and women take a “Christian” or “Biblical” name in keeping with a common practice among the Dinka who are given this name at birth as well as a traditional Dinka name. Common Christian names might be John, James, Rachel, Sarah, and so forth. The Christian name reflects their strong affiliation with their Christian faith. Family life is at the core of Dinka culture. Although many health care professionals are familiar with strong family systems among the family groups that they care for, they still may have difficulty comprehending the differences inherent in Dinka culture. The Dinka family life has a profound influence on well-being. The Dinka tend to socialize almost exclusively with other Dinka and with extended family members. This can cause conflict when they live in the United States because there may be geographic distances between the family members, thus making frequent visits very difficult. The Dinka also go to considerable efforts to maintain ties with family members back in the Sudan. Modern technology, for example, the use of cell phones as we mentioned earlier, has greatly enhanced communication with family members back home. This group communality provides an important buffer for the refugees, especially new arrivals. Dinka communities usually have a Sudanese community church, which serves as the religious and social center for the members. During weekly services, traditional cultural practices including chanting Christian hymns in the Dinka dialect, accompanied by tribal drums, is a common practice. Social events held at the church might include birthday celebrations, baby showers, as well as memorial services for those family members who have died in Sudan. In addition, the church provides updates on the current political and social situation in Sudan. Newly arrived refugees came to the church services and stand before the congregation to announce which village in Sudan they were from and how long they had been in the United States. Women are able to continue the Dinka traditions of language, dress, food, and music through their association with the church. The weekly events at the church allow the Dinka to stay connected with each other and give them a sense of belonging and familiarity.

Many social concerns that are relevant to the Dinka community are addressed through the Sudanese church. Sermons might include lessons about issues that face Dinka families such as the importance of continuing education or methods to resolve domestic disputes. Often there is a women’s group at the church that provides help to Dinka families when there is illness or financial problems; they collect money or cook food for a family in need. It is through attendance at the Sudanese Church that the Dinka values of respect for the elderly is reinforced in the socialization of Dinka children.

Dinka Women’s Roles

The Dinka are strong Christians and the Sudanese churches provide an important buffer against the changes that refugee women face when they are resettled in the United States. Dinka traditions such as patriarchy, bridewealth, and polygamy, which have been a part of the family clan system in Sudan for centuries, have created conflict for Dinka women (and Dinka men, too) who resettle in the United States. Women experience conflict over their freedom, conflict between maintaining traditional values and becoming Americanized, role overload from adding new American roles to Dinka roles, a lack of suitable spouses for single women, and parenting difficulties. In the traditional patriarchal culture of the Dinka, women are dependent and subservient to men. The family clan system in the Dinka culture continues to subjugate women, even after they are resettled in the United States. At the same time that women are learning English, learning to drive, and taking jobs outside of the home, the families back in Sudan as well as Dinka men (usually the husbands) are trying to control and manage those very women. If difficulties arise between a husband and wife, the husband is likely to communicate with his family back in Sudan by telephone and soon, the family members will call the recalcitrant wife and apply pressure on her to maintain traditional ways. For example, the Dinka culture values large families and encourages women to have many children as children are a sign of prosperity. However, refugee women soon learn that large families are not affordable or practical in the United States. Baird (2009) described an interaction that occurred between a husband and wife at a hospital after the birth of their fourth child. The physician broached the subject of a tubal ligation. The woman was interested, but it was the husband who said “No”. When the physician persisted, saying that the woman should have input into the decision, the husband replied again “No. We will talk with her at home.” If a woman is reluctant to have another child or refuses outright, the family back in the Sudan might arrange for a second wife for the husband. Often resettlement to the United States leads to dissolution and separation of families as husbands must choose only one wife and their children. This, of course, poses difficulties for the wives as well as the husband. Children are affected by these situations as well. Women who pursue a divorce because of domestic violence or polygamy are discouraged by their families back in Sudan as well as the Dinka community in the United States.

When a woman seeks a divorce, her family may be expected to return the bridewealth that was paid to her husband’s family as part of the marital contract. The loss of the bridewealth can lead to serious financial problems for the woman’s family back in Sudan. If a Dinka woman should seek a divorce in the United States, she will face considerable stigma and she will be censored by friends and her community. Baird (2009) described a situation wherein a divorced woman was shunned at her Sudanese church because of her divorce. This left her very isolated and without friends at a very difficult time in her life. Resettlement to the United States provides the Dinka refugee women with opportunities that were not possible back in Sudan. Like many American families, it is necessary to have two breadwinners to adequately support a family, so women seek work outside of the home. They learn new skills that are necessary to parent children in the foreign U.S. culture. They struggle to learn a new set of rules and social norms for themselves as well as for their children. Taking a job usually means a woman has to learn to speak English to her coworkers, and she must find transportation to work—either by taking public transportation by herself or by learning to drive an automobile. For the first time ever, she must learn how to earn and manage money, including the use of credit and debit cards as well as their monthly payments. When Dinka mothers work outside of the home, they find that arranging for adequate child care can be very difficult. They have been accustomed to extended family members who were able to help with child-care arrangements. Many Dinka women reported that placing their children with strangers made them very uncomfortable (Baird, 2009). The freedoms and opportunities that Dinka women gain when they come to the United States may create conflict and power imbalances in their marriages. Husbands are sometimes threatened by their wives’ newfound sense of equality and independence, and this often leads to marital discord and sometimes to domestic violence. Women learn very quickly that they do not have to tolerate beatings from their husbands and that they can call 911 and the police will intervene. Dissolution of marriage and the breakup of families has been a grave concern to Dinka communities and in many instances, community elders have met with local police departments to discuss alternatives to arresting Dinka husbands and removing them from their homes. Sudanese churches have also become involved, encouraging men to support women as they learn to be American wives and mothers. Couples are encouraged to discuss their problems openly with each other and work out their differences among themselves. This means learning new skills and coping strategies for both men and women. Raising children in the American culture has proved challenging for Dinka mothers. They struggle to help their children with their homework, and it is a struggle as often the mothers’ English reading skills are limited and they do not have the background or education to help their children. Mothers can experience pressure from their children to cook “American food,” such as apple pie. Children want to participate in Halloween activities and they want toys from Santa Claus at Christmas time; all celebrations and activities that are unknown and strange to Dinka parents.

Disciplining children by using corporal punishment is not acceptable in America, and mothers are afraid that they might be reported to authorities who would then take their children away from them. Dinka mothers and father soon learn that in the United States, children are expected to express their feelings and opinions openly and to question rules and authority. This is rather shocking to Dinka parents. Many mothers are concerned that their children will identify with the antisocial behaviors they see in their neighborhood or on television—smoking cigarettes, drinking alcohol, and sexual promiscuity.

In summary, Dinka women, like other women refugees, have experienced profound role changes. In traditional Sudanese culture, a woman’s proper place is in the home. However, in the United States, it has been necessary for many Dinka women to work outside the home. As women’s roles have changed, their husbands have often reacted with frustration. Of course, their roles have been changing too. Some men have begun to drink heavily or abuse family members, increasing the stress and pressure on women and families. Dinka parents worry about raising their children in the United States. As children are exposed to American culture at school and on television, sex, violence, and other controversial aspects of American life are pervasive and difficult to avoid. Children tend to acculturate more rapidly than their parents, learning English more quickly and, in general, adapting to new social roles and gender identities as well as establishing roots in American culture. This does not imply that Dinka childhood is free from conflict. On the contrary, the cultural clash between generations can be profound, given that Dinka parents are often opposed to many of the American cultural values and behaviors their children have acquired. This can be a source of great conflict and dissension.

Health Care for Dinka Families and Communities

The Deng family came to the United States in 2001 after an extended stay in Egypt. Rachel and Paul had fled their Dinka village during an attack by an Arab militia, known as the Janjaweed. Like other Dinka refugees who experienced similar circumstances, they fled the village with their two young children, a 4-year-old boy and an 8-month-old baby girl. They hid in “the bush” until after dark when the attackers had left the area. When they made their way back to their village, they found it destroyed and their neighbors and family members dead. They originally fled to Kenya where Paul had relatives who were living there. They applied to the UNHCR for refugee status in Kenya and were denied. The family then migrated to Egypt where Rachel helped to support the family by working as a domestic housekeeper. They again applied for refugee status and this time were successful. In 2003, Rachel and Paul were resettled with their two children in California. Three years after living in the United States, Paul decided to return to the Sudan because he was unable to find suitable employment. This left Rachel alone in a new country to support herself and the two children. Even though the family has lived in the United States for more than 6 years, they still struggle with the difficulties of adjusting to a new and different life. Resettlement and adjustment in the United States have not been easy for them. Rachel was immediately confronted with the markedly different roles of women in the United States. American gender roles are much more egalitarian and American women fill roles that only men were traditionally allowed in Sudan. Rachel became the head of household after Paul returned to the Sudan. She struggled to learn English in classes offered at the local refugee center. With the social worker’s help, she found a job working as a maid in a large hotel. Constant contact with coworkers enabled her to improve her English. She took a city bus to work but after several months, she was able to save up sufficient money for a down payment on a used car.

The pastor at the Sudanese community church and his wife were helpful new friends and Rachel relied on them for advice and support. Rachel developed confidence in her ability to depend on herself and to take care of her children. She explained how depending on herself has changed the way that she perceives herself since coming to the United States. “I don’t depend on anything. I don’t relay on anybody now. I depend on me to do something.” Still, without the social support and interaction of her family, she feels lonely and has experienced some depression, which is not uncommon for refugee women. She has learned through family members that Paul has taken another wife back in Sudan. This has been upsetting to her. The Sudanese Community church has been a source of support and comfort for Rachel and she attends services and the many social activities that the church sponsors. She has been able to maintain close and consistent ties with other Dinka refugees who have been resettled in the United States. Although many Dinka men and women had horrific experiences in Sudan and the subsequent escape from their village and county, they are adjusting to life in the United States and are coping as well as possible with their past experiences. Their lives are not stress free by any means, but Rachel, her friends, and other refugees have demonstrated considerable strength in adjusting to traumatizing experiences and the stress of adapting to life in the United States.

Rachel does worry a great deal about her children: her son, James, is now 12 years and her daughter, Ester, is 8 years old. Rachel is worried about raising the children in American society. She is distressed by what she sees on television, and she is shocked by the explicit sex and violence portrayed in the media. She is told by other Dinka refugees that drugs are easily available and that she should warn James about them. Rachel and her children live in a poor urban neighborhood and James is exposed to boys his age who smoke, swear, and occasionally are in trouble with the law. Rachel often calls the boy’s father, Paul, in Sudan and he talks to his son, encouraging him to mind his mother and to do well in school. Rachel believes that she must work very hard to instill traditional Dinka values and norms in her children. Sometimes her son says: “Mom! You don’t understand. I am not Dinka. I am an American from San Diego!” Rachel worries that her children are exposed to negative aspects of American culture at school and on television as controversial aspects of American life are difficult to avoid. James learned English at school and from his classmates, and he has acculturated much more rapidly than his mother. Ester is also in school and has learned English very quickly too. Ester was recently invited by a classmate to a “sleep over”. Rachel could not understand what such an event might be and she refused to allow Ester to accept the invitation. This precipitated a minor crisis in family relations.

Planning Nursing Care for Refugee Families

Careful assessment of cultural backgrounds and individual factors can help nurses anticipate and work with difficulties that are experienced by refugees and immigrants who seeking health care.

The Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families used in this text (see Appendix A) is recommended for use with clients and their families.

We have listed topics discussed by Lipson and Meleis (1983) below to provide minimum information for the nurse to plan culturally competent care.

• Length of time the client and family have been here, and where the client was raised. Not only is the country important, but rural and urban differentiation may also be important, as well as social, political, and economic levels

• Language spoken in the home and language skill in English

• Nonverbal communication style

• Religious practices

• Ethnic affiliation or identity

• Family roles and how they are influenced by the resettlement experience

• Social support or networks, especially relatives or family members in the new country Assessment of these factors will assist the nurse in planning health care for Rachel and her children as well as other refugee and/or immigrant families. Health services, preventive care, and health education have been identified as important needs in health surveys that have been conducted in refugee communities (Lipson, Omidian, & Paul, 1995).

The stress of resettlement is often a significant problem for members of refugee communities. Stress is related to the refugee experience and also to inadequate income, work-related problems, and loss of culture and tradition. The lack of mental health services is a grave concern in refugee and immigrant communities and should be addressed by creative and innovative solutions. In refugee communities, a church, synagogue, or mosque can play a positive and important role as religion is often identified as a protective factor by refugees in facilitating wellness and increasing quality of life. Refugee men may be reluctant to seek mental health services because of the stigma of mental illness as well as their traditional male roles. Postmigration stress may be exacerbated by unemployment or underemployment and may contribute to depression, PTSD, alcohol abuse, and poor general health status. Preventive care in the areas of dental health, breast self-examination, mammography, and Papanicolaou (Pap) smears are important for refugee women. Refugee men have dental problems too, and need regular prostrate and testicular exams. Many of these procedures may be new to refugees who are not familiar with them. However, many barriers to good preventive care are environmental and social rather than cultural. Constraints are based on the refugees’ individual situations as well as language, economic, occupational, and transportation problems.

Cultural groups differ in regards to the priority given to individual goals versus those of the larger group. For example, many refugee communities, such as those of the Dinka, are a collectivist society that values the good of the group, traditional values and group loyalty. This often conflicts with the individualistic American society. Many African refugees may suffer from racism and discrimination when they resettle in the United States and this too, impacts mental health and successful resettlement. As many refugee women may have experienced gender-based violence including torture, rape and human rights abuses, nurses and other health professionals must learn sensitive ways of broaching these subjects and helping refugee women access culturally appropriate care. Health care professionals, especially women physicians and nurses, can design programs that consider problems in access and appropriate language as well as culturally sensitive health care for women who have experienced gender-based violence. Health education, including information about access to care, is always important in planning services for refugee and immigrant communities. Many refugees and immigrants do not use health education services, not necessarily because of cultural barriers but because of difficulties with language and access, the need for translation and transportation, and the desire for women health care providers, as well as other barriers such as child care.

Health care institutions and agencies, from the beginning, should include bicultural health care providers on their staff. Community health workers could be trained to serve as interpreters and translators. It is always problematic for health care providers to use various family members as interpreters because of divisions along age and gender lines. Children do learn English more quickly than their parents, but it would be very insensitive to expect a young boy to interpret a conversation about results of his mother’s pap smear. The health care provider’s gender is important as many refugee women are not comfortable with male doctors or nurses and might avoid health care altogether if female care providers are not available. Obviously, health care providers must be knowledgeable about the refugees’ or immigrants’ experiences and background, cultural and social factors, and other unique aspects of the population they serve. Refugees and new immigrants need access to language-appropriate and culturally sensitive health care. Many refugees from community-oriented societies prefer to receive such information in a group or social setting rather than a one-to-one basis that is common in the U.S. health care setting. For many refugee or immigrant communities, churches, mosques, and/or synagogues are appropriate settings for health education. The traditional or classic definition of community uses a geographic boundary, such as a village, town, or an urban settlement such as a city. This sense may be conveyed somewhat in terms such as Little Havana, Little Kabul, and Little Saigon, but such designations do not really convey the nature or quality of the refugee or immigrant experience, which tends to cross geographic boundaries. Although refugees from certain geographical areas such as Sudan tend to be sent to common locations, they may later move to be closer to relatives or families who came from the same village back home. The sense of shared displacement or “uprootedness” that serves to unite and distinguish immigrant or refugee communities from other groups or communities is quite profound and cannot be ignored when planning for community-based health services. Immigrants are often seen by health professionals as dominated by psychoemotional experiences and consequences of relocation. In other words, we focus on the effects of stress, relocation, and human rights violations. Indeed, much of the literature on immigrants and refugees focuses on PTSD. Although many immigrants and refugees have endured horrific experiences, this focus alone is not holistic. This view, according to DeSantis (1997), focuses on the primacy of the individual (an American value) rather than the community and thus prescribes psychiatric treatment instead of addressing the sociocultural and economic barriers at the macro level. It is at the macro level that transcultural health care providers must be engaged if they are to be effective participants in building healthy refugee and immigrant communities. This does not mean that individual health care should be ignored; it simply acknowledges that it can be more effective when incorporated within a community focus, especially when dealing with immigrant or refugee communities.

Maintenance of Traditional Cultural Values and Practices

An important aspect of transcultural nursing is the collection of cultural data and the assessment of traditional values and practices and how they are maintained over time. The processes of assimilation and acculturation can be briefly defined as those ways in which individuals and cultural groups adapt and change over time. Yet, at the same time, both individuals and groups may be resistant to some changes and retain many traditional cultural traits. Hispanics are the largest cultural/ethnic group in the United States, and in several large American cities, they constitute large percentages of the population. Obviously, in these ethnic communities, it is easier to speak Spanish and to maintain other traditional cultural practices. Because traditional health beliefs and practices influence health and wellness, it is important for the nurse to understand the degree to which clients, families, and communities adhere to traditional health values and how nursing practice should reflect those values. Spector (2008) suggests that a person’s health care and behavior during illness may well have roots in that person’s traditional belief system. Unless community health nurses understand the traditional health beliefs and practices of their clients and communities, they may intervene at the wrong time or in an inappropriate way. Many factors influence the likelihood that clients, families, and communities will maintain traditional health beliefs and practices. For example, the length of time a person lives in the new host country will influence factors such as language and the use of media such as radio and television. Teenagers may quickly adjust to American culture and prefer headphones with a CD player or an iPod. The ability to speak English and to communicate with members of the majority culture is crucial to acculturation. The size of the ethnic or cultural group is also important; obviously, if the group is small, individuals from that group are more likely to be exposed to outsiders and will not spend all their time within their own group or community. Although this may hasten their acculturation, it deprives members of an immigrant or refugee community the social support and presence of a large ethnic community. Generally, children acculturate quicker because they are exposed to their peer group through schooling and they learn cultural characteristics through that association. The need to work outside the household often exposes women from traditional cultures to others of the majority culture;thus, they learn English more quickly than if they remain isolated at home. When individuals from other cultures seek health care in their Western host country, they become familiar with its health care system. This does not necessarily mean that they comply with all health advice, but contact with the system decreases anxiety and confusion, and individuals are more likely to seek care again. In addition, if individuals or groups have distinguishing ethnic characteristics such as skin color, they may be more isolated because of discrimination and thus retain traditional values, beliefs, and practices over a longer time. Some factors that influence the likelihood that clients, families, and communities will maintain traditional health beliefs and practices are shown in Box 11-2.

Access to Health and Nursing Care for Diverse Cultural Groups

Members of diverse cultural groups, especially those who are poor and without health insurance face special problems in accessing health and nursing care. Access to care is often determined by economic and geographic factors. Community nurses who focus on the care of aggregates face the challenge of promoting the health of populations even when there are new and different causes of morbidity and mortality (such as HIV/AIDS or the “new” influenza, H1N1) as well as underserved populations who are more likely to experience health problems. Certain cultural groups have faced discrimination and poverty, and their ability to access care has been compromised. Sensitivity to cultural factors has often been lacking in the health care of traditional communities and identified minority groups. In addition to economic status and discriminatory factors that limit access to care, geographic location plays an important role. Many rural areas lack medical personnel and the variety of health facilities and services that are available to urban populations. For example, Native Americans, living in sparsely settled and isolated reservations in the western part of the United States, must travel long distances over primitive roads to obtain health care services. Individuals who have type 1 diabetes and live on the Navajo or Hopi reservations may be picked up very early in the morning by a shuttle van that takes them into Tuba City for renal dialysis. The van takes them home later in the afternoon; this arduous routine may take place as often as three days each week. Other factors may also limit access to care. Many clients from culturally diverse backgrounds seek the services of health care professionals who speak their language. When this is not possible, they are reluctant to seek care or may not understand the importance of following medical advice.

Factors Influencing Traditional Beliefs and Practices

1. Length of time in the new host country.

2. Size of the ethnic or cultural group with which an individual identifies and interacts.

3. Age of the individual. As a general rule, children acculturate more rapidly than adults or seniors.

4. Ability to speak English and communicate with members of the majority culture.

5. Economic status. For example, if the family economic situation necessitates that a Salvdoran woman work outside the home, she may learn English more quickly than if she remains within the household and speaks only Spanish with her family members.

6. Educational status. In general, higher levels of education lead to faster acculturation.

7. Health status of family members. If individuals and their families seek health care in their host country, they begin to “learn the system,” so to speak. This does not mean that they comply with all of the health advice by any means, but contacts with the system should decrease anxiety and confusion.

8. Individuals and groups who have distinguishing ethnic characteristics, such as skin color. These individuals may be more isolated because of discrimination and thus may retain traditional values related to health beliefs and behavior.

9. Intermarriage. Ethnic intermarriage is associated with a greater loss of traditional ethnic identity.

10. Rigidity or flexibility of the host society. This refers to the extent to which the host society is willing to allow members of different ethnic groups, along with their traditions, beliefs, and practices, into their structure, culture, and identity. Another common and significant factor that limits access to health services is a lack of understanding by clients of how to use health resources.

This lack of understanding may be due in part to cultural factors. Often this lack of understanding means that members of diverse cultural groups are less able to adequately cope with health problems than are other members of the community. Nurses can develop sensitivity to diverse groups within communities and reach out to them with culturally specific health programs.

Box 11-3 lists some important factors that nurses must take into account for culturally appropriate community-based care. Box 11-3 Factors to Consider in the Nursing Care of Culturally Diverse Groups

1. Lack of employment opportunities and finances for health care services

2. Different traditional belief systems as well as different norms and values

3. Lack of cultural sensitivity on the part of social service and health care workers

4. Lack of bilingual personnel or staff members or the lack of interpreters to assist clients and care providers

5. Rapid changes in the U.S. health care system, where clients are “lost” in the gaps between agencies and services

6. Inconvenient locations or hours that preclude clients from accessing care

7. Lack of understanding, trust, and commitment on the part of health care providers.

Assessment of Culturally Diverse Communities

A cultural assessment is the processes used by nurses to assess cultural needs of individual clients (Leininger, 1991, 1995; see also Appendix A). In general, all successful cultural assessments have at their foundation the extensive data base to help health professionals better understand and address the specific health needs and interests of their target populations. Individual cultural assessments are accomplished through the use of a systematic process. In community health nursing, the community is considered the client, and several models have been proposed to help nurses assess the community (Clark, 2008; Stanhope & Lancaster, 2006), including the Andrews/Boyle Transcultural Nursing Assessment Guide for Individuals and Families in Appendix A. A community nursing assessment requires gathering relevant data, interpreting the database (including problem analysis and prioritization), and identifying and implementing intervention activities for community health (Stanhope & Lancaster, 2006). Although the community nursing assessment focuses on a broader goal, such as improvement in the health status of a group of people, it is important to remember that it is often the characteristics of people that give every community its uniqueness.

These common characteristics, which influence norms, values, religious practices, educational aspirations, and health and illness behaviors, are frequently determined by shared cultural experiences.

An overview of selected cultural components . These components can be used to assess diverse cultural groups within a community. For example, using these components, a cultural assessment of a Native American would provide much of the general data detailed in Appendix B shown at the end of this text. Box 11-4 Basic Principles of Cultural Assessment

1. All cultures must be viewed in the context in which they have developed. Cultural practices develop as a “logical” or understandable response to a particular human problem, and the setting as well as the problem must be considered. This is one reason why environmental and/or contextual data are so important.

2. The underlying premises of the behavior must be examined. For example, the Hispanic client’s refusal to take a “hot” medication with a cold liquid is understandable if the nurse is aware that many Hispanic patients adhere to hot/cold theories of illness causation. There is often a range or spectrum of illness beliefs, with one end encompassing illnesses defined within the Western biomedical model and the other end firmly anchored within the individual culture (Huff & Kline, 1999). Obviously, the more widely disparate the differences between the biomedical model and the beliefs within the cultural group, the greater the potential for encountering resistance to biomedical interventions.

3. The meaning and purpose of the behavior must be interpreted within the context of the specific culture. An example would be the close relationship that is often seen in Hispanic cultures between mother and son; such an intense relationship might be viewed as abnormal in European American families.

4. There is such a phenomenon as intracultural variation. Not every member of a cultural group displays all the behaviors that we might associate with that group. For instance, not every Hispanic client will adhere to hot/cold theories of illness, and not every Hispanic mother will have a close personal relationship with her son. It is only by careful appraisal of the assessment data, and validation of the nurse’s assessment with the client and family, that culturally competent care can be provided.

Community Nursing Interventions Cultural Competence in Health Maintenance and Health Promotion

Leininger (1978, 1995) suggested that cultural groups have their own culturally defined ways of maintaining and promoting health. Nursing interventions to improve the health of individuals, groups, and communities can best be planned and implemented by considering persons within their social, cultural, and environmental contexts. Community nurses who have direct access to clients in the context of their daily lives should be especially aware of the importance of cultural knowledge in promoting and maintaining health because the promotion and maintenance of health occurs in the context of everyday lives rather than in the doctor’s office or in a hospital. The range of cultural influences on health maintenance and promotion is considerable. Major cultural issues and considerations must be addressed before health maintenance and promotion programs are implemented for culturally diverse groups. First, it is important to involve local community leaders or “elders” who are members of the cultural group being targeted to promote the acceptance of health promotion programs. Such a leader, for example, might be the pastor of an African American church in the rural south or a member of the tribal council for a Native American tribe. The nurse must also be sensitive to cultural differences in leadership styles. For example, the African American pastor may not speak in favor of the health education program from his or her pulpit but might choose instead to work through more informal networks. Numerous nurse researchers (Abrums, 2004; Shambley-Ebron & Boyle, 2006) have found that many African Americans rely on spirituality and/or religious practices when they are ill and in general, a health program that has the support of the church pastor would be favorably viewed by the church community. In addition to local community and religious leaders, it is important in the planning process to involve those who are most affected by the health-related problem. Those involved in planning and participating in the program’s activities should likewise participate in its evaluation. Collaboration between the planner and the participants is often the key to success in community-based health programs (Clark, 2008). Second, family members, churches, employers, and community work sites need to be involved in supporting health promotion/education programs through the use of networks that already exist. For example, a health education program about the importance of having a routine screening such as a mammography can be established at a work site that employs mostly women. A display could be set up in the cafeteria, dining room, or other accessible site. Women could view the educational material during breaks or after lunch. Providing information about sites where women could obtain a mammography would be an important component of such a program. Third, health messages are more readily accepted if they do not conflict with existing cultural beliefs. If the nurse plans to talk about prevention of teenage pregnancy to mothers and daughters at a local conservative church, he or she could discuss these plans in advance with some of the mothers and the pastor and ask for ways to strengthen the church’s support of abstinence programs. This is not the appropriate time to focus on contraception methods but to be sensitive to the group’s religious values. Fourth, language barriers and cultural differences are very real problems in many large U.S. cities as well as rural areas. For example, in the U.S.– Mexico border areas, promotoras (community health workers) are used to disseminate messages in their own language (Spanish) and to help organize and present information that is culturally appropriate and understood by community members. Many Native American tribes make use of community health representatives (CHRs) to assist native individuals to improve their health and/or access care. The health care professional should not be afraid to ask for help and suggestions, and should make it a point to find educational material such as brochures or videotapes in the appropriate language as well as with the “culturally acceptable” message. Last of all, sensitivity is essential to meeting health needs that exist within diverse cultural groups. For example, HIV/AIDS is spreading rapidly in some Hispanic and African American populations and is associated with intravenous drug use, violence, and the use of crack cocaine. In addition, the root causes of poverty and unemployment should be examined, and programs that improve overall economic status of culturally diverse communities should be developed. Culturally relevant treatment programs should be implemented. Many minority women who seek treatment programs for cocaine addiction encounter barriers that seem insurmountable. Treatment programs are not available in many areas, and child-care facilities are not provided—even in day-treatment programs. Thus, a young mother living in a rural area with children would not be able to find a treatment center that meets her needs. If she seeks admittance to a residential treatment program, she might have to agree to place her children in foster care.

Family Systems

Because the family is the basic social unit, it provides the context in which health promotion and maintenance are defined and carried out by family members within culturally diverse communities. The nurse can recognize and use the family’s role in altering the health status of a family member and in supporting lifestyle changes. This requires an appreciation of the role of the family in diverse culture groups. African American families, for example, may demonstrate interchangeable roles for their male and female members, extended ties across generations, and strong social support systems, including the African American church, all of which can be tapped by a community health nurse to activate health and wellness in families (Abrums, 2004). Immigrant and refugee families also tend to have strong extended ties with their kin and changes in lifestyle, diet, and other established patterns of daily life that influence health status will need the understanding and support of all family members.

Coping Behaviors

Culturally diverse clients often have distinct behaviors to cope with illness as well as to maintain and promote health. These behaviors may be traced to the health–illness paradigms that were discussed earlier in Chapter 4. Beliefs about hot and cold, yin and yang, harmony and balance may underlie actions to prevent disease and maintain health. Community nurses who understand their clients’ cultural values and beliefs can assess their understanding of health and illness. These assessment data serve as the basis for planning health guidance and teaching strategies that focus on incorporating cultural beliefs and practices in the nursing care plan. It seems likely that clients in the process of coping with illness and seeking help may involve a network of persons, ranging from family members and select laypersons to health care professionals. Seeking social support is often seen as a means of coping. It is now evident that social support varies widely across people, cultural groups, and circumstances. An individual’s coping behaviors during an illness of a family member may differ remarkably at any one time during the illness, depending on intrapersonal, interpersonal, and environmental factors. Certainly, nurses working with diverse cultural populations will want to learn and understand how coping styles are used by individuals and family members as well as how these coping styles change over time as these factors are often influenced by culture.

Lifestyle Practices

Cultural influences have a significant impact on such health-promoting practices as diet, exercise, and stress management. Community health nurses should assess the implications of diet planning and teaching to clients and family members who adhere to culturally prescribed practices concerning foods. Some cultural groups believe that certain foods maintain or promote health. Some foods often are restricted during illness, just as there are “sick foods”—special dishes served to an ill person, such as the proverbial chicken soup. Cultural preferences determine the style of food preparation and consumption, the frequency of eating, the time of eating, and eating utensils. Milk is not always considered a suitable source of protein for Native Americans, Hispanics, Blacks, and some Asians because of their relatively high incidence of lactose intolerance. Nurses who work with culturally different clients must evaluate patterns of daily living as well as culturally prescribed activities before they suggest forms of physical activity or exercise to clients. Exercise is often defined in terms of White middle-class values. Not everyone has access to the tennis court at a local country club or a gym and many individuals would not feel comfortable in such surroundings or in aerobics classes regardless of the setting. Some men might feel more comfortable playing basketball or hiking. Traditional tribal dancing has become popular on some reservations for Native Americans. In the past, members of the Hopi tribe were superb distance runners and the tribe still sponsors running events for its members. Helping clients plan physical activities that are culturally acceptable is only the first step in implementing a program of physical activity. Another aspect of lifestyle that must be understood for the successful promotion of health and wellness is the manner in which culturally different clients manage stress. Stress management is learned from childhood through our parents, our social group, and our cultural group. Smoking and/or chewing tobacco, although not healthy habits, are often used to manage stress. Persons who choose to use tobacco products greatly increase the risk of the development of heart disease and cancer. Debates currently rage about smoking in public places and the use of tobacco, although the trend is toward banning the use of tobacco in public places.

Cultural Competence in Primary, Secondary, and Tertiary Preventive Programs

Nurses working in community settings use health-related concepts that are identified with the practice of community health nursing. Concepts such as “community as client” and “population-focused practice” were discussed briefly in the first sections of this chapter. Another important concept to community nurses is that of levels of prevention. Preventive care, consisting of primary, secondary, and tertiary activities, is directed toward high-risk groups or aggregates within a community setting. Primary prevention is composed of activities that prevent the occurrence of an illness, disease, or health risk. The preventive actions take place before the disease or illness occurs. Secondary prevention involves the early diagnosis and appropriate treatment of a condition or disease. Tertiary prevention focuses on rehabilitation and the prevention of recurrences or complications. The major aim of community-based preventive programs is to reduce the risk for the population at large rather than to prevent illnesses in specific individuals. As long as preventive actions are directed toward a given population rather than toward individuals, there is a chance of altering the general balance of forces so that even though not all will benefit, many will have a chance to avoid illness. This last section of this chapter discusses the use of cultural knowledge to plan communitynursing interventions for diverse cultural groups at the primary, secondary, and tertiary levels of prevention.

Primary Prevention:

Prenatal Services in Mexican American Communities Overview of the Health Concern When viewed as a group, racial and ethnic minorities suffer from worse health compared to their U.S. counterparts. Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions exist among ethnic population groups in the United States (Minority Health: Health Quick Facts, 2009). This is certainly the case for maternal and infant health. For many years, public health agencies have tried to improve maternal and infant services to high-risk populations. As long ago as 1985, a special government report on minority health reported that many minority women do not begin prenatal care during the first trimester (Heckler, 1985a, 1985b) and that this has serious consequences for mothers and infants. The risk factors of pregnancy include age (both extremes), parity, low socioeconomic status, as well as other factors such as diabetes, and alcohol and tobacco use. In addition, numbers of children within the family (need for child care), transportation problems, and less assistance from a support system influence use of prenatal care and other health services. Many women of Mexican American origin fall in these categories. Furthermore, an infant with health concerns is at risk for further problems as there may be negative and long-term consequences for the child and the mother as well as other family members. Obtaining early and regular prenatal care greatly enhances a young woman’s chance of delivering a healthy, full-term baby. A program of primary prevention would focus on preventing infant morbidity and mortality and other health problems in Mexican American mothers and their infants. Early prenatal care may enhance pregnancy outcome and maternal health by assessing risk, providing health advice, and managing chronic and pregnancy-related health conditions (Martin et al., 2009). Nursing care must be broadly focused, providing some specific services but also helping clients access other resources in the community.

Access to Care

There are various reasons why Mexican American women might not seek care during pregnancy. Cost is often a factor, and in many areas of the country, Mexican Americans have tended to belong to poorer socioeconomic groups. Mexican Americans are concentrated in blue-collar jobs, farm work, and service occupations; lower status jobs translate into lower income and higher poverty rates (ERIC Digest, 1990). In 2005, the Pew Hispanic Center estimated that nearly 11 million undocumented immigrants live in the United States, 6 million of who are from Mexico (Passel, 2009). Undocumented immigrants face special problems with access to care: They lack health insurance, language, and knowledge regarding health services, and they fear that they may be arrested and deported because of their legal status. The value of routine prenatal visits to a health care provider should be repeatedly emphasized by nurses, otherwise some Mexican American women may stop their regular visits because they are feeling well and are not accustomed to seeing a health care provider unless they are ill. The community health nurse can provide information about community resources and help clients access care early in pregnancy by referral to appropriate agencies. Nearly all states now provide programs that provide funds and services for low-income pregnant women, although in the financial crises of the late 2000s, these services are being reduced or eliminated in some states. Although not a health program specifically, the Women, Infants, and Children (WIC) Program provides nutritious food and nutrition education to low-income pregnant and breast-feeding mothers, their infants, and their children under age 5 (U.S. Department of Agriculture, Food and Nutrition Service, 1999). The rate of low birth weight babies among infants born to women on WIC is 25% lower than for infants born to similarly situated women not on WIC. WIC is an example of one of the most popular, successful, and cost-effective public health programs (U.S. Department of Agriculture, Food and Nutrition Service, 1999; U.S. Department of Agriculture, Food and Nutrition Service, n.d.). Referring pregnant women to WIC services is a strong primary prevention intervention by community nurses. Many Mexican Americans are more comfortable accessing health educational services in a setting that is known to them and where they feel comfortable. Neighborhood churches are excellent settings for health education as women know where they are located and are familiar with them in contrast to a hospital or clinic setting away from their neighborhood. Often churches can provide child care so that mothers can leave their children in a safe place while they are attending prenatal classes.

Cultural Views About Modesty

Any prenatal program that serves Mexican American women may be underused unless consideration is given to some Mexican American women’s modesty and reluctance to be examined by male health care providers. The use of female nurse practitioners and midwives is ideal for this population. In addition, some consideration should be given to incorporation of the traditional parteras (lay midwives) or promotoras (health workers) into the preventive educational services. Promotoras, those community health workers who speak Spanish, are especially effective in delivering primary health care services to expectant mothers either in community settings or in the client’s home.

Language Barriers

It is absolutely essential in a prenatal program for a Mexican American population that the majority of health care professionals in the program be bilingual. If that is impossible, interpreters must be employed to facilitate the professional services. All prenatal classes should be offered in Spanish and English. This sometimes means that two classes must be offered concurrently; many Mexican American women speak predominantly either Spanish or English and would choose the class where they understand the language. The availability of health education material in Spanish is critical to reinforce teaching and anticipatory guidance. Videos may be more effective than brochures or other written material. In Berry’s study (1999) of Mexican American women and prenatal care, the key informants who were bilingual spoke only Spanish within their homes because they did not want their children to forget their heritage. In some border communities such as Nogales, Arizona, the Hispanic population is high (93.6%), and most residents speak Spanish in their homes (Arizona Department of Health Services, Office of Health Systems Development, 2005).

Cultural Views of Motherhood and Pregnancy

Some evidence indicates that women of Mexican American culture may adhere to slightly different value orientations and cultural views of motherhood and pregnancy than those found in mainstream American culture (Burk, Wieser, & Keegan, 1995). The Mexican American culture traditionally values motherhood, and young women are encouraged to prepare themselves for this role. Community health nurses, nurse practitioners, and professional midwives are in important positions to help pregnant women prepare for motherhood and its associated responsibilities. Understanding and reinforcing the approved cultural views of pregnancy will be helpful for clients because trust and mutual goal setting can develop more rapidly. All nursing interventions should incorporate family members, especially mothers and sisters, for support of the pregnant woman. Emphasizing the responsibility for the mother to be healthy for her baby’s health and welfare is appropriate for this cultural group.

Traditional Pregnancy-Related Folk Beliefs of Mexican Americans

Many Mexican Americans may adhere to some traditional beliefs and practices related to pregnancy and childbirth. Additionally, children are greatly valued and are desired soon after marriage. Census data indicate that Mexican Americans tend to marry and have children at earlier ages (ERIC Digest, 1990). As in many other cultures, Mexican Americans consider pregnancy, birth, and the immediate postpartum period as a time of great vulnerability for women and their newborns. Box 11-5 shows selected beliefs and practices of pregnancy and childbirth in traditional Mexican American culture. It is important for the culturally sensitive nurse to assess each client because each generation of childbearing women perceives pregnancy and birth differently (Nichols & Zwelling, 1997). In the Mexican American culture, it is important for the nurse to assess the views of members of the pregnant mother’s support system, especially her mother, who belongs to an earlier generation and may adhere to more traditional values. It is always necessary to assess intracultural variation as not every member of any given culture adheres to the same beliefs and behaviors typical of that culture.

Selected Beliefs and Practices of Pregnancy and Childbirth in Traditional Mexican American Culture

• Avoid strong emotions such as anger and fear during pregnancy.

• Cool air is dangerous during pregnancy and should be avoided.

• Bathe often during pregnancy; be active so that the baby will not grow too big and hinder delivery.

• Eat a nutritious diet; “give in” to food cravings.

• Massage is helpful to place the baby in the right position for birth.

• Don’t raise your arms above your head or sit with your legs crossed during pregnancy because these actions will cause knots in the umbilical cord.

• Moonlight should be avoided during pregnancy, especially during an eclipse, because it will cause a birth defect.

• After delivery, a 40-day period known as la diet or la cuarentena is observed. Certain activities and foods are restricted.

• Chamomile tea will relieve nausea and vomiting in pregnancy.

• Heartburn can be treated with baking soda.

• Laxatives and purges may be used to “clean” the intestinal tract.

Mexican American Cultural Networks

Traditionally, the family is very important in Mexican American culture, and nursing care should be family focused. The most important social structural factor in the Mexican American culture is family and kinship ties. These ties often go beyond the family to a wide network of kin. If nursing care is to be effective, nurses must tap these kinds of cultural networks to ensure the support of family members, neighbors, or friends. Nurses face challenges such as language barriers, literacy levels, socioeconomic and educational levels, cultural backgrounds, and other subtle differences when they work with the varied Hispanic groups in the United States. It is also critically important to remember that there is tremendous diversity within Hispanic groups living in the United States. Mexican Americans are but one example, other major Hispanic groups include Puerto Ricans, Cubans, and Central and South Americans.

Using Cultural Competence at the Primary Level of Prevention

The community health nurse should target certain high-risk behaviors for change during pregnancy, such as smoking, using drugs, consuming alcohol, and maintaining poor nutritional habits. Although there is no set rule of thumb, a Mexican American mother-to-be may respond to suggestions for change if she is convinced that her behavior will cause harm to her baby. Family and social support groups in Mexican American culture can also be helpful and supportive to expectant mothers wishing to make lifestyle changes. Some researchers have found that pregnant Latin women will attempt to stop smoking and will be successful with the help, support, and assistance of their families (Pletsch & Johnson, 1996). Family members can play important supportive roles in terms of primary prevention that requires behavioral and lifestyle changes. Prenatal services should go beyond the birth of the baby to include information about breast-feeding and family-planning services. Traditionally, some health care professionals have assumed that familyplanning services will not be accepted in a Mexican American population because of religious opposition and machismo—the need of the man to prove his manhood by having children or to believe in the biologic superiority of men. However, it may be that Mexican American men as well as women are interested in family planning and are concerned about the number of children they can support. This issue should be validated with individual clients and their spouses. During la cuarentena, the 40 days after the birth of the baby, women kin of the new mother often help with infant care, household tasks, and preparation of special foods for the mother (Berry, 1999). Many Hispanic families believe that chili and other spicy foods should be avoided during and immediately after pregnancy. Strategies for promoting breast-feeding should be identified and encouraged. For example, educational levels, family experiences with breast-feeding, the husband’s attitude, the need to return to work, and feelings of embarrassment are associated with infant-feeding choices among Mexican American women as well as other groups. These factors need to be explored with individual women to help them make the best choices for themselves and their babies. Fortunately, breast-feeding is becoming commonplace in the United States and mothers realize the advantages that breast-feeding can provide for a new baby. Traditionally, Hispanic mothers may bind their abdomen as well as their baby’s abdomen during the postpartum period. These customs should be supported by nurses who work with postpartum Mexican American women and their babies.

Secondary Levels of Prevention: Type 2 Diabetes and Native Americans Overview of the Health Concern Non–insulin-dependent diabetes (NIDD), or type 2 diabetes, is seen commonly among many Native Americans, and certain tribes have extremely high rates of the disease. At nearly 17%, Native Americans and Alaska Natives have the highest adjusted prevalence of diabetes among all U.S. racial and ethnic groups (American Diabetes Association, Native American Programs, 2009). By all accounts, the high rate of diabetes in Native North American groups is a leading health concern because diabetes is a leading cause of outpatient visits at Indian Health Service facilities. Equally of concern, Indian deaths resulting from renal failure alone were reported to be 290% higher than the national average in the United States (U.S. Department of Health and Human Services, 1993). Type 2 diabetes has become an epidemic and a national tragedy among many Native peoples. The reasons for the epidemic of type 2 diabetes among some Native North Americans are not clear. It has long been believed that some Native North American tribes have an underlying genetic propensity for the disease that is triggered by major changes in dietary practices, a sedentary lifestyle, and increasing obesity (Neel, 1962; Young, 1994). These factors have been complicated by social conditions such as poverty, inadequate access to health care, as well as by problems of compliance or lack of adherence to medical regimens. Because of the high rate of diabetes on some reservations, numerous secondary preventive services that focus on early diagnosis and treatment have been initiated. Many of them are modeled after programs that have been successful with White middle-class North Americans. Box 11-6 shows culturally related factors that could influence the success of secondary preventive programs for diabetes. Readers are cautioned that validation of beliefs and practices should always take place with individual clients and families, and stereotyping (thinking that all Native Americans are the same) should be avoided.

Using Cultural Competence at the Secondary Level of Prevention

Nursing interventions at the secondary level of prevention should focus on the implementation of healthful lifestyle changes that will ultimately decrease the complications of diabetes. Most of these are related to what health professionals call diet and exercise, but what is appropriate for Native North American culture is an emphasis on health and a healthy lifestyle. Nurses should emphasize health and a healthy lifestyle rather than negative factors such as control of diabetes, prevention of complications, weight reduction, and exercise. The choice of words, as well as the emphasis, is important. For example, when teaching the client and family about diabetic diets, the nurse can substitute the word “nutrition” for “diet,” thus removing the negative perceptions and leading to a nursing plan that emphasizes substitution of healthy foods rather than deprivation. Substituting fruits for candy bars and packaged pastries, whole grains for French fries, potato chips or doughnuts, and vegetables for sugared snacks will improve the client’s nutritional status and lead to a healthier lifestyle. Special traditional foods, even fried bread, can be eaten on special occasions, and other types of bread can be substituted during regular meals. Health education can be oriented toward individual clients and directed toward the family rather than provided in an impersonal clinic situation. Physical activities that are culturally congruent can be encouraged; again, the value of health and a healthy lifestyle should be stressed over exercise and weight reduction. Physical activities that are congruent with overall lifestyle and cultural context will be easier to incorporate into daily living situations. Usually, the Native American family system is an extended family that includes several households of closely related kin. Family members become exceedingly important during times of crisis because they are a source of support, comfort, assistance, and strength. The importance of cultural ties with kin and other members of the reservation community always must be considered in planning for early diagnosis and treatment programs. It is in this context (family and community) that clients are encouraged and supported not only to seek care but also to institute lifestyle changes that are congruent with cultural practices and that will enhance the health status of all members of the family and, ultimately, the tribal community.

Beliefs and Practices Related to Diabetes in Some Native Americans Nutritional Practices

• Diets are high in calories, carbohydrates, and fats.

• Sharing communal meals is a common and valued cultural practice.

• Some groups have a high incidence of obesity.

• Food preparation often adds fats and calories.

• Snack foods (potato chips, carbonated beverages, prepackaged pastries) are common.

• High intake of alcohol seriously compromises the treatment of diabetes. Activity Levels/Fitness Practices

• Sedentary lifestyles have become common.

• Many reservations lack recreational facilities.

• Formal exercise activities are associated with the White man’s culture and are not thought to be appropriate for Native Americans. Beliefs and Values Related to Diabetes • Ideal body image favors a heavier physique, and weight gain is considered normal; thinness is a cause for worry and concern.

• Concept of “control of one’s body,” that is, weight, glucose levels, blood pressure, may conflict with values and norms of Native American culture. For example, Native American clients may be uncomfortable with comparison of individual performance against others or against the norms and standards of biomedical care.

• Many Native Americans are uncomfortable with discussing or exposing private body functions, such as providing urine samples or participating in blood testing in a public situation.

• Illness is a personal and unpleasant topic, and Native American clients may be uncomfortable when asked to talk about it.

• Diabetes is a “White man’s disease”; Native Americans did not have diabetes until Whites came to this continent.

• The term “diabetic” may be offensive to some, and the label “diabetic clinic” may discourage clients from seeking health care services.

• White health professionals may be viewed with some suspicion and distrust, given the history of cultural contact between Whites and Native Americans.

• Because diabetes is so common in some tribal groups, there is a fatalism about the disease, especially if a family member already has diabetes.

• Beliefs and health practices surrounding diabetes may vary according to the Native American tribe.

The increasing rates of type 2 diabetes are of great concern to Native American communities. Introducing preventive health programs requires great sensitivity to cultural traditions and to the past experiences that native communities have had with health care and health research. Understanding the needs of community members is essential for the development of culturally appropriate programs, and each Native American community has its own cultural traditions and beliefs that make up the details of daily life. Understanding the needs of Native communities begins by asking them what they want and need from preventive programs rather than imposing ideas upon them. The best way to find out what matters to people is to get out into the community and talk to them. In Native American communities, it is wise to begin with respected and esteemed members of the tribal council. Serious behavioral and social problems contribute to the high-risk factors in American Indian groups. Suicide rates are rising, and deaths resulting from homicide, accidents, and injuries have resulted in increased American Indian mortality (Strickland et al., 2006). In fact, suicide is the third leading cause of death among American Indian youth, ages 15 to 24 years (CDC, 2004.

Tertiary Levels of Prevention: Hypertension and African Americans

Overview of the Health Concern African Americans are a highly heterogeneous group and display considerable variation in health beliefs and behaviors. For the most part, this section will discuss a more traditional, rural African American culture, and the reader is advised to validate beliefs and behaviors with individual clients and communities. Hypertension is a major risk factor for heart disease and stroke. Mean blood pressure levels are higher in Blacks than in White Americans, with a marked excess in Blacks. A decade ago, in a government study on minority health, the chairperson pointed out improvements in the treatment of hypertension in Blacks. In reviewing the data, she stated, “Hypertensive Blacks were at least as likely as Whites of the same sex to be treated with antihypertensive medication and nearly as likely to have their blood pressure controlled” (Heckler, 1985a, p. 110). Heckler also noted that from 1968 to 1982, stroke mortality in Blacks declined 5%, and coronary heart disease also had decreased dramatically. Control of hypertension has certainly been one factor responsible for this improvement. It is critical that efforts to treat hypertension in African American populations be continued. Unfortunately, appropriate care often has been complicated by discrimination, poverty, and limited access to care. The goal of tertiary prevention is to reduce disability and prevent complications from developing further. A major aim of nursing care in the implementation of tertiary activities is to help clients adjust to limitations in daily living, to increase their coping skills, to control symptoms, and in general to minimize the complications of disease by reducing the rate of residual damage in a given population.

Using Cultural Competence at the Tertiary Level of Prevention Community nurses have demonstrated competence in the management of community hypertension programs. Although these programs are vital to the early diagnosis and management of hypertension, they also include a component that focuses on helping clients manage a chronic disease—an aspect of tertiary prevention. Numerous studies have shown that African American churches are excellent sites for community-based health programs such as hypertension clinics. The African American community should be involved in every aspect of community-based programs. The goals, objectives, and interventions of the services should reflect the expressed needs of the community target group as well as their values, beliefs, and interests. Poverty is often a problem in rural

African American communities and, combined with the lasting effects of racism and discrimination, African Americans often experience severe economic deprivation. In 2007, 24.5% of all African Americans were living below the national poverty level (Poverty in the United States, 2007). Forty percent of African American households are headed by females, often another contributing factor to families having insufficient socioeconomic resources (U.S. Census Bureau, 1998). Community health nurses are in the advantageous position of assessing clients and families in their own homes and neighborhoods. This provides an understanding of the daily life situation faced by clients that other health care professionals often lack. Community health nurses can bring this understanding to bear on helping clients with tertiary preventive activities.

Cultural Factors to Consider in Planning Tertiary Prevention for a Traditional African American Population

Language African American communication concepts and patterns can be identified and used in community education programs. Cultural Health Beliefs Good health comes from good luck. Health is related to harmony in nature.

Illnesses are classified as “natural” or “unnatural.” Illness may be God’s punishment. Maintenance of health is associated with “reading the signs,” for example, phase of the moon, seasons of the year, position of the planets. Cultural Health Practices The use of herbs, oils, powders, roots, and other home remedies may be common. Cultural Healers Older woman (“old lady”) in the community who has knowledge of herbs and healing. Spiritualist who is called by God to heal disease or solve emotional or personal problems. Voodoo priest/priestess who is a powerful cultural healer who uses voodoo, bone reading, and so on, to heal or to bring about desired events. Root doctor who uses roots, herbs, oils, candles, and ointments in healing rituals. Time Orientation May be present-time oriented, which makes preventive care more difficult to implement and maintain. Nutritional Practices Soul food takes its name from a feeling of kinship among Blacks and may be served at home, provided at church dinners, or served at home-style restaurants. Diets may reflect traditional rural Southern foods such as fried chicken, greens, grits, corn bread, and chickpeas. Dessert may be peach cobbler. Economic Status African Americans account for many persons in the lower socioeconomic strata in American society. Educational Status High aspirations for education, but socioeconomic status and other complex factors limit educational opportunities.

Family and Social Networks Often strong extended family networks with a sense of obligation to relatives. Self-concept The importance of race has been a continual issue for the self-identity of African Americans. Impact of Racism Unfortunately, racism is still present, and a negative perception of the African American’s skin color by health professionals will seriously interfere with efficacious health care. Religion African American churches have tremendous influence on the daily lives of their members because they serve as a source of spiritual and social support.

The African American church acts as a caretaker for the cultural characteristics of Black culture. Biologic Variations There is a high incidence of lactose intolerance and lactase deficiency; this has implications for diet planning if Black clients cannot tolerate milk or milk products. There is a higher prevalence of hypertension among African Americans than among Americans of European heritage. Sickle cell anemia is more common among African Americans.

Adapted from Andrew, M. M., & Bolin, L. (1993). The African American community. In J. M. Swanson & M. Albrecht (Eds.).

Community health nursing: Promoting the health of aggregates (pp. 443–458). Philadelphia: W.B. Saunders.

SUMMARY

Cultural concepts related to community health nursing practice were discussed. A framework for providing culturally competent nursing care was introduced to help nurses and other health professionals provide care to individuals and groups with diverse cultural backgrounds. Such frameworks help nurses use cultural knowledge in assessing, planning, and implementing nursing care. This chapter explored the role of the family in transmitting beliefs and practices concerning health and illness. Cultural diversity within communities was addressed, and various subcultures, including refugees and immigrants, were discussed. A community case study of Dinka Sudanese refugees was provided. Special concerns related to refugee populations were described. Cultural data about traditional Dinka culture were related, and examples of culturally competent care were provided. Cultural concepts were explored as they relate to the community at large. A cultural assessment was described as an integral component of a community nursing assessment. Culturally competent nursing interventions for community health maintenance and health promotion were presented. Preventive care in the community is of particular importance to community health nursing. The use of cultural knowledge in primary, secondary, and tertiary levels of prevention was introduced. Examples of cultural diversity and levels of prevention were described to illustrate how cultural knowledge can be used in community health nursing practice.