One Name, Many Faces

The next time you read a statistic such as “there are 2 million Asian Americans and Pacific Islanders in the U.S. with no health insurance” or “visits to the emergency room represent 18.8% of total visits to health care facilities by Asian Americans and Pacific Islanders, compared with 11.7% for whites,” stop and think for a moment. What exactly does the term “Asian Americans and Pacific Islanders” really mean?

Did you know, for example, that this simple-sounding classification actually encompasses more than 30 different countries and 100 languages? Are you aware that there are very few links connecting these different ethnicities other than the government-assigned label? How much do you really know about the people, their cultures and their health?

“The majority of Asian American and Pacific Islander subgroups each have their own distinct language, history, culture and migration pattern [to the U.S.],” explains Kem Louie, RN, PhD, FAAN, associate professor in the Department of Nursing at William Paterson University, Wayne, N.J., and president of the Asian American/Pacific Islander Nurses Association (APINA). “Even though there seems to be a clustering of Asian immigrant groups in larger cities, especially on the East and West Coasts, there is no common thread among them.”

That said, it should come as no surprise to learn that health beliefs, behaviors and risks can vary substantially between the different Asian American and Pacific Islander (API) populations in this country–including Chinese, Japanese, Filipinos, Koreans, Vietnamese, Native Hawaiians, Samoans and many more. Unfortunately, medical researchers traditionally have classified Asian Americans and Pacific Islanders as one broad umbrella group with similar, if not identical, health care concerns. Few, if any, research studies have bothered to make distinctions between Native Hawaiians and Hmong, for example, despite the fact that the people are dramatically different in their diets, languages and traditional beliefs.

But today, in response to federal mandates for increasing cultural competence in health care and eliminating racial and ethnic disparities in health outcomes, this oversimplified view of the nation’s API populations is finally changing. Recent culturally sensitive research studies have begun to uncover groundbreaking information about how the multiple subgroups differ from one another. Here’s an in-depth look at some of the initial findings that are helping to paint a more definitive picture of the health needs of Asian Americans and Pacific Islanders–and the implications of those findings for the nurses who provide them with care.

The Past

According to Census 2000 figures, there are approximately 11.2 million people of Asian and Pacific Islander descent living in the U.S.–up from 9 million in 1990. This increase reveals a significant immigration movement. In fact, 24% of foreign-born U.S. residents in 1997 were Asians or Pacific Islanders. In other words, six out of 10 API persons living in the United States at the time were born elsewhere. That diversity–and varying degrees of acculturation–creates an interesting and complex situation for health care providers.

“There is a changing of demographics for the Asian-American population in general and there are so many nuances and variations from one [API] culture to another,” says Daisy Rodriguez, RN, MN, MPA, an administrative nursing supervisor at San Ramon Regional Medical Center in San Ramon, Calif., and coauthor of a recent study on the health status of Filipino immigrants in the San Francisco Bay area.

Each API subgroup possesses its own cultural characteristics that are just now being examined in terms of how they impact the overall health of the people. The lack of focus on such differences in the past, say some practitioners, may have resulted from a long-held stereotype of Asians as the healthy “model minority.”
“Asians are often seen as a self-sufficient minority group, but that might simply mean that the issues are hidden,” asserts Rodriguez.

Adds Louie, “Many Asian Americans, like those of Chinese and Japanese descent, have been here for generations and have done very well through the acculturation process. But perhaps because they have done so well, the government hasn’t taken seriously the thought of examining [population-specific] health care issues.”

To fill these information gaps, API health care professionals like Rodriguez are initiating their own research to gain insight into the specific health issues affecting their communities. In addition, several federal agencies, such as the Office of Minority Health, have begun investigating health differences between API populations. The 1999 White House Initiative on Asian Americans and Pacific Islanders and the more recent Initiative to Eliminate Racial and Ethnic Disparities in Health are two such endeavors that have dispelled the misconception that Asian Americans have few major health care worries compared to other racial and ethnic groups.

The Present

Although much of the current research data on minority health disparities suggests that Asian Americans and Pacific Islanders generally fare better than African Americans and Hispanics when it comes to health outcomes, this does not mean that API communities don’t suffer from their share of disproportionately high health risks and mortality rates. In fact, recent reports have raised a number of red flags indicating serious API health concerns that physicians, nurses and other health professionals urgently need to address. Some of the most critical areas of concern include:

Cancer
This deadly disease appears to be a prevalent health problem for Asian Americans and Pacific Islanders in general, regardless of differences between specific subgroups. There is overwhelming evidence that many types of cancer are more common among Asians and Pacific Islanders than even heart disease, which still ranks as the leading cause of death for the U.S. population as a whole. “This is the first time that cancer is the leading cause of death among any [racial or ethnic] group,” Louie points out.

More Asian Americans and Pacific Islanders suffer from liver, stomach and nasopharyngeal cancer than Caucasians, according to the Asian/Pacific Islander National Cancer Survivors Network. More specifically, Vietnamese Americans are 11 times more likely to develop liver cancer than whites, and Chinese Americans report the highest rate of nasopharyngeal cancer among all racial or ethnic groups, according to The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination and Ensuring Equality, a 1999 report ordered by the U.S. Commission on Civil Rights.

But what has many caregivers particularly worried is the growing numbers of API women diagnosed with breast and cervical cancer. Again, incidence rates vary among subpopulations, but Native Hawaiians top the list of breast cancer sufferers, with 106 cases occurring per 100,000 people. Vietnamese women are 2.5 times more likely to develop cervical cancer than women in any other racial or ethnic population. Both anecdotal and qualitative research suggests that these disparities are linked to cultural issues that may be creating barriers to early diagnosis and preventive care.

For example, says Rodriguez, “Some Filipino women who feel lumps in their breasts may not be reporting them to their physicians because it involves a sensitive part of their bodies and they don’t want to be examined.”

Dorothy E. Schmidt-Vaivao, coordinator of the Samoan National Nurses Association (SNNA)’s cervical cancer program, based in Carson, Calif., has encountered similar resistance to cancer screening among Samoan women. “We have had women comment that they don’t want anyone other than their husbands touching them.”

Statistics from the API Cancer Survivor Network further confirm the prevalence of these attitudes. A study of Vietnamese women living in California revealed that 34% had never had a mammogram and 54% had never had a Pap test. The Network also notes that Asian American and Pacific Islander women, as a whole, have the lowest screening rates for breast and cervical cancer among all ethnic groups.

Recognizing the immediate need for interventions in their community, SNNA has initiated two outreach programs in Southern California: the Pacific Islander Women’s Breast Health and Breast Cancer Early Detection Program, and Breast Cancer Awareness–The Fa’a Samoa Way Project. “We go to community churches where we talk to the women members,” explains Schmidt-Vaivao. “Afterwards, the women tell us that they now know why they have to follow up [and get breast exams].”

Although these programs are relatively young, Schmidt-Vaivao believes the grassroots effort is making an impact. “Our goal is to create a prevention awareness in the Samoan community,” she emphasizes.

Tuberculosis and Hepatitis
More than a decade ago, researchers discovered a worldwide resurgence of tuberculosis (TB). This time, however, the airborne, infectious disease had mutated into a new, drug-resistant strain. Even though health experts in various countries had hoped to curtail its spread by developing more aggressive medications and treatment programs, TB remains a serious public health issue, especially in API communities.

The World Health Organization (WHO) estimates that, under current conditions, nearly 1 billion people will become newly infected with TB by 2020, and 35 million will die from it. Many of these victims will be from Southeast Asia, which is already recording 3 million new TB cases per year. These predictions worry U.S. public health officials because of the increased immigration from that part of the world. According to WHO, nearly half of all TB cases in industrialized countries occur in foreign-born people. In the United States, 40% of TB patients are immigrants, many of them from Southeast Asia.

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In fact, the American Lung Association reports that Asian Americans and Pacific Islanders are 15 times more likely to contract an active case of TB than Caucasian Americans. As with cancer, this disparity is often exacerbated by cultural taboos that can prevent Southeast Asian immigrants from seeking treatment.

“In some Asian cultures, TB is a stigma,” notes Louie. “And if patients perceive they are being chastised by health care providers, they may not come back for follow-up care or take the treatment at all.” Such behaviors can result in a significant public health risk, experts warn, because untreated or half-treated TB can evolve into a drug-resistant form of the disease.

Similarly, hepatitis B seems to be hitting the API population harder than other racial or ethnic groups. Again, the concern in the public health arena is the effects that can develop if the disease isn’t identified and treated early enough. While not an airborne contaminant like TB, hepatitis B is the leading cause of liver cancer–and as noted earlier, Asian Americans and Pacific Islanders, especially those of Vietnamese descent, have a higher incidence of this cancer than whites.

“The rate of hepatitis B [among Asian Americans] is on the rise, and we weren’t looking in that direction,” says Louie. “Children who contract it are especially at risk for developing cancer later in life.”

Obesity, Diabetes and Kidney Disease
Interestingly, many Asian Americans, and especially Pacific Islanders, are following in the footsteps of other minority groups when it comes to problems with obesity and sedentary lifestyles–unhealthy behaviors that can increase the risk of developing diabetes. In fact, type 2 diabetes has become so prevalent among Americans of all races that health experts have virtually declared it a national epidemic.

Diet, of course, plays a huge role in the both the cause and the treatment of diabetes. While Pacific Islanders have traditionally been known for their healthy eating habits, Schmidt-Vaivao is concerned that this pattern is changing as the people become more acculturated to the American “burgers and fries” lifestyle.

“We [Samoans] have the highest incidence of obesity among the Pacific Islander community,” she says, adding that it’s a problem both in the U.S. and on the island of American Samoa. “There are a lot of fast food places over there now. The people on the island are turning to that eating habit versus the fresh fish and fruit that’s been traditional. It’s scary to see that happening, because it can create problems with diabetes and hypertension.”

Diet is also a leading suspect behind the unprecedented number of renal problems among API subgroups. “I’ve noticed a lot of Samoan people on the island, young and old, on dialysis,” Schmidt-Vaivao reports. “We need to find out why. Is it because of our diet? Is it hereditary? Has this always been going on but we weren’t testing for it before?”

Southeast Asians in the U.S. are also on dialysis in record numbers, says Ana Schaper, RN, MSN, PhD, an epidemiologist at Gundersen Lutheran Medical Center in La Crosse, Wisconsin. Currently there is no conclusive research available to shed light on why so many Asians and Pacific Islander are requiring this complicated treatment.

HIV/AIDS
Generally speaking, America’s API population has some of the lowest numbers of HIV and AIDS cases compared to other minority groups. The Civil Rights Commission report states that Asian Americans accounted for eight AIDS cases per 100,000 people in 1996, which is extremely low compared with the 111 and 52 cases for African Americans and Hispanics, respectively. But within the Asian community, Filipinos lead the subgroups in known AIDS cases, with 45 cases per 100,000.

Furthermore, both Louie and Rodriguez suggest that these statistics may be misleading. “We believe there are more API people who are infected but are not reporting it because of the cultural barriers in their communities,” explains Rodriguez.

In addition to cultural mores, factors such as language barriers and lack of education about the disease may also be clouding statistical findings and preventing people from seeking care. Some research suggests that awareness and understanding of AIDS and its risk factors among the more recently immigrated Asians lags behind that of their counterparts who have lived in America for some time. For example, a 1992-94 National Health Interview Survey found that 21.2% of Vietnamese adults in the U.S. admitted knowing nothing about AIDS and its transmission, compared to only 5.1% of Japanese-American adults.

As more research among API subgroups is conducted, and as community education efforts broaden, the number of reported HIV/AIDS cases among Asian Americans and Pacific Islanders could start to inch upward as more people come forward for testing and treatment.

The Future

Because there has historically been so little definitive research into differences between API subgroups, the current body of knowledge about their health care needs is all relatively recent and preliminary. But now, nurse researchers who are concerned about providing better care to Asian American communities are hoping to make up for lost time–and Asian American/Pacific Islander nurses are leading the way.

“There has been more printed about Asians in the medical literature in the past five years compared with the previous 25 years,” Louie comments. “Still, we need to do a better job in specific data collection if we are really to get a handle on health care concerns among Asian Americans and Pacific Islanders. Currently, we’re dependent on government-gathered data. So much depends on how well the Health Department and other agencies define their categories.”

Adds Rodriguez, “There may be many differences between the various API groups, but the only way to know is to do the research.” That’s exactly why she, along with colleagues from the Philippine Nurses Association of Northern California, initiated their in-depth study of Filipino Americans’ health status, risk behaviors and health promotion practices.

What started as a local survey of older Filipino adults in the Bay Area has expanded into a comprehensive national project, Rodriguez reports. “We realized our focus needed to extend beyond just the elderly because there were so many health care issues in the Filipino community that needed to be addressed.” The study’s initial findings will be presented this summer at the 2002 Philippine Nurses Association of America national conference in Philadelphia.

Schaper recently concluded a project examining the existence of postpartum depression in Hmong women. Wisconsin is home to a large Hmong population and state officials had done some initial research on this issue. Their report concluded that this condition was not prevalent in the Hmong community. However, translators working with Hmong maternity patients at Gundersen Lutheran told Schaper and her colleagues they believed this conclusion was incorrect.

“Because of those initial research results, we weren’t screening Hmong women for postpartum depression like we did with other patients,” she says. As a result, Schaper and several local midwives embarked on a two-year project to clarify the issue. Her findings proved that there was indeed a growing presence of postpartum depression in young Hmong mothers, but because of cultural and linguistic misunderstandings, it had been overlooked by the previous research.

“We didn’t realize how difficult it was to become trusted within the Hmong community,” Schaper adds. “Confidentiality is a big part of their lives. Issues surrounding childbirth are not usually talked about with people outside the family for fear of starting rumors.”

Through her research, Schaper determined that a more symptomatic-oriented screening tool was able to better identify postpartum depression in Hmong women. “Now we screen all our patients for postpartum depression,” she says. “We’ve also developed [educational] materials for Hmong families to help them prepare for the birth of their babies.”

Schaper also discovered some interesting generational and acculturation issues impacting the women in her focus groups. Generally speaking, the younger women who were either born in the U.S. or had lived here since childhood had more “Americanized” expectations about motherhood. It was often the clash between these views and the traditional Hmong philosophies that caused much of the anxiety and depression.

“There was a difference in how the young women saw their world compared with their mothers who had given birth in Laos,” Schaper explains.

The Providers

Other recent studies have confirmed that the degree of acculturation in Asians and Pacific Islanders who have migrated to the U.S. has both direct and indirect connections with their health and their use of health care providers. For example, the Civil Right Commission’s research found that the longer Korean women had lived in the United States, the greater their risk was for developing breast cancer. Furthermore, it’s often the newly immigrated who lack access to health care services the most, in part because of such factors as poverty, language barriers, lack of insurance and unfamiliarity with the American health system.

But that’s also why it’s important for nurses and other health care professionals to approach Asian and Pacific Islanders with cultural sensitivity and an open mind. “While we may not know all the specifics about health care issues in API communities, we do know what makes for good health. Now we have to look at these factors within the framework of their culture,” Schaper advises.

For nurses, that process must begin with taking the time to listen as well as learning to ask the “right” questions. “Samoans don’t believe in saying much,” comments Schmidt-Vaivao. “As health care providers, you have to dig because they won’t volunteer information.”

Such cultural barriers to communication are common among many API subgroups, Louie agrees. For instance, there’s often an attitude of “automatic” respect assigned to health care professionals that can actually be counterproductive. “Asians don’t want to offend a care provider, even if they don’t agree with him or her,” she explains. “Nevertheless, nurses have to find a way to get an accurate assessment. You have to take the time to listen and ask many questions. It seems like a simple philosophy, but when you do it, they’ll respond.”

Nurse researchers who have studied health issues affecting Asians and Pacific Islanders advise nurses in clinical practice who care for API patients to seek out as much information about Asian cultures as possible, whether it’s from published research or simply talking with colleagues who have firsthand knowledge in this area. After all, most hospital staffs are a microcosm of the communities they serve. Don’t hesitate to ask for translation assistance, or for information on traditional diet, religious beliefs or anything else that can help you provide more culturally competent care.

Above all, cautions Louie, avoid the stereotype that all Asians and Pacific Islanders are alike. “The API population is a diverse group,” she says, “and I can’t stress enough the importance of not generalizing.”

New Kidney Disease Detection Guidelines Target Minority Patients

by | Mar 30, 2013 | Magazine

According to the National Kidney Foundation (NKF), one in nine adults in the U.S. has chronic kidney disease (CKD), yet most of them are undiagnosed and are not receiving medical treatment. More than 20 million other Americans are at increased risk for this serious condition, which may lead to kidney failure if left untreated. In addition to people with a family history of kidney disease, this high-risk population includes African Americans, Hispanics, Asians, Pacific Islanders, American Indians and persons with diabetes or high blood pressure.

Because early diagnosis of kidney disease and proper treatment in the illness’s early stages can help prevent or delay kidney failure, the NKF has issued its new 2002 clinical practice guidelines for CKD. Developed as part of the foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI), the guidelines were originally published in the February 2002 issue of the American Journal of Kidney Diseases.

The guidelines recommend that all individuals who are at high risk for chronic kidney disease have their blood pressure measured and their blood or urine tested for signs of impaired kidney function. Specifically, the NKF advises that checking for creatinine in the blood and for persistent protein in the urine (proteinuria) are the best tactics for diagnosing early kidney damage. The guidelines also include a five-stage clinical action plan based on the severity of the patient’s disease.

The NFK reports that the guidelines are the culmination of two years’ work by volunteer experts in nephrology, pediatric nephrology, epidemiology, laboratory medicine, nutrition, gerontology and social work who conducted a systematic study of evidence published in peer-reviewed medical journals.

The new clinical practice guidelines for chronic kidney disease can be purchased in either book or CD-ROM formats for $25 each. The guidelines are also accessible online at the National Kidney Foundation’s Web site. For nurses interested in conducting patient education programs about CKD, the foundation offers the guidelines in a “caddy” format that includes a poster, patient guides and more; the caddy version sells for $60.

For more information, visit www.kidney.org (click on “K/DOQI”) or contact the NKF at (800) 622-9010, email kdoqiinfo@kidney.org.

CDC Examines STD Health Disparities

by | Mar 30, 2013 | Magazine

A recent study on sexual transmitted disease (STD) trends in the United States, “Tracking the Hidden Epidemics” by the Centers for Disease Control and Prevention (CDC), examines the magnitude of STD epidemics by race and ethnicity.

Its key finding: While STDs like chlamydia, human papillomavirus (HPV) and herpes are commonly found across all racial and ethnic groups, STD rates tend to be higher among racial and ethnic minority groups than for white Americans.

According to the study, chlamydia is widespread among all populations, regardless of race/ethnicity, age or gender—but prevalence is slightly higher among racial and ethnic minorities, and most often, among minority women.

Gonorrhea rates have increased for all races and ethnic groups since 1997—after declining in all groups for the past few decades—but this STD is more commonly reported among African Americans. Black’s infection rates are 30 times higher than rates among Caucasians and 11 times higher than those of Hispanics. Between 1997-1999, gonorrhea among African Americans increased from 802.4 to 848.8 cases per 100,000; from 67.4 to 75.3 cases per 100,000 for Hispanics; from 99.4 to 110.7 for American Indians/Alaskan Natives, and from 19.5 to 22.1 for Asian and Pacific Islanders.

Syphilis also disproportionately affects African Americans, leading the CDC study to call it “one of the most glaring examples of existing gaps in minority health status.” Reported cases of syphilis are 30 times higher for African Americans than for whites. This STD is also an issue for Hispanics—their rates of infection increased 20% during the two years covered by the study.

Genital herpes is on the rise for young Caucasians, the researchers reported, but is still more common among African Americans, who have a seroprevalence of more than 45%, as compared to 17% whites. Similarly, Hepatitis B, a serious viral disease that attacks the liver, has a seroprevalence of 12% for African Americans, compared to three percent for whites and 4.4% for Hispanics.

The study emphasizes the need for increased STD prevention education in minority communities, stating, “Efforts are underway to increase both public and private sector HIV and STD prevention efforts in communities at risk throughout the nation. Yet, research demonstrates that some groups at very high risk still lack even basic information about STD prevention.”

Posters and Buttons Promote Multicultural Dialogue About Domestic Violence

by | Mar 30, 2013 | Magazine

Innovative posters and buttons designed to foster dialogue about domestic violence between victims and health care providers are now being distributed to clinics throughout California. The culturally sensitive materials are available in a variety of languages including English, Spanish, Chinese, Russian and Vietnamese. The posters feature racially and ethnically diverse images designed to reach African-American, Caucasian, Latina, Asian American and Native American women.

These new resources were created by the Family Violence Prevention Fund (FVPF) as part of its California Clinic Collaborative on Domestic Violence to raise awareness about the role nurses and other health care providers can play in helping victims escape abusive relationships. Designed for clinics, hospitals and physicians’ offices, the materials are available to health care providers nationwide.

Bright black-and-blue buttons designed to be worn by nurses and doctors read, “Is someone hurting you? You can talk to me about it.” Eye-catching posters to be placed in health care settings feature the tagline, “Is someone hurting you? Talk to a health care provider. We can help. Together we can stop family violence.” All the posters also include the National Domestic Violence Hotline number. Safety cards with information on how to escape an abusive relationship are also available and can be distributed in restrooms, waiting rooms and examination rooms.

“We will only stop domestic violence if we talk about it,” says FVPF Executive Director Esta Soler. “The new materials from our Clinic Collaborative project can help end the silence on domestic violence. Almost every woman visits a health care provider for routine or emergency care. This puts doctors and nurses in a strong position to help victims escape abuse—these materials can be a catalyst to life-saving discussions.”

Nurses can order California Clinic Collaborative on Domestic Violence materials online at www.fvpf.org/store or by calling (415) 252-8089.

Lupus a Growing Threat for Minority Women

by | Mar 30, 2013 | Magazine

While efforts to close racial and ethnic health gaps in such areas as cancer, diabetes, HIV/AIDS and cardiovascular disease are frequently in the national spotlight, lupus is one minority health disparity that has received relatively little attention. Yet this serious arthritis-related disease, which primarily affects women ages 15 to 45, is three times more likely to occur in African-American women than in their Caucasian counterparts.

The Arthritis Foundation estimates that as many as one in every 250 black women has lupus–and many of them are not even aware that they are living with the disease. In addition, some data suggest that the illness may also occur more frequently in Asian and Latino populations than in whites. While the cause of lupus is unknown, recent research suggests that it may be an inherited condition.

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Lupus, which affects nearly 250,000 Americans, is a chronic, sometimes life-threatening autoimmune disease in which antibodies attack the body’s own tissue. It can involve the skin, kidneys, blood vessels, joints, nervous system, heart and other internal organs. Symptoms vary, but may include a skin rash, arthritis, fever, fatigue, anemia, hair loss, ulcers in the mouth, and kidney sediment. The good news is that lupus, once it is diagnosed, can be controlled with medication and exercise.

Because early detection is key to successful treatment of lupus, the Arthritis Foundation offers a number of resources for increasing minority women’s awareness of the disease, its symptoms and the importance of seeing a doctor if they are experiencing signs of the condition. These educational materials include a free booklet, a fact sheet, lists of lupus support groups in various parts of the country, and an online discussion forum for lupus patients. To find out more, contact the Foundation at (800) 283-7800 or visit www.arthritis.org (search for “lupus”).

Minority Health Professions Foundation
100 Edgewood Avenue, Suite 1020
Atlanta, GA 30303
(678) 904-4217
www.minorityhealth.org

One of the things we’re preparing for is the Annual Symposium on Career Opportunities in Biomedical Sciences. We bring together approximately 1,000 high school and university students to highlight the kinds of health professions and biomedical careers they could pursue. Our aim is to encourage and motivate participation of underrepresented minorities in the sciences and health professions and thereby increase their presence in the physician and scientific workforce.

The changing ethnic/racial climate in the United States demands an increase in the number and diversification of biomedical scientists and health professionals. However, African Americans and other underrepresented minorities (URMs) continue to be significantly underrepresented among the Nation’s scientists and health professionals.

According to the 2000 U.S. Census Report, the U.S. population consisted of approximately 12.3% blacks, 0.9% American Indian/Alaska Natives, 3.6% Asians, 12.5% Hispanic/Latino and 75.1% whites. URMs remain well below the national average with regard to education, employment and health status. While today these minorities make up more than 25% of the U.S. population, historically they continue to be underrepresented in the medical and research professions. Among the nation’s scientists, blacks represent 2.3%, Hispanics 2.8% and American Indian/ Alaskan Natives 0.3%. There have been modest increases of underrepresented minority physicians over the past 20 years. In 2000, the U.S. physician workforce was comprised of 5.1% Hispanics, 4.4% African Americans and 0.2% American Indians.

The symposium features people in health and science fields who can talk to students about what they do and serve as live role models. We’re expecting over 1,000 students from across the country who will attend 16 workshops led by caring professionals from similar backgrounds who role model the lifestyle, behavior and determination that it takes to become a scientist or health professional.

How does Minority Health Professions Foundation connect with students on a national level?

We work with Historically Black Colleges and Universities from all over the country to recruit students. We recruit American Indian and Hispanic students from national organizations similar to the MHPF that focus on the specific interests of these groups, i.e., the American Indian Higher Education Consortium and the Hispanic Serving Health Professions Schools. These students include high school students in the 11th and 12th grades and college students.

We get a lot of requests for not only for steering students to majority schools but also to recruit minority faculty. For example, we’ll contact the HBCUs to post jobs at majority schools when we hear of them.

Do you also work with community colleges to connect with students who are studying in one of the allied health fields?

One of the things we will probably do more of this year is have direct contact with community colleges for the symposium. More students are going to community colleges as an introduction to four-year colleges.

We are cooperating with the U.S. Agency for International Development to support faculty to attend training for tuberculosis prevention and elimination. Through this program, we provide support for MHPF faculty to receive training and to serve on international assessments teams with organizations like the World Health Organization (WHO). This training is held in Tanzania and Vietnam.

Does the foundation help provide any other training programs for students or professionals?

Yes. One way the MHPF is currently supporting professional development of students is through an internship program at Florida A&M University where the emphasis is on the development of research skills related to assessing and analyzing disease and health problems that primarily affect disadvantaged populations. This includes the human affects associated with environmental pollution, environmental and occupational health concerns, and health promotion and disease prevention through community involvement and education. Through the internship process, students learn about public health data sources, such as medical data, environmental data and survey data.

Part of the foundation’s mission is to support research. What is MHPF doing now in terms of research?

The Foundation is participating in a Cooperative Agreement with the CDC/Agency for Toxic Substances and Disease Registry where research projects in the MHPF member institutions are being undertaken to understand the link between exposure to several hazardous substances and their human health effects. Results will reduce the uncertainties of public health assessments and will provide the most effective measures to prevent or mitigate the adverse human health effects of these toxic substances. Lead exposure, for example, remains a significant health threat to the nation’s population, especially children. Yet it is not clear at what level of exposure this damaging effect occurs. The relationship between lead exposure and elevated blood pressure needs also to be clarified. Human studies at Charles Drew University of Medicine and Science and Morehouse School of Medicine as well as animal and cellular studies at the Colleges of Pharmacy of Texas Southern and Florida A&M Universities are being conducted to answer these uncertainties about lead toxicity.

An environmental multimedia study of lead, cadmium, zinc and manganese is being conducted at Xavier University College of Pharmacy. The aim of this study is to develop a comprehensive understanding of routes of exposure of toxic substances from an urban environment and from environmental media of soils, water, sediments and aquatic organisms to people. Analysis of these different environmental media in various areas of New Orleans revealed that these hazardous substances co-exist and are higher in the inner city regions. These findings have been shared with the scientific community through many peer-reviewed publications.

Health care has been changing a great deal in the last few years. How has this affected the evolution of the MHPF’s work?

We are about to develop a five-year strategic plan based on what we see in health care today and what the role of an organization like the MHPF should be. The health profession’s workforce is aging. We’ve got to ensure that a younger generation of minorities becomes a part of the workforce of the future.

We need to encourage, motivate and train young people to be a part of the health professions. People now who are in those professions are retiring, so we’ve got to get a new group of people in those fields.

Part of our challenge is getting the word out to young people. A lot of the kids just don’t know about the opportunities. We have a charge to make known what you can do. Students often say to us, “Oh, we never knew that these fields existed.”

At the symposium, we conduct over 16 workshops on different professions. In addition, one of the things we’re going to do with the Web site is highlight health professions. All of the kids who have ever attended a symposium can go to the Web site and access this information.

What do you see as Minority Health Professions Foundation’s primary task for the future?

I see our focus being how we can impact the health profession’s workforce. Even now we’re seeing that minorities are not appropriately represented. I think its been shown that people of the same ethnic group can better serve and identify with that group’s needs. It’s important that we increase the numbers of minorities who provide health care services so that minority populations are better served

Public Works

by | Mar 30, 2013 | Magazine

Even though it happened almost 30 years ago, Azella Collins, MSN, RN, can still remember one of the first patients she encountered when she was a young community health nurse working for a visiting nurses association. The man was living in a tiny apartment behind a printer’s shop in inner city Chicago. Although bedridden, he refused to go to a nursing home or live with relatives.

When Collins walked into the apartment, rats skittered in the corners as the elderly man struggled to sit up. The scene was so horrifying that she feared the rats would jump up on the bed at night and nibble his toes.

“I thought, ‘when I leave here, this man is leaving with me,’” she recalls.

Collins made arrangements with a nearby nursing home, whose director she knew, and persuaded the man that he needed to move to get the care he needed. By the end of the day he was out of the unsafe apartment and content in a clean bed in the nursing home.

Collins, who is second vice president of the National Black Nurses Association, has been a community and public health nurse for most of her career and is now an administrator for the Illinois Department of Public Health’s Illinois Perinatal HIV Elimination Program. Rather than working inside a hospital, Collins wanted to reach patients right where they lived, like the old man in the apartment, and to apply her skills and tenacity to help them get better.

Community and public health nurses work with individuals, families and groups, focusing on populations to improve the overall health of the public. They work for government agencies (such as county, state and city health departments and the U.S. Public Health Service), private nonprofit organizations, community-based clinics and in other settings. They teach people how to stay healthy and prevent disease and they collaborate with doctors, community leaders, teachers, social workers and other professionals and lay people.

The work they do runs the gamut, from vaccinating youngsters to teaching chronically ill patients about nutrition to advocating for the passage of legislation that will improve health care delivery. Public health nurses see the whole spectrum of life, from infants to geriatric patients, and they often work with the most underserved populations in the community.

“Community health nursing is so diverse. It requires everything you learn [as a nurse]. It uses all of you, and you never get bored,” says Aisha El-Amin, MSN, RN, who recently retired from a 40-year career in community health. Most recently she served as director of nursing for the Daughters of Charity Health Center at Carrollton in New Orleans, working with uninsured and underinsured patients.

She treasures memories of the proud mothers showing off their healthy school-age children, whom El-Amin had treated when they were infants, and the diabetes patients who successfully changed their lifestyles to lower their blood pressure and cholesterol. “They’d say, ‘Miss Aisha, look! Look at my weight!’ It was so rewarding when they would come back and tell their stories.”

Making a Bigger Impact

Nurses who have chosen careers in community and public health don’t just make a difference in individual patients’ lives. They impact entire communities, and this is what drives them forward to meet tough challenges.

“When I see families and communities empowering themselves to take care of their own health problems and advocating for themselves because we as nurses have helped them to do that, that is the most exciting thing,” says Kathleen Russell, DNS, RN.

Early in her career, as a young nurse in a public hospital in Indiana, Russell kept seeing the same patients with chronic health conditions, such as diabetes, being readmitted every three or four months because their conditions kept spinning out of control. As she learned about the challenges that minority and low-income urban neighborhoods faced to stay healthy, she yearned to the work in the community to make a difference through prevention.

After returning to school to get her master’s and then doctorate, Russell worked for county and state health departments. She also worked with the Indiana state health commissioner and the state legislature to develop county minority health coalitions to ensure that health care is provided in culturally and linguistically appropriate ways.

Now an associate professor at the Indiana University School of Nursing and president of the Black Nurses Association of Indianapolis, she continues to focus on improving the health of racial and ethnic minority populations, such as doing research on breast cancer screening among medically underserved African American women.

Edythe Harding, BSN, RN, also was drawn to public health nursing after she found that working in critical care in a hospital wasn’t quite the right fit. Even though she knew she was helping her patients in the hospital, she longed to do more for them. Two years ago, she took a job with the Mecklenburg County Health Department in Charlotte, N.C., and is now a clinical nurse supervisor working in family planning, women’s health and sexually transmitted disease prevention.

Harding, who is African American, likes the holistic approach of public health.

“We’re not just treating clients for the moment,” she says. “We’re getting to know them and what’s going on in their lives.”

In community and public health, nurses work autonomously and on interdisciplinary teams, often as leaders. They can also work in administrative roles, planning and managing efforts to serve populations.

Collins, for instance, works with agencies around the state to coordinate efforts to eliminate perinatal HIV transmission. She helps the organizations plan their programs, develop budgets and leverage other resources to sustain their work. Her role involves a creative mix of training, coaching and support, she says.

Strong Demand for Minority Nurses

Demand for community and public health nurses is high, and career opportunities in this specialty are expected to increase even more in the coming years. Experts believe more nursing services will shift from hospitals to community-based health centers, says Maxine Nunez, DPH, RN, a professor at the University of the Virgin Islands and secretary of the Association of Community Health Nursing Educators. Nunez, a native of the Virgin Islands, studied nursing in the United States and worked in community health on the mainland, then returned home to work and teach.

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Because public health nursing often involves working to improve the health of medically underserved and economically disadvantaged minority communities that lack access to private health care services, nurses of color can make especially strong contributions in this field.

“In order for us to understand the issues of populations of color and provide culturally relevant care, we’ve got to have nurses from those communities working alongside other nurses and professionals to help educate them about the cultures,” Russell explains.

There is also a strong need for more bilingual nurses, adds Harding. For instance, almost 50% of the patients served by her county’s health department speak only Spanish, so the department prefers hiring nurses who speak both English and Spanish.

While salaries in public and community health are lower than those for some hospital nursing positions, nurses who love their jobs in public health say the satisfaction they get from their work makes up for that. But getting enough funding to hire the staff with the necessary experience and education to make a real difference in the field remains a challenge for leaders in public health, Russell believes.

In most cases, nurses must have a BSN degree to work in community and public health, although some health departments are hiring nurses with two-year degrees because of the nursing shortage. Community health educators, though, recommend at least a bachelor’s degree, and Russell advises graduate-level education for nurses who want to hold leadership positions. “To make system changes, it takes advanced education,” she says.

Treating Patients on Their Own Turf

Community health nursingquick improvement

“You have to understand this concept: Growth and improvement are slow. Change is very slow, almost invisible sometimes. You have to look deep to see it,” El-Amin says. “You have to meet people where they are, and that’s what community nursing is all about. You give more than you think you can give.”

Public Information To learn more about community and public health nursing, check out the following organizations and online resources: The American Public Health Association (APHA), www.apha.org, offers news about public health issues, links to state public health associations, job and resume postings, journals and publications, a Community Solutions to Health Disparities database, plus information on public health standards, health policy, evidence-based practice, grants and more. Designed especially for nurses, APHA’s Public Health Nursing (PHN) Section, www.csuchico.edu/hcsv/, is an excellent introduction to the field. It provides information on the roles and functions of public health nurses, standards of practice and PHN competencies, as well as links to online journals and PHN publications, such as a community health nursing textbook. The U.S. Public Health Service Nursing Web site, http://phs-nurse.org/, contains information about career opportunities in the Public Health Service’s Commissioned Corps, a national nonmilitary uniformed service of public health professionals. The site also includes lists of employment opportunities, a listserv and information about the PHS Nursing Mentoring Program. The Association of Community Health Nursing Educators (ACHNE), www.achne.org/i4a/pages/index.cfm?pageid=1, provides a meeting ground for nurses committed to excellence in community and public health nursing education, research and practice. The association provides networking and educational opportunities through a newsletter, publications and an annual conference. The Society for Public Health Education (SOPHE), www.sophe.org, is an international professional association of health education professionals and students, with an emphasis on public health education. The services it provides include continuing education and training opportunities, scholarships and fellowships, and several Special Interest Groups, including one on cross-cultural health.

Nurses must also be able to assess both individuals and groups, and they must be self-confident, creative and forward-looking, Nunez emphasizes.

“You have to figure out how you are going to address not only the public health problem that’s currently on the scene but also the next one arising,” she explains. “You have to be able to work not only in the here and now but begin to visualize what you will see in the future.”

Cultural sensitivity is critical, because community health nurses work with extremely diverse populations. For instance, Harding tells of a patient from an African nation whose husband did all the talking in the consultation about contraception. To treat the woman patient, she had to respect the culture and communicate through the husband.

Working in a community setting means nurses will not only encounter different cultures but also widely varying lifestyles within those cultures. “I stopped being judgmental toward patients a long time ago. Once I did, doors opened for me,” says Chris Ortiz, PhD, RN, PHN, who worked as a community health nurse for a public health department and for hospice and home health agencies. She is now an assistant professor at California State University, Fresno.

Nurses who are used to providing care in a hospital setting will find that the tables are turned when working with patients where they live, Ortiz continues. “In acute care, nurses have a captive audience. We label patients, dress them, tell them what to eat. But in the home, we’re the guests. We’re coming into their world. You have to listen—really listen—to the patient.”

As a home health and hospice nurse, Ortiz made home visits in tough neighborhoods, such as the Tenderloin district in San Francisco. She found that by showing respect to her patients, they responded with respect for her. Often patients would send someone into the street to meet her and escort her to their apartment.

But she also needed to maintain strong boundaries. She recalls once having to leave a home because the air inside was thick with marijuana smoke. Without condemning the people, she explained why she couldn’t stay, and the patient called later to apologize. “You have to be willing to walk into any situation and be able to size it up,” she notes.

Russell says community and public health nurses must have a sense of social justice and responsibility, and they can’t fall into blaming the victims. They must also be good problem solvers, have excellent negotiation skills and be able to work with other professionals and organizations as part of a team.

To be effective in community health, nurses must also guard against burnout. El-Amin says she had to learn that she couldn’t do everything. “All I could do was do my best in the time I had.”

Getting Involved

Russell advises nurses who are considering careers in public health to get involved in their communities by serving on the boards of neighborhood associations and community agencies. She also recommends that they participate in professional organizations to advocate for eliminating health disparities and for improving the quality of life for disadvantaged families and communities.

Ortiz suggests talking to nurses who work in public health, home health and hospice to get a feel for the specialty and whether it might be a good fit for you.

Many years have passed since Azella Collins helped the elderly man in the rat-infested apartment find a safer place to stay. Yet her passion for public health nursing is still as strong as ever. “I really do love this,” she says.

Trialblazers

by | Mar 30, 2013 | Magazine, Minority and Community Health, Nurse Recruitment

Deborah Dawson, MSN, RN, is a special nurse with a very special career. As a clinical trials research nurse for the Diversity Enhancement Program (DEP) at Ohio State University’s Arthur G. James Cancer Hospital and Richard J. Solove Research Institute–known as The James–she is making a difference in the lives of many people who, until recently, were often overlooked: minority cancer patients.

Dawson, who is African American, says she wanted to be a clinical trials research nurse because it would enable her to enhance communications and cultural relations between The James and local minority and medically underserved communities in the Columbus area.

“Caregivers who are of the same race or cultural background as minority patients are often able to establish a greater level of trust with them,” she explains. “These patients often feel more comfortable when they can talk with someone who understands their background, customs and beliefs. [In my role] within the DEP, I am able to work with these patients and establish that trust. It’s extremely rewarding.”

The James launched the Diversity Enhancement Program in 2003 to raise awareness of cancer prevention, early detection and treatment in minority communities, with an emphasis on increasing minority participation in clinical trials. One of the program’s early objectives was to recruit more minority staff like Dawson to help patients feel more welcome, at ease and understood.

Historically, cancer patients of all races have sometimes been reluctant to participate in clinical trials–either out of fear of the unknown or a concern that they may be used as “human guinea pigs.” These fears are often magnified among minority patients, who may feel that majority health care personnel do not understand their culture and specific needs.
People who have these misgivings may not realize that clinical trials can offer improved outcomes for cancer patients. This is especially important for people of color, who are disproportionately affected by this disease. For example, according to the American Cancer Society, African-American men have a 20% higher incidence and a 40% higher death rate from all cancers combined, compared with Caucasian men.

The DEP is a multifaceted initiative that is working to reduce minority cancer disparities on several fronts. It has five objectives:

1: Recruit Minority Staff Members

Many health care professionalsoncology

To change these attitudes, DEP staff members work with health system recruiters and students in local health care education programs to improve their perception of oncology and to emphasize the opportunities that exist within this field. Staff members also mentor student nurses through the Columbus Black Nurses Association as a means of sharing their enthusiasm for cancer nursing.

Bringing culturally diverse nurses into the fold is mutually beneficial, according to Melissa Lowe, nurse recruiter at The James. “While nurses who share cultures with minority patients can help put patients at ease, the DEP’s mission also presents a unique opportunity for nurses,” she says. “Nurses with a special interest in reaching out to minority groups find working with the program very fulfilling.”

2: Promote Cancer Awareness and the Benefits of Routine Cancer Screening

Because cancer can be so devastating, people naturally fear it–perhaps more than any other disease. They therefore are often reluctant to visit, or seek information from, any facility where cancer is diagnosed and/or treated. The DEP is working to remove the mystery and fear associated with cancer by communicating the advantages of routine cancer screenings, early detection and lifestyle changes throughout the community.

DEP staff members have made presentations at senior centers, public schools, local colleges and universities and to associations of medical professionals. Other outreach efforts have included a seminar series specifically designed for African-American men. The DEP successfully recruited seminar attendees through grassroots outreach to churches, social groups and African-American fraternities.

In addition, the DEP sponsors a monthly hour-long radio program, “It’s All About Health,” which airs on a local gospel station. Hosted by William J. Hicks, MD, medical oncologist and co-director of the DEP, the show addresses cancer-related topics, including cancer types, cancer prevention and screening. Dawson, a regular guest on the show, presents information about specific clinical trials and how individuals may participate, as well as the important roles research nurses have in the clinical trials process. On another station, the DEP sponsors “Medical Minute,” a series of 60-second cancer-awareness messages.

“We want to make the public aware that what works for Caucasian patients may not work for African Americans and other minorities–and vice versa,” says Dawson. “Data collected during clinical trials can help determine different patients’ reactions to specific drugs and methods of treatment and improve outcomes for everyone.”

Dawson has received many calls from listeners who have heard the radio program and want more information. The show has prompted people to seek more details about the trials, the criteria for participation, the length of the studies and how the research can benefit them. “The radio program has helped listeners to link names and personalities with The James,” Dawson adds. “It has been a great tool for communicating with the public.”

3: Provide Cultural Competency Training

To help staff members at The James better understand the unique cultural needs of their patients, the DEP provides cultural competency training to boost comfort levels and enhance communication among caregivers, their patients and patient families.

For example, it’s helpful for hospital dietitians to understand why many African-American patients add animal fats such as pork grease to their vegetables and greens during preparation. Even though the practice is unhealthy, this cooking method dates back to a time when slaves received the leftover ingredients that were not used to prepare their master’s meals.

While some topics, like the origins of dietary and other health-related customs, can be uncomfortable for some minority patients to discuss with health care providers, cultural competency training enables nurses, physicians and others to explore and discuss lifestyles and habits of people from diverse backgrounds so these professionals are better prepared to approach and discuss treatments and alternatives with their patients.

4: Accelerate Minority Enrollment in Clinical Trials

Clinical trialscancer clinical trials

The DEP also has several ongoing outreach programs, such as monthly presentations to individuals at Maryhaven, an addiction treatment and mental health facility in Columbus. Although the main discussion may focus on a specific type of cancer, presenters will mention clinical trials as an opportunity.

The DEP’s “Grandma’s Hands” program also reaches out to minorities and medically underserved individuals. Funded by a grant from the Columbus affiliate of the Susan G. Komen Breast Cancer Foundation, “Grandma’s Hands” includes 10 volunteer grandmothers who have agreed to help present breast cancer awareness programs to women in their communities.

The idea of using grandmothers to communicate the clinical trial message originated from the words of a popular song that talks about the wisdom among the grandmother population and how these women can influence their families, friends and communities. During the “Grandma’s Hands” sessions, a DEP presenter talks about breast cancer, cancer prevention and the opportunity for cancer patients to become involved in clinical trials.

The presentation is followed by a group activity selected by the grandmother who hosts the session. One grandmother chose the activity of creating photo collages while another helped her group create quilt squares. “Grandma’s Hands” sessions are held in the hosting grandmothers’ homes, in participants’ homes, and at churches and other locations. The DEP has conducted these sessions, for example, at area schools and government offices. The DEP provides all invitations, snacks and any needed supplies.

In 2004, the DEP identified and educated 500 women through the “Grandma’s Hands” sessions. While the program has been targeted mostly toward African-American women, DEP planners hope to expand it to reach other medically underserved community segments.

The DEP has created educational tools for use in “Grandma’s Hands” sessions and other outreach programs. Participants receive awareness pins, designed by Ohio State University, that sport the red, black and green found in the flags of several African countries, along with pink to signify breast cancer awareness. Black represents the African people, red is a reminder of past bloodshed and green foretells the future and the hope represented by new programs that will help eliminate health care disparities.

These pins are great conversation starters. The program leaders ask participants to accept the pins with the promise that they will help spread the word about breast cancer prevention and the important role of clinical trials.

The James has also developed a video that staff members use to help recruit minority cancer patients for clinical trials. The video includes testimonials from several minority patients who have benefited from their participation in this type of treatment.

5: Encourage Researchers to Design Trials Specifically for Minorities

Many minority cancer patientsminority patients

Through regular communication, the DEP is encouraging researchers at The James to design studies targeted to patients who have health problems in addition to cancer. Developing protocols for patients with pre-existing conditions to participate in cancer trials would provide more opportunities for African Americans and other minorities to become involved in critical studies.

Planning for the Future

Although the DEP is still in its infancy, planning is underway to expand the program. For example, staff members are considering initiatives to reach more Latino, Asian and Native American populations. The DEP is also looking at ways to reach more African-American men through an existing program called the Men’s Health Initiative. This project will be expanded to provide education and screening information for all types of cancer to large groups of African-American men.

“Historically, the American health care system has not been set up to provide education to keep minority patients well,” Dawson says. “Education is an area where minority nurses and other health care professionals can really make a difference in communicating with minorities and the underserved in our communities and in helping to improve cancer outcomes for current and future generations.”

Divine Inspiration

by | Mar 30, 2013 | Magazine

Linda Smith, BSN, RN, MBA, remembers the exact date and time that she decided to start her own health care college. It was 1:05 a.m. on July 31, 1991, when Smith says God called her by name.

Smith, a native of San Bernardino, Calif., and founder, president and CEO of Four-D College in Colton, Calif., says she had recently gone through some difficult times and had asked God to help her use her skills as a nurse to make a major difference in someone’s life. She sat down on that late July night and began to write.

“The mission statement that hangs in Four-D College is what I wrote that night,” she explains. “I wanted to create an opportunity for entry-level education in nursing and allied health, and I wanted to create an avenue where individuals are able to continue their education.”

Today, Four-D College graduates between 200 and 250 students a year from its licensed vocational nurse (LVN) program and several other allied health programs. The college is accredited by the Accrediting Bureau for Health Education Schools (ABHES) and the Department of Education. The vocational nursing program is accredited by the Board of Vocational Nurses and Psychiatric Technicians (BVNPT).

Cynics might dismiss Smith’s story of divine inspiration. But even the most jaded unbeliever would have to admit that the things Smith has accomplished over the past 14 years are phenomenal, and that the unexplained ways in which events have unfolded are, at the least, unusual–and at the most, possibly even miraculous.

A Stroke of Luck

After writing the college’s mission statement that night, Smith next wrote the words “Four-D Success Academy,” the name she first gave the school that has gone on to graduate more than 5,000 students and currently employs a staff of 60. The four D’s stand for the Desire to achieve, the Determination to follow through, the Drive needed to maintain consistent efforts toward success, and the ability to Deliver by reaching one’s goals.

Soon after, Smith, who has been a registered nurse for 29 years, quit her job and began developing a certified nurse assistant (CNA) program that she planned to teach. She had done a little teaching before starting Four-D College, but not on the scale she would soon reach. She planned to convert her garage into a classroom until a state official told her that California law required her to hold classes in a building separate from her home. So she contacted a real estate agent friend and said she wanted to rent space in Claremont, on Foothill Street, and at the outrageously low rate of 50 cents per square foot.

Claremont is considered an oasis in the area. It’s a well-kept community and one that Smith lived in and wanted to be close to. But office space on Foothill Street was running $1 to $1.25 per square foot and her real estate friend doubted she would find what she wanted.

Two weeks later, the friend returned, astounded by the news he was about to deliver. He had found the 1,000 square feet of office space on Foothill Street at 50 cents a square foot, and the owner had even agreed to repaint the interior, install new carpet and put air conditioning units in each room. He also gave Smith four months free rent.

“The gentleman had never met me or talked to me,” she says. She met him right before moving in and thanked him for the free rent. “He just looked at me and said, ‘OK.’ I don’t think he had an explanation .”

In September 1992, Four-D College enrolled its first class, which consisted of two students. The free rent came in handy, because Smith had no revenues for the first three months. Two weeks before her rent was due she received her first payment from the county for a student she was training. She taught her two students in the morning, developed programs in the afternoon and did community outreach and marketing to attract more students. Six months later she had outgrown her space.

She moved the school to a larger location and by 1995 decided she needed even more space. She ended up in Colton in a 5,000-square-foot building where the rent was more than $5,000 a month. “I went there knowing I was going to have to work 10 times harder doing what I needed to do to make this work,” she recalls.

Counting Her Blessings

Fast forward to 2000. Because of the college’s continued growth, it was again time to move to a larger facility. Smith says she prayed for a 30,000-square-foot building with freeway access, parking for students and nearby restaurants. She also wanted it to be large enough to accommodate a childcare center, because difficulties in finding affordable childcare options were causing many of Four-D’s students to drop out.

Smith not only found a building, she decided to make an offer to buy it. She had tried to borrow money from banks in the past and had been turned down. Then she remembered a brightly colored flyer she had recently received in the mail. It said: “If you need a million dollars, call this number.”

She needed a million and more, so she called and left a message. A short time later, a loan officer from a bank called and they made an appointment to meet. Smith says she once again turned to prayer for help. “I walked into his office, he looked at my papers and in two minutes he said, ‘Linda, I think we can do this,’ and I almost fell off of my feet.”

The building would cost $1.6 million and Smith needed to come up with $200,000 on her own. The college had only $50,000 in its accounts and things were looking bleak. Then someone from the bank called to say the February 2000 closing would have to be delayed because of problems with the paperwork. “That was a big blessing for me because I did not have the money at that time,” she says.

In April, she attended a religious conference and decided to step into the main hall to listen to a speaker who was addressing a group of 1,500 to 2,000 women. “When I walked into the room,” Smith relates, “she stopped speaking and pointed to [me]. She said, ‘You in the back of the room, in the white suit and the salt-and-pepper hair. God has a word for you. God told me to tell you that you have been a true and faithful servant and your blessings are coming.” Smith says the woman told her that she would receive a blessing in 21 days.

Twenty-one days later, on April 24, 2000, Smith got a call from the bank telling her she had qualified for the loan. And by June of that year, Four-D College had moved to its present location at 1020 E. Washington Street in Colton.

This time, even Smith herself was a little nonplussed by this latest “miraculous” occurrence. “It’s hard for me to explain how this happened,” she says.

Helping Students Succeed

Four-D College is the first and only African American-owned vocational college in California that is licensed to teach vocational nursing and other allied health programs. In addition to the LVN program, the fully accredited college helps prepare students for careers as medical assistants, dental assistants, pharmacy technicians, medical billing specialists and health claims examiners. Four-D also has CNA and home health aide pre-certification programs and offers 30 continuing education courses on subjects like cardiopulmonary disease, congestive heart failure, IV therapy and more.

Both Smith and her college have received many awards and honors through the years. To cite just a few examples, in 1997 Four-D College was named the Outstanding Business in San Bernardino County by the Private Industry Council, as well as Outstanding School of the Year by the City of San Bernardino. In 2001, Smith received an award from the San Bernardino Black Culture Foundation honoring her for her contributions to the African American community. And in 2004, she received the Wells Fargo/Turning Point Living History Maker Entrepreneur Award.

Helping low-income people get off welfare was one of Smith’s primary goals in starting Four-D College. The school now has an enrollment of around 330 at any given time. The student body is roughly 40% African American, 20% Hispanic and 20% Caucasian. The rest of the students are Samoans, Asians and people of other ethnicities. Between 80% and 90% of Four-D students qualify for financial aid.

Smith says her students face a host of problems that make graduation difficult. Some are on welfare. Others come from broken homes. Some live with an abusive mate, while others have difficulty meeting family obligations. And then there are those who have poor study habits, lack basic math and reading skills or aren’t willing to apply themselves. According to Smith, most programs at Four-D College experience a dropout rate of 10% to 20%, while the dropout rate in the LVN program is around 30%.

Therefore, the college has developed a number of programs designed to help students overcome these barriers to success. Four-D offers such support services as an on-site childcare center that cares for 50 kids a day, financial aid, tutoring for students who need to improve their basic math skills and an “Encouragement Committee” to help struggling students.

When a student is referred to the committee, says Smith, “that student is told they’re not coming in for disciplinary issues. They’re coming in because we want to find out from them what is going on and how we can help them improve their attendance or their academics.”

The Encouragement Committee often finds that students are having problems with issues such as finances, marital difficulties or transportation. The school helps by providing counseling, paying for car repairs, providing gas money or assisting with whatever else is needed. In one instance, Smith herself paid a student’s rent for six months. The student graduated as valedictorian, passed the boards and got a job.
“We have to show our students that we really do care about them and that’s the cost of doing business,” Smith emphasizes.

She believes students should not only be taught what to do but why they’re doing it. If you teach a student theory, she says, their work will have more meaning and they’ll perform better. She also believes that the faculty’s attitude is critical in helping students succeed.

“I know that what a faculty member says and does to a student can have a lifetime effect on them,” she explains. “I strive very hard with my faculty to make sure that the message we send to the student is a positive message. You can have as negative and devastating an effect on an adult as you can on a child if you don’t think they can do well.”

It’s important to send positive messages to students in nonverbal ways as well, Smith adds. She makes sure the Four-D campus is clean and well maintained, and the faculty dresses in a professional manner. Students are not allowed to use profanity and everyone is expected to show respect for one another.

Doing It All on Faith

Looking back over the years, Smith says she has endured many hardships to make Four-D College a success. She remembers one five-year “storm,” as she puts it, when financial difficulties and other troubles almost defeated her. Owing hundreds of thousands of dollars can literally drive you crazy, she says. “Only my husband and children know the tears and screams I let out in this house because I didn’t know how I could hold out anymore,” Smith remembers.

But these experiences, like everything else in Linda Smith’s life, have been part of a faith-building process. “My CPA recommended to me at least three different times that I should close the doors because I had no revenues,” she says. “I looked at him and said, ‘don’t you ever tell me to close again, because you don’t know the God that I know.’”

These days, Smith is focusing more on opening doors than closing them. She plans to establish a second branch of Four-D College this year, and a third within the next two years. She sees her efforts as simply a continuation of the desire she has had since age five when she first realized she wanted to become a nurse: “I just knew in my own spirit that I wanted to grow up and help people.”

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Till Death Do Us Part

by | Mar 30, 2013 | Magazine

As a Chinese American patient neared death in a nursing home, her family members wanted to follow their Buddhist tradition of gathering around their loved one to chant for 12 hours before and four hours after her passing.

It was an unusual request for the nursing home, but hospice nurse Saijing Xu, RN, CHPN, made sure the family’s wishes were honored. She worked with the facility’s staff to move the patient to a private, single room where her relatives could be alone with her before and after death. For the family, this was priceless. They believed the chanting would help their loved one’s soul pass to heaven and bless the younger generation.

As a case manager and nursing liaison for Beacon Hospice in Boston, Xu helps terminally ill patients achieve the best quality of life possible in their last months, weeks and days. She also plays an important role in reaching out to diverse communities. Numerous studies have shown that Americans of color are far less likely to use hospice care than the Caucasian majority population. Minority nurses such as Xu, who speaks Mandarin and Cantonese, can help bridge the gap by providing culturally and linguistically competent care that is sensitive to these patients’ customs and beliefs about death and dying.

Hospice and palliative care nurses provide pain management and comprehensive, holistic care in the final stages of life. They work as members of interdisciplinary teams with physicians, chaplains and social workers to address patients’—and their families’— physical, social, emotional and spiritual needs as they face terminal illness and bereavement.

This specialty encompasses a broad spectrum of nursing professionals—from nursing assistants to advanced practice nurses—and their numbers are growing rapidly. Membership in the Hospice and Palliative Nurses Association (HPNA) has tripled in the last seven years, says the association’s CEO, Judy Lentz, MSN, RN, NHA. She estimates that 20,000 nurses currently work in the specialty, including 14,000 who are Certified Hospice and Palliative Care Nurses (CHPNs).
The hospice care movement in the United States began about 30 years ago and has evolved slowly. “In America, people don’t like to talk about dying,” Lentz says. “Less than 30% of terminally ill patients receive hospice care, and those who do receive it are getting an average of only five to six weeks. Medicare covers hospice care for the last six months of life.”

With the government defining hospice care as the last six months of life, the newer specialty of palliative care emerged about 10 years ago to address the needs of patients who are who have incurable, progressive illnesses but are not yet ready for hospice. It is aimed at providing comfort and symptom relief rather than a cure.
“What palliative care is all about is the patient and [his or her] significant others defining what they want as their goals for the remainder of life,” Lentz explains. “It’s not what medicine tells you [should be done], but what the patient wants.”

Hospice nurses provide care in patients’ homes, long-term care facilities or in hospice units. Palliative care nurses practice in hospitals, nursing homes and rehabilitation units. Nurses in both specialties may also work as end-of-life care educators and researchers.

Breaking Down the Barriers

A variety of issues have led to the disproportionately low use of hospice care in communities of color. Among patients who died while in hospice care in California, the most ethnically diverse state in the nation, only 4% were Asian American, 6% were African American and 15% were Hispanic, according to reports commissioned by the California HealthCare Foundation. The vast majority—74%—was white.

To help Latino families remember their loved ones who have passed away, Central Texas Medical Center Hospice celebrates the traditional Mexican Day of the Dead holiday.

The researchers found that many black and Hispanic patients wanted aggressive, life-prolonging treatment, which is often not covered while patients are in hospice care. Some minority patients mistrust the health care system, fearing that hospice and palliative care may be a form of discrimination because it does not focus on a cure.
Cultural differences also play a role. “We [Latinos] take a lot of pride in taking care of our elders and our sick,” says Linda Lopez, MSHP, MSN, RN, director of the Central Texas Medical Center (CTMC) Hospice. Many Latinos, she explains, don’t want outsiders taking away their role as caregivers. Sometimes family members refuse the services available through hospice because they feel like they are the ones who should provide that care.

Language differences can also create barriers. For example, according to a recent report on National Public Radio, there is currently no word for “hospice” in Spanish. Furthermore, recent immigrants may be unfamiliar with the U.S. health care system, and with the concept of hospice care in particular.

“For Chinese patients and their families, hospice is new,” Xu says. “A lot of them do not know that hospice services are available.”

A growing number of hospice and palliative care programs are working hard to reach out to diverse communities—and minority nurses are playing a key role in these efforts.

About 40% of the population in San Marcos, Texas, where CTMC Hospice is based, is Latino. Lopez, a retired college educator, is hiring more bilingual caregivers and educating her staff about cultural beliefs and traditional health practices, such as the use of herbs and folk remedies. Some Latino families, for instance, believe that receiving shocking news can result in a “fright illness” called susto. The remedy requires a ceremony in which a healer, often the eldest female member of the family, prays over the person and brushes the body with a bouquet of fresh herbs, such as basil.

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When nurses demonstrate cultural knowledge, it lets the patients know their ways are accepted, Lopez believes. “If they know we understand, the relationship is stronger, which can only be a benefit to the patient and family.”

To help Latino families cope with bereavement, CTMC Hospice celebrates the Day of the Dead (Dia de los Muertos), a traditional Mexican holiday in which families remember their loved ones who have passed away. Last year the hospice partnered with the Hispanic Chamber of Commerce and local restaurants to sponsor altars where community members could place artifacts representing the lives of their loved ones. The event helps educate the community about hospice and allows people to express their feelings, Lopez says.

Beacon Hospice, the largest provider of end-of-life services in New England, began a concerted outreach effort to local minority communities two years ago. The hospice opened an office in Roxbury, a primarily African American neighborhood in Boston, and staffed it with mostly African American nurses and home health aides. Beacon also hired more bilingual nurses to provide linguistically competent care in Asian, Latino, Portuguese and French-speaking communities.
“When someone is at the end of life, the patient should not have to struggle to understand the nurse. The nurse should understand the patient,” says Betty Brennan, the hospice’s president and CEO.

As more minority families become aware of the benefits of hospice, they help spread the word. Stephanie Harriston-Diggs, who is African American, began volunteering for Beacon Hospice after her grandmother received care there. She spoke passionately about the service to friends and is now the hospice’s public relations director and president of its Lighthouse Foundation.

Hospice Nursing in Indian Country

In the Midwest, Hospice of Siouxland has been working to reach out to local American Indian communities. The hospice serves a 60-mile radius around Sioux City, Iowa, including two Indian reservations in Nebraska. But until recently, very few of its patients were tribal members.

With grant funding from the Nebraska Department of Health and Human Services, the hospice partnered with the Omaha and Winnebago tribes to create a culturally sensitive palliative care program. Before the program existed, tribal members with serious chronic diseases made frequent trips to the hospital emergency room. But when palliative care became available, they were able to manage their diseases better. The number of hospital visits dropped and the patients’ quality of life improved.

The hospice’s staff learned about the cultures of the tribes and worked with local hospitals to help accommodate tribal customs and rituals. For instance, when tribal members wanted to perform a smudging ceremony—a ritual purification that involves burning cedar, sage or other herbs and is believed to create a more peaceful transition to death—for a patient in a hospital ICU, hospice nurses explained the cultural reasons for the ceremony to the hospital staff and persuaded them to temporarily relax their fire safety rules so that the ceremony could take place.

“The team really became advocates,” recalls Hospice of Siouxland director Linda Todd, RN, BA.

There is a great need for more Native nurses who can work in palliative and hospice care programs in Indian Country, Todd adds. Her hospice is now working with Briar Cliff University in Sioux City to create scholarship opportunities for Indian students interested in nursing or social work.

“The Heart of Hospice”

Hospice and palliative nursing isn’t for everyone. Nurses who want to focus on end-of-life care must be mature enough to have come to terms with their own mortality and to have had some experience with death and dying.

“[At Beacon], we really look for people who have what we call ‘the heart of hospice,’” says Brennan. “It’s an element that goes beyond being a caregiver. It’s a real desire to promote the highest quality of living in the last days of life.”

Lucia Stevens, RN, CHPN, began her nursing career in cardiac surgery, then worked as a nursing director at a nursing home. But because she yearned to care for patients in a more holistic way, she became a hospice nurse for Beacon. “Hospice addresses everything that’s going on with the patient—spiritually, psychosocially and physically,” she says.

Resources on the Web Hospice and Palliative Nurses Association
http://www.hpna.org National Resource Center on Diversity in End-of-Life Care
http://www.nrcd.com Palliative Care: One Vision. One Voice.
http://www.palliativecarenursing.net End-of-Life Nursing Education Consortium (ELNEC)
http://www.aacn.nche.edu/elnec

Nurses in this specialty form strong bonds with patients and their families. Stevens, who is African American, recalls one patient, a woman from Barbados who came to the U.S. with her husband for medical treatment and had no family nearby. Stevens cared for her for six months. “She was around the age of my mom, and we bonded so quickly. She started calling me her daughter.”

In her current position as account manager for Beacon’s South Boston office, Stevens meets with community members in the Roxbury and Dorchester areas to educate them about the benefits of hospice care.

Many people assume that working in end-of-life care would be depressing for nurses because their patients die. Certainly, hospice nurses do grieve. But the emphasis is really about making the most of life.

“You’ve got to live as if this is your last day—patients teach us that every day,” Lopez says. “We’re very blessed [to be caring for these patients] because they teach us so much about living.”

For Xu, the reward comes from knowing she made the most difficult time in someone’s life a little easier. “[It’s good to know] I helped a person leave this world with some comfort,” she says. “I know I made a difference in not only the patient’s life but also in the family’s life.”

Hospice and Palliative Nursing 101

Betty Davieslung cancer

Nothing in her schooling had prepared her for this. Not knowing what to do, Davies lowered the head of the bed because she had seen nurses do that on TV, and then went to get help.

She later thought, “If caring for people who are dying is part of nursing, why aren’t nursing schools teaching it?”

For many years, nursing curricula did not emphasize end-of-life care. But that’s starting to change. There are currently 10 master’s degree programs around the country that focus on palliative and hospice nursing, as well as many certificate programs in the specialty, says Judy Lentz, MSN, RN, NHA, who is CEO of the Hospice and Palliative Nurses Association (HPNA).

In 2000, the American Association of Colleges of Nursing (AACN), in partnership with City of Hope National Medical Center of Los Angeles, launched the End-of-Life Nursing Education Consortium (ELNEC) project, a national “train the trainer” initiative designed to provide nursing school faculty and other nurse educators with training in end-of-life care so that they can teach this information to nursing students and practicing nurses. As of April 2007, over 3,700 nurses coast to coast have received ELNEC training.

Davies, who has spent much of her career researching and working in end-of-life care, is now a professor in the Department of Family Health Care Nursing at the University of California, San Francisco, which recently started a new acute care pediatric nurse practitioner program with an emphasis on palliative care. She says the school recognized that many pediatric NPs were getting jobs in hospitals but didn’t have the training for acute care. Because most children who die do so in the hospital, nurses working in these settings need to know how to address end-of-life issues.

“Nurses play a critical role in how families deal with the death of a child,” Davies explains. “Just by what they say and do, they can send a family on a course of bereavement that’s either helpful or not. If anyone needs to know about death and dying, it’s nurses.”

Excelsior College, an online college based in Albany, N.Y., recently launched a Hospice and Palliative Care Certificate Program with a strong focus on cultural competency and serving the needs of diverse communities. In creating the program, which was funded by a grant from the U.S. Department of Labor, the school contacted hospices around the country to learn which concepts should be included in the curriculum. “One of the [most important ones] was culture,” says Deborah Sopczyk, PhD, RN, director of the college’s Health Sciences Programs. “This was something hospices told us again and again.”

Excelsior staff and faculty also visited hospices that provide exemplary care to minority populations, such as Hospice of Siouxland and the Central Texas Medical Center Hospice. The certificate program includes case studies and video clips based on these hospices’ best practices to teach students about the importance of addressing cultural issues at the end of life.

“We were very careful not to use a cookie-cutter approach,” Sopczyk says. Students are taught to not make assumptions that all members of a particular ethnic group share the same beliefs.

For instance, the Omaha and Winnebago Indian tribes served by Hospice of Siouxland take opposite approaches to grief. The Omaha tribe believes tears help the passage of loved ones to the next world. They often cry and wail to express their grief in the presence of their loved ones, says faculty member Linda F. Kennelly, PhD, RN. The Winnebago, however, try not to cry, because they believe tears may block the dying person’s passage into the next world.

Excelsior College has also worked with the Rainbow Access Initiative to teach nurses how to provide hospice care that is sensitive to the needs of gay, lesbian and transgendered patients and their loved ones.

A University of California, San Francisco study found that California hospitals in areas with large minority populations are more likely to be overcrowded and divert ambulances, delaying timely emergency care.

The study, published in the August issue of Health Affairs, examined ambulance drivers in hospitals around the state to assess whether overcrowding in emergency rooms disproportionately affects racial and ethnic minorities. Researchers say this is the first study using hospital-level data to show how diversion affects minorities, and research found minorities are more at risk of being impacted by ER crowding and by diversion than non-minorities.

Ambulance diversion takes place when hospital emergency rooms are too busy to accept new patients, so they’re rerouted to the closest available ER. This is especially common in urban areas.

Researchers looked at 2007 data from 202 hospitals around the state, which showed hospitals that served the greatest percentage of minority patients turned away ambulances because of overcrowding far more than those that served the smallest number of minorities.

Researchers found that 92% of the hospitals experienced a median diversion of 374 hours over the course of the year. Those serving high numbers of minorities experienced ambulance diversion for 306 hours, compared to 75 hours with fewer minority patients.

Lead author Renee Y. Hsia, M.D., assistant professor of emergency medicine at University of California, San Francisco, notes that these diversions put patients suffering from conditions like heart attack or stroke at a much higher risk. “Minutes could mean the difference between life and death,” she says in a press release.

There are several reasons that cause emergency rooms to become overcrowded. First, many patients—especially those who are uninsured and don’t have access to primary care services—end up there for less urgent reasons or serious conditions that could have been treated earlier. Additionally, hospitals lack the proper staffi ng to admit patients into the hospital, so patients are stuck waiting. Lastly, hospitals sometimes don’t have the equipment or services needed to treat specifi c medical problems.

The study authors say their research points to the need for systemic reform, including better management of hospital flow and statewide criteria regulating diversion policies.

Spike in maternal opiate use, infant withdrawal

by | Mar 31, 2013 | Magazine

Researchers at the University of Michigan Health System, Ann Arbor, and the University of Pittsburgh found maternal opiate use had increased nearly five-fold between 2000–2009. Researchers call the increase an “epidemic,” and subsequent neonatal abstinence syndrome (NAS) and hospitalization costs saw substantial growth as well.

The study cites research from the Substance Abuse and Mental Health Administration showing just over 16% of pregnant teens and 7.4% of pregnant women aged 18–25 used illicit drugs. When those drugs were used during pregnancy, newborns experienced a higher risk of “adverse neonatal outcomes,” including low birth weights, as well as withdrawal symptoms such as respiratory and feeding problems, seizures and tremors, and increased irritability. Among those fetuses exposed to heroin or methadone, 60%–80% displayed these and other NAS characteristics.

The number of newborns experiencing NAS increased three-fold during this same period, from 1.2 to 3.39 per 1,000 hospital births annually—that’s roughly one birth every hour. Medicaid covered almost 80% of the infants and their mothers, and 36.3% lived in the lowest-income areas. Associated hospital costs for these newborns, who “experience longer, often medically complex and costly initial hospitalizations,” increased by 35%, from $39,400 to $53,400 per year. Total costs, as adjusted for inflation, grew from $190 million to $720 million.

The researchers called for increased public health measures, particularly regarding initial exposure to opiates, and considerably more research. Results of this study can be found in the Journal of the American Medical Association. It was presented at the Pediatric Academic Societies Annual Meeting in May. Visit http://jama.ama-assn.org for more information.

Minority Children’s Health Gets Poor Report Card

by | Mar 30, 2013 | Magazine

In the year 2000, 86% of Caucasian children in the U.S. were reported by their parents to be in excellent or very good health, compared to only 75% of Hispanic children and 74% of African-American children. In addition, about 70% of youngsters from families living below the poverty line were reported as being very healthy, while the figure for children in higher-income families was 85%.

These are some of the key health-related findings of the sixth annual America’s Children: Key National Indicators of Well-Being report, published in July 2002. Compiled each year by the Federal Interagency Forum on Child and Family Statistics, the report monitors the status of the nation’s children in several critical areas, including health, education and economic security.

Other interesting minority health statistics in the study include:

• The percentage of low-birthweight babies varies widely within Hispanic and Asian/Pacific Islander subgroups. For example, women of Chinese origin had the lowest percentage of low-birthweight infants (5.1%) while women of Filipino descent had the highest (8.5%).
• In 2000, birth rates for pregnant teen girls ages 15 to 17 were 16 per 1,000 for Caucasians, compared to 40 for Native Americans, 52 for African Americans and 60 for Hispanics.

Copies of the 2002 America’s Children report are available from the Health Resources and Services Administration Information Center while supplies last; call (888) Ask-HRSA or email ask@hrsa.gov. The complete report can also be accessed online at http://childstats.gov.

Helping At-Risk Kids Get “Teen Smart”

by | Mar 30, 2013 | Magazine

Editor’s Note: This article, which is adapted from the research paper “Using a Web Site to Enhance Adolescent Health Promotion in an Inner-City High School,” was written by a group of culturally and ethnically diverse student nurses at the University of Washington School of Nursing in Seattle, in collaboration with the nurse practitioner and two health educators from the high school where the “Teen Smart” Web site project was implemented. The nursing students’ project was supervised by University of Washington Associate Professor Cathy Strachan Lindenberg, RN, DrPN, a Hispanic nurse of Costa Rican descent.

Today, at the dawn of the 21st century, the Internet is a major presence in our world and in our personal lives. It has already transformed the way we perform such day-to-day activities as buying books and CDs, checking the weather and chatting with friends. In the near future, the Internet will become an even more integral part of the way our society gathers information and communicates, with computer terminals available on airplanes, in every library and in every classroom.

The advent of the Internet as a daily presence in our lives has created unprecedented opportunities to transmit and share critical information, especially in the domain of health education. Physicians, nurses, corporations and health care agencies alike are now equipped with a powerful new tool for reaching large sectors of the population quickly and simultaneously.

Teenagers are one special population who are taking full advantage of the benefits the Internet has to offer. Adolescence is a crucial time in a person’s life when we first begin to develop a strong sense of individuality as we transition from childhood to adulthood. During this often turbulent and confusing period, lifelong patterns of problem solving and health habits are developed.

According to the Centers for Disease Control and Prevention, six common risk behaviors contribute to 75% of morbidity and mortality in the United States: tobacco use, alcohol and drug use, risky sexual behaviors, lack of physical exercise, poor nutritional habits and intentional and unintentional injuries. Many of these behaviors are established during adolescence and persist into adulthood. Because teenagers’ problem-solving abilities are not fully developed, they are at higher risk than adults for such serious health problems as substance abuse, sexually transmitted diseases, unwanted pregnancies and poor nutrition. Racial and ethnic minority teens growing up in disadvantaged or medically underserved communities are often at especially high risk, because of their unequal access to health care services and education about health issues.

Because most of these risky health behaviors are preventable, providing high-risk teens with information on health promotion is crucial. Today’s teenagers’ medium of choice, the Internet, with all its interactive possibilities, is the ideal vehicle for getting the word out in a format that is irresistible to young people.

In a recent article in the journal Adolescent Medicine, D.N. Paperny noted that “Adolescent health education, both problem-based and preventive care, in the new millennium will likely be predominately multimedia-based, making it accessible … to adolescents for use in their home computer. . .The computer can act as a mediator to facilitate mature, informed decision-making for adolescents without [their] suffering the embarrassment or actual consequences of poor health choices.”

These were the factors that prompted a group of University of Washington nursing students to explore the feasibility of developing a health promotion Internet site for at-risk teens that could be used to enhance health education in the high school classroom and also provide a source of confidential information for students who are hesitant to identify and discuss personal health problems, particularly those related to sex and drug use. The result was the “Teen Smart” Web site project, a community partnership with the faculty and students of Cleveland High School in Seattle’s Inner City.

Collaboratively developed and designed by a racially and culturally diverse group of students, faculty and staff from the nursing school and the high school, the bilingual (English/Spanish) Teen Smart site is located at www.son.washington.edu/teensmart. Minority Nurse readers can access the site for demonstration purposes only by logging on with the user name “chaz” and the password “chaz.”

Filling a Double Need

Cleveland High School serves a student body of 750 ethnically diverse and economically disadvantaged teens in grades 9 through 12. Forty-six percent of the students are Asian Americans, 31% African Americans, 12% Caucasians, 9% Latinos and 2% American Indians. Many of the students identify themselves as multiracial; many come from first- and second-generation immigrant families. With such a culturally diverse mix of students, one of the biggest challenges we faced in developing the health promotion Web site was to provide information that would be of interest to all students in a manner that all could easily access and use.

While the project’s primary purpose was health education, it was also designed to address another identified need: to enhance educational technology in a school where reading, writing and math scores fell below the state average. At the time, Cleveland High was one of only two schools in the district that did not have a Web site. Therefore, the creation of Teen Smart was envisioned as a catalyst to improve students’ computer literacy while simultaneously promoting adolescent health.

In the spring quarter of 2000, as part of a course in community health, the nursing students participated in a 10-week clinical rotation at the high school, where they interacted primarily with two health teachers and approximately 40 ninth grade students enrolled in two health class sections. Health education is a required curriculum element for all students and is taught in an interactive format that includes units on stress reduction, self-esteem, nutrition, fitness, smoking, alcohol, drugs and sex education.

The student nurses also collaborated with the nurse practitioner from the high school’s on-site Teen Health Center. This clinic, which is open year round, provides the students with primary health services as well as mental health, reproductive health, drug and alcohol counseling.

Building Trust

At the outset of the project, we determined that a vital requirement for the health promotion Web site’s success was gaining the teenagers’ trust. The student nurses spent a few weeks getting to know the high school students, both individually and as a group. We sat in on their health classes and engaged in activities designed to help us learn more about the teens’ health interests and needs. In addition, we familiarized ourselves with the school’s health education curriculum, teaching materials and methods through participative observation and meeting with the teachers weekly after each class session.

These activities allowed both the teachers and the students to get to know us better and increase the level of trust before we attempted to introduce the idea of the Teen Smart Web site to this group of students. Often, when individuals sense that someone is genuinely interested in their thoughts and behaviors, they are more likely to actively participate in the relationship. We felt that by gaining the students’ trust we could promote greater participation and openness to using the Teen Smart Web site to enhance their health knowledge and skills.

Once the basic framework for a trusting, open and mutually participatory relationship had been established, the next step was to determine which health topics the Cleveland High students were most interested in. We also wanted to find out where they obtained their information and what being healthy meant to them. To evaluate the needs and health concerns of students in the freshman health classes, we conducted focus groups using a semi-structured interview format.

The main areas of interest and concern the students expressed were issues related to weight, nutrition, drugs, sleep and sex (see “What Teens Want to Know About Health” sidebar). The recurring themes they cited as the meaning of good health were eating right, exercising and feeling good about oneself (good mental health). It is important to note that many of the students were reluctant to talk openly or expand upon sensitive areas of concern, such as sex and drug use, in a public focus group forum.

Computer-Savvy Kids

We then turned our attention to evaluating the high school students’ access to computers as well as the computer literacy of students in the health classes and the student body as a whole. We constructed a survey designed to elicit information on the students’ use of computers, knowledge of computers and frequency of use. This helped guide us in deciding what level of Internet instruction to provide to the students in their orientation to the Web site.

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To further determine whether or not a Web site was an appropriate venue for distributing health education information to these particular students, we also gathered demographic information, such as ethnicity and gender. This allowed us to assess whether the students who would be participating in the project were representative of the overall school population, and whether some groups would need differential approaches to instruction.

All of these pieces of information were vitally important to assessing the feasibility of integrating a Web site into the existing health class curriculum and teen clinic services. We distributed the computer use survey to the health classes and then to the entire school during a lunch period. Over 300 students participated in this voluntary and anonymous survey.

The results revealed that most students had high levels of access to computers and the Internet. Of the students surveyed, 99% had used a computer and 75% said they used the computer at least every week. Students used the computer most often for schoolwork, games and job-related information. In addition, 67% said they used the Internet at least once a week.

We also learned that 72% of the respondents had access to a computer at home, and 83% of those computers had Internet access. This was surprising given the high proportion of low- income and immigrant students in the school. Both genders were well represented in the survey as were the different ethnic groups found at the school.

Welcome to Our Web Site

After weeks of preparatory work, we were finally ready to invite and orient students to the Teen Smart Web site. For those students who were less experienced with using a computer and accessing the Internet, we developed simple instruction sheets. To engage the students’ interest and introduce them to the Web site’s wide variety of information and interactive components, we created special games and assignments tied in with each week’s health education classroom content.

The weekly assignments, which required the students to utilize different aspects of the Web site, included such activities as taking a health quiz, finding information on a topic related to what had been discussed in health class, asking an online question to a nurse, and/or analyzing a problem-based case study and posting their responses on a message board. In turn, the students’ responses to the case studies generated new material and opportunities for class discussion. To further increase the students’ motivation to use the Web site, the health education teachers allocated grade points to some of these exercises. Similarly, an online “scavenger hunt” assignment allowed students to earn extra credit if they finished early.

We were pleasantly surprised with the lack of difficulty the students experienced when using this unfamiliar method of completing assignments. Although the skill level varied among students, almost all of them easily performed the basic tasks required, such as starting the Web browser, finding the Web site with the URL and using the mouse to navigate the site. Most students needed only minimal assistance locating the section of the Web site that would contain the information they sought. Nearly all of the students completed their assignments in the time allotted and many had time to complete the extra-credit scavenger hunt.

Health Education, Cyber Style

The computer-based exercises provided new avenues for student participation in class discussion as well as more opportunities for the teens to use their reading, writing and critical thinking skills. But the implementation of Teen Smart also focused on raising the students’ interest in health promotion.

For example, online self-assessment quizzes entitled “How Healthy Are You?” were linked to the topics covered in the weekly health education classes. The quizzes gave each student immediate individual feedback, scoring their health behaviors from low to high and providing them with links to other health-related Web sites relevant to their answers. This empowered the teens by providing them with information they could use to improve their health decision making.

Another Teen Smart feature, “Ask A Nurse,” was designed to give the students a private and confidential forum to discuss health questions with the Teen Health Center nurse practitioner. Individual students’ questions were published and answered anonymously in the Web site’s “Frequently Asked Questions” section so that all the students could benefit from the information.

Interestingly, the questions the students posed online were much more likely to address health concerns of a sensitive nature–i.e. sex and drugs–which they had been reluctant to volunteer in the focus group discussions. This suggests that an interactive Web site provides an excellent way for high-risk teens to get accurate information on topics they may not feel comfortable asking an adult in person. Teen Smart also provided a way for the teen clinic to reach students who were uninterested or unwilling to come in for face-to-face health services.
The Web site’s “Discussion Board” feature, which was supervised by the health education teachers, provided the students with opportunities to analyze common life situations where decision-making is crucial to their health and safety. Each week, the discussion board presented a problem-based scenario on topics such as drinking and driving, unprotected sex or using illicit drugs. Individual students could post a response describing what they would do in that situation and also view other students’ answers. The teachers were then able to use the posted responses for further class discussion.

The discussion board case scenarios were designed to help the teens build skills in anticipatory problem-solving by placing them in hypothetical yet realistic situations in which they were requested to share what they would do in such a situation and why. Like “Ask a Nurse,” this interactive feature also provided another confidential forum for students to share their own values, perspectives and behaviors while exercising reading, writing and critical thinking skills. Still another benefit was that it allowed them to practice psychosocial communication skills needed in risky social situations.

Learning From the Students

Making Teen Health Education Interactive, Fun—and Private The Teen Smart Web site invites at-risk adolescents to “inform yourself and empower yourself” about good health habits by exploring these eight sections, in either English or Spanish:

• Welcome to Teen Smart–A general introduction to health that encourages teens to “take control of your personal health and your future.”
• How Healthy Are You?–A series of nine health-assessment quizzes on topics like general health, nutrition, safety, emotional well-being, stress and sex.
• Health Topics—Detailed and honest information about health issues important to teens, including birth control, fitness, smoking, preventing STDs and substance abuse.
• Internet Links–Links to other health-related Web sites, many of them targeted specifically to teens.
• Resources in Your Area—A listing of community health resources for teens, ranging from substance abuse hotlines and counseling centers to youth employment programs.
• Get Advice: Ask a Teen Clinic Nurse—A confidential section in which students can ask health questions and receive answers from the high school’s Teen Health Center nurse practitioner. Questions and answers are posted anonymously under “Frequently Asked Nurse Questions” so that all students can learn from them.
• Chat Room—A teacher-supervised online discussion board in which problem-based scenarios relating to risky health behaviors are posted for student analysis and decision-making. Students can not only post their opinions anonymously but also read how other students would handle the situations.
• What Teens Say—A sampling of students’ anonymous responses to thought-provoking health questions, enabling teens to learn from their peers.

To measure Teen Smart’s effectiveness in serving the students, we included a “Feedback” section. By clicking onto a button, the teens were able to rate the Web site’s features and assignments in such areas as ease of use, fun, aesthetics, usefulness, appropriateness and relevance.
The feedback we received regarding the site’s content and the opportunity to ask confidential questions was quite positive. The majority of the students found Teen Smart to be interesting (78% of respondents), fairly easy to use (80%) and easy to understand (93%).Asked to identify the most useful aspect of the project, the majority responded that the Web site contained health information they were interested in knowing about.

In other areas, however, the students felt that improvements were needed. They recommended that the schools’ computers be upgraded to allow greater speed and that the login process be streamlined. Some students thought the Web site’s design and colors needed a makeover. While the teens reported enjoying the discussion board, they suggested that it could be improved by allowing simultaneous chat and including students from other schools.

What advice do we have for other nurses and health educators who may be interested in starting a similar program? From both the Cleveland High School students’ feedback and our own observations, we identified four key factors that we feel are essential to the successful implementation of a health promotion Web site for high-risk teens: simplicity, privacy, interactiveness and sustainability.
First, it is essential that teens are able to easily access the Web site. This means not only providing ready access to good-quality computers but also making sure the site has a simple Web address (URL). While computers were readily available at Cleveland High, they lacked the memory and speed which interactive Web-based learning requires. We also found that our URL, www.son.washington.edu/teensmart, was difficult for the students to remember and they would often mistype it.

We have already mentioned that the students we worked with appreciated the opportunity to ask questions and search for answers in a confidential, private environment. However, privacy not only has to be provided on the Web site but also in the students’ working space. We observed that students would often peek at each other’s computer monitors out of curiosity or for assistance, and that this would occur while students were taking personal health quizzes or looking up private information. We recommend that schools establish a designated computer area that will protect teens’ privacy when they are looking up sensitive information, and that computers in the classroom be distanced far enough apart to avoid exposing confidential material.

Thirdly, the Web site should make maximum use of interactive features. Not only did the students enjoy the interactive sections the most, but the teachers and nurse practitioner also found them to be the most useful teaching tools. Students showed the most enthusiasm about Teen Smart when they were accessing the discussion board, receiving instant feedback from the “How Healthy Are You?” quizzes and getting answers from “Ask a Nurse.” Because features like these involve more than just passively receiving information, they make learning active and fun for the students by involving them in the learning process.

Finally, sustainability and maintenance of the Web site is a very important issue. The site’s interactive components require human response, which involves both time and money. Maintaining the Web site—including updating the contents and adding new material to keep it fresh and interesting–requires the active participation of students, teachers and nurses.

Therefore, sustainability must involve incorporating teachers and students into the planning, management and continual evaluation of the site, which requires ongoing training for both teachers and students in Web site use and maintenance. This is a major factor in keeping the Web site viable and encouraging students to continue to use it as an independent learning tool.

These four lessons are crucial if the Web site is to become an active component of the school’s health education curriculum. By integrating Teen Smart into the existing coursework, the teachers at Cleveland High School are motivating their students to access the Web site for information relating directly to their everyday assignments. They are also providing them with a much-needed confidential health resource. Teen Smart not only provides at-risk minority teens with an invaluable and easily accessible source of information about healthy living and health risks, but also empowers them to assume responsibility for making the right health decisions.

What Teens Want to Know About Health—and How They Want to Know It

These results from focus groups conducted with the high school students were instrumental in helping the team of nursing students and health educators develop the content and structure of the Teen Smart Web site. The teens’ answers are listed in descending order of frequency.

Q: What kinds of health issues do you and your friends think/talk about?

• Weight issues
• Nutrition, drugs, stress
• Sleep, sex
• Other frequently mentioned issues included: Exercise, weight lifting, smoking, money/work, AIDS, alcohol, pregnancy, menstruation, fighting

Q: If you have questions about health, do you ask someone? If so, who?

• Friends
• Parents, health teacher
• School nurse
• Doctor
• Mom
• Aunt
• Cousins
• Counselor, siblings, friends’ Moms

Q: Where else do you get health information?

• Magazines
• Books
• Internet, media
• Movies, library, dictionary, clinic, classes

Q: What does being healthy mean to you and your friends?

• Exercising
• Eating right
• Feeling good about self
• Not doing drugs; correct weight
• Having energy
• Getting enough sleep
• Regular doctor check-ups

Culturally Competent Disaster Nursing

by | Mar 30, 2013 | Magazine, Nursing Careers, Veterans in Nursing

Natural disasters are colorblind in terms of whom and how they strike. “When a disaster hits, it doesn’t hit by race, color or creed. It hits people who are humans and bleed,” says Marilyn Pattillo, PhD, GNP, CNS, deputy team commander of the Federal Emergency Management Agency (FEMA)’s National Nurse Response Team. Yet, how disaster victims react to displacement, illness and stress is very much culture-based.

“Cultural competence is an integral part of any disaster behavioral health intervention,” says Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness at the University of South Florida College of Public Health in Tampa. “In order to be effective, [health workers responding to disasters] must be aware of cultural differences among survivors and patients.”

This issue has taken on additional urgency in the aftermath of the heavily criticized government response to the devastation wrought by Hurricane Katrina. The delayed and muddled relief efforts were perceived by many African Americans as the product of institutional racism.

Nurses responding to natural disasters have precious little control over how government resources are apportioned, but they do have control over how they treat patients. The consensus among many nurses who responded to Katrina is that cultural competence was the norm in the immediate wake of the hurricane. This was because the first wave of responders consisted of local nurses with first-hand knowledge of the affected communities’ cultural needs.

“The immediate disaster response was handled by the local people,” explains Trilby Barnes, RNC, president and CEO of Medi-Lend Nursing Services in New Orleans and a member of the board of directors of the National Black Nurses Association (NBNA). Although the availability of care at some of the city’s hospitals was severely disrupted by the hurricane and subsequent flooding, Barnes says she was “one of the nurses who was still there to provide normalcy for the patients. [We were there] providing our cultural know-how [and] I do feel like it had a positive effect on the patients.”

“I didn’t see a [great] amount of discord [between health care workers and patients],” adds Father James Deshotels, SJ, APRN, a nurse and Jesuit priest who treated evacuees at the Superdome.

What Went Wrong

However, significant shortcomings in cultural competence arose in the following weeks and months, as new waves of disaster responders from across the nation–who lacked the local health professionals’ cultural familiarity with the affected communities of color–began to arrive.

Jennifer Field Brown, PhD, APRN, is the only white professor in the Nursing Department at historically black Norfolk State University in Virginia. When asked by the federal Substance Abuse and Mental Health Services Administration to work in a Louisiana shelter some six weeks after Katrina hit, Brown admits she was excited and jumped at the opportunity. But the racial and cultural tensions she observed during the two-week assignment have left her thinking for months.

“Many of the nurses were angry with the [largely African American] population that was still at the shelter,” she says. “There were many times when evacuees [said], ‘they don’t care about us.’”

Brown believes this perception was fueled by the cultural gap between the predominately poor and African American evacuees and the mostly middle class and white shelter staff. “[Some of] the response workers were appalled that some of the evacuees would not cash their checks because they had no family member with a checking account, [or] that they’d cash their checks and buy a TV. [The prevailing attitude among many of the shelter staff seemed to be] if you didn’t lose anything you are not entitled to anything.”

Deshotels, whose parents grew up in New Orleans, points out that strained race relations are not a new phenomenon in the Crescent City. “Because we have such a long history of racism and oppression [here], there is an always an air of tension and mistrust,” he says.

New Orleans used to have–and perhaps still has–a majority black population. Katrina scattered tens of thousands of the city’s African Americans throughout much of the country, so it is impossible to know for sure. But much of the city’s longstanding black middle class and working class have been displaced and have not returned. Cheryl L. Nicks, RN, CNNP, CGT, CLNC, CPLC, president of the New Orleans chapter of the NBNA, has been in touch with only three out of 65 members since the hurricane struck. She says, “Our chapter has basically been demolished.”

Caught Unprepared

Another shortfall in culturally competent health care that has worsened in New Orleans post-Katrina is the result of a dramatic and largely unforeseen population shift. In the place of many African American evacuees have come many thousands of Hispanic workers hired to help clean up and rebuild the city. Their arrival, a direct consequence of the hurricane, has amplified the difficulties the city’s public health system already faced in treating Hispanic patients.

The Roman Catholic Archdiocese of New Orleans created the Latino Health Access Network (LHAN) three years ago in response to the lack of sufficient health services for the Hispanic community. Shaula Lovera, director of LHAN, cites the absence of any evacuation information in Spanish as what she considers a typical example of the neglect faced by the Hispanic population before Katrina.

Now, the huge influx of Hispanic workers has dramatically increased the need for Spanish-speaking nurses and doctors. What used to be a small community of 14,000 in 2004 has grown to become a significant minority population whose access to health care is challenged by cultural, linguistic and economic barriers.

“These workers don’t make great salaries,” Lovera explains. “They have no access to Medicaid or Medicare. They don’t get health insurance from their employers.”
But often the biggest obstacle, she says, is simply navigating the hospital admissions process, with its personnel who don’t speak Spanish and its English-language forms that must be signed.

Before the hurricane, LHAN ran a Saturday clinic staffed by Spanish-speaking volunteer physicians and nurses. In 2002, before the clinic was established, only 2% of patients using LHAN’s services were Hispanic. But the number shot up to 17% after the clinic opened in 2003. This proves that Spanish-language medical attention was urgently needed, says Lovera.

The clinic, which was run by the Daughters of Charity, was badly damaged during the hurricane. Given the difficulties faced by Latino workers in getting treatment at local hospitals, LHAN has opted to bring bilingual nurses and doctors directly to the worksites. They give workers tetanus shots to guard against infections from accidents on the job and treat a series of common medical complaints. The lack of work boots, masks and gloves means that broken bones, sinusitis and cuts are a constant problem.

While this approach has been helpful, LHAN is stretched thin and has had to rely on volunteer doctors and nurses from outside the region. In lieu of always being able to find Spanish-speaking clinicians, they provide qualified medical translators.

Closing Knowledge Gaps

Based on these lessons learned the hard way, Lovera feels strongly that the federal government must focus on enhancing the cultural competence of disaster response teams. And she’s not alone. How agencies such as FEMA will respond to these recommendations from health professionals, if at all, remains to be seen. But in the meantime, a growing number of nursing educators are beginning to look at ways to fill this crucial knowledge gap.

Laura Terriquez-Kasey, RN, MS, CEN, is a member of a New York-based Disaster Medical Assistance Team (DMAT) that was sent to Louisiana following Katrina. The Department of Homeland Security’s National Disaster Medical System relies, in part, on a number of DMATs stationed throughout the country. The DMATs consist of highly skilled medical professionals that can be quickly deployed following a natural or man-made disaster.

Terriquez-Kasey’s previous disaster experience includes 9/11 and Tropical Storm Allison. “When I went into Allison and the flooding in Texas in 2001, we were a large group of nurses and it was very helpful to have the capacity to speak Spanish,” she says. Too often, Terriquez-Kasey believes, in the rush to “get everyone treated right away” the “cultural piece” of disaster nursing is simply overlooked.

It is an oversight that she tries to correct as a clinical lecturer at SUNY-Binghamton’s Decker School of Nursing. “There is a tremendous knowledge deficit in our health care where we don’t necessarily take the time to understand where the [patient] is coming from,” Terriquez-Kasey contends. “You can’t help someone if you can’t assess them, and if the patient doesn’t open up to you then you are really not doing your job.”

Pattillo, in her role with the National Nurse Response Team and as an assistant professor at the University of Texas at Austin School of Nursing, worries that too few nursing students receive proper training in this area. “Is cultural competency in disaster nursing being addressed? No. [Nursing schools] are not even addressing disaster nursing [in general] adequately.”

Still, Maria Warda, PhD, RN, dean of nursing at Georgia Southwestern State University in Americus, Ga., and vice president of the National Association of Hispanic Nurses (NAHN), believes there has been at least some progress in recent years. “[Considering that we were starting from zero], it is certainly a move in the right direction,” she argues.

Warda, who is an expert in Latino cultural competence, says she tries to instill in her students “an appreciation for and even a celebration of diversity. Then [I try to teach] basic communication skills that may not be perfectly culturally congruent but at least will convey human kindness, concern and empathy without offending. All that you can expect is that [nurses will develop] cultural competence for those patients whom they typically care for.” She insists that “it is not that complicated” to acquire cultural competence.

Norfolk State University’s Brown believes cultural competence must become part of disaster planning for every community, because in any disaster response there will always be outsiders arriving to help. Outsiders, that is, who may or may not speak the language of the community’s ethnic populations and who may or may not be familiar with local cultures and mores. Outsiders who need to be provided with information about what to expect regarding “the values and beliefs of the people [they] are going to work with,” Brown says.

She is critical of the prevailing approach to teaching cultural competence. “We talk about it in such broad, abstract terms of what we need to know about a person’s cultures, values and beliefs,” she explains. “We teach stereotypes even though we are trying to teach acceptance of differences. The only way we know is to teach those basic generalizations.” Brown points to work being done by the Florida Center for Public Health Preparedness (see sidebar) as “a great possible model. They are really getting things together.”

Beyond Cultural Competence

Local minority nurses from the Gulf Coast have other lessons from Katrina to share, including general advice about the more practical aspects of responding to natural disasters. Yevonne Means, LPN2, a medical-surgical nurse at Biloxi Regional Medical Center in Mississippi, recommends that nurses “bring your own food, your own water, your own blanket, whatever you need to camp out. [And] be prepared to stay for a while.”

Trilby Barnes stresses the importance of being mentally prepared for the long haul and having deep reserves of empathy for people whose lives have been devastated by a catastrophe.

“I would never want to remove the idea that there is a definite importance to cultural competence,” she says. “But I also believe there was something within me as a nurse, as a woman, as a mother, that allowed me to care for those patients. I couldn’t speak Spanish, but I still felt like I [conveyed the message] that ‘I am going to figure out what it is you need or die trying.’ I feel any nurse who [has] that compassion [can develop] the cultural competence.”

Take a Free Online Course in Culturally Competent Disaster Response

In 2004, the Florida Center for Public Health Preparedness at the University of South Florida (USF) in Tampa began offering a short online course called “Assuring Cultural Competence in Disaster Response.” The 1.5-hour course was developed by Jennifer Baggerly, PhD, LMHC, RPT-S, a professor at USF who responded to Hurricane Katrina as well as the 2004 tsunami in south Asia.

According to the center’s Web site, the course is designed to prepare public health professionals to offer culturally competent disaster interventions to survivors, witnesses and responders to bioterrorism and other major public health threats and community disasters. The course helps build competencies in such areas as:

• Identifying the role of cultural factors in determining and delivering disaster intervention services.

• Identifying cultural barriers to offering disaster intervention services.

• Approaches, principles and strategies for developing cultural competency in assisting disaster survivors from diverse populations.

• Using appropriate methods for interacting sensitively, effectively and professionally with persons from diverse cultural, socioeconomic, racial and ethnic backgrounds, and persons of all ages and lifestyle preferences, when assisting disaster survivors, their family members, witnesses and disaster responders.

Baggerly says the purpose of the course is threefold. “The first reason is to prevent harm to the individual you are attempting to help. There are numerous examples of well-intentioned public health workers actually hurting [patients]. If you are not careful you can end up promoting harm. The second reason is for [health professionals] to be more effective and achieve faster results in recovery. Third, it protects the public health worker from harm. Sometimes [you can make] an unintentional faux pas that may anger some [patients].”

Anyone who signs up can take the online course for free, although you have to pay in order to receive continuing education credits. According to Baggerly, the course was envisioned as a convenient and immediate training option. “Especially in disaster response where [it is] very fast-paced, [health workers] are trying to respond quickly, so there is some anxiety that builds up.”

Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness, stresses the course’s importance by citing research that indicates “those who are at greatest risk for adverse outcomes following any disaster are. . .non-English-speaking [and] economically disadvantaged [persons].” The course, she says, helps bridge the cultural gap to those very groups.

For more information about the “Assuring Cultural Competence in Disaster Response” online course, visit www.fcphp.usf.edu/courses/search/search.asp.

A recent study hosted by the Centers for Disease Control and Prevention (CDC) found that minority women in the United States are more likely to die during or soon after childbirth than white women.

The study looked at black, Hispanic, and Asian women, and some white women not born in the United States. These minorities accounted for 41% of all births nationwide between 1993–2006, but for 62% of pregnancy-related deaths.

Dr. Andreea Creanga, medical epidemiologist of the CDC, and her research team found that for every 100,000 babies born to white women, seven to nine mothers died from pregnancy-related complications. On the contrary, 32–35 African American women died for every 100,000 live babies. Deaths among Hispanic and Asian women were around 10 per 100,000.

A total of about 7,500 women died of complications related to pregnancy within the 14-year period. Heart problems and general cardiovascular disease, including high blood pressure, were the most common causes of death in childbirth for both white and black women.

Additionally, older women were most likely to die during childbirth. Eighteen white mothers ages 35 and older died for every 100,000 babies born, as did 99 black women of a similar age per 100,000—almost one death for every 1,000 babies.

Researchers used collected data on all women who died within a year after pregnancy, as well as birth records for their babies. They also conclude that some differences may be due to minority women’s lack of access to good prenatal care, noting that pre-existing health problems likely contributed to their deaths as well. Some heartrelated deaths are due to genetic or dietary differences between women, but deaths related to bleeding at childbirth are preventable with medical care.

Researchers didn’t have access to clinical details such as birth method and mothers’ weight, both of which could affect pregnancy risks.

Study finds more hospital-related infection due to burned-out nurses

by | Mar 31, 2013 | Magazine

Two kinds of hospital-acquired infections—catheter-associated urinary tract infections and surgical site infections—have been on the rise, according to a new study. The research shows that the busy schedule and heavy workload of nurses were contributing factors to the rise in these infections.

According to an NBC news report, heavy patient loads and chronic burnout have long been among the top complaints of bedside nurses. The Maslach Burnout Inventory—a well-known scale that measures factors like emotional exhaustion, depersonalization, and sense of personal accomplishment—showed more than one-third of nurses reported levels of job-related burnout.

Researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing found that for every extra patient added to a nurse’s workload, there was about one additional hospital-acquired infection per 1,000 patients.

Also, according to a study in the American Journal of Infection Control, for each 10% jump in the proportion of nurses who reported higher levels of “burnout,” about one additional catheter-associated infection and two surgical site infections were found per 1,000 patients.

The nurses in the study, on average, cared for 5.7 patients each; a number that, if reduced, could help eliminate nurse burnout, and thus cut back the number of infections. The report states that reducing nurse burnout by 30% would cut urinary tract infections by more than 4,000 and surgical site infections by more than 2,200, which would save $28–$69 million per year in estimated costs to treat those infections in patients.

Previous research also supports the conclusions reached in this most recent study. Another University of Pennsylvania study found that adding a single patient to a nurse’s workload increased the risk of dying within a week by 7%. Additionally, a 2010 study found that patient deaths in New Jersey and Pennsylvania would drop 14% each if those states adopted California‘s mandated nurse-to-patient ratio of one to five in surgical units.

The NBC News report stated that some hospitals in the United States have worked hard to address these kinds of issues. Nearly 400 hospitals have achieved so-called “magnet” status, which recognizes health care organizations that achieve structural and clinical practices that empower nurses and lead to good patient results.

Neither the American Nurses Association nor the American Hospital Association tracks statistics on nationwide patient loads, which can vary from as low as one or two patients per nurse to more than five per nurse.

Study finds black youth in California targeted by tobacco marketing

by | Mar 31, 2013 | Black and African-American Nurses, Magazine

Academic researchers, funded by California’s Tobacco Related Disease Research Program, found a greater number of menthol cigarette advertising at retailers near high schools with a high African American student population.

Lisa Henriksen, Senior Research Engineer at the Stanford Prevention Research Center, studies environmental influences on adolescent tobacco use, particularly with tobacco marketing in smoking initiation and maintenance. She presented the findings at a legislative hearing in Sacramento in late April 2012.

The research found as the percentage of black students increased at a California high school, so did the existence of both menthol-related advertising and Newport brand promotions at retailers near the schools. The study looked at all cigarette advertising, but specifically observed promotions and price discounts for Marlboro and Newport, two of the most popular brands with underage smokers.

Henriksen’s study of cigarette marketing also found African American teens were better able to recognize a Newport advertisement than teens of other races. And in analyzing California’s K–12 schools, the research observed 24% of school campuses had tobacco retailers within 600 feet, and 38% of schools were within 1,000 feet of a store where cigarettes were sold. Stores near high schools, on average, featured 25 cigarette ads.

Additionally, Robert Lipton from the University of Michigan presented research showing that in the Los Angeles area, dense, poor, and minority communities had greater rates of underage tobacco sales.

California has the second-lowest smoking rate in the country at about 12%. But according to the California Department of Public Health, tobacco use among African Americans in the state is between 3%–6%, higher than the statewide average.

The Federal Trade Commission’s most recent California statistics show the tobacco industry spent over $10 billion on marketing in 2008.

Health care workers at risk

by | Mar 31, 2013 | Magazine

According to a recent study done by the University of Michigan Comprehensive Cancer Center, researchers are now doing their best to implement safety measures for nurses when administering toxic drugs, such as chemotherapy.

Although chemotherapy can save lives, it can be dangerous to any person unintentionally exposed. Exposure to “secondhand chemo” is putting health care workers’ lives at risk and has the potential to effect the nervous system, damage the reproductive system, and increase the risk of blood cancer in the future.

Christopher R. Friese, Ph.D., R.N., A.O.C.N., along with his colleagues from the University of Michigan School of Nursing, surveyed 1,339 oncology nurses, from only one state, that work in outpatient chemotherapy. The survey measured the likelihood of self-reported exposure in relation to their working environment, nursing workloads, and safety standards. The study shows about 17% of nurses working in outpatient settings reported exposure to their skin or eyes in the past year. (All results can be found online in theBMJ Quality and Safety journal.)

According to the study, the researchers found the amount of exposure seemed to be reduced in hospitals containing more staff. Nurses with a higher workload tended to report more incidences than those with lower workloads. Exposure also appeared to decrease in hospitals where two or more nurses were required to administer the drugs. According to the findings, Friese believes it may be possible that unintentional exposure is not always reported, perhaps for fear of embarrassment.

Organizations such as the National Institute for Occupational Safety and Health have issued guidelines to decrease the number of unintentional exposures, but they have not yet been made mandatory. It is recommended that nurses use gowns and protective gear when handling chemotherapy drugs, but these guidelines may not be enforced. However, the American Society of Clinical Oncology plans to issue revised guidelines in 2012, in hopes of stressing the importance of the safety of the staff as well as the patients.

World AIDS Day: Getting to Zero

by | Mar 31, 2013 | Magazine

On December 1 each year, you will find countries around the world commemorating World AIDS Day to raise awareness of the spreading of HIV infection. Each year, a theme is chosen for the campaign by UNAIDS. Starting in 2008, the World AIDS Campaign’s Global Steering Committee has chosen the theme, with the input from other organizations and government agencies. This year’s theme is “Getting to Zero,” which refers to zero new HIV infections, zero discrimination, and zero AIDS-related deaths this year.

One way to accomplish “getting to zero” is implementing vaccine trials, according to a release issued by GeoVax Labs, a biotechnology company located in Atlanta, Georgia, that creates and tests HIV/AIDS vaccines. However, a common problem many trials face is recruiting participants from at-risk communities. To reveal the reasons behind the lack of participation, researchers from the University of Toronto coordinated a study targeting nine focus groups made up of at-risk persons. In the end, the surveys exposed many misconceptions the individuals had regarding the vaccine trials. Recently, TheBody.com reported that many people do not take part in these trials because they believe it puts them at risk of getting AIDS, and they are skeptical of why the trials target people living in at-risk communities.

Gay and bisexual black men are one of the most susceptible populations and account for almost 25% of new HIV infections in the United States. The number of new infections overall has not changed significantly, with roughly 50,000 cases every year. However, vaccine developments and social initiatives are developed with frequency. A new $2.4 million campaign by the CDC was announced in November 2011, targeting gay and bisexual black men and encouraging them to be tested.