reinforce cultural standards and expectations and provide emotional support and practical assistance.
Health Problems
Health problems among Native Americans tend to be both chronic and socially related. One third of Native Americans
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103live in abject poverty and experience the afflictions associated with poor living conditions, including malnutrition, tuberculo- sis (TB), and high maternal and infant death rates (Spector, 2009). The highest-ranking health problems in children include a postneonatal mortality rate double that of White infants (due largely to sudden infant death syndrome [SIDS], injuries, and congenital anomalies); overweight, obesity, and type 2 diabetes; and morbidity and mortality as a result of unintentional and intentional injuries (often motor vehicle injuries) (Brenneman, Rhoades, & Chilton, 2006). For adults, diabetes, TB, and obesity all rank higher among Native Amer- icans than in the general population. Deaths from TB (seven times higher), alcoholism (six times higher), motor vehicle crashes (three times higher), diabetes (almost three times higher), unintentional injuries, and suicide and homicide (both 1.6 times higher) are higher for Native Americans than other Americans (Indian Health Service, 2006). Poor sanitation, crowded housing, and low immunization levels contribute to the prevalence of a variety of communicable diseases. On the other hand, the prevalence of heart disease is slightly lower in this population than among the population as a whole (236.2 versus 247.8 per 100,000) (Indian Health Services, 2006).
Alcoholism is the major health problem of Native Americans. Both traditional/cultural and medical explana- tions exist for the disproportionate number of alcohol- related health problems in Native Americans. Tribal medi- cine men have attributed the problems of alcoholism to losing “the opportunity to make choices,” stating that until
“people return to a sense of identification within themselves they will not rid themselves of this problem of alcoholism”
DISPLAY 5.4
All of creation/universe has Spirit and is considered equal in value.
Everything is considered alive with energy and impor- tance.
People have universal connectedness.
Harmony is a way of life based on cooperation and sharing.
Dignity of the individual, family, and community is valued.
Respect for advancing age is valued; elders are leaders.
There is present-time orientation, grounded in what is happening at the moment.
Symbolic arts and crafts are valued.
Life is lived in the present, with little concern for the distant future.
Generosity, harmony, and sharing are valued.
Religion is integrated into everyday life.
Herbal medicines and traditional healing practices are used.
Rituals and ceremonies are valued.
Silence is used as a way to practice presence and strength.
Thoughtful speech is valued.
Patience is valued.
Adapted from Lowe, 2002; Lowe and Struthers, 2001; and Spector, 2009.
SIMILARITIES AMONG NATIVE AMERICAN CULTURES
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(Spector, 2004, p. 199). Medically, it appears that Native Americans have a much lower tolerance for alcohol and there- fore demonstrate the effects of alcohol with lower amounts consumed. When individuals are under the influence of alco- hol, other health and safety problems occur. Instances of domestic violence, child abuse and neglect, traffic injuries and deaths, and homicides are more frequent because of the abuse of alcohol. Along with these high rates of injuries and deaths, alcohol’s destructive effects on the unborn lead to a high inci- dence of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Substance abuse is also prevalent among those living on reservations, and increasingly among youth using alcohol, tobacco, and other drugs (Substance Abuse & Men- tal Health Services Administration [SAMHSA], 2004).
Health Beliefs and Practices
Native Americans as a group prefer traditional healing prac- tices and folk medicine to Western medicine. Most Native Americans today still seek out a medicine man or rely on tra- ditional remedies before going to a health clinic. Many of their beliefs about health and illness have common traditional roots, regardless of tribe or location. Health and dietary practices are closely tied to cultural and religious beliefs. Beliefs about health reflect living in total harmony with nature. The Earth is considered a living organism that should be treated with respect, as should the body (Spector, 2009). Native Americans practice purification rituals such as immersion in water and the use of sweat lodges to maintain their harmony with nature and to cleanse the body and spirit. The basis of therapy lies in nature, with herbal teas, charms, and fetishes used as preven- tive and curative measures (Kavasch & Baar, 1999).
Because of decades of racism and government paternal- ism, many Native Americans feel oppressed and dehumanized and carry considerable resentment and lack of trust toward Whites. As a result, many maintain a degree of separateness from overall American culture. Nurses must overcome these barriers through patience, acceptance, and respect for their clients’ culture, as illustrated in the case study of the commu- nity health nurse, Sandra Josten, and her new client from a Native American community (see From the Case Files II).
Blacks or African Americans
Some of the ancestors of Black Americans, or African Americans, originally came to this continent as free settlers as early as 1619, but most of the approximately 4 million who followed came as slaves in the 17th and 18th centuries, mostly from the west coast of Africa (Byrd & Clayton, 2002). Most African Americans living today were born in the United States; some, however, have recently emigrated from African countries. Other Black Americans come from the West Indies, the Dominican Republic, Haiti, and Jamaica, often to escape poverty or political persecution.
These people do not self-identify as African Americans but as Hispanics, a fact that may cause some difficulty for oth- ers trying to identify and accommodate to their culture.
(Similarly, some people from the Philippines have Hispanic surnames and skin tones similar to those of Mexicans or other Latinos; when Filipinos—a culturally distinct group—settle in areas with large Hispanic populations, they can be similarly misidentified and misunderstood [Spector, 2009].)
Population Characteristics and Culture
In 2004, African Americans numbered 38.6 million and con- stituted approximately 13% of the U.S. population; projec- tions show an increase to 15.4% by the year 2050 (National Center for Health Statistics, 2007a; U.S. Census Bureau, 1992; U.S. Department of Commerce Bureau 2001). One- third of the African American population is younger than 18 years of age. Slightly more than 8% of African Americans are older than 65 years, and most of them are women; in comparison, 13% of the total population is older than 65 years of age. Fifty-eight percent of Black children live with their mothers only, compared with 21% of White children.
Despite improvements in the legal and social climate for African Americans, great disparities exist between them and White Americans (Byrd & Clayton, 2002). Average family income for African Americans is 62% of the income earned by White families. More than 26% of African Americans live in poverty, compared with 8.9% of Whites. Although African Americans make up only 13% of the population, more than 50% of prison inmates are Black. A greater percentage of Blacks use illicit drugs (7.7%), compared with Whites (6.6%) or Hispanics (6.8%) (Antai-Otong, 2002). Approxi- mately 36% of African American families in households headed by women live below the poverty level. Unemploy- ment among African Americans is 8.9%, compared with 3.9% for Whites (U.S. Department of Commerce, 2001).
Educational disparities also exist. Among people age 25 years and older, 76% of Blacks and 83.7% of Whites have a high school education. More than half of those African Americans with less than a high school education are not in the workforce, compared with 36% of Whites with a similar education. However, 89% of both Blacks and Whites with a college degree are employed; 14.7% of Blacks and 25% of Whites are college graduates (Williams & Collins, 2001).
African American women acquire more educational training than their Black male counterparts do, but their earnings are lower than those of the men, as is also the case with White and Hispanic women compared with men in those groups.
Like Native Americans and Asian Americans, African Americans do not comprise a single culture; rather, this group forms a heterogeneous community. As with other large ethnic and racial groups, many factors influence their culture, result- ing in much diversity within the African American popula- tion. Among the variables determining specific microcultures within the African American community are economic level, religious background, education, occupation, social class identity, geographic origin, and residence in an integrated or segregated neighborhood. For community health nurses, this means that specific groups of African Americans have their own unique values, character, lifestyle, and health needs.
The primary language of most African Americans is English. Recent Black immigrants from Caribbean or other countries may retain the language of their country of origin, but usually learn to use English as well. Many African Americans speak nonstandard dialects of English, also called Black English, Ebonics, or African American Vernac- ular English. These dialects evolved from pidgin English spoken during the era of slavery, and they have become a dynamic and meaningful language of their own. For some African Americans, Ebonics symbolizes racial pride and identity—it can also be used to differentiate them from the mainstream culture (Novak, 2000; Spector, 2009).
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African Americans have much higher mortality rates than White Americans, with a life expectancy of 71.1 years (U.S. Department of Commerce, 2001). This number is the same as the life expectancy of Whites in 1966, revealing a 35-year lag for the Black population compared with the White population. This demonstrates the inequality in mor- tality and life expectancy, an outcome of health care, eco- nomic, and educational disparity (Levine et al., 2001). Life expectancy for Whites in 2000 was 76.8 years (U.S.
Department of Commerce, 2001). The gap for Blacks is 6.3 years for males and 4.5 years for females (Harper, Lynch, Burris & Smith, 2007). The major health problems for Blacks include cardiovascular disease and stroke, can- cer, diabetes mellitus, cirrhosis, a high infant mortality rate
(twice that of whites), homicide, accidents, and malnutri- tion (Display 5.5).
Stress and discrimination, poverty, lack of education, high rates of teen pregnancy, inadequate housing, and inadequate insurance for health care are among the risk factors influencing the health of this population. In the last three decades, a dra- matic increase in Black households headed by women, single- parent births (most frequently among teenagers), and a limited presence of male role models has further exacerbated family vulnerability (Lewis, Gutierrez, & Sakamoto, 2001).
Leading causes of death for African Americans are heart disease, cancer, and stroke. As noted, infant death rates are higher in Blacks than in other groups (13.6 per 1,000 live births), leading many health departments to provide Black Infant Health programs (National Center for Health Statis- tics, 2007a). Mortality rates for communicable diseases, CHAPTER 5 Transcultural Nursing in the Community
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105From the Case Files II
Sandra’s New Clients
As she drove up the dirt road and parked her car next to the community hall, Sandra Josten felt apprehensive. She had been alerted by the previous community health nurse about the difficulty of working with these Native American people: “This tribe is lazy and unappreciative. You can’t get any- where with them.” Only through the urging of Mrs. Brown, an Indian community aide, had a group of the women reluctantly agreed to meet with the new nurse. They would see what she had to say.
Sandra’s steps echoed hollowly as she walked across the wooden floor of the large room to the far corner where a group of women sat silently in a circle. Only their eyes turned; their faces remained impassive. Mrs. Brown rose slowly, greeted the nurse, and introduced her to the group. Swallowing her fear, Sandra smiled. She told them of her background and explained that she had not worked with Indian people before. There was a long silence. No one spoke. Sandra continued, “I’d like to help you if I can, maybe with problems about care of your children when they are sick or questions about how to keep them healthy, but I don’t know what you need or want.” Silence fell again. She would like to learn from them, she repeated. Would they help her? Again Sandra felt an uncomfortable silence.
Then one woman began to speak. Quietly, but with deep feeling, she described several bad expe- riences with the previous nurse and the county social worker. Then others spoke up: “They tell us what we should do. They don’t listen. They say our way is not good.” Seeing Sandra’s interest and concern, the women continued. One of their main concerns was their children’s health. Another was the high incidence of accidents and injuries on the reservation. They wanted to learn how to give first aid. Other concerns were expressed. The group agreed that Sandra could help them by teaching a first-aid class.
In the weeks that followed, Sandra taught several classes on first aid and emergency care. She then began a series of sessions on child health. Each time, she asked the women to choose a topic or problem for discussion and then elicited from them their accustomed ways of dealing with each problem; for example, how they handled toilet training or taught their children to eat solid foods.
Her goal was to learn as much as she could about their culture and incorporate that information into her teaching, which preserved as many of their practices as possible. Sandra also visited informally with the women in their homes and at community gatherings.
She learned about their way of life, their history, and their values. For example, patience was highly valued. It was important to be able to wait patiently, even if a scheduled meeting was delayed as much as 2 hours. It also was important for others to speak, which explained the Indian women’s comfort with silences during a conversation. Other values influenced their way of life. Courage, pride, generosity, and honesty all were important determinants of behavior. These also were values by which they judged Sandra and other professionals. Sandra’s honesty in keeping her promises enabled the women to trust her. Her generosity in giving her time, helping them occasionally with some household task and arranging for child care during classes won their respect.
The women came to accept her, and Sandra was invited to eat with them and share in tribal get- togethers. The women criticized and advised her on acceptable ways to speak and act. Her openness and patience to learn and her respect for them as a people had paved the way to improving their health. At first, Sandra felt that her progress was slow, but this slowness was an advantage. She had built a solid foundation of cross-cultural trust, and in the months that followed she saw many changes in her clients’ health practices.
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including the acquired immunodeficiency syndrome (AIDS), also are higher for Blacks than for Whites. The incidence of TB in this population is rising, with many cases being diagnosed in conjunction with AIDS (see Chapters 8 and 26). Other infectious and parasitic diseases are three to six times more prevalent among African Americans than among Whites (U.S. Department of Health and Human Ser- vices, 2000). Hypertension is a real concern in this popula- tion (37% of men and 41% of women over the age of 20 report having hypertension). In the same age group, 66% of men and 79% of women are reported as overweight (National Center for Health Statistics, 2007a). In two health- related areas, Blacks demonstrate a lower incidence than Whites: suicide is 50% less prevalent among Blacks, and the rate of chronic obstructive pulmonary disease (COPD) is 20% to 30% less. All other leading causes of death are higher for Black populations, much of which can be attrib- uted to lifestyle and poverty (Hong et al., 2006). However, some genetic studies have shown significant differences between African Americans and Whites in those genes asso- ciated with hypertension and cardiovascular disease (Lange et al., 2006; Wang et al., 2006).
Blacks may have specific skin problems (e.g., keloids, melasma). In addition, sickle cell anemia occurs in Blacks, an inherited genetic trait thought to have originated in Africa as a defense against malaria (Spector, 2009).
Health Beliefs and Practices
Although African Americans have assimilated into the more dominant European American culture in the United States,
some retain aspects of their ancestors’ traditional values and practices. Some, for example, hold traditional African beliefs about health being a sign of harmony with nature and illness being evidence of disharmony. Evil spirits, the pun- ishment of God, or a hex placed on the person might account for this disharmony. Healers treat body, mind, and spirit.
Prayer, laying on of hands, magic or other rituals, special diets, wearing of preventive charms or copper bracelets, ointments, and other folk remedies sometimes are practiced (Spector, 2009). A recent study by Aaron, Levine, and Burstin (2003) found that, for African Americans, church attendance is significantly associated with positive health care practices (e.g., blood pressure measurements, Pap smears, mammograms, dental visits). This was even stronger for the chronically ill and uninsured subgroups. This is an important consideration when public health nurses plan pro- grams targeting this population. Each African American community has its own set of health beliefs and practices that must be determined by the community health nurse before any interventions are planned.
Asian Americans
A third cultural cluster is composed of immigrants and refugees from various Pacific Rim countries, such as China, Korea, Japan, Thailand, Laos, the Philippines, Viet- nam, and Cambodia (Display 5.6). Some Asian Americans have been transplanted fairly recently from their native countries and cultures to an entirely different culture, whereas others may have lived here many years or were born in America.
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UNIT 1 Foundations of Community Health Nursing DISPLAY 5.5Nations of Origin • Many West African countries (as slaves)
• West Indian Islands
• Dominican Republic, Haiti, Jamaica
Environmental Control • Traditional health and illness beliefs may continue to be observed by “traditional”
people
Common Biological Variations • Sickle-cell anemia
• Hypertension
• Cancer of the esophagus
• Stomach cancer
• Coccidioidomycosis
• Lactose intolerance
Social Organization • Family: many single-parent households headed by females
• Large, extended family networks
• Strong church affiliations within the community
• Community social organizations
Communication • National languages
• Dialect: Pidgin
• French, Spanish, Creole Spatial Distancing • Close personal space Time Orientation • Present over future
Adapted from Spector, R.E. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
EXAMPLES OF CULTURAL PHENOMENA AFFECTING HEALTH CARE AMONG BLACK OR AFRICAN AMERICANS
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107DISPLAY 5.6
Asian refers to: Pacific Islander refers to:
Chinese Polynesian
Filipino Hawaiian
Japanese Samoan
Asian Indian Tongan
Korean Micronesian
Vietnamese Guamanian
Laotian Melanesian
Thai Fijian
Cambodian Tahitian
Pakistan Marshallese
Indonesian Trilese
Hmong Mien