“You are talking about parents who are medieval, com- ing to a country that is hundreds of years ahead of theirs. They’re trying to catch up, but it’s hard.”—
Mymee (college instructor)
“There is much research that shows people who stand in the middle of two cultures are really at risk of depression and anxiety.”—Valerie (psychologist)
“The kids are constantly living between two cul- tures. At some point, they may give up.”—Leng (psy- chologist. Southeast Asian adult services center)
“I think it’s a topic that nobody wants to talk about.
It’s hard for me to say if the Hmong community is ready to deal with it.”—Xong (social worker, Hmong suicide task force)
“We parents think we know only one way to raise our kids. We ignore that these children are living in America and are espousing everything that is American, good and bad.”—Andy (Hmong parent)
Ellis, A.D. (2002, August 11). Hmong Teens:
Lost in America [Special report].
The Fresno Bee, pp. 1–12.
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Magicoreligious View
Magicoreligious themes of health and illness, which focus on the control of health and illness by supernatural forces, are prominent in some cultural groups. Diseases occur as a result of “committing sins” or “going against God’s will.”
Good health is a gift from God, and illness is a form of pun- ishment that affords an opportunity to be forgiven and to realign oneself with God. Prayer to God or other religious figures is used to cope with illness, seek intervention for healing, and ask for forgiveness and entrance into heaven, if death be God’s will.
Some cultures mix traditional folk beliefs with organ- ized religious practices and participate in forms of magic or voodoo. In cultures that have such beliefs, a hex or spell can be placed on another person through the use of incantations, elixirs, or an object resembling the person. For some, illness results from a look or a touch from another person consid- ered to have special powers or intent to harm (Leininger, 2006; Spector, 2009). Later in this chapter, we discuss some specific health beliefs and practices common to cultural groups in North America.
Religious beliefs, an individual’s spirituality, and how these factors interface with feelings of wellness and specific healing practices are personal and important to clients and cannot be separated from their culture. This makes it imper- ative for community health nurses to be familiar with folk beliefs commonly seen in their practice. Only then can cul- turally competent nursing care be provided.
Holistic View
Holistic health believers come from many different cultural groups and generally view the world as being in harmonious balance. If the principles guiding natural laws to maintain order are disturbed, an imbalance in the forces of nature is created, resulting in chaos and disease. For an individual to be healthy, all facets of the individual’s nature—physical, mental, emotional, and spiritual—must be in balance.
Some cultural groups believe that all things in creation or the universe have a spirit and therefore are considered equal in value, purpose, and contribution (Lowe, 2002). Individuals have universal connectedness and are viewed as holistic beings.
Persons are extensions of and integrated with family, commu- nity, tribe, and the universe. For example, “mother and fetus are viewed as interrelated and as affecting each other: They are one, but also they are two. In the circle of life, each individual is believed to be on a journey experiencing a process of being and becoming” (Lowe & Struthers, 2001, p. 6).
Folk Medicine and Home Remedies
Many of us remember our mothers giving us hot herbal tea with lemon, or slathering on ointments and piling on blan- kets to lessen the effects of a mild illness. Many folk medi- cines and home remedies came about as a means of provid- ing health care to family members when no medical care was available or deemed affordable.
Folk medicineis a body of preserved treatment practices that has been handed down verbally from generation to gener- ation. It exists today as the first line of treatment for many indi- viduals. Some clients may never plan to seek Western medical treatment but may share with you, the community health
nurse, a practice they are using to treat a family member. Your response and actions may mean the difference between health and illness or injury. Some maternal–child health practices from the U.S. rural Midwest or South that may be encountered in community health nursing practice include the following (Giger & Davidhizar, 2004; Spector, 2009):
◆ Not reaching above your head if you are pregnant, because doing so will cause the umbilical cord to strangle the baby
◆ Pregnant women eating handfuls of clay, dirt, or cornstarch
◆ Taping coins over a newborn’s umbilical area to prevent hernias
◆ Giving catnip tea to infants because it saves their lives
◆ Holding a baby upside down by her heel to “wake up her liver”
◆ Not letting a cat in a room with a sleeping baby, because the cat will “suck the life” out of the baby Home remediesare individualized caregiving practices that are passed down within families. Even individuals who routinely seek the guidance of a health care practitioner for diagnosis and treatment may try home remedies before seek- ing professional advice. Each of us has a set of home remedies our parents used on us that we are likely to use on our own children before or instead of calling the pediatrician. Examples include using baking soda paste on a bee sting, ice on a “cold sore,” or cranberry juice to prevent a urinary tract infection.
Herbalism
Textbooks have been written on the many uses of medicinal herbs (Gruenwald, 2004). The use of some herbs has waxed and waned in favor. Some continue to be much touted, whereas others have been designated as dangerous and to be avoided (Medline Plus, 2007). Increasingly, the public is using herbal preparations in the form of self-selected over-the-counter (OTC) products for therapeutic or preventive purposes.
In an increasingly multicultural society, the source, form, and identity of many herbs, roots, barks, and liquid preparations become impossible for most community health nurses to distinguish. The most astute among us may be famil- iar with herbs used by one cultural group, whereas herbs used by another escape us. A book with pictures and descriptions, botanical form, purported indications and uses, and implica- tions for nursing management is an important tool to keep handy when interacting with clients. Nursing Herbal Medi- cine Handbook (Lippincott, Williams, & Wilkins, 2005) is also available in software version for PDAs (Handango, 2007)—an even more efficient method of retrieving informa- tion quickly. Basic safety questions that community health nurses should answer about an herb when teaching or inter- acting with families include the following:
◆ Is the herb contraindicated with prescription med- ications the client is taking?
◆ Is the herb harmful? Does it have negative side effects?
◆ Is the client relying on the herb, without positive health changes, while neglecting to get effective treatment from a health care practitioner?
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Herbs are not regulated as drugs and are not risk free.
Dosages are not standardized and are left to the individual.
Quality of the product may be suspect. For these reasons, herbs must be used only in moderation and with caution, preferably with guidance by a health care practitioner.
Prescription and Over-the-Counter (OTC) Drugs The cautions mentioned about herbs can also apply to pre- scription and OTC medications. First, they are not risk free.
In this country, prescription drugs are reviewed and tested by the U.S. Food and Drug Administration (FDA)’s Center for Drug Evaluation and Research (CDER), and OTC drugs go through a somewhat less-rigorous process through the CDER’s Division of OTC Drug Products. Over-the-counter drugs comprise six out of every 10 medications bought in the United States (U.S. FDA, 2007). However, many OTC drugs were once available only by prescription, and remain powerful medicines. All drugs can have major side effects, may be contraindicated in people with certain conditions, and may not be safe to use in combination with certain other drugs. Medication instruction and review is an important part of the community health nurse’s role on home visits, especially with elderly clients (see Chapter 24).
Second, some new prescription medications are so expensive that clients cannot afford to take them as pre- scribed. Often, older, less expensive, and more frequently used drugs work as well as the newer, more expensive ones, which are heavily marketed by drug companies to health care practitioners and consumers. If you encounter clients who are unable to pay for drugs, you may need to advocate for them with health care providers to prescribe a less expensive medication or change to the generic form of the same drug, usually sold at a fraction of the cost.
Some health care practitioners have samples of drugs available and may be able to use them for medically indi- gent clients. Many pharmaceutical companies now have low-cost prescription assistance programs for those in need (NeedyMeds.com, 2007).
Third, the efficacy of medications must be assessed. At times, the use of a new drug or an additional drug does not have the intended effect. As someone who sees the client managing at home over time, the community health nurse may be able to give the best information to the health care provider about the effectiveness of new medications for a particular client.
Complementary Therapies and Self-care Practices
Complementary therapies(also called alternative medi- cine or alternative therapies) are practices used to comple- ment contemporary Western medical and nursing care and are designed to promote comfort, health, and well-being (Snyder, 2001). The range of complementary therapies is broad and includes:
◆ Therapies (cancer diets, juice diets, fasting)
◆ Treatments (coffee enemas, high colonic enemas)
◆ Exercise activities (t’ai-chi, yoga)
◆ Exposure (aromatherapy, music therapy, light therapy)
◆ Manipulation (acupuncture, acupressure, reflexology)
Most cultural groups engage in some form of complemen- tary therapy, either alone or in conjunction with Western medicine. Integrated health care is defined as the combi- nation of complementary therapies with biomedical or West- ern health care (Snyder, 2001). Complementary therapies have become so commonplace today that many states are developing policies and guidelines for their use.
Consumers need to be well informed regarding the effi- cacy and safety of complementary therapies and how they can be true complements to other treatment modalities. The com- munity health nurse should be aware of the variety of thera- pies available and how to get information for clients while remaining objective and supportive of the client’s choices. At times, if a therapy contradicts the recommendations of the client’s health care practitioner, the nurse may be in a position to provide the pros and cons of continuing the complementary therapy. On the other hand, the nurse may be able to suggest therapy forms that would complement Western medicine for the client, such as music therapy to promote relaxation and reduce stress or biofeedback for chronic pain management.
Self-care activities include complementary therapies, medications, and spiritual and cultural practices. They are uniquely individual for each person, as well as among dif- ferent cultural groups. Chapter 19 includes a Self-Care Assessment Guide that may be helpful in assessing the self- care practices of families.
Role of the Community Health Nurse
When working with different cultural groups in the area of health care practices, the community health nurse can be an effective advocate for the client. First, however, the nurse must be prepared to speak knowledgeably about health care practices and choices. The nurse also must be able to assess the client or family adequately, so as to know what belief system motivates their choices. Finally, the nurse must be prepared to teach clients about the limits and benefits of cul- tural health care practices. The community health nurse should always individualize assessment and caregiving for the client within her culture and should not generalize about the client based on cultural group norms.
Preparation of the Community Health Nurse To be effective when working with clients in the area of cul- tural health care and spirituality, the nurse must be prepared.
Many ways exist for you to increase your cultural awareness and promote sensitivity to the differences among people from ethnocultural groups different from your own. You can acquire information from peers who are from the same cul- tural group as your clients; attend workshops or conferences on chosen cultural topics; read books on ethnocultural health care practices, herbalism, or complementary thera- pies; talk with clients about their views and practices and learn from them; keep an open mind and be curious about various practices; or attend community cultural events such as Native American powwows, ethnic food events held in some cities, or Cinco de Mayo celebrations. There are textbooks, novels, and articles about cultures in the community in which one practices. For example, the book The Spirit Catches You and You Fall Down (Fadiman, 1997) describes a Hmong child, her American doctors, and the collision of two cultures.
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Assessment
When beginning to work with a group or family, it is important for you to become as familiar with them as pos- sible. In addition to a family assessment or an individual health assessment, you can enhance your aggregate care by doing an ethnocultural or self-care assessment. Such an assessment reveals information about day-to-day living, cultural/spiritual influences, traditional/cultural health care choices and practices, and cultural taboos. Often this type of information is most useful as you work with clients on a regular basis. Useful tools include the two cul- tural assessment reviews at the end of this chapter (see Tables 5.7 and 5.8) and the self-care assessment tool in Chapter 19.
Teaching
As you are aware from your studies and preparation, teach- ing is a most important role in nursing, both in acute care settings and in the home. When working with families as a community health nurse, teaching takes a good deal of your time, because health care education is vitally important to communities, groups, and families. However, teaching that is undertaken in ways that are incomplete, culturally inap- propriate, or inadequate may be frustrating and even harm- ful to your clients. Becoming ethnoculturally focused and prepared to teach from the client’s view of the world will start you in the right direction. The suggestions in Display 5.3 offer ideas for providing culturally competent care.
Chapter 11 on Health Promotion and Education will help prepare you as well.
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101From the Case Files I
Learning About Other Cultures
I was always interested in learning about other countries and cultures, but I didn’t realize that an overseas assignment would teach me so much about myself, in addition to other cultures and ways of living. The lessons were sometimes difficult, but always rewarding. I knew that my expec- tations would not always be met, yet it did surprise me how different the experience was from what I had imagined. My job assignment, location, and team members changed frequently. Flexibility, comfort with ambiguity, a sense of humor, a deeper reliance upon my faith, patience when results were not forthcoming, trust in others, and the ability to cross multiple cultures with some degree of ease were all skills that I developed over time. Most important to being successful at my job was to maintain the attitude of a “learner,” not a “solver of problems” or the person “with all the answers.”
I made friends with people from all over the world who graciously accepted me into their lives, thus enriching mine. I learned that we all are different, but that every behavior has a reasonable expla- nation when you take the time to listen with your heart as well as with your ears. I found that I actu- ally preferred other ways of doing and being while still maintaining those parts of my identity that were valuable to me. When I returned home, I found that my newly developed skills were still necessary—I had changed and had to adjust to re-entry back into my home culture!
Karin Urso, PHN