Nurses vs. HIV/AIDS Disparities: Creating Culturally Competent Interventions
Editor’s Note: Part one of this series, showcasing the innovative work of minority nurses who have created successful solutions for improving HIV/AIDS treatment and prevention in communities of color, appeared in the Fall 2006 issue of Minority Nurse.
What’s working these days in the ongoing, urgent effort to close the gap of HIV/AIDS disparities in America’s communities of color–and especially among racial and ethnic minority populations that have traditionally been the most vulnerable, marginalized and medically underserved? Consider the following success stories:
- Project YEAH (Youth Empowerment Around HIV), an innovative program that emphasizes Internet outreach to increase HIV testing and treatment among college-age young men of color who have sex with men.
- “¡Cuidate!” (Take Care of Yourself!), a culturally tailored HIV prevention program that is helping to reduce risky sexual behavior among Hispanic teenagers.
- The Mother/Daughter HIV Risk Reduction (MDRR) intervention, which uses a variety of culturally sensitive exercises, games and life skills tools to help low-income mothers teach their children to protect themselves from getting HIV.
- The JACQUES Initiative, a community-based treatment compliance project that has been so effective in helping patients manage their HIV treatment regimens that it has been expanded into a national pilot program.
These interventions–profiled in depth, along with several others, in part one of this series–have three key things in common. First, they are not abstract concepts but practical solutions that work, in the sense that they are making an immediate impact. Secondly, they work because they are culturally sensitive approaches that have been painstakingly customized to fit the needs of the specific minority populations they are targeting. And last but absolutely not least, they were all developed and implemented by nurses of color.
Looking at strategies that other minority nurses are using to eliminate racial and ethnic disparities in HIV/AIDS care is an excellent starting point for getting ideas that can be used to create your own culturally competent solutions. Some of these nurse-led interventions are still being tested, but you can use their sound, evidence-based methods and adapt their tools to the needs of your particular patient community. For example, check out the various strategies for breaking through stigma and mistrust, overcoming language barriers, partnering with faith-based and community organizations and using nursing students as a valuable resource.
But don’t stop there. A wealth of additional knowledge and resources lies at your fingertips. Investigate popular cultural competency models and multicultural best practices–general, HIV/AIDS-specific and population-specific–developed by cross-cultural health experts and HIV/AIDS training centers. Take advantage of programs, tools, funding and population-specific data available from numerous federal government health agencies. Network with HIV/AIDS experts from minority nursing associations and minority health organizations to learn what has worked for them and what has been less successful.
Above all, keep in mind this advice from transcultural nursing expert Josepha Campinha-Bacote, PhD, MAR, APRN, BC, CNS, CTN, FAAN, founder and president of Transcultural C.A.R.E. Associates in Cincinnati. According to Campinha-Bacote, the development of a cultural competency model must be driven by an initial desire for competency. “Cultural desire is motivation of the nurse to want to engage in the process of becoming culturally competent, not to have to,” she explains. “Cultural desire is the spiritual and pivotal construct of cultural competence that provides the energy source and foundation for one’s journey toward cultural competence.”
The BE SAFE Model
Campinha-Bacote’s well-known model for cultural competency in health care, initially developed in 1991 and revised/expanded several times since then, is a staple of the transcultural nursing literature that has been used by many organizations and researchers as a foundation for building their own culturally competent programs.1 Although it is not AIDS-specific, Campinha-Bacote’s model–along with her additional input–were used by the National Minority AIDS Education & Training Center (NMAETC), a HRSA-funded training and technical resource based at Howard University in Washington, D.C., to develop its BE SAFE series of cultural competency models for health care providers. In turn, a number of minority HIV/AIDS nurses are now adapting the BE SAFE model as a launching point for new projects.
Designed to help clinicians understand and address the cultural needs of HIV/AIDS patients from specific racial and ethnic minority populations, the BE SAFE series currently includes culturally competent models for African Americans (published in 2002), Latinos (2004) and American Indians, Alaska Natives and Native Hawaiians (2006). All three publications can be downloaded from www.nmaetc.org free of charge. A fourth BE SAFE model, for Asian Americans and Pacific Islanders, is in the works.
Here’s what the BE SAFE mnemonic covers:
- Barriers to Care–real or perceived gaps to receiving/providing quality care that are compounded by the relationship of HIV/AIDS to ethnicity (e.g., mistrust of the medical community, lack of access to care, stigmas surrounding HIV, and bias in medical decision-making).
- Ethics–the science of the human condition as it applies to morality, belief systems and “right” vs. “wrong” behavior.
- Sensitivity of the Provider–cultural awareness and self-examination of one’s biases and prejudices toward other cultures as well as one’s own cultural background.
- Assessment–ability to collect relevant patient health history data in the context of the patient’s culture (e.g., being attuned to how the patient’s cultural needs affect outcomes, adherence and follow-up).
- Facts–understanding of physiology, behavior, health disparities, patients’ cultural beliefs and values, patients’ perceptions of their illness, and biological variations in HIV/AIDS.
- Encounters–communicating effectively with minority patients in face-to-face clinical interactions; awareness of cultural norms related to communication.
Keep in mind that the BE SAFE tips and strategies are not cookie cutters to pop right into practice. You still have to do the work of developing cultural competency. Furthermore, the six components of the BE SAFE process are not neatly separated. Look for a pattern after you add in such factors as specific cultural heritage, degree of acculturation, language, values and traditional attitudes about health and illness–and after you have assessed your own cultural competency.
Ethics, Spirituality and History
The first “E” in the BE SAFE framework merits particularly careful consideration. The ethics component also engages religion, spirituality and social justice issues along with cultural heritage–all of which will affect your sensitivity in assessing and treating patients. An ethics model developed by Beauchamp and Childress–recommended in the BE SAFE books and widely used in Western medicine and health care–rests on the four secular principles of autonomy, beneficence, non-maleficence and justice.2 As you weigh these principles in making decisions about confidentiality and other sensitive issues in HIV/AIDS care, you will find that some cultures place less of a premium on autonomy and individualism than others.
Look also at models such as nursing codes of ethics as well as care-driven systems that make room for spiritual assessment and understanding of historical trauma, such as racism and genocide. For example, the BE SAFE cultural competency model for American Indians, Alaska Natives and Native Hawaiians notes that “the words ‘current’ and ‘history’ should not be dealt with lightly in any setting, medical or otherwise, in a Native community. In many instances, the ‘current’ health problem or issue is well rooted in the past.”
Campinha-Bacote emphasizes that “it is important to incorporate the patient’s spiritual resources, such as the Bible” when developing culturally competent interventions. Based on her recent graduate work in theology, Campinha-Bacote has developed a biblically based model that is built on a spiritual foundation and incorporates theological, intellectual and moral concepts into the process of becoming culturally competent.
Models such as BE SAFE also recognize that spirituality, traditional beliefs and health care are closely interconnected in some cultures. For instance, in some Native American populations, tribal medicine men and women are the primary care providers and Western medicine is the “alternative.” “Indigenous health care providers will deal with the spiritual, mental and a portion of the physical needs” in treating Native patients, the BE SAFE authors explain. A well-informed non-Native provider should consider incorporating the healing beliefs that are found within the patient’s tradition.
Religion and morality also figure in the continuing controversy about the effectiveness of “abstinence only” vs. “abstinence plus” approaches to sex education and STD prevention. Gihan ElGindy, MSN, RN, executive director of the Transcultural Education Center (TEC) in McLean, Va., and an expert on Muslim culture, points out the importance of distinguishing between religious and health counseling in Islam. Sexual activity outside marriage is forbidden in Islam and is considered a major sin. To prevent the spread of STDs as a result of adulterous behavior, Muslim men are permitted (under certain conditions) to marry up to four wives. Harming the self by use of drugs and alcohol is also forbidden. Therefore, ElGindy believes, the risk and incidence of HIV infection among strictly observant Muslims is relatively low; for non-practicing or less observant Muslims, the risk may be higher.
If a Muslim woman is infected by her husband, ElGindy continues, she has the right and duty to protect her health–including use of a condom–and her husband must get treatment. Non-observant Muslims who contract HIV would be expected to seek care in nonreligious facilities. In addition, age is an important consideration in allowing co-ed education of any kind, especially sex education. According to ElGindy, this is permitted (though discouraged) in Muslim culture only after a person reaches adulthood.
Culturally Competent Assessment Tools
Another key vowel in the BE SAFE mnemonic is the “A.” Conducting culturally competent patient assessments is the first step in the development of prevention and treatment programs customized to minority HIV/AIDS patients’ specific cultural needs.
“We use BE SAFE with some adaptations to our populations through culturally sensitive interviewing,” reports Hazel Jones-Parker, MSN, CRNP, AACRN, a nurse educator who delivers holistic primary care at the University of Maryland-affiliated Institute of Human Virology’s AIDS Education and Training Center (AETC) in Baltimore. She says the biggest barriers she encounters in her work are related to mental health and substance abuse. That’s a tricky area for assessing patients.
Jones-Parker has developed a pocket guideline for clinicians, HIV Risk Assessment: A Quick Reference Guide (see sidebar on page TK). She has also created a culturally sensitive pre- and post-test in a provider manual for clinicians who work with Lumbee Indians, a North Carolina tribe who, she says, “everyone thinks are Latinos.” She teaches risk assessment at her AETC, which is part of a HRSA-funded network of training centers across the country, offering programs ranging from basic “HIV 101” courses to preceptorships.
Other popular cultural assessment tools that can be adapted for use with many different populations are the LEARN model (published in 1983 by Berlin and Fowkes)3 and the GREET model (Chong, 2002).4 (See page TK.) The BE SAFE workbook for Latinos describes GREET as “a model [that] presents the opportunity for providers to collect necessary cultural and background information while simultaneously allowing for the demonstration of interest in the lives of their Latino patients, thus enabling the establishment of confianza (trust).”
“I use LEARN for everything,” attests Gayle Tang, MSN, RN, director of national linguistic and cultural programs at Oakland, Calif.-based Kaiser Permanente, where she has designed and implemented several strategic initiatives and new culturally competent service delivery systems. “It works very well for cross-cultural dialogue. [The model] builds in time for reflection and questioning, allows you to ‘recommend’ without being too domineering and then facilitates a way to incorporate the patient’s beliefs and traditional healing practices, or perhaps alternative medicine.
“Language and culture are interconnected–you can’t talk about either one without recognizing nuances of the other,” Tang continues. “Language access is a huge problem in the HIV/AIDS crisis. Think about what you have to consider: Does a newer immigrant have the same language and same concept of the disease as someone from an older generation living here in the U.S. or in the country of origin? Will a difference in values affect adherence? I always do a very thorough cultural assessment before imposing any treatment plan.“
Guidelines such as the Office of Minority Health’s National Standards on Culturally and Linguistically Appropriate Services (CLAS) can provide helpful ideas for breaking down language barriers–and some of the CLAS standards are actually mandatory for health care facilities that receive federal funding. Tang, who teaches in Kaiser Permanente’s Health Care Interpreter Certificate Program, which she developed, warns against the pitfalls of using linguistically inappropriate approaches, such as “do-it-yourself” interpreting and asking patients’ children or other family members to serve as interpreters.
“Don’t take the easy way out and use a family member, ” she emphasizes. “One, you have no way of knowing about the linguistic proficiency of the family member. Two, you don’t know whether the person will be–or even can be–neutral. Three, you have no way of making sure the interpretation is accurate or complete. Finally, you can’t assume that family members always have a patient’s best interests at heart. We’ve encountered abusive situations.”
1. Campinha-Bacote, J. (1998, 2002 rev.). The Process of Cultural Competence in the Delivery of Healthcare Services: A Culturally Competent Model of Care. Cincinnati: Transcultural C.A.R.E. Associates.
2. Beauchamp, T.L. and Childress, J.F. (2001). Principles of Biomedical Ethics, Fifth Edition. Oxford: Oxford University Press.
3. Berlin, E.A. and Fowkes, W.C., Jr. (1983). “A Teaching Framework for Cross-Cultural Health Care–Application in Family Practice.” The Western Journal of Medicine, Vol. 139, No. 6, pp. 934-938.
4. Chong, N. (2002). The Latino Patient: A Cultural Guide for Health Care Providers. Yarmouth, Me.: Intercultural Press.
A Wealth of Resources at Your Fingertips
Use this handy “menu” of informational resources to research and design culturally sensitive HIV/AIDS interventions tailored to your specific patient population and project goals. Mix and match HIV/AIDS, minority health, nursing, cultural competency, ethics and faith-based resources with your own knowledge, expertise, best practices and cultural desire. While this resources list is by no means exhaustive, it’s a good centralized starting point that can lead to many additional discoveries.
|Minority Population||Patient Profile||Patient Care/Outreach Setting||Nursing Role|
Migrant farm workers
MSM (men having sex with men)*
People with disabilities
Religious tradition/ belief (e.g., Christian, Muslim)
Sexual abuse victims
|Academic institution/nursing school|
Adult day health care center
AIDS residential care
Camps (summer and year-round)
Community-based comprehensive care
Community-based nursing Correctional facilities/detention centers
Entertainment/clubs/sex tourist sites
Faith-based community (church, mosque, etc.)
Health care program for uninsured patients
Indian Health Service/tribal facility
Migrant farm worker communities
Pregnancy counseling center
Primary care–comprehensive, HIV/AIDS
Public health agency/facility
Public places/neighborhood celebrations
Substance abuse treatment center
Transitional housing program
|Advanced practice nurse|
Association leader/board member
Clinical practice nurse
Gatekeeper (tribal) nurse
Public/community health nurse
Federal Government Resources
Agency for Healthcare Research and Quality (AHRQ)
• AHRQ Focus on Research: HIV Disease
• Specific Populations pages (e.g., minorities, women, children, elderly, rural, urban, inner city)
Centers for Disease Control and Prevention (CDC)
• Division of HIV/AIDS Prevention
• National Prevention Information Network (NPIN)
• Diffusion of Effective Behavioral Interventions (DEBI) Project (in collaboration with the Center on AIDS & Community Health at the Academy for Educational Development)
Department of Health and Human Services
• AIDS.gov (a centralized information gateway to federal HIV/AIDS information and resources)
• Health Resources and Services Administration (HRSA)
• HRSA HIV/AIDS Bureau (administers the Ryan White CARE Act)
• Innovative Approaches to HIV Outreach Along the U.S./Mexico Border
• Cultural Competence Resources for Health Care Providers (includes many HRSA HIV/AIDS resources targeted to specific minority populations)
• Indian Health Service (IHS)
• HIV Center of Excellence (HIVCOE) at the Phoenix Indian Medical Center. (Web page includes links to many other Native American AIDS-specific resources.)
• National Institutes of Health (NIH)
• AIDSinfo Web site
• Office of AIDS Research (OAR)
• National Institute of Nursing Research (NINR)
• National Center on Minority Health and Health Disparities
• Office of Disease Prevention and Health Promotion (ODPHP)
• Healthy People 2010 initiative
• Office of Minority Health (OMH)
• HIV/AIDS Web site section (click on “HIV/AIDS” under “Health Topics”)
• OMH Center for Cultural and Linguistic Competence in Health Care (includes information on the CLAS standards)
• National Action Agenda to End Health Disparities for Racial and Ethnic Minority Populations
• Culturally Competent Nursing Modules
HIV/AIDS RESOURCES, ORGANIZATIONS AND TRAINING CENTERS
• AIDS Action (resources include What Works in HIV Prevention guides for various populations)
• AIDS Education and Training Centers (AETC) National Resource Center
• AIDS Education Global Information System (AEGIS), an extensive free-access “virtual AIDS library,”
• Asian & Pacific Islander Coalition on HIV/AIDS (APICHA)
• The Banyan Tree Project (a national campaign to eliminate HIV/AIDS-related stigma in Asian and Pacific Islander communities)
• Black AIDS Institute
• Black Coalition on AIDS (BCA)
• The Body: The Complete HIV/AIDS Resource (comprehensive topic coverage for patients and providers, including population-specific prevention resources)
• Hawaii AIDS Education and Training Center: AIDS Education Project
• HIV InSite (comprehensive, up-to-date information from the Center for HIV Information at the University of California San Francisco School of Medicine)
• Minority Healthcare Communications, Inc. (sponsors annual national conferences on HIV/AIDS in the African American and Latino communities)
• National Health Care for the Homeless Council (clinical practice resources include Health Disparities Collaboratives and HIV/AIDS resources)
• National Minority AIDS Council (NMAC)
• National Minority AIDS Education & Training Center (NMAETC)
• National Native American AIDS Prevention Center (NNAAPC)
• Asian American/Pacific Islander Nurses Association (AAPINA)
• Association of Nurses in AIDS Care (ANAC)
• National Alaska Native American Indian Nurses Association (NANAINA)
• National Association of Hispanic Nurses (NAHN)
• National Black Nurses Association (NBNA)
• National Coalition of Ethnic Minority Nurse Associations (NCEMNA)
• Philippine Nurses Association of America (PNAA)
• Transcultural Nursing Society
CULTURAL/LINGUISTIC COMPETENCY RESOURCES
• Clinical Cultural Competence (Web page developed by the University of Michigan School of Nursing)
• “Cultural Desire: The Key to Unlocking Cultural Competence” (Campinha-Bacote, J., 2003), Journal of Nursing Education, Vol. 42, No. 6, pp. 239-40
• “Culture, Illness and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research” (Kleinman, A., Eisenberg, L. and Good, B., 1978), Annals of Internal Medicine, Vol. 88, No. 2, pp. 251-258
• Diversity Rx (resources include multicultural health best practices, cultural and linguistic competency models and a CLAS listserv)
• EthnoMed (“information about cultural beliefs, medical issues and other related issues pertinent to the health care of recent immigrants to Seattle or the U.S., many of whom are refugees fleeing war-torn parts of the world”)
• National Center for Cultural Competence (NCCC), Georgetown University Center for Child and Human Development
• A Provider’s Handbook on Culturally Competent Care, a series of handbooks published by Kaiser Permanente’s Institute for Culturally Competent Care (includes books for African American, Latino, Asian/Pacific Islander and LGBT populations). To order, call (510) 271-6663.
• Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies (a curriculum developed by the Center for the Health Professions at the University of California San Francisco)
• Transcultural C.A.R.E. Associates (offers numerous cultural competency resources, including models, training, publications, tools and links)
• Transcultural Communication in Nursing, Second Edition (Muñoz, C. and Luckman, J., 2005), Thomson Delmar Learning
• Transcultural Nursing: Concepts, Theories, Research and Practice, Second Edition (Leininger, M. and McFarland, M., 1995), McGraw-Hill.
ETHICS, SPIRITUALITY AND FAITH-BASED RESOURCES
• The Balm in Gilead (a non-profit international collaborative of black churches working to address the HIV/AIDS crisis in the black community)
• A Biblically Based Model of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote, J., 2005), Transcultural C.A.R.E. Associaties
• Cross-Cultural Perspectives in Medical Ethics, Second Edition (Veatch, R.M., 2000), Jones & Bartlett
• Ethics, Trust and the Professions: Philosophical and Cultural Aspects (Pellegrino, E.D., Veatch, R.M. and Langan, J.P., 1991), Georgetown University Press
• HIV/AIDS Initiative, Saddleback Church (the megachurch founded by evangelist and AIDS activist Rick Warren, author of The Purpose Driven Life)
• National African American Catholic HIV/AIDS Task Force (a project of the U.S. Conference of Catholic Bishops)
• National Catholic AIDS Network
• Nursing Ethics Network (NEN)
• “Nursing in the Native American Culture and Historical Trauma” (Struthers, R. and Lowe, J., 2003), Issues in Mental Health Nursing, Vol. 24, No. 3, pp. 257-72
• Transcultural Education Center (TEC) (offers cross-cultural training, consulting, publications and other resources with an emphasis on Muslim culture and Islamic practices)