The United States is in the midst of an epidemic. Obesity rates across the country are staggering, having increased dramatically over the last 25 years. Research suggests that more than one third of adults, or over 72 million people, were obese in 2005–2006.1
Though there was no significant change in obesity numbers between 2003–2004 and 2005–2006 for men or women, this does not negate the need to direct attention and intervention efforts into mitigating the effects of obesity and addressing the underlying reasons for its high prevalence.2 And while this problem runs rampant among adults, it has been steadily encroaching upon children and is particularly disproportionate among minorities.
Defining obesity: a refresher
According to the Centers for Disease Control and Prevention (CDC), the body mass index (BMI), which correlates with body fat, determines overweight and obesity ranges using weight and height. An adult with a BMI of 25–29 is considered overweight; a BMI of 30 or higher is considered obese.3 BMI is calculated by weight in kilograms and height in meters squared (kg/m2); for English measurements, use lb/in2 x 703. BMI charts are also widely available on the Web, including at the CDC website (www.cdc.gov).
Obesity has been linked to a number of chronic health conditions, including diabetes, cardiovascular disease, and some forms of cancer, as well as increased health care expenditures—it simply costs more to be obese.4 In particular, an obese person spends $1,429 more in medical bills compared to a person of a healthy weight. The annual obesity expenditure in the United States is an estimated $147 billion dollars.5
While the pervasiveness of obesity is troubling in and of itself, some of the more shocking statistics are found amongst minority populations. A 2009 CDC Morbidity & Mortality Weekly Report revealed that from 2006–2008 African Americans had 51% higher prevalence of obesity compared to Caucasians, with Hispanics having a 21% higher prevalence.6 African American and Hispanic women seem to be particularly vulnerable and representative among these numbers. Recent data show racial and ethnic obesity disparities for women, but not for men. Non-Hispanic black and Mexican American women were more likely to be obese than non-Hispanic white women. For men in general, obesity prevalence rose from 27.5% in 1999–2000 to 32.2% in 2007–2008.2
The disproportionate instances of obesity within minority populations may have roots in a number of factors. However, none can be addressed without examining the effects of U.S. health disparities, as well as the impact of social determinants of health. Two overarching national public health goals in the United States are to increase healthy life expectancy at all ages and to eliminate health inequalities according to gender, race or ethnicity, education or income, disability status, geographic location, and sexual orientation.7 But persistent health disparities—inequalities in health outcomes because of social disadvantages—have been an ongoing challenge within minority communities, hindering those national goals.4 According to Carter-Pokras & Baquet (2002), any health disparity should be viewed as a chain of events signified by a difference in environment; access to, utilization of, and quality of care; health status; or a particular health outcome that deserves scrutiny.8 Education and income levels contribute to disparities, but living conditions and behavioral risk factors also impact health.
These disparities become more notable considerations as the minority population increases. A U.S. Census Bureau population profile of 2010 indicates that over the past decade America’s population has grown by 9.7%, accounting minorities for 92% of that growth. The number of Hispanics grew approximately 43%, with the Asian population at the same rate, and the African American population increased in number by 11%. The total minority population increased 29% over the past decade, and now comprises approximately one-third of the American population.9,10
Evidence also suggests a relationship between socioeconomic status, income, education, and higher rates of overweight and obesity.1 Members of minority communities often reside in more urban areas, and these areas may provide limited or no access to healthy options for food, physical activity, or security. Residents in low-income urban areas are more likely to report greater neighborhood barriers to physical activity, such as limited opportunities for daily walking or exercise and reduced access to stores that sell healthy foods, especially large supermarkets.11
Nurses in the fight against obesity
Public health nurses are effective in responding not just to the needs of the majority population, but also allowing for, even ensuring, the inclusion of minority segments. Aware of the unique challenges these populations face, nurses can educate—and advocate—for change where they work and live. After all, isn’t the term “public” indicative of representation of diversity among the population?
Obesity is a complex problem, and finding the root causes will help to inform possible solutions. Contributing to the problem is a lack of income and education, cultural differences, environmental changes, learned behaviors for coping, and food advertisements. From an economic perspective, people purchase foods they can afford; they are not necessarily thinking about the future consequences of those choices. And with lower-income populations—also consistently disproportionately composed of minorities—affordable healthy food alternatives should be strongly advocated, (i.e., farm cooperatives, farmers’ markets, free community nutrition workshops, etc.). Safety concerns might also make it hard for people to walk about their neighborhoods and for children to go out and play; nurses can inform their patients of known safe exercise areas and other community resources, like high school gymnasiums or free athletics classes at a public park or YMCA.
The influence of social factors, access to quality food and exercise, and individual factors around maintaining a healthy weight must be addressed. Each has an indirect and direct influence on behavioral choices and may ultimately impact weight. Individual-level characteristics (including income, cultural preferences, and genetic predisposition) contribute to macro-level considerations (neighborhood services, government health initiatives, education, etc.). These all feed the obesity epidemic, the significance of which public health nurses cannot overlook. Structures that affect physical activity behaviors and dietary choices are emerging as important and are potentially amenable to public health intervention efforts.
Yet, nurses cannot fight alone. A collaborative effort must be sought to help sustain community programs, which means establishing dialogue and partnerships between all stakeholders. Key legislative offi cials, health care providers, local businesses, community residents, journalists, educational administrators, nursing organizations—all must rally to address the problem of obesity systemically. The CDC’s Division of Nutrition, Physical Activity, and Obesity and the American Obesity Society (www.obesity.org) have online resources to help nurses and other health care professionals combat obesity. On an individual level, nurses can assess their own living, working, social, and other environments. They can engage and advocate for their immediate community and, ultimately, their state and country. Nurses working in public health facilities can be especially influential, as they may treat patients with the fewest resources. Educating one’s patients—whether through simple instructions during an exam, dispersing informational brochures, or even volunteering to speak at local schools and community centers—is the fi rst step in prevention.
Though health care is not yet available to all at this moment in history, public health nurses can reduce the impact of obesity on the nation’s most vulnerable populations.
References
C.L. Ogden, M.D. Carroll, M.A. McDowell, and K.M. Flegal, “Obesity among adults in the United States—No Statistically Significant Change Since 2003–2004,” NCHS Data Brief No 1, National Center for Health Statistics (2007). Accessed 2011. www.cdc.gov/nchs/data/databriefs/db01.pdf.
K.M. Flegal, M.D. Carroll, C.L. Ogden, and L.R. Curtin. “Prevalence and Trends in Obesity Among US Adults, 1999-2008,” The Journal of the American Medical Association, 303, no. 3 (2010): 235–241. Accessed 2011. doi:10.1001/jama.2009.2014.
Centers for Disease Control and Prevention, “Defining Overweight and Obesity,” (2010). Accessed 2011. www.cdc.gov/obesity/defining.html.
A. Stratton, M.M. Hynes, and A.N. Nepaul. “The 2009 Connecticut Health Disparities Report,” Connecticut Department of Public Health (2009). Accessed 2011. www.ct.gov/dph/cwp/view.asp?a=3132&q=433794.
Diana Holden. Fact Check: The Cost of Obesity. “Fit Nation” coverage, February 2010. CNN. com, accessed 2011. www.cnn.com/2010/HEALTH/02/09/fact.check.obesity/index.html.
L. Pan, D.A. Galuska, B. Sherry, A.S. Hunter, G.E. Rutledge, W.H. Dietz, and L.S. Balluz. “Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006–2008.” Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report 58, no. 27 (2009): 740–744. Accessed 2011. www.cdc.gov
Sam Harper and John Lynch. “Trends in Socioeconomic Inequalities in Adult Health Behaviors Among U.S. States, 1990–2004.” Public Health Reports 122 (2007): 177–189.
Olivia Carter-Pokras and Claudia Baquet. “What is a ‘Health Disparity’?” Public Health Reports 117 (2002): 426–434.
“The Census: Minority report,” The Economist, Accessed March 31, 2011. www.economist.com/node/18488452.
“Population Profi le of the United States.” U.S. Census Bureau. Accessed 2011.
J.L. Black and James Macinko. “Neighborhoods and Obesity.” Nutrition Reviews 66, no. 1 (2008): 2–20.
A recent Institute of Medicine report documented evidence that minorities in the United States received lower levels of mental health care, even when variables such as insurance status and income were controlled, says Debbie Stevens, P.M.H.C.N.S.-B.C., a doctoral student at Emory University’s School of Nursing in Atlanta, Georgia. That’s because nurses play a major role in helping reduce these disparities by educating patients, families, and their communities, Stevens says.
Overcoming cultural barriers
Finding treatment for an illness, such as depression, can be difficult for members of minority groups because they may face stumbling blocks to care, says Vicki Hines-Martin, Ph.D., R.N., F.A.A.N., a professor in the University of Louisville School of Nursing in Louisville, Kentucky.
A major barrier is a perceived cultural stigma of mental health issues. Hines-Martin says some minority populations don’t talk about suicide or depression because it’s seen as shameful. “You may have people who say, ‘I know about suicide, but it has nothing to do with my family or my group,'” she says.
Another problem is that many people may not understand the seriousness of their needs, says Harriett Knight, R.N., a nurse at Sinai Hospital in Baltimore, Maryland. Some people may initially seek an appointment with a specialist, but if treatment involves ongoing medication for an illness, such as depression or schizophrenia, the patient may be resistant to taking the drug as prescribed, or they don’t fully accept that they should continue to take it, says Knight.
Sylvia Hayes R.N., M.S.N., is a nurse in the mental health unit of Peninsula Regional Medical Center in Salisbury, Maryland. She says many patients she sees also don’t accept that mental health is a specific medical science. “They tend to believe their issues are caused by a physical problem,” she says. So they may seek help for a persistent headache, when the real issue may be anxiety related, she says.
In many cases, if a patient realizes that his or her medical issue does involve mental health, they may face another barrier—the fear of being stigmatized. Hayes says she’s seen many African American patients who are afraid that they’ll be “labeled” if they admit to having mental health issues.
“They don’t want to be considered ‘crazy,’ and their family doesn’t want them to be considered ‘crazy,'” says Hayes. “They may be afraid their family will isolate them if they seek help, because then they’ll become an embarrassment.”
Of course, many families support their loved ones suffering from mental illness, regardless of any perceived social stigma. In fact, when relatives are accepting of their loved ones and are willing to help them find care, they can be a vital part of the recovery plan. Many patients will even turn to family members for help before they turn to the medical system, says Hayes. This is good, as long as well-meaning relatives encourage patients to seek professional help when necessary. “It can be a negative if the family delays the patient from receiving the treatment they need,” she says.
Many families actually hold the key to helping patients understand their medical histories, Hayes says. “I’ve seen people with family secrets. They had an uncle or aunt who may have dealt with the same mental health issue,” she says. But if the family shunned that aunt or uncle, the patient may not be as open to finding help.
Family cooperation is also important in treating children and teens. Hayes says many mental illnesses are present at a young age. “I’ve worked with kids as young as two years old,” she says.
However, it may be difficult for well-meaning families to receive satisfactory care. A recent press release from the National Alliance on Mental Illness (NAMI) reports “63% of families reported their child first exhibited behavioral or emotional problems at seven years or younger,” but at the same time, “only 34% of families said their primary care doctors were knowledgeable about mental illness.”
Language and cultural obstacles present another challenge for mental health patients. If a person can’t find a medical professional they can simply talk to, they are less likely to seek medical care, says Patricia Lazalde, Ph.D., Director of Behavioral Health at San Ysidro Health Center in San Diego, California.
San Ysidro serves many Spanish-speaking Latino clients, so it’s important for minority nurses to be able to speak Spanish too, she says. “Minority clients may come in with a variety of stressors, but due to language issues they often don’t seek help until it reaches a crisis,” says Lazalde.
Immigrants of various backgrounds encounter similar stressors. In Louisville, Kentucky, there are increasing numbers of members in immigrant and refugee communities, particularly form Somalia and Myanmar, says Hines-Martin. “They’re newcomers, and they’re dealing with the stressors of changing from one environment to another,” she says. “How they deal with these stressors and whether they want to talk about them is important.”
Members of minority populations may also postpone or avoid seeking care for mental health issues, Hines-Martin says. It’s not so much related to an ethnicity or racial group, but it’s associated with people who hold more traditional values related to their culture, and are less likely to follow mainstream care, she says. “People who are less acculturated into the general population may be less likely to seek help if their culture says it’s not something they should do.”
Financial stress and mental health
The slow economy is also creating a barrier to care for some people, even as it’s identified as a stressor for many. Patients are dealing with the stress of lost jobs, eviction, and foreclosure, says Hines-Martin. She recently completed a study of 127 people in a low-income area and found that poorer residents had almost double the rate of depression as the general public.
“When you look at the economic factors they have to deal with, it makes perfect sense,” Hines-Martin says. The stress of constantly figuring out how to survive can wear down a person, and those factors are associated with depressive systems, she says. “If you have problems in several areas of your life, it can affect your mental health.”
Obviously, financial setbacks don’t always cause mental illness, but they can exacerbate problems in people who are vulnerable, says Knight. “A lot of patients don’t know they’re getting sick until there’s a trigger,” she says. For example, a person may get a call from their mortgage company informing them that they’re being foreclosed on, and they can’t handle their emotions, she says.
Lazalde agrees that whenever there is a loss of financial status within the family, nurses tend to see people with increased levels of depression and anxiety, particularly with wage earners.
“Traditionally, Latino males are the primary breadwinners for families, so the loss of a job and the inability to properly care for the family can really create an additional sense of anxiety, depression, and worry. It’s because they can’t live up to the more traditional roles that they would typically fulfill for the Latino family,” Lazalde says. As a result, there’s an increase of male Latinos coming to seek help for depression and anxiety, she says. The issues affect the entire family. “It creates marital problems. Parents are fighting, and we see the kids coming in with levels of anxiety as well,” Lazalde says.
Residents often have to move out of their homes and move in with relatives and extended family because of financial problems, she says. “Family members have to change schools and meet new friends, and there are not a lot of places they know to go to in terms of seeking resources and finding a shoulder to cry on,” Lazalde says.
Financial problems can also limit access to health care, including treatment for mental health needs. “Many clients are losing medical or health insurance coverage,” says Lazalde. This means fewer people can afford their doctor visits, and they have a more difficult time paying for their prescriptions.
Immigration issues are another stressor in many minority communities. There’s a lot of anxiety and depression when people hear about immigration reform on the news, and they’re worrying about what the outcomes and changes will be, says Lazalde.
“Many of our families are being impacted. A number are split up, with half the family living in the United States and the other half in the native country,” Lazalde says. As a result, wage earners have to support two homes, while they’re responsible for the cost of attorneys and other fees. “They have the stress of keeping the family together.”
Getting involved
One way nurses can help patients deal with their stresses, and improve mental health care overall, is to become active in the communities they serve. This helps build trust between residents and medical professionals, says Hines-Martin.
She says that’s a goal of the Office of Disparities within the University of Louisville’s School of Nursing, where she serves as the center’s Director. The office was started because the school of nursing identified a need to focus on how nursing education, practice, and research could help populations that experience disparities in health, Hines-Martin says.
The Office of Disparities sponsors a variety of programs, including faculty and student activities. Hines-Martin’s most recent project involves working with an entire low-income public housing community. “There are about 700 people in a one-block area,” she says. “It’s a way for us for us to see how economics, food, and trans-generational housing affect how people cope.”
Hines-Martin and her nursing students have found they don’t necessarily see people who are actively engaged in behaviors that are detrimental, such as self-inflicted violence or substance abuse. “But I do see people taking risky behaviors because they don’t care anymore,” Hines-Martin says. These people put themselves in dangerous situations, such as drinking excessively, and the drinking is actually related to depression or a depressed state of mind, she says.
There are many challenges, but the program is yielding results for patients who receive care, says Hines-Martin. She says she’s seen people who received help for psychological conditions and didn’t need to be readmitted to a medical facility after receiving treatment.
There’s also been a decrease in the number of people who have been evicted from their homes because of problems that could be tied to mental illness, such as drug use, says Hines-Martin.
“The community is in partnership with us,” Hines-Martin says. “We’ve learned that people are really invested in having a better understanding of their lives and mental health. It makes it easy to partner with them and invest in them.”
Another way to help build trust is to work with other professionals and community leaders to help educate the population about mental health topics. “Many Latino families aren’t likely to go to a behavioral health specialist initially. Instead, they’re more likely to seek help from clergy or a medical doctor,” Lazalde says. With regards to minority nurses, if they are connected to these influencers, they can help patients find needed behavioral care more quickly, she says.
Identifying red flags
Finding good mental health care is not simply a task reserved for nurses who specialize in behavioral health. Minority nurses in all specialties can help identify red flags that a patient may need a referral for a behavioral health specialist, Lazalde says.
When a nurse in any practice area sees a patient, he or she should look for issues such as a high frequency of usage, she says. The primary care doctor is usually the first person a potential mental health patient will visit, Lazalde says. If a patient has historically only visited the doctor’s office once or twice a year, but now they’re visiting two or three times a month, that’s a red flag, she says. These patients tend to have physical complaints with no apparent cause, so the real issue could be stress or anxiety related, she says.
Minority nurses also need to pay attention to comments patients make during their visits. “They may see a doctor and complain about a headache, or pain in the chest or back, but at the end of the session they bring up family problems,” Lazalde says.
Another red flag could be visits from multiple family members. “If you’re seeing a mom, dad, and siblings for physical problems, all within the space of a month, it could be a sign that there’s some sort of turmoil in the family,” Lazalde says.
And nurses shouldn’t wait until the visit is nearly over before addressing mental health issues. “I think it’s really important for nurses to ask questions early on,” says Lazalde. “Ask how things are going in the family and at home. If the questions are addressed by the medical provider or nurse, it normalizes the situation and allows the family to speak more freely,” she says.
When nurses are rushed for time, sometimes really important pieces of information fall through the cracks. This can be prevented by having a patient fill out a survey at the start of their visit, Lazalde says. She encourages the use of a questionnaire, such as the Generalized Anxiety Disorder 7-item scale (GAD7), to help assess a patient’s mental health needs. “It only takes a few minutes and can be completed in the waiting room, and it doesn’t take away the nurse’s time,” she says.
If it’s determined that a patient should receive specialized care, Lazalde recommends that referrals be “normalized.” For example, when nurses make a referral to a provider who’s an oncologist, it’s normal because the oncologist is simply a member of the health care team, she says.
“So we have to find a way to make the behavioral health provider a member of a team. Instead of making the client feel as if there’s something wrong with them when they receive a referral, they’ll know that they’re just meeting another member of the team,” she says.
Lazalde also has another important piece of advice for minority nurses: don’t give up on your patients. “It often takes more than one referral to be successful. Sometimes we have to refer the patient three, four, and five times,” she says. If nurses approach their roles knowing that it takes multiple referrals before they reach a successful linkage to the other provider, then nurses may be less likely to get discouraged, she says. “We’ll know that the family hears the referral more times and there’s a higher likelihood the patient will go and complete the referral and receive the services they actually need.”
Erasing stereotypes
Perhaps the most disappointing barrier minorities face are the ones caused by the attitudes of medical professionals. Minority nurses can exhibit the same biases about their patients as anyone else, and if they’re not careful, they may start to form negative opinions that could affect their levels of care, says Stevens. “Just because a nurse is a minority doesn’t mean they’re immune to stereotyping,” she says.
Some nurses, particularly those who serve low-income communities, fall into the trap of assuming that some poorer patients check into medical facilities to access prescription drugs, three square meals, or a warm bed, she says. “I’ve heard people say ‘the patients are looking for three hots and a cot,'” Stevens says.
These biases are often reinforced when patients have high rates of repeat visits, she says. But despite the challenges, many minority patients who do receive appropriate care become better and are able to function in society, she says. Minority nurses must provide the best service possible by making a sincere effort to view each patient as deserving of quality medical attention, Stevens says. “Nurses have to fight to eliminate negative stereotypes they see, even if they may have had those same stereotypes themselves,” Stevens says.
Translating policy into practice can be difficult because of how pervasive some biases are, but it can be fought the way any ethnic or cultural stereotype is fought, says Stevens. “It starts with education and awareness.”
Some patients will be difficult, Stevens concedes. But if mental health care is your specialty, you should remain confident that you are helping your patients. Standards of care have to be the same, regardless of who the patient is or where he or she comes from, Stevens says.
Minority nurses are specially suited to help break down barriers and stigmas, build trust among their communities, and help their patients live the best lives possible.
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program”
Majestic mountain peaks, abundant wildlife and unlimited natural beauty have made Alaska a vacation dreamland for millions of people from all over the world. But while tourists come and go, America’s northernmost state is also home to thousands of indigenous peoples, including Aleuts (people native to the Aleutian Islands), Eskimos (natives who live primarily in Alaska’s coastal regions) and many smaller tribal groups. Collectively, Alaska Natives constitute one of the smallest ethnic minority populations in the U.S.—only about 2 million people in the entire country.
According to the 2000 U.S. Census, there are nearly 100,000 Alaska Native and American Indian (AN/AI) people living in Alaska. By no means a homogeneous population, this group breaks down into numerous subgroups, each with its own distinct culture and, in many cases, its own language or dialect. In fact, the Women of Color Health Data Book, published by the Department of Health and Human Services’ Office of Women’s Health, estimates that there are more than 300 languages spoken among American Indians and Alaska Natives.
Unfortunately, awareness of Alaska Natives and their health care needs is extremely limited outside their home state. Down in the “lower 48,” as Alaska residents call the continental U.S., medical researchers and health care providers have traditionally lumped Alaskan Natives together with American Indian tribes from other parts of the country, even though they live thousands of miles apart and have different cultures and living environments.
The good news is that as researchers delve deeper into investigating the disparities in health outcomes between Americans of color and the white majority, Alaska Natives are finally being addressed as a group with its own identity. The bad news is that this research clearly indicates that Alaska Natives face many of the same serious health problems, in varying degrees, as minority populations in the rest of the nation.
“Overall, [the health issues here] are very much like those for people of color in the rest of the United States—they just differ in magnitude,” says Kathleen Kinsey, RN, BSN, MPA. “For example, Alaskan Natives’ smoking and obesity problems are greater.” Kinsey, an American Indian nurse originally from Washington state, is administrator of nursing services for Mt. Edgecumbe hospital in Sitka, Alaska, part of the Southeast Alaska Regional Health Consortium (SEARHC).
Here’s a closer look at what nurses interested in working in Alaska need to know about the major health care issues affecting Alaskan Native communities, both historically and in the context of current initiatives to close the minority health gap in the 21st century.
Alaska Native Health 101
Heart Disease [N Elia – These headings under the main subhed are sub-subheds. Please format this section the same way you did the section called “The Present” in the “One Name, Many Faces” article in the previous issue.]
For decades, the number one cause of death for Alaska Natives was infectious diseases. But as medical advances brought these illnesses increasingly under control, the mortality picture shifted toward chronic conditions. Today, one of the leading killers of Alaska Natives is heart disease, as it is for the rest of the U.S. population. According to the American Heart Association (AHA), 25.2% of all American Indian and Alaska Native males who died in 1999 suffered from heart disease or stroke. Women fared even worse, with 27% of all deaths attributed to these causes.
Interestingly, even though the Centers for Disease Control and Prevention (CDC) still rank it as the number one cause of death for Americans as a whole, the mortality rate for cardiovascular disease (CVD) in the United States has dropped by more than 50% during the past 40 years. Experts say much of this decrease is a direct result of improved medical technology and earlier diagnosis. But during this same period, according to the Indian Health Service, the incidence of CVD among Alaska Natives and American Indians rose dramatically.
In fact, Indians and Alaska Natives between the ages of 35 and 44 have a CVD risk at least two times higher than that of their Caucasian counterparts. Even though this gap diminishes with age, it doesn’t disappear: AN/AI people in the 55-64 age group are still 1.5 times more likely to suffer from heart disease than whites of the same age.
Researchers and health professionals alike point to increased tobacco use as one of the key factors contributing to this disparity. Both the AHA and the American Lung Association (ALA) report that nearly 40% of all American Indian and Alaska Native men and women over the age of 18 smoke regularly, compared with only about 26% of Caucasians in the same age bracket.
Obesity
Why the rising occurrence of heart disease among young Alaska Natives? Is smoking the lone contributing element? Health experts who work in Alaska Native communities believe changing dietary habits are also to blame.
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In recent years, many Alaska Natives have moved away from their traditional diet of seafood and game to embrace fast food and prepackaged meals, especially in the state’s more urban areas. (According to 1990 figures, 69% of Aleuts and 50% of Eskimos in Alaska live in cities.) As the food choices increased, so did Alaska Natives’ weight. Just two or three generations ago, malnutrition had been a pressing concern. But as AN communities became more urbanized, or as native people left their villages for larger cities, their diets began to include more saturated fats and processed foods.
Former U.S. Surgeon General Dr. David Satcher declared obesity a national epidemic in 2001 when research revealed that 60% of all Americans were overweight or obese. But the Alaska Native population has been hit especially hard. SEARHC routinely conducts a health survey of the various AN communities and tribes it serves. Its most recent survey (April 1998) found that 46% of adult participants were overweight. For such a small sample, that’s a staggering statistic. Additionally, SEARHC found that one in three youths in Alaska qualify as overweight, compared with one in five for the country as a whole.
“I grew up in an Aleut community in Kodiak, Alaska, on what was basically a subsistence diet of fish and venison,” says Kathy Belanger, RN, BSN, CNOR, nurse manager of surgical supply services at the Alaska Native Medical Center in Anchorage. “I didn’t eat beef until I was in the sixth grade. Our eating habits have gotten much worse and as that changed, so did the health of our people.”
Diabetes
Not only does obesity increase people’s risk of developing cardiovascular disease, it can also increase their likelihood of suffering from diabetes—the sixth leading cause of death in the U.S. Most racial and ethnic minority groups have been disproportionately affected by this serious chronic disease and its related conditions, such as renal failure, amputations and blindness. However, the disparity gap for Alaska Natives is narrower than for other Americans of color. For example, Hispanics and American Indians have two to six times the incidence rate of diabetes compared to Caucasians. Alaska Natives, on the other hand, are also more likely to have diabetes than whites, but their incidence rate is less than twice as high.
Still, the number of cases diagnosed each year in AN communities continues to climb. According to the Women of Color Health Data Book, the rate of diabetes mellitus in Alaska Natives has grown tenfold in the past 30 years. Not surprisingly, the disease is less common in the more remote villages where people maintain their subsistence-like diets.
Tuberculosis
While obesity and diabetes are relatively recent health problems for Alaska Natives, AN communities have been battling tuberculosis for generations. Indeed, TB was once called “the scourge of Alaska.” According to a report recently published on http://www.tribalnews.com/, an online AN/AI news source, when the state first started recording the number of TB cases in 1952, officials were stunned to learn that there were nearly 400 cases per 100,000 Alaskans. But the epidemic was far worse for Alaska Natives, with more than 1,800 cases per 100,000. Throughout the past 50 years, Alaska’s health care providers have struggled to treat and prevent the spread of this highly infectious disease.
Although never completely eradicated, up until the 1990s health experts believed the disease was on the decline. Unfortunately, it rebounded with mutated, drug-resistant forms, and Alaska is once again the hardest-hit state. In 2000, the CDC reports, there were 17.2 TB cases per 100,000 people in Alaska—the highest incidence in the nation. The 108 new cases reported that year represented a 75% increase over 1999 statistics.
“As a nursing student working in public health, I was surprised at the number of TB cases, especially among children,” Belanger remembers. “Today, I still see the isolation signs when I walk through the hospital.”
The threat of tuberculosis is greatest for Alaska Natives who live in the farthest reaches of the state. A full 90% of adults age 60 and older in remote Alaskan territories have had positive TB skin tests. Of those positives, approximately 10% develop active cases, which can pose a significant public health risk if left untreated or partially treated.
Cancer
A new study published this year in the journal Alaska Medicine confirms that cancer has moved up from second place to become the leading cause of death for the Alaska Native population. In particular, Alaska Natives are now 40% more likely to die of lung cancer than white Americans, and their risk of colorectal cancer is also greater. Breast cancer rates are also high among Alaska Native women, especially those who live in remote areas with limited access to health care facilities that can provide screening and early detection. Again, doctors and nurses point their fingers at the high rate of tobacco use in AN communities and the steady movement away from traditional foods as key factors behind the rise in this once-rare disease.
In the 1950s, cancer was hardly found among the aboriginal peoples of Alaska, according to TribalNews.com. But in 1988, former Alaska Native Medical Center Director Robert Fortuine drew statewide attention to the fact that rising rates of cancer and heart disease were directly linked to a drastic change of diet and lifestyle among Alaska Natives. Low-income people were especially at risk, he noted, because “they tend to eat more inexpensive meats like bologna and hot dogs.” These types of foods lack the healthier, unsaturated oils found in such traditional staples of the Alaskan Native diet as fish, seal, whale and walrus.
However, the results of the Alaska Medicine study did contain some good news: Alaska Natives are less likely to die from prostate cancer, leukemia, lymphoma and uterine cancer than members of other racial and ethnic groups.
HIV/AIDS
Although this deadly infectious disease is on the rise among Alaska Natives, the actual number of cases reported throughout the past 20 years is still quite low when compared with the rest of the U.S. population. According to the ALA, which tracks AIDS-related respiratory diseases, Native Americans as a whole represent less than 1% of all AIDS cases in the nation.
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program
“The low incidence of AIDS [in Alaska Natives] might be because of our lifestyle,” suggests Belanger. “The village setting with its small group of people is not necessarily exposed to the risk behaviors associated with the big cities. But that is changing as well.”
Much of this change has occurred rapidly over the past ten years. From 1992 to 1993, the CDC recorded a nearly double jump in the total number of AIDS cases in American Indian and Alaska Native communities—from 445 to 818. Just two years later, that figure hiked to 1,333 cases, of which less than 400 were reported in Alaska. By June 2001, the number of cases had again nearly doubled, reaching a total of 2,433. Additionally, at least 25% of new AIDS cases in Alaska are reported by young people.
Alaskan health officials remain uncertain as to how any future spread of the immune-attacking disease will develop, but they do acknowledge that at-risk behaviors appear to be on the rise. For example, alcohol and drug use is abundant among Alaska Natives. In fact, the SEARHC survey respondents listed alcohol and drugs as their leading health care concerns.
While alcohol abuse is disproportionately high among American Indians, the SEARHC survey concluded that the drinking habits of Alaska Native teens do not differ significantly from those of their counterparts in the majority population. But Alaska Native youths use marijuana at nearly twice the rate of whites. Moreover, suicide rates among Alaska Natives are four times higher than in the rest of the United States, with AN males between the ages of 15 and 34 at the higher risk.
Access Issues
As serious as these illnesses all are, one of the most critical health crises facing Alaska Natives is not a disease at all—it’s lack of access to health care services. While the larger cities, such as Anchorage and Juneau, offer a reasonable choice of health care options, native people who live in outlying areas and remote villages are often cut off from even the most basic care. Transportation can become a formidable obstacle when emergencies or acute care issues arise, especially during the winter.
“Our facility is located in a region where the only way to get into town is by plane or boat, which can take several hours,” explains Kinsey. “For many people, they’re only making the trip to the hospital because they have an acute health care need.”
The state government, however, is taking steps to bridge these access gaps. One solution has been to provide outlying areas with community health aides, who work under the guidance of physician consultants. While they’re not nurses, the aides are trained in a wide range of health care assessment skills, from baby wellness to trauma.
In addition, new advances in telecommunications technology are enabling more hospitals and clinics to reach out across the miles and bring their services directly to remote communities. Although it’s still a relatively new option, Kinsey says SEARHC has begun to use telemedicine as a means to help villages maintain their health. Doctors and nurses can now provide patients with one-on-one consultations via telephone, videoconferencing and even cyberspace, as more villages gain computer access.
“We need to ask how we can keep health care delivery in the villages and support them in real time,” Kinsey emphasizes. “I think telemedicine is an important issue for this region, especially because I don’t see transportation improving significantly.”
But geographical isolation is not the only problem that can limit Alaska Natives’ access to quality health care. Cultural differences can also be a significant barrier, especially when Alaska Native patients are hospitalized. Because the state’s health facilities typically have many staff interpreters or bilingual providers, language isn’t usually an obstacle per se. However, the way in which Alaska Natives speak is different from what most Americans are used to, which can often lead to communication breakdowns.
For example, says Kinsey, Alaska Natives often talk slowly with pauses, and they communicate through storytelling with the most important elements at the end of the speech. “Nurses should expect to sit and listen to patients and not talk over them. That’s probably the biggest cultural difference,” she advises. Belanger adds that nurses should look beyond the surface response to make sure Alaska Native patients truly comprehend their instructions for treatment and follow-up care. “Natives are trusting people and they may say they understand, but that isn’t always the case,” she says. “In training new nurses, we tell them what clues to look for to see if the native patient is really understanding what they say.”
Wanted: Alaska Native Nurses
This need for cultural competence training is extremely important given the fact that the majority of Alaskan hospitals’ nursing staff comes from outside the state. Furthermore, the University of Alaska Anchorage School of Nursing estimates that American Indians and Alaska Natives make up more than 15% of the state’s total population but only 2% of Alaska’s registered nurses.
The school hopes to change this situation through its Recruitment and Retention of Alaska Natives into Nursing (RRANN) Program, launched in 1999. RRANN offers Alaska Native students in associate and baccalaureate degree programs a variety of resources, including tutoring, mentoring, support groups and “student success facilitators,” to aid them in completing their nursing studies and transitioning into the workforce.
Kinsey, too, has been working to increase the number of Alaska Natives in SEARHC’s nursing rosters. She helped establish an LPN program to assist Alaska Natives’ entry into the profession. From there, the nurses are encouraged to pursue a degree leading to RN status. “Right now, we have eight employees signed up for the LPN program and we expect all of them to move on to the RN program,” she notes. “Of those eight, half are Alaska Natives.”
It’s probably the best working example of universal health care in America. It’s a system that provides millions of people with a widely comprehensive range of health and wellness services–everything from disease prevention programs to dental and optical services to hospital and ambulatory medical care. Its goal is to “ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaska Native people.”
It is the Indian Health Service (IHS) and it remains the nation’s largest employer of American Indian and Alaska Native nurses. But regardless of race or ethnicity, if you’re a nurse who has a strong desire to experience different cultures, work with medically underserved communities, fight minority health disparities and reap the benefits of a career that offers chances to advance to leadership roles, working for the Indian Health Service may be just the opportunity you’ve been looking for.
The Details
In 1921, Congress passed the Snyder Act, which established the Indian Health Service as the primary federal health care provider and health advocate for Indian people. It’s a role the agency has continued to play for 80-plus years, providing a comprehensive national health delivery system designed to elevate the health status of American Indian and Alaska Native people to the highest possible level and to encourage the maximum participation of tribes in the planning and management of those services.
Although Native tribes are sovereign nations, the IHS is a U.S. government organization operating under the Department of Health and Human Services (HHS) umbrella. Today, it cares for 1.6 million of the nation’s estimated 2.6 million Native Americans from more than 560 federally recognized Indian tribes and Alaska Native corporations coast to coast.
The IHS is an extensive system, divided into 12 regional areas, that encompasses 36 hospitals, 63 health centers, 44 health stations and five residential treatment centers in 35 states. In addition to these facilities, most of which serve American Indians who live on or near reservations, the IHS also has 34 urban Indian health projects that provide a variety of services. Some IHS facilities are managed by the tribes themselves with financial and administrative support from the federal agency. At others, all daily operations are completely managed by IHS.
Nurses hired at tribally operated facilities (“direct hires”) are considered employees of the tribe. If the nurse is recruited by the IHS to work at a federally operated facility, then he or she is a federal employee. In addition, some nurses who work for the IHS do so as officers in the U.S. Public Health Service Commissioned Corps, a federal program under the direction of the U.S. Surgeon General in which nurses work for local, state, federal or international health agencies in a variety of capacities. Generally, nurses in the Commissioned Corps tend to have more experience and education and receive an expanded benefits package.
According to IHS statistics, there are currently more than 2,500 nurses in the organization working in inpatient, outpatient and ambulatory settings. Additionally, the agency employs public health nurses and nurse educators to carry out its numerous health awareness programs, among other duties. Many of these campaigns are created with input from tribal and spiritual leaders to address a particular community’s specific health care and cultural concerns.
Of course, like any large health care system, the Indian Health Service also provides opportunities for experienced clinicians to move into management positions on local, regional and national levels. But it’s the challenge of working with a unique patient population in a specialized environment that many IHS nurses cite as the most rewarding aspect of their career.
The Need
Like other health care employers today, the IHS is struggling under the weight of a severe nursing shortage and the increasing financial burdens of doing business in the current economic environment, despite a proposed budget of $2.9 billion for fiscal year 2004.
“We have a 14% nursing vacancy rate right now, compared with the national average of 13%,” says Celissa Stephens, RN, MSN, acting principal nurse consultant and senior recruiter for the IHS national headquarters in Rockville, Maryland.
The reasons for the nurse staffing crisis within the IHS mirror those for the health care industry in general. Fewer young people are choosing nursing as a career, while at the same time, the current RN population continues to inch toward retirement age. But this second factor has had an even bigger impact on the IHS than on private sector nursing employers. “The average age of nurses in the IHS is 48 years old, which is even older than the national average of 43 years,” Stephens explains.
More specifically, the IHS reports that approximately 755 of its 2,500 nurses are 41 years old or older. Of those, 8% were eligible for retirement last year. Even more alarming is that another 20% will be reaching retirement in the next five years.
While skilled, experienced nurses are urgently needed throughout the IHS system, Stephens says some specialties are in more demand than others. “At the present time, the greatest needs are in the areas of emergency, operating room, ICU and obstetrics,” she reports. “We’re also interested in Certified Registered Nurse Anesthetists (CRNAs).” There are also many career opportunities open for advanced practice nurses and Certified Nurse-Midwives.
The People
“Everything you do [as an Indian nurse working for IHS], you can see it making a difference. You’re working toward a goal to improve the health of our families and communities,” says LaVerne Parker, RN, MS, an IHS nurse consultant in the Aberdeen Area of South Dakota and a member of the Turtle Mountain Band of Chippewa Indians.
Indeed, there seems to be a very strong connection between American Indian/Alaska Native nurses and careers in the IHS. The agency reports that approximately 66% of nurses working in the federal system or for tribally operated health care organizations are Native Americans. While this may be partially due to the fact that IHS has Congressional authority to give American Indians and Alaska Natives preference in hiring, working for the IHS also appears to be a traditional career path for many Indian nurses.
For instance, Parker grew up relying on the IHS as her own health care provider. When she became interested in a nursing career, IHS was foremost in her mind. “I always wanted to work with my own people,” she explains.
“There was never any doubt that I would be working for my [Indian] community,” says Lisa Sockabasin, RN, BSN, of her career choice as diabetes nurse coordinator for the North American Indian Center of Boston, an urban IHS facility in Boston, Massachusetts. “I saw so many health disparities among American Indian communities during my experience as a research fellow at Harvard Medical School, including cardiovascular disease, diabetes and cancer. I really wanted to work in preventing morbidity and mortality in our communities.”
While it may be a sense of community that brings Native nurses to IHS facilities, it’s the rewarding work and career advancement opportunities within the system that are keeping them there. Working for an IHS or tribal-run hospital or clinic is different than the “typical” nursing job in a number of ways. First and foremost, the patient population is almost exclusively American Indian or Alaska Native. Therefore, culture plays a very prominent role in health care delivery.
“There are so many different meanings of what good health is and how it’s perceived in so many different cultures,” says Sockabasin, who is half Patsanaquoddy Indian.
Culturally and linguistically, Indian tribes are by no means all alike, even though there may be some common threads among the different groups when it comes to health issues–such as high incidence rates of heart disease and diabetes–as well as general beliefs about health and illness, such as an emphasis on the use of natural remedies.
“You can’t make generalizations about the tribes because they’re all different,” emphasizes Stephens, a member of the Choctaw tribe. “It’s important at the local level that new employees are provided with culturally appropriate orientation to the tribal communities they will serve.”
Language can also impact health care delivery in Indian communities, especially with older patients who may not speak English very well or at all. The majority of IHS settings have an interpreter on staff, or other bilingual staff members who can help with translation. However, caution must be used in this circumstance, because when it comes to health care terms there is little room for misinterpretation.
“Some medical terms, such as cancer, don’t translate into the Navajo language, for example,” Stephens explains. “The term for cancer in Navajo could be described as ‘lood doo na dziiyigii,’ which means ‘a sore that does not heal.’
“Traditional Navajos believe that spoken words are like arrows, and arrows can wound people,” she adds. “Therefore, it would not be appropriate to discuss the patient’s mortality or potential outcomes in the first person. In order to avoid ‘inflicting wounds,’ the care provider must discuss the medical condition in the third person–for example, ‘some people experience x, y and z.’”
The Setting
One of the most distinguishing features of a nursing career with the IHS is where you work. The vast majority of IHS hospitals and clinics are set on or near Indian reservations, which are usually in rural areas. Not only are they small communities, but they’re often located at substantial distances from the nearest town or city, which can be problematic for nurses who have families or are not accustomed to small-town life. For example, there may not be immediate access to employment and social outlets for spouses and children.
“Families have to adopt a certain lifestyle to live in our communities,” notes Stephens. “We need nurses who have a sense of adventure, are willing to accept the challenges of a rural lifestyle and are interested in being involved in the communities they serve. On the other hand, IHS nurses get to experience the [richness of] Native community life and culture. You may not get that opportunity in the private sector.”
Indeed, when HHS Secretary Tommy G. Thompson announced the awarding of $1.7 million in grants to six American Indian and Alaska Native tribes and organizations last fall to assist them in recruiting and retaining health care professionals, he specifically cited location as a contributing factor to the ongoing need for health care personnel. “The national shortages of nurses, physicians, pharmacists and many other health professionals is particularly serious in the remote and isolated areas where many tribal communities are located,” Thompson noted.
The HHS grant recipients were the Maniilaq Association in Alaska ($99,931), the Ketchikan Indian Corporation in Alaska (($91,693), the Seneca Nation of New York ($96,467), the Nisqually Indian Tribe in Washington state ($100,000), the Confederated Tribes and Bands of the Yakima Nation in Washington ($100,000) and the Northwest Portland Area Indian Health Board in Oregon ($92,209).
The Opportunities
Like other health care employers that urgently need more nurses, the IHS is intensifying its recruitment and retention efforts, both within and outside the American Indian and Alaska Native communities it serves.
“Having Native American nurses in the community is probably our biggest retention key,” says Parker. “Many of them have been able to go to nursing school through IHS scholarships and they come back here [to work] and they stay. They are our staple staff.”
For More InformationFor general information about career opportunities in the Indian Health Service:
www.ihs.gov To view current IHS job listings:
www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/Index.cfmFor information about the U.S. Public Health Service Commissioned Corps:
www.usphs.govFor information about the IHS Loan Repayment Program:
(301) 443-3396
www.ihs.gov/JobsCareerDevelop/DHPS/LRP/lrpsc.asp
Of course, another key to attracting and retaining nursing talent is to offer plenty of professional development opportunities. And the IHS certainly has its share. For example, new RN graduates can compete for a position in the RN Internship Program, which allows them to rotate through a variety of different nursing specialties in a preceptor-like training environment.
Another option is the Public Health Nurse Internship, where nurses with BSN degrees receive specialized training as health educators and advocators. For nurses with at least one year of clinical experience, the IHS offers residency programs in critical care, OR and obstetrics, often with the opportunity to become certified upon completion.
To participate in any of these programs, however, nurses must be willing to move around, because they are only offered at specific IHS facilities. “We have the most difficulty recruiting in obstetrics or the OR because there are so few IHS hospitals in our area that offer those training programs,” states Parker. “We’re trying to develop more programs locally, but for now, we also work with outside hospitals that might provide our nurses with training services.”
Then there are long-term training and continuing education opportunities that help nurses at various career levels pursue academic degrees. For example, American Indian and Alaska Native nurses employed with IHS, tribal or urban facilities can take advantage of long-term training opportunities such as the Section 118 program. In this program, which is sponsored by the IHS Headquarters Division of Nursing, LPNs can pursue either an associate’s or bachelor’s degree in nursing; RNs with associate’s degrees can pursue BSN degrees.
“To date, more than 55 nurses have received advanced training and additional degrees through IHS long-term training programs,” says Stephens. “Currently we have 18 nurses in advanced training. Nurses receive full salary, benefits, books and tuition while pursuing advanced education. That’s a benefit the private sector usually does not offer.”
In addition, financial aid opportunities for third- and fourth-year student nurses are available through COSTEP, the U.S. Public Health Service’s Commissioned Officer Student Training and Extern Program.
But perhaps the single most irresistible benefit for nurses is the IHS Loan Repayment Program. Simply put, this program offers nurses–including tribal direct hires–repayment of up to $20,000 per year toward nursing education loans. In return, the nurses agree to a minimum two-year service contract at an IHS facility, usually one that has a high nursing vacancy rate.
The Experience
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Being an Indian Health Service nurse is an opportunity for minority nurses of all races and ethnicities to live a unique personal and professional experience that is simply not available anywhere else. Not only will you encounter a fascinating culture and people, but your expertise as a nurse will be valued and broadened. Within a health care system that offers such a broad spectrum of services, the opportunities to explore different career specialties and gain additional skills are wide open.
“When I worked in the private sector, I didn’t have the ability to move from clinics to ambulatory to inpatient or emergency,” says Parker. “But within the IHS, you can work in a variety of areas and with a variety of cultures.”
You’ll also see how your efforts to care for, educate and advocate for patients can have a ripple effect on the entire community. As Sockabasin explains, “When you work for the IHS, you have the ability to touch a population that is in so much need of good nurses.”
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