“Sticks and stones may break my bones,” the familiar children’s rhyme goes. But if you are a nurse suffering from osteoporosis (porous bones), such routine on-the-job activities as lifting patients or carrying heavy medical equipment could put you at risk for a serious fracture of the hip, spine or wrist.
Osteoporosis is a metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue. It is often called the “silent disease,” because victims have no symptoms of how fragile their bones have become until a fracture occurs. According to the National Institutes of Health (NIH)’s Osteoporosis and Related Bone Diseases National Resource Center, osteoporosis is a major public health threat for 25 million Americans. Two key factors put today’s aging RN population at especially high risk: 80% of osteoporosis victims are women, and the risk increases after menopause.
Asian nurses, in particular, have strong reason to be concerned about developing this serious disease. The National Asian Women’s Health Organization (NAWHO) estimates that more than one-fifth of Asian American women currently suffer from osteoporosis. The NIH notes that Caucasian and Asian women are more predisposed to the condition than black or Hispanic women, due largely to differences in bone mass and density.
“Asian nurses typically have a shorter body stature than Caucasian nurses,” adds Alice Chan, RN, a Sacramento, Calif.-based public health nurse who serves on the national advisory board for NAWHO’s Living Healthy osteoporosis education program. “Even when a hospital bed is adjusted to the lowest level, there is still potential for us to strain our backs when leaning over to lift heavy patients. In many cases, hospitals’ physical standards do not accommodate nurses whose height is less than five foot two.”
But even though Asian nurses are at the top of the risk ladder, osteoporosis doesn’t discriminate. African-American and Hispanic nurses are threatened by the disease as well.
“All women are at risk,” maintains Dr. Felicia Cosman, associate professor of medicine at Columbia University and clinical director of the National Osteoporosis Foundation. “Even African-American women, who seem to have the lowest risk of all the racial and ethnic groups, have a one-in-eight chance of suffering a significant fracture due to osteoporosis, compared to one-in-two for a Caucasian or Asian woman. That’s still a fairly high risk, and it may increase substantially with age.”
Boning Up on Osteoporosis Prevention
Although a number of medications are available for treating osteoporosis, the disease has no cure—making prevention the best defense. The NIH offers these recommendations for keeping bones strong:
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Eat a balanced diet rich in calcium. According to Cosman, 1,200 milligrams of calcium daily is advisable.
Exercise regularly, especially weight-bearing activities. Chan recommends swimming for 20-30 minutes a day.
Don’t smoke. “Too many nurses are still smoking,” Cosman cautions.
Limit alcohol and caffeine intake. “Many nurses drink a lot of cola and coffee at work,” Chan observes, “because nursing can be exhausting and we feel like we need a boost to keep us energized. But caffeine, like alcohol, is one of those agents that contributes to lower bone density.”
Women who have a family history of osteoporosis or are otherwise at high risk should see their physician for a bone density test in order to determine a further course of action. “When your periods start to become very irregular, that’s the time to get a bone density test—and push for it if your doctor says no,” advises Cosman. “Not everyone needs a bone density test at menopause, but if you have any of the clinical risk factors, you should strongly consider getting the test. If the results reveal that you fall into or close to the osteoporosis range, you will probably need to be treated with some medication.”
More information about osteoporosis risk factors and treatment, targeted to specific racial and ethnic minority groups, can be found online at www.osteo.org.
Taking Precautions at Work
If you are a nurse who has been diagnosed with osteoporosis, it doesn’t necessarily mean you’ll have to give up your physically strenuous career. But what will you have to do differently on the job to reduce your risk of suffering a debilitating fracture or other bone injury? Chan and Cosman have these suggestions:
“Generally, we recommend not lifting heavy things, such as patients,” says Cosman. “I would also really stress the use of good body mechanics in the workplace—e.g., taking most of the force in your legs rather than your back and no lifting while leaning forward.” She suggests consulting a physical therapist for more specific recommendations.
Take special care to avoid falls. “Even though hospitals take great pains to prevent this, I have seen incidents where nurses did slip and fall at work—it’s a hazard that can occur in a workplace where you’re often in a hurry,” Chan points out. “Even if you’ve only spilled a few drops of medicine or IV fluid on the floor, there’s always a chance you could slip on it.”
Above all, Chan emphasizes, don’t be afraid to ask for help if an activity proves too physically challenging. “Sometimes in an emergency, it’s easy to think only about the patient and forget about yourself,” she says. “But if the height or weight of the patient creates a situation you can’t handle physically, always ask for help. Sometimes even two nurses may not be able to lift a patient who weighs close to 300 pounds; you might have to wait for a third or fourth person to help you.”
For over 30 years, Christine Yee, RN, has worked as a nurse in the neonatal intensive care unit at Kaiser Permanente in Oakland, Calif., and in the pediatric clinic at Kaiser Richmond. In recent years she had witnessed an increase in the number of young patients suffering from chronic conditions such as diabetes and asthma, and she wished there was another way to help improve their health.
She found the solution five years ago, when she offered to teach a group of Bay Area youths, ages 13 to 18, the basics of dragon boating.
Dragon boat racing is an ancient sport that began over 2,300 years ago in China. Generally, each dragon boat team has a crew of 20 paddlers, a steersperson and a drummer, who beats out a rhythm on a large drum to help the paddlers synchronize their strokes. The boat itself is a 45- to 48-foot canoe weighing from 500 to 1,200 pounds and adorned at the bow and stern with a colorful carved dragon head and tail. Today, dragon boating is one of the world’s fastest-growing sports and is practiced in more than 35 countries.
Yee was introduced to dragon boating 10 years ago by a friend and immediately became addicted to it. “I was hooked from the first day,” she says. “It’s a fantastic sport.”
Yee’s team participates in races from March through October of each year. In addition to local competitions, the team travels to Portland, Ore., and Southern California to compete in races there. This year, they’ve added the Hawaiian dragon boat races in Honolulu to their schedule. The team members meet twice a week for regular practices.
“In a race, we always dress our boat with a head and a tail,” Yee says. “Our boat was built in Vancouver and an artist paints each head differently, so we have a unique dragon boat head.”
Although Yee is very athletic and has long enjoyed physical activities like hiking, dancing, scuba diving and backpacking, she admits she wasn’t initially prepared for her first dragon boat race. “It was a grueling experience, because my first dragon boat team was not properly instructed in how to paddle,” she recalls. “After that first race, we began to learn correct paddling techniques.”
For the dedicated dragon boat racer, the commitment to proper paddling technique is always evolving in the search for the perfect stroke. Team members are supportive and camaraderie is quickly formed.
“Being out on the water refreshes the mind after a hard day at work,” Yee adds. “It is a great way to beat stress.”
Teaching Teamwork
Yee soon realized how dragon boating could benefit the health and overall well-being of many of her young patients. Five years ago, she began volunteering to teach local teenagers the fundamentals of dragon boating. Last year, Yee was presented with a Jefferson Award for Public Service for her ongoing work mentoring Bay Area youths.
“The experience of dragon boating has had such a positive impact on my life that I knew it could also be a positive experience for teens,” she says. “For some of these kids, this is their only regular form of exercise.”
To date, Yee has introduced over 100 youths to the sport. Some of them are at-risk kids from disadvantaged backgrounds who learn the importance of hard work, mutual respect, cooperation and pulling together to work as a team. Others come from immigrant families. Yee cites statistics showing that many immigrant youths are fighting chronic health conditions or are at risk for obesity.
“Dragon boating requires upper and lower body strength and can be very challenging as all 20 paddlers attempt to synchronize their strokes and then increase their endurance and power,” she says. “It’s exciting to see the teens develop as a team and form friendships and camaraderie that is so important at this time in their lives.”
Yee’s dragon boating teammates help out by providing the necessary equipment and volunteering their own time to help coach the youths. “The kids are so inspiring,” Yee says. “They come from so many different cultural and socioeconomic backgrounds, and it’s such a great opportunity for them to learn how to communicate with one another and how to work together.”
While she admits to being shy and reserved, Yee feels that dragon boat racing has helped to make her more assertive. Dragon boating, she says, is about more than just what happens on the water. It also stresses teamwork on land.
“We are encouraged to stay in shape by continuing to do aerobic exercise and weight training. Team members are also encouraged to be friendly with competing teams and to show good sportsmanship,” she explains. “I’m used to doing athletic activities by myself, but dragon boating taught me how to be part of a team.”
Christine Yee (standing) steers her teams dragon boat in a race in Long Beach, California.
Even an injury couldn’t prevent Yee from participating in the sport she loves. Three years ago, she broke her shoulder and may need additional medical procedures. While she has not been able to paddle, she now stands at the back of the narrow boat and steers her teammates to victory.
Her enthusiasm and prowess for the sport recently earned her an invitation to the 2008 Club Crew World Championships in Penang, Malaysia, to compete as part of a women’s master (over 40) dragon boat team.
“I hope to continue dragon boating for years to come,” she says. “It’s inspiring to see people who are well into their 80s continue to enjoy this sport.”
The year was 2002. Gathered together in a small Asian diner in Hawaii, the board of the Asian American/Pacific Islander Nurses Association (AAPINA) was discussing whether or not their young organization had enough membership support to hold a national conference. Who would attend and why? What would be the criteria for determining whether the event was a success?
Back then, the board, consisting of 14 members, didn’t have answers to these questions. But today AAPINA has held four successful national conferences in different cities across the country and is preparing to hold its fifth annual conference, “Achieving Health Parity for Asians and Pacific Islanders through Practice, Research and Education,” on May 22-24 in Las Vegas.
The national conferences have given AAPINA members the opportunity to come together in one place to network, gain support and mentorship, and discuss issues facing Asian/Pacific Islander (API) nurses. This in-person camaraderie is important, because many members have little interaction with other API nurses in their day-to-day working lives.
“I didn’t feel like I had a political voice in any other nursing organization,” says SeonAe Yeo, PhD, RNC, FAAN, associate professor at University of North Carolina at Chapel Hill School of Nursing and immediate past president of AAPINA. “I felt that it was critical to bring our voice to the nursing profession.”
The idea of holding a national conference was implemented during Yeo’s presidency. “Prior to that, the association mainly communicated with its members through newsletters,” she explains. “Now that we have an annual conference, members get to see each other at least once a year. That’s one reason why membership grew during my tenure to about 200 members. When I began my presidency in 2001, we had less than 20. And it continues to grow.”
According to its mission statement, AAPINA has four main objectives:
• To identify and support the health care needs of API people in the United States and globally;
• To implement strategies to act on issues and public policies affecting the health of APIs;
• To collaborate with other interdisciplinary health and professional organizations; and
• To identify and support professional and nursing concerns of API nurses in the U.S. and globally through active networking and empowerment.
“We try to appeal to nurses working in different areas of the profession, including clinical, research and administration, and we’ll continue to do that,” says Yeo. “But what I’ve found is that this type of organization is particularly attractive to many international Asian graduate students [studying in America]. If you look at any major nursing school in the nation, about half of the graduate students are from various countries in Asia. These students are typically isolated. I’ve also found that many API nurse clinicians working in hospitals in staff or administrative roles are more isolated in their work environments and feel the glass ceiling effect more.”
Yeo notes that these nurses often have impressive titles and have earned graduate-level degrees and certifications, yet cannot advance to higher levels in hospital settings. “AAPINA provides them with a way to start thinking in terms of asking why they can’t get on a career path the way [majority nurses] are doing,” she says. “We’re [helping them address] the language barriers and cultural isolation that API nurses face. We also provide connections to other Asian and Pacific Islander nurses.”
Laying the Foundation
Compared to some other minority nursing associations, such as the National Black Nurses Association and the National Association of Hispanic Nurses, which have been in existence for more than 30 years, AAPINA is a relatively young organization. It was founded in 1991.
“That year, several of us [founding members] were attending a conference for ethnic minority nurses. This was the first time I had ever seen a group of Asian American nurses together in one place,” says Kem Louie, PhD, RN, CS, FAAN, associate professor at William Paterson University Department of Nursing in Wayne, N.J., and a past president of AAPINA. “We were all very concerned about [diversity in the nursing profession and creating more leadership opportunities for] minority nurses. So before we left the conference, I suggested that we stay connected, not realizing that this would be the impetus for forming AAPINA.”
AAPINA began with a group of 14 members who were committed to being advocates for Asian American and Pacific Islander nurses. These founding members represented a variety of geographic areas, from Hawaii to the East Coast. The fledgling association established bylaws and set out to bring the diverse voices of API nurses to the forefront of professional nursing issues.
Louie points out that one of the reasons why an association like AAPINA didn’t form earlier is because the API population is very diverse, encompassing many different ethnic subgroups. But even though, for example, the health care needs of Native Hawaiians are different from those of immigrants from Southeast Asia, “we are trying to [address the health concerns of the overall API population] and health disparities in particular,” she says.
Adds another AAPINA founding member, Mi Ja Kim, PhD, RN, FAAN, professor and dean emerita of the University of Illinois at Chicago College of Nursing, “Since we serve such a diverse population, language barriers can be a problem. English isn’t always [patients’] primary language.”
Over the years, AAPINA has been involved in several initiatives that have made a major difference in increasing national awareness of API health disparities and advancing health policy agendas that benefit the API population. In the late 1990s, under Louie’s leadership, the association worked with a coalition of other groups, such as the Asian and Pacific Islander American Health Forum, to get President Bill Clinton to establish a White House Initiative on improving the health status of API communities. Prior to this, the API population had been falsely stereotyped as a “model minority group” with few health problems. Therefore, they were rarely included in federal minority health programs or government-funded health disparities research studies.
There had already been many federal initiatives aimed at improving the quality of life for underserved African American, Hispanic and Native American communities, Louie explains. “It was quite exciting to be part of this movement that was saying, ‘Look, Asian Americans and Pacific Islanders would like some recognition that we, too, face great health disparities [and that we need more federal resources directed toward this problem’]. As president of AAPINA, I was invited to be a part of these important discussions.” President Clinton signed the executive order authorizing the API Initiative in June 1999.
Two years later Louie, representing AAPINA, published a landmark white paper on the health status of Asian Americans and Pacific Islanders in the journal Nursing Outlook. “The white paper was a review of API health disparities, what we need to do to remove them and recommendations for research,” she says.
Louie’s article noted, for example, that “Asian Americans and Pacific Islanders exceed other groups in health disparities in the areas of tuberculosis and hepatitis B, whereas cancer and cardiovascular diseases are leading causes of death within the Asian American and Pacific Islander populations.”
Sharing a Common Vision
In much the same way that AAPINA was established from a common bond among like-minded API nursing professionals, the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) grew from discussions among leaders of several prominent minority nursing organizations. These dialogues revealed that the individual associations all shared a common goal—advocating for equal opportunity in nursing and better health care for communities of color.
“We decided to work together as a single unified force instead of each association separately competing for funding when we have such common missions and goals,” says Louie, who holds the position of secretary on NCEMNA’s board of directors.
NCEMNA, incorporated in 1998, serves as the umbrella organization for five associations: AAPINA, the National Alaska Native American Indian Nurses Association (NANAINA), the National Association of Hispanic Nurses (NAHN), the National Black Nurses Association (NBNA) and the Philippine Nurses Association of America (PNAA). Collectively, NCEMNA gives voice to 350,000 minority nurses and to the lived health experience of a constituency marginalized from mainstream health delivery systems.
Being part of the NCEMNA collaborative has enabled AAPINA to receive federal funding that an association of its size would have difficulty obtaining on its own. Each year, through a grant from the National Institute of General Medical Sciences (NIGMS), a different NCEMNA member association receives funding to support its annual conference. AAPINA is the 2008 recipient.
“The grant has helped in getting keynote speakers and panels for the conference,” says Jillian Inouye, PhD, APRN-BC, AAPINA’s newly elected president. “[On a broader level], it is stimulating research and development of minority nurse scientists.” NCEMNA is also using the $2.4 million NIGMS grant to fund the Nurse Scientist Stimulation Program, a five-year initiative to increase the number of minority nurse researchers who can investigate the causes of health disparities and develop culturally appropriate interventions.
“When we incorporated all the minority nurse associations through NCEMNA, it gave AAPINA a lot of energy and financial support to become more organized,” continues Inouye, who is a professor and graduate chair at the University of Hawaii at Manoa School of Nursing and Dental Hygiene. “Kem Louie was the association’s driving force throughout the early years. Now, [thanks to our involvement in the coalition], more people have become interested in AAPINA. We have more members, we’ve gotten our Web site up, we’ve started to hold conferences. And through NCEMNA’s Aetna Foundation grant, we’re able to offer scholarship opportunities to pre-doctoral or even master’s students. That has really helped draw more people to our organization.”
The annual Aetna/NCEMNA Scholars Program is another NCEMNA project designed to introduce nurses of color to careers as nurse scientists and socialize them into the research agenda to eliminate health disparities. Each year, the program provides financial and mentoring support to 10 nursing students—two from each of the coalition’s five member associations.
Mentoring is also an important part of AAPINA’s mission to support and empower Asian and Pacific Islander nurses and students.
“I’ve served as a mentor through AAPINA as well as through NCEMNA,” says AAPINA president-elect Oisaeng Hong, PhD, RN, associate professor, Department of Community Health Systems and director of the Occupational Health Program at the University of California San Francisco School of Nursing. “Our mentees are mostly doctoral students who are matched with a mentor based on areas of interest, research topic and target population. We spend one to two years together, but we don’t have to be in the same city. Communication happens through phone calls and email. We get face-to-face time during our annual conferences.”
Onward and Upward
With membership on the rise and the success of the national conferences firmly established, AAPINA’s leaders are setting goals to ensure the association’s future growth and sustainability while continuing to increase its value as a resource for Asian and Pacific Islander nursing professionals.
“One of our most important objectives at the moment is to expand our efforts in growing our membership and to reach more API nurses,” says Hong. “It’s hard work because we have no hired staff.”
Inouye says that implementing a strategic plan is one of her goals during her presidency. “I also plan to update our mission statement and Web site,” she adds. “Now that we have some funds, we’re able to hire an attorney for the first time to update our bylaws. I’d also like to expand our board of directors and [create more opportunities for our members to get involved as leaders in the association]. Currently, we only have an executive board, which includes the president, president-elect, secretary, treasurer, past president and the chairs of the membership and newsletter committees. So I’d like to create a board aside from that to help manage AAPINA. It’s a slow process, but it’s working.”
The strategic plan will also focus on establishing local AAPINA chapters in various parts of the country. “We currently have a student chapter in San Francisco and one that’s starting in Chicago. These are things that will be fleshed out as we develop the plan,” says Inouye.
Of course, AAPINA will continue to promote the expertise of Asian American and Pacific Islander nurses as culturally competent advocates who can play a crucial role in improving the health of API populations. “The health care issues that we [APIs] face are similar to those of other ethnic minority groups,” says Inouye. “These include diabetes and obesity. It may not seem that obesity is a problem for APIs, but their BMIs are increasing, which puts them at risk for cardiovascular disease and cancer. Our Native Hawaiian population is at risk for every kind of disease. They have very poor health outcomes.”
The association keeps its members abreast of key API health issues through its newsletter, Web site and workshops at the national conference. In 2005, AAPINA was one of several nursing associations that received grant funding from the national Nurse Competence in Aging (NCA) program to disseminate information to its members about the health care needs of minority elders. As a result, AAPINA was able to add a new section to its Web site focusing exclusively on gerontology/geriatrics issues and resources.
These successes are only the beginning of what AAPINA will continue to achieve through its dedicated and determined leadership. “In the future, I would like to have more [API] scholars and clinicians united in voice so that we can promote the AAPINA organization and our mission,” says Kim.
For more information about the Asian American/Pacific Islander Nurses Association, visit www.aapina.org.
If there is one thing surgical nurse Rochelle Scott has learned from her patients, it is to assume nothing. No matter how well she might think she understands a culture or a tradition important to her patients, Scott learned through repeated interactions that each patient, no matter what his or her heritage, will interpret and use cultural norms in slightly different ways.
“Giving the culture respect, and honoring that when it is appropriate, shows the patient they can trust you,” says Scott, who is midway through her master’s degree in the nurse practitioner program at Mount Saint Mary College in Newburgh, New York.
When you care for patients of Southeast Asian descent, with cultures that may include but are not limited to Hmong, Vietnamese, Chinese, or Thai people, learning a bit about the cultural norms and traditions can positively impact health care outcomes. But the languages and traditions of this group are incredibly diverse and have many nuances that impact literacy, child-rearing practices, elder care, and self-healing. Thankfully, nurses are in a great position to do some research, interact frequently, and discover the individual subtleties of their patients’ heritages.
When Dr. Madeleine Leininger introduced the idea of transcultural nursing in the 1950s, the idea was outside the norm. As cultural diversity and the promotion of cultural competence in health care settings becomes more mainstream, the idea continues to take shape in nursing programs. Dr. Priscilla Sagar, R.N., A.C.N.S.-B.A., C.T.N.-A., professor of nursing at Mount Saint Mary College, says nurses are often called on to lead the journey, bringing cultural competence standards into practice in academic settings, health care practices, and research.
“One of the biggest barriers is the lack of research about the populations,” says Sagar, referring to Southeast Asian patients. “Usually [research] has lumped them in saying ‘Asian/Pacific Islanders’ instead of separating them.”
The distinctions are vitally important when trying to determine something like typical growth and development for instance, says Sagar. Growth and development in a Filipino child might look delayed to some when, in fact, it is normal for that group, she says.
On the job
When on the job, though, cultural competence may not be as well defined. For instance, Dr. Margaret Andrews, R.N., F.A.A.N., C.T.N., Director and professor of nursing at the University of Michigan-Flint, cites instances of health care practitioners suspecting child abuse when children have shown up at doctors’ offices with red marks from the Asian practice of coining. Coining—the custom of rubbing coins over the skin (especially ribs of children with a cold) to create friction and warmth to rid the body of what is assumed to be bad winds or to fight off a cold—also leaves red marks on the skin. If you are not aware of the practice, it might raise suspicions of maltreatment.
The idea of coining, says Andrews, is not so different from Western practices of trying to restore balance to the body. The outcome looks a little different, but it helps if the medical staff is aware of the practice and any other practices of the cultures they frequently treat. They can then respectfully and effectively treat the patient without seeming to dismiss their beliefs. For example, if a child’s cough really is pneumonia, more intervention is necessary. If any herbs have been used for self-treatment, there has to be enough trust so the patient will share what has been used without fear of rebuke. Andrews recommends nurses reference the National Center for Complementary and Alternative medicine’s website at nccam.nih.gov for more in-depth information.
For many nurses, the desire to understand other cultures is the first step toward effective change. “Without the desire, it would be difficult for health care providers to embark on this journey,” Sagar says.
For instance, many cultures in Southeast Asia are family focused and oriented, Sagar says. In the United States, where medical decisions are generally made independent of the extended family, a medical decision that weighs the opinions of many family members might seem different. “But in many of these cultures, the family is involved,” she says.
And while the health care providers have to recognize that, they also have to gain a sense of any underlying factors. Sometimes, especially for immigrants, there is a sense of being in two worlds, both of which might have conflicting values, Sagar says. “If they are second generation and if they were born here and have grown up here, their values may be more Western than Eastern,” while the family values remain decidedly Eastern. The opinions can create a real family conflict.
For nurses, it is a matter of figuring out how it all reflects on the patient’s care. “When you first get educated, it is all about retaining it and incorporating it into the health care with the patient,” Scott says. Even something as simple as being aware of major holidays for that culture can make a patient feel recognized and feel his or her culture is respected. No one wants to schedule a procedure around a major celebration if it is not necessary.
Perform cultural assessments and learn about the top three or four cultures you work with, even small details like how to address the patient, Andrews recommends. In some Asian cultures, the first and last names are in reverse order from Western usage. “Ask them, ‘By what name may I call you?’” Andrews says. “Generally, it is better to address more formally and wait to see if they give you permission later to call them something else.”
Andrews also recommends being aware of the tradition of wearing an amulet to bring good luck or a talisman to ward off bad luck that many Southeast Asian populations honor. “That may give a signal to the nurse that they have spiritual beliefs they are bringing to a health care setting,” Andrews says. “You need to respect those.”
When traditions or beliefs that are important to the patient are not recognized, it can set up a rocky start to a relationship between nurse and patient. “It is the little things that can be frustrating for the patient,” Scott says. “Then the patient feels neglected or disregarded.”
According to Guadalupe Pacheco, Senior Health Advisor at the Office of Minority Health, there is a disconnect that exists between the demographics of the nation and that of health care professionals. Pacheco says that while various ethnic groups compose nearly one-third of the population, the nursing population does not mirror that proportion.
When the patient and provider come from a similar cultural background, the common factor often inspires trust Pacheco, says, but even the most radically different backgrounds can still work well. “It is all about communication,” says Pacheco. “If you establish that rapport with a provider and patient, they will come back to you. They are going to trust the diagnosis you make and the treatment you are prescribing.” And while health care professionals work hard to overcome any language barriers, understanding the cultural barriers as well will ensure that a patient not only trusts a provider, but also understands what is being prescribed and why it is important to follow through.
Think like your patient
Imagine being in your patients’ shoes, says Pacheco, where the system may seem very foreign and difficult. Creating a calm environment is a big step toward putting a patient at ease, he says, despite the difficult time and pressure nurses are under.
Sometimes thinking like your patient, even briefly, gives clues as to how to proceed. Eunice Lee, Ph.D., G.N.P., a UCLA School of Nursing associate professor, had success in implementing change to get more Korean American women to have mammograms. Even the cultural differences between Korean and Korean American women can be vast. “I am struck by how cultural norms impact women’s behavior,” Lee says. “Korean American women do not tend to take care of themselves. Women prioritize family needs first with husbands and children. They are at the bottom of the list, especially if they have no symptoms.”
In the late 1990s, only 10%–20% of Korean American women were getting mammograms, says Lee. The number has since doubled but is still very influenced by the cultural context.
Lee implemented a program where she used a popular Korean vegetable dish as the program’s acronym, KIM-CHI (Korean Immigrants and Mammography: Culture-Specific Health Intervention). By presenting mammography as a normal, routine health screening and educating the husband and the woman together, screening rates jumped 15% in Lee’s intervention group.
“When you educate the woman, you need to consider and evaluate her support system and how they can help her, rather than have it purely focused on the individual,” Lee says. Health care providers might want to encourage the husband to support the woman in taking time off from work or family obligations to get screened. Lee also expressed the strong cultural resistance to getting treated, even in a screening manner, for illness in the absence of any symptoms. “When you don’t have symptoms, you are not ‘sick,’” she says of some patients’ beliefs.
Use your resources
At Lowell General Hospital in Massachusetts, Brenda Murphy, R.N., a med/surg float, works closely with the hospital’s cultural interpreters to give her patients the best care. In addition to taking advantage of work-sponsored cultural education and training, she picks up appropriate behaviors within each culture from observing and asking questions.
Murphy, who works with Lowell’s extensive Cambodian population, says she always put her hands together to give an elderly patient a small bow as a sign of respect when leaving. At the advice of a cultural interpreter, she adjusted the height of her hands, as hands that are placed too low can be seen as insulting, rather than respectful. Murphy also says she is careful when touching the head of a Khmer patient as the cultural traditions of some Khmer say the soul resides there. If it is possible to ask permission, she always does. Eye contact might be unnerving to Khmer patients as well, who sometimes avoid it as a sign of respect. They may prefer also very limited physical contact.
Many hospitals prefer to use medical interpreters to ensure accuracy in translation of complex medical terms and to protect a patient’s privacy. In their absence, nurses might have to rely on more rudimentary methods like flash cards or pictures to help both patient and nurse. Pacheco discourages the use of family members as interpreters, especially children. “Sometimes you have no choice, but it is best to introduce a bilingual neutral party who also understands medical terms,” he says. Family members can help fill in the missing information about symptoms the patient is experiencing or treatments used.
Moving forward
“It is encouraging,” Sagar says of the progress being made. In the next couple of decades, as minority populations grow, cultural competence in nursing will become much more crucial to quality patient care. “I am passionate about cultural diversity and the promotion of cultural competence,” she says. As an immigrant herself, Sagar says she knows the experience of “being different from the rest.”
When Lowell General Hospital was forming plans for diversity training, staff recognized that diversity was as much of an essential component of patient care as medicines and procedures, says Deborah Bergholm-Petka, Manager of Training and Development. Nurses have the opportunity to learn about cultures through monthly celebrations in the hospital. The staff is also encouraged to reference the book Culture & Clinical Care,which gives general summaries of many cultural beliefs and attitudes. Use what your work environment offers and know a little bit about the cultures served. “Know who your resources are and how to access them,” Murphy suggests. “Now we are more proactive and aware of who makes up our communities.”
Be ready for all situations when you work with many different cultures. Continually ask yourself reflective questions, suggests Venus Watson, chair of Lowell General’s Diversity Council. For instance, how will you navigate various cultural wishes and accommodate a patient while ensuring the best care and follow up? If family members want to speak for a patient, how can you best introduce an interpreter?
“It is not about the nurse,” Scott says. “It is about the patient. You can offend people when it comes to culture.” Never assume you know what a patient wants, she says. Rather, gain knowledge, be aware, and ask the patient—the solution is often that simple. “People do pass judgment on beliefs,” Scott says, “but it is education that will change the system.”
The next time you read a statistic such as “there are 2 million Asian Americans and Pacific Islanders in the U.S. with no health insurance” or “visits to the emergency room represent 18.8% of total visits to health care facilities by Asian Americans and Pacific Islanders, compared with 11.7% for whites,” stop and think for a moment. What exactly does the term “Asian Americans and Pacific Islanders” really mean?
Did you know, for example, that this simple-sounding classification actually encompasses more than 30 different countries and 100 languages? Are you aware that there are very few links connecting these different ethnicities other than the government-assigned label? How much do you really know about the people, their cultures and their health?
“The majority of Asian American and Pacific Islander subgroups each have their own distinct language, history, culture and migration pattern [to the U.S.],” explains Kem Louie, RN, PhD, FAAN, associate professor in the Department of Nursing at William Paterson University, Wayne, N.J., and president of the Asian American/Pacific Islander Nurses Association (APINA). “Even though there seems to be a clustering of Asian immigrant groups in larger cities, especially on the East and West Coasts, there is no common thread among them.”
That said, it should come as no surprise to learn that health beliefs, behaviors and risks can vary substantially between the different Asian American and Pacific Islander (API) populations in this country–including Chinese, Japanese, Filipinos, Koreans, Vietnamese, Native Hawaiians, Samoans and many more. Unfortunately, medical researchers traditionally have classified Asian Americans and Pacific Islanders as one broad umbrella group with similar, if not identical, health care concerns. Few, if any, research studies have bothered to make distinctions between Native Hawaiians and Hmong, for example, despite the fact that the people are dramatically different in their diets, languages and traditional beliefs.
But today, in response to federal mandates for increasing cultural competence in health care and eliminating racial and ethnic disparities in health outcomes, this oversimplified view of the nation’s API populations is finally changing. Recent culturally sensitive research studies have begun to uncover groundbreaking information about how the multiple subgroups differ from one another. Here’s an in-depth look at some of the initial findings that are helping to paint a more definitive picture of the health needs of Asian Americans and Pacific Islanders–and the implications of those findings for the nurses who provide them with care.
The Past
According to Census 2000 figures, there are approximately 11.2 million people of Asian and Pacific Islander descent living in the U.S.–up from 9 million in 1990. This increase reveals a significant immigration movement. In fact, 24% of foreign-born U.S. residents in 1997 were Asians or Pacific Islanders. In other words, six out of 10 API persons living in the United States at the time were born elsewhere. That diversity–and varying degrees of acculturation–creates an interesting and complex situation for health care providers.
“There is a changing of demographics for the Asian-American population in general and there are so many nuances and variations from one [API] culture to another,” says Daisy Rodriguez, RN, MN, MPA, an administrative nursing supervisor at San Ramon Regional Medical Center in San Ramon, Calif., and coauthor of a recent study on the health status of Filipino immigrants in the San Francisco Bay area.
Each API subgroup possesses its own cultural characteristics that are just now being examined in terms of how they impact the overall health of the people. The lack of focus on such differences in the past, say some practitioners, may have resulted from a long-held stereotype of Asians as the healthy “model minority.”
“Asians are often seen as a self-sufficient minority group, but that might simply mean that the issues are hidden,” asserts Rodriguez.
Adds Louie, “Many Asian Americans, like those of Chinese and Japanese descent, have been here for generations and have done very well through the acculturation process. But perhaps because they have done so well, the government hasn’t taken seriously the thought of examining [population-specific] health care issues.”
To fill these information gaps, API health care professionals like Rodriguez are initiating their own research to gain insight into the specific health issues affecting their communities. In addition, several federal agencies, such as the Office of Minority Health, have begun investigating health differences between API populations. The 1999 White House Initiative on Asian Americans and Pacific Islanders and the more recent Initiative to Eliminate Racial and Ethnic Disparities in Health are two such endeavors that have dispelled the misconception that Asian Americans have few major health care worries compared to other racial and ethnic groups.
The Present
Although much of the current research data on minority health disparities suggests that Asian Americans and Pacific Islanders generally fare better than African Americans and Hispanics when it comes to health outcomes, this does not mean that API communities don’t suffer from their share of disproportionately high health risks and mortality rates. In fact, recent reports have raised a number of red flags indicating serious API health concerns that physicians, nurses and other health professionals urgently need to address. Some of the most critical areas of concern include:
Cancer
This deadly disease appears to be a prevalent health problem for Asian Americans and Pacific Islanders in general, regardless of differences between specific subgroups. There is overwhelming evidence that many types of cancer are more common among Asians and Pacific Islanders than even heart disease, which still ranks as the leading cause of death for the U.S. population as a whole. “This is the first time that cancer is the leading cause of death among any [racial or ethnic] group,” Louie points out.
More Asian Americans and Pacific Islanders suffer from liver, stomach and nasopharyngeal cancer than Caucasians, according to the Asian/Pacific Islander National Cancer Survivors Network. More specifically, Vietnamese Americans are 11 times more likely to develop liver cancer than whites, and Chinese Americans report the highest rate of nasopharyngeal cancer among all racial or ethnic groups, according to The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination and Ensuring Equality, a 1999 report ordered by the U.S. Commission on Civil Rights.
But what has many caregivers particularly worried is the growing numbers of API women diagnosed with breast and cervical cancer. Again, incidence rates vary among subpopulations, but Native Hawaiians top the list of breast cancer sufferers, with 106 cases occurring per 100,000 people. Vietnamese women are 2.5 times more likely to develop cervical cancer than women in any other racial or ethnic population. Both anecdotal and qualitative research suggests that these disparities are linked to cultural issues that may be creating barriers to early diagnosis and preventive care.
For example, says Rodriguez, “Some Filipino women who feel lumps in their breasts may not be reporting them to their physicians because it involves a sensitive part of their bodies and they don’t want to be examined.”
Dorothy E. Schmidt-Vaivao, coordinator of the Samoan National Nurses Association (SNNA)’s cervical cancer program, based in Carson, Calif., has encountered similar resistance to cancer screening among Samoan women. “We have had women comment that they don’t want anyone other than their husbands touching them.”
Statistics from the API Cancer Survivor Network further confirm the prevalence of these attitudes. A study of Vietnamese women living in California revealed that 34% had never had a mammogram and 54% had never had a Pap test. The Network also notes that Asian American and Pacific Islander women, as a whole, have the lowest screening rates for breast and cervical cancer among all ethnic groups.
Recognizing the immediate need for interventions in their community, SNNA has initiated two outreach programs in Southern California: the Pacific Islander Women’s Breast Health and Breast Cancer Early Detection Program, and Breast Cancer Awareness–The Fa’a Samoa Way Project. “We go to community churches where we talk to the women members,” explains Schmidt-Vaivao. “Afterwards, the women tell us that they now know why they have to follow up [and get breast exams].”
Although these programs are relatively young, Schmidt-Vaivao believes the grassroots effort is making an impact. “Our goal is to create a prevention awareness in the Samoan community,” she emphasizes.
Tuberculosis and Hepatitis
More than a decade ago, researchers discovered a worldwide resurgence of tuberculosis (TB). This time, however, the airborne, infectious disease had mutated into a new, drug-resistant strain. Even though health experts in various countries had hoped to curtail its spread by developing more aggressive medications and treatment programs, TB remains a serious public health issue, especially in API communities.
The World Health Organization (WHO) estimates that, under current conditions, nearly 1 billion people will become newly infected with TB by 2020, and 35 million will die from it. Many of these victims will be from Southeast Asia, which is already recording 3 million new TB cases per year. These predictions worry U.S. public health officials because of the increased immigration from that part of the world. According to WHO, nearly half of all TB cases in industrialized countries occur in foreign-born people. In the United States, 40% of TB patients are immigrants, many of them from Southeast Asia.
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In fact, the American Lung Association reports that Asian Americans and Pacific Islanders are 15 times more likely to contract an active case of TB than Caucasian Americans. As with cancer, this disparity is often exacerbated by cultural taboos that can prevent Southeast Asian immigrants from seeking treatment.
“In some Asian cultures, TB is a stigma,” notes Louie. “And if patients perceive they are being chastised by health care providers, they may not come back for follow-up care or take the treatment at all.” Such behaviors can result in a significant public health risk, experts warn, because untreated or half-treated TB can evolve into a drug-resistant form of the disease.
Similarly, hepatitis B seems to be hitting the API population harder than other racial or ethnic groups. Again, the concern in the public health arena is the effects that can develop if the disease isn’t identified and treated early enough. While not an airborne contaminant like TB, hepatitis B is the leading cause of liver cancer–and as noted earlier, Asian Americans and Pacific Islanders, especially those of Vietnamese descent, have a higher incidence of this cancer than whites.
“The rate of hepatitis B [among Asian Americans] is on the rise, and we weren’t looking in that direction,” says Louie. “Children who contract it are especially at risk for developing cancer later in life.”
Obesity, Diabetes and Kidney Disease
Interestingly, many Asian Americans, and especially Pacific Islanders, are following in the footsteps of other minority groups when it comes to problems with obesity and sedentary lifestyles–unhealthy behaviors that can increase the risk of developing diabetes. In fact, type 2 diabetes has become so prevalent among Americans of all races that health experts have virtually declared it a national epidemic.
Diet, of course, plays a huge role in the both the cause and the treatment of diabetes. While Pacific Islanders have traditionally been known for their healthy eating habits, Schmidt-Vaivao is concerned that this pattern is changing as the people become more acculturated to the American “burgers and fries” lifestyle.
“We [Samoans] have the highest incidence of obesity among the Pacific Islander community,” she says, adding that it’s a problem both in the U.S. and on the island of American Samoa. “There are a lot of fast food places over there now. The people on the island are turning to that eating habit versus the fresh fish and fruit that’s been traditional. It’s scary to see that happening, because it can create problems with diabetes and hypertension.”
Diet is also a leading suspect behind the unprecedented number of renal problems among API subgroups. “I’ve noticed a lot of Samoan people on the island, young and old, on dialysis,” Schmidt-Vaivao reports. “We need to find out why. Is it because of our diet? Is it hereditary? Has this always been going on but we weren’t testing for it before?”
Southeast Asians in the U.S. are also on dialysis in record numbers, says Ana Schaper, RN, MSN, PhD, an epidemiologist at Gundersen Lutheran Medical Center in La Crosse, Wisconsin. Currently there is no conclusive research available to shed light on why so many Asians and Pacific Islander are requiring this complicated treatment.
HIV/AIDS
Generally speaking, America’s API population has some of the lowest numbers of HIV and AIDS cases compared to other minority groups. The Civil Rights Commission report states that Asian Americans accounted for eight AIDS cases per 100,000 people in 1996, which is extremely low compared with the 111 and 52 cases for African Americans and Hispanics, respectively. But within the Asian community, Filipinos lead the subgroups in known AIDS cases, with 45 cases per 100,000.
Furthermore, both Louie and Rodriguez suggest that these statistics may be misleading. “We believe there are more API people who are infected but are not reporting it because of the cultural barriers in their communities,” explains Rodriguez.
In addition to cultural mores, factors such as language barriers and lack of education about the disease may also be clouding statistical findings and preventing people from seeking care. Some research suggests that awareness and understanding of AIDS and its risk factors among the more recently immigrated Asians lags behind that of their counterparts who have lived in America for some time. For example, a 1992-94 National Health Interview Survey found that 21.2% of Vietnamese adults in the U.S. admitted knowing nothing about AIDS and its transmission, compared to only 5.1% of Japanese-American adults.
As more research among API subgroups is conducted, and as community education efforts broaden, the number of reported HIV/AIDS cases among Asian Americans and Pacific Islanders could start to inch upward as more people come forward for testing and treatment.
The Future
Because there has historically been so little definitive research into differences between API subgroups, the current body of knowledge about their health care needs is all relatively recent and preliminary. But now, nurse researchers who are concerned about providing better care to Asian American communities are hoping to make up for lost time–and Asian American/Pacific Islander nurses are leading the way.
“There has been more printed about Asians in the medical literature in the past five years compared with the previous 25 years,” Louie comments. “Still, we need to do a better job in specific data collection if we are really to get a handle on health care concerns among Asian Americans and Pacific Islanders. Currently, we’re dependent on government-gathered data. So much depends on how well the Health Department and other agencies define their categories.”
Adds Rodriguez, “There may be many differences between the various API groups, but the only way to know is to do the research.” That’s exactly why she, along with colleagues from the Philippine Nurses Association of Northern California, initiated their in-depth study of Filipino Americans’ health status, risk behaviors and health promotion practices.
What started as a local survey of older Filipino adults in the Bay Area has expanded into a comprehensive national project, Rodriguez reports. “We realized our focus needed to extend beyond just the elderly because there were so many health care issues in the Filipino community that needed to be addressed.” The study’s initial findings will be presented this summer at the 2002 Philippine Nurses Association of America national conference in Philadelphia.
Schaper recently concluded a project examining the existence of postpartum depression in Hmong women. Wisconsin is home to a large Hmong population and state officials had done some initial research on this issue. Their report concluded that this condition was not prevalent in the Hmong community. However, translators working with Hmong maternity patients at Gundersen Lutheran told Schaper and her colleagues they believed this conclusion was incorrect.
“Because of those initial research results, we weren’t screening Hmong women for postpartum depression like we did with other patients,” she says. As a result, Schaper and several local midwives embarked on a two-year project to clarify the issue. Her findings proved that there was indeed a growing presence of postpartum depression in young Hmong mothers, but because of cultural and linguistic misunderstandings, it had been overlooked by the previous research.
“We didn’t realize how difficult it was to become trusted within the Hmong community,” Schaper adds. “Confidentiality is a big part of their lives. Issues surrounding childbirth are not usually talked about with people outside the family for fear of starting rumors.”
Through her research, Schaper determined that a more symptomatic-oriented screening tool was able to better identify postpartum depression in Hmong women. “Now we screen all our patients for postpartum depression,” she says. “We’ve also developed [educational] materials for Hmong families to help them prepare for the birth of their babies.”
Schaper also discovered some interesting generational and acculturation issues impacting the women in her focus groups. Generally speaking, the younger women who were either born in the U.S. or had lived here since childhood had more “Americanized” expectations about motherhood. It was often the clash between these views and the traditional Hmong philosophies that caused much of the anxiety and depression.
“There was a difference in how the young women saw their world compared with their mothers who had given birth in Laos,” Schaper explains.
The Providers
Other recent studies have confirmed that the degree of acculturation in Asians and Pacific Islanders who have migrated to the U.S. has both direct and indirect connections with their health and their use of health care providers. For example, the Civil Right Commission’s research found that the longer Korean women had lived in the United States, the greater their risk was for developing breast cancer. Furthermore, it’s often the newly immigrated who lack access to health care services the most, in part because of such factors as poverty, language barriers, lack of insurance and unfamiliarity with the American health system.
But that’s also why it’s important for nurses and other health care professionals to approach Asian and Pacific Islanders with cultural sensitivity and an open mind. “While we may not know all the specifics about health care issues in API communities, we do know what makes for good health. Now we have to look at these factors within the framework of their culture,” Schaper advises.
For nurses, that process must begin with taking the time to listen as well as learning to ask the “right” questions. “Samoans don’t believe in saying much,” comments Schmidt-Vaivao. “As health care providers, you have to dig because they won’t volunteer information.”
Such cultural barriers to communication are common among many API subgroups, Louie agrees. For instance, there’s often an attitude of “automatic” respect assigned to health care professionals that can actually be counterproductive. “Asians don’t want to offend a care provider, even if they don’t agree with him or her,” she explains. “Nevertheless, nurses have to find a way to get an accurate assessment. You have to take the time to listen and ask many questions. It seems like a simple philosophy, but when you do it, they’ll respond.”
Nurse researchers who have studied health issues affecting Asians and Pacific Islanders advise nurses in clinical practice who care for API patients to seek out as much information about Asian cultures as possible, whether it’s from published research or simply talking with colleagues who have firsthand knowledge in this area. After all, most hospital staffs are a microcosm of the communities they serve. Don’t hesitate to ask for translation assistance, or for information on traditional diet, religious beliefs or anything else that can help you provide more culturally competent care.
Above all, cautions Louie, avoid the stereotype that all Asians and Pacific Islanders are alike. “The API population is a diverse group,” she says, “and I can’t stress enough the importance of not generalizing.”
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