A love of nature and the importance of living a simple, natural life are the basis of Hinduism, a faith that originated in India and is generally acknowledged to be the world’s oldest and third largest religion. Like Buddhism, the Seventh-day Adventist Church and other religions that promote a vegetarian lifestyle, the Hindu faith encompasses a number of health beliefs and dietary practices arising from the idea of living in harmony with nature and having mercy and respect for all of God’s creations.
Followers of the Hindu religion, which is practiced primarily in India, Nepal and Sri Lanka, believe that the body is made up of natural elements: earth, air, fire, water, etc. The proper balance of these elements indicates good health, while an imbalance indicates the opposite. Hindus believe self-control and meditation is the path to health, with prayer to the Almighty God being the last resort. For many Hindus, yoga is a means by which to bring the integration of the body, mind and intellect together in order to achieve perfect harmony or alignment.
The four Vedas (which means “the Wisdom and the Knowledge”) are among the most important of the Hindu holy books. For devout believers, these sacred texts address every aspect of their lives that are controlled by their faith, including their daily practices, their yearly calendar and their use of water in acts of worshipping. For Hindus, water is believed to be a purifier and a rejuvenating agent for religious acts, as evidenced, for example, in the traditional practice of bathing in sacred rivers during pilgrimages.
The Hindu Dietary Code
Devout Hindus believe that all of God’s creatures are worthy of respect and compassion, regardless of whether they are humans or animals. Therefore, Hinduism encourages being vegetarian and avoiding the eating of any animal meat or flesh. However, not all Hindus choose to practice vegetarianism, and they may adhere to the religion’s dietary codes in varying degrees of strictness. For example, some Hindus refrain from eating beef and pork, which are strictly prohibited in the Hindu diet code, but do eat other meats.
Some Hindu Sayings and Beliefs Related to Health and Diet Live a natural, healthy life—i.e., be like the birds and animals. “The treatment is a learning process, but sometimes an old patient is worth more than a young doctor.” In other words, knowledge, wisdom and experience are valuable to the process of staying healthy. Showing care for what you eat can save your body and mind. Eat moderately and consume simple, pure, healthy foods (a Sattvic diet) even when not fasting.
Like Buddhists, Hindus believe that food affects both body and mind. Food is considered to be a source of the body’s chemistry, which affects one’s consciousness and emotions. Thus, expression of the soul depends on the body, which depends on the food. A proper diet is considered vital for spiritual development in Hinduism. The Hindu diet code divides food into three categories, based on the food’s effect on the body and the temperament:
Tamasic food is leftover, stale, overripe, spoiled or other impure food, which is believed to produce negative emotions, such as anger, jealousy and greed.
Rajasic is food that is believed to produce strong emotional qualities, passions and restlessness in the mind. This category includes meat, eggs, fish, spices, onions, garlic, hot peppers, pickles and other pungent or spicy foods.
The most desirable type of food, Sattvic, isfood that is non-irritating to the stomach and purifying to the mind; it includes fruits, nuts, whole grains and vegetables. These foods are believed to produce calmness and nobility, or what is known as an “increase in one’s magnetism.”
Hindus believe that for true service to God, purity of food is necessary to maintain the desirable state of mind that leads to enlightenment. Food is consumed not only to survive but also to stay healthy and maintain mind/body equilibrium. By eating a purer quality of food, such as a Sattvic diet, and regulating food consumption, one can ensure a pure heart, long life, cheerful spirit, strength, health, happiness and delight. Good and pure food promotes a peaceful—not agitated—mind, which is needed to see the Truth as the Truth. Sin, or an agitated state of mind, prevents the journey to moksha (divine supreme knowledge, which leads to freedom from the cycle of birth, life, death and rebirth).
Some specific Hindu dietary customs and practices include the following:
A true devotee will refuse to accept any food that is not offered first to God. Gaining God’s blessing before consuming the food is essential. Hindus may do this is by placing their daily food before the particular deities they worship and by reciting shlokas(prayers). Once the food is offered to God, it is eaten as prasador blessed food.
Before starting any daily meal, a devout Hindu first sprinkles water around the plate as an act of purification.
Five morsels of food are placed on the side of the table to acknowledge the debt owed to the devta runa (divine forces) for their benign grace and protection.
For a child’s birthday celebration, the sacred symbol “OM” is added onto the birthday cake along with “Happy Birthday.” Also, a lamp is lit instead of having the child blow out the candles. In the Hindu faith, lighting a lamp is symbolic of new life, a new beginning or the spreading of knowledge.
The Practice of Fasting
Some Hindus practice the tradition of fasting during special occasions, such as holy days, new moon days and festivals. As is also the case in a number of other religions, fasting is seen as a way of staying close to God and attaining a close mental proximity to Him. Hindus fast in various ways, depending on the individual: They may choose to not eat at all during the fasting period, or to eat only once, eat only fruits or restrict themselves to a special diet of simple foods.
Fasting is believed to help reinforce control over one’s senses, squelch earthly desires and guide the mind to be poised and at peace. Hindus also believe that when there is a spiritual goal behind fasting, it should not make the body weak, irritable, or create an urge to later indulge. Rather, rest and a change of diet during the fasting time is considered to be very good for the digestive system and the entire body. The idea is that every system needs a break and an occasional overhaul to work at its best.4
Health Considerations of the Vegetarian Diet
There is a myth that vegetarians suffer from vitamin deficiencies. The truth is that all needed nutrients are found in vegetables, fruits and nuts when eaten in sufficient amounts; the only exception is vitamin B12. To overcome this potential deficiency, which can cause anemia and other disorders, vegetarians need to markedly increase their protein intake. According to the recommendation of the American Dietetic Association (ADA), vegetarians should increase their consumption of rice milk, soy milk, yeast extracts and breakfast cereals to ensure a sufficient intake of vitamin B12.
Ask the Cultural Competence Expert Minority Nurse’s cultural competence expert, Gihan ElGindy, MSN, RN, is an internationally recognized authority on cross-cultural issues in nursing. This column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace. Do you need advice on how to provide culturally sensitive care to patients from a particular ethnic or religious background? Are you looking for ways to increase understanding and acceptance of cultural differences in your work environment? Our expert can help! Send your Cultural Competence Q&A questions to [email protected].
Some vegetarians refrain from eating meat, fish or fowl but do consume eggs and/or dairy products. In contrast, a vegan diet is a total vegetarian diet that excludes any and all animal products (i.e., no meat, eggs and dairy). Therefore, vegans generally have a lower calcium intake than non-vegetarians, but they may have lower calcium requirements as well. Vegans are advised to increase their intake of Omega-3 fatty acids found in flax seed, walnuts, soybeans and dark green vegetables.
The ADA is just one example of a major health organization that recognizes that a well-planned vegetarian or vegan diet can reduce the risk of many chronic conditions, such as heart disease, obesity, diabetes, asthma, high blood pressure and cancer. Because vegetarians are less susceptible to major diseases, they can live healthier, longer and more productive lives, with fewer visits to doctors, fewer dental problems and lower medical bills.
Here are some additional health benefits of the vegetarian diet:
Food is easier to digest, provides a wider ranger of nutrients and requires less effort to purify the body from its wastes.
Vegetarians’ immune systems are stronger, their skin is less flawed and their bodies are more pure and refined.
Finally, because meat is expensive compared to fruits, vegetables, etc., a vegetarian diet can also have financial benefits for low-income populations. Unfortunately, lack of sufficient access to food stores that sell good quality fresh produce continues to be a serious health problem in disadvantaged communities.
Editor’s Note: Previous articles in the culturally competent dietary assessments series, including “Meeting Jewish and Muslim Patients’ Dietary Needs” and “Understanding Buddhist Patients’ Dietary Needs,” are available online.
As nurses, you know that health care is always changing. Nursing is not the same profession today as it was when you started five, ten, or twenty years ago. Part of these changes steep in a better or evolved understanding of what it means to care for patients, but others are out of nurses’ control and reflect changes both in the health care industry generally and in-patient populations.
The introduction and expansion of new tech in the health care setting combined with the rapid rate of change in patient populations mean that nursing is more dynamic than ever before. And you need to keep up.
What are the most pressing changes nurses are facing right now? These are a few of the things that will change the way you practice your profession over the next few years.
Nurses Will Need to Balance the Hands-on/Hands-off Approach
Nursing is, by definition, a very hands-on practice. Care requires a nurse to be wholly present with a patient. But some of that is already changing, and the rate of change could grow substantially over the next few years. Why? Because the Internet of Things (IoT) and all its sensors are gaining ground in hospitals and clinics.
Wearable tech and smart sensors have the ability to record and remotely transmit health data from patients directly to care providers. Everything from vitals to movement is now trackable with current tech, and nurses are increasingly responsible for patients who use it.
The implications are huge for nurses. On one hand, nurses can spend less time on rote tasks, which will make a difference in daily activities and relieve a small amount of pressure as nurses deal with a continued labor shortage. At the same time, it will also change the way nurses care for patients: how will nurses provide bedside care if they no longer need to attend to patients at their bedside?
Nurses Will Find New Colleagues to Work With
Nurses work as a team with physicians, specialists, and administrative staff to keep their organization functioning. However, the continued introduction of new technology in the health care industry will demand nurses to work more closely with two emerging groups: IT professionals and medical coders.
At the same time, the growth of IT professionals in clinical settings offers an opportunity for nurses. They will help nursing staff stay at the forefront of tech and learn how to balance patient care with technology in a way that’s effective and safe. Working closely with IT teams can also help nurses better protect vital health data and avoid HIPAA violations by avoiding simple mistakes and identifying vulnerabilities.
Patient Self-Advocacy Will Continue to Grow
The role of the nurse as an advocate will also be challenged over the next few years. Already, patients have benefited from advancements like AI and wearable tech. However, as more and more companies insert themselves into the American health care system, the role of the patient as a self-advocate will also begin to grow because they have new resources outside the hospital and clinic system.
Improved self-advocacy is good news for patients and nurses alike. Nurses do their best to encourage patients to ask questions, seek answers, and share their health goals. A more educated and self-empowered patient population benefits everyone, and self-advocacy is a key indicator of patient satisfaction.
However, you can expect to also see it challenge the role of the nurses. Self-advocacy is also empowering non-health care businesses to get involved in certain items. For example, Amazon now allows customers to use their Health Savings Account (HSA) funds to pay for certain items. Nurses will need to adjust to the potential of patients taking on more of their care outside the purview of a clinic. And Amazon isn’t just interested in selling diabetes supplies: you could see giants like these trying to insert themselves into catastrophic disease management and treatment.
Patients Will Be More Diverse in Almost Every Way
Already, nurses need to have a strong understanding of caring for diverse patient populations. However, the changes in demographics, social systems, and epidemiological patterns will only continue, and nurses need to prepare themselves to care for increasingly diverse patients and learn to navigate the ethical challenges that can come with adapting to new patient populations.
Nursing in a diverse context means doing more than providing interpreters and using intake forms in multiple languages: though, these things are vital first steps. It also means learning about the most prominent patient groups and to gain a better understanding of their social, cultural, and religious contexts.
For example, if caring for an elderly Hindu woman, a nurse may find that they need to be specific when they require the woman to fast. In Hindu culture, fasting is part of a religious practice but it can allow them to eat fruit and drink water. Nurses need to be specific about what ‘nothing by mouth’ means. The difference is important and could dramatically impact a patient’s outcomes.
How Will Nursing Challenge You?
These upcoming changes in the health care industry will change the way you practice nursing once again. The addition of new tech, changes in the shape of self-advocacy, and shifts in patient populations all present both opportunities and challenges for both nursing and health care as a whole.
Most importantly, these changes can help you and your colleagues be better, more dynamic nurses and contribute to improved health for your communities. So, don’t fear these changes. Embrace them. If anyone can meet the challenges facing health care over the next few years, it’s nurses.
By providing health education and wellness promotion in religious communities of color, minority nurses of all faiths can make a powerful difference in eliminating health disparities.
Not that long ago, nurses who answered a calling to promote physical and spiritual health in their places of worship were known as parish nurses or congregational health nurses. But in today’s unprecedentedly multicultural America, where many of the faithful are just as likely to attend a Muslim mosque or Hindu temple as a church or synagogue, this specialty area of nursing has acquired a new, more all-embracing name: faith community nursing.
“When what we do was first recognized by the American Nurses Association [ANA] as a specialty practice in the late 1990s, it was under the title ‘parish nursing,’” says Nancy Rago Durbin, RN, MS, FCN, interim director for faith community nursing for the Health Ministries Association (HMA), a professional association for faith community nurses (FCNs). But by 2005, when Durbin was part of a team working with ANA to update the specialty’s Scope and Standards of Practice, the limitations of that name had become glaringly obvious.
“One of the ANA leaders said: ‘Do you have to be Christian to claim this specialty?’” recalls Durbin, who is also director of Advocate Parish Nurse Ministry and the Parish Nurse Support Network for Advocate Health Care in the Chicago area. “When I said, ‘No, this is by no means an exclusive specialty, any nurse from any faith is welcome to practice,’ she said: ‘Well, your name doesn’t seem to include that.’ And she was right!”
Of course, the term “parish nurse” is still alive and well. It’s widely used to denote FCNs who work to improve health in specifically Christian settings. But professional organizations like HMA and the International Parish Nurse Resource Center (IPNRC), a ministry of the Church Health Center, now recognize that church-based nursing is one thread in a much bigger tapestry that encompasses many different faith traditions. In fact, the Church Health Center, despite its name, teaches FCN training courses to nurses of all faiths all over the world.
When and how did traditional parish nursing evolve into this broader, more culturally inclusive specialty? “I’ve always known it to be all-inclusive,” says Maureen Daniels, RN, MN, FCN, an IPNRC faith community nurse specialist. “I think it’s just the organic nature of it that’s helped it grow into more of these other faith settings. One of the things that’s so beneficial about this model is that it’s meant to be adapted to the community and to where the needs are.”
Different Faiths, Same Roles
No matter whether the faith they practice is Baptist, Buddhist, or Baha’i, minority nurses need to be involved in addressing the health and wellness concerns of their own faith communities. Even though most FCNs do this work on a volunteer basis while also holding regular nursing jobs, they can make a tremendous difference in improving health outcomes and reducing health disparities in communities of color—especially those that are economically disadvantaged and/or medically underserved.
“[Places of worship] can be a very important resource for promoting health, because they reach so many people on a regular basis,” explains Ann Littleton, a congregational health advocate at Sacred Heart Catholic Church in Greenville, Mississippi, which serves a predominantly African American congregation plus a smaller Hispanic congregation. “At our church, we probably have more people from the community gathered together in one place every weekend than anywhere else. We can pass out information about cancer, heart disease, stroke, and diabetes just like we pass out the Sunday bulletin.”
The roles FCNs perform are remarkably similar from faith to faith. The Canadian Association for Parish Nursing Ministry organizes those functions into this easy-to-remember acronym:
H – Health advisor
E – Educator on health issues
A – Advocate and resource person
L – Liaison to faith and community resources
T – Teacher of volunteers and developer of support groups
H – Healer of body, mind, spirit, and community
For example, Ameena Hassan, RN, a Muslim nurse who works in the ICU at Las Colinas Medical Center in Irving, Texas, has been providing faith community nursing services at her mosque, the Islamic Center of Irving, since 2009. It’s a large mosque, serving approximately 500 families in the Dallas area.
“We do health education classes here every month,” says Hassan, coordinator of the mosque’s Health Advisory Committee. “We do blood pressure screenings and cholesterol screenings. We do mammograms every year, usually in April. During flu season, we do flu shots.”
The mosque also holds an annual health fair. At last year’s event—attended by almost 200 community members—local physicians, nurses, and dentists provided 100 cholesterol and diabetes screenings, 33 bone density screenings, 67 dental exams, and 42 vision exams. In addition, they gave 90 attendees nutrition advice and distributed 100 bicycle safety helmets to children.
At New Horizon Church International in Jackson, Mississippi, “cardiovascular disease is the number one health problem among my congregation, so we do lots of CVD screenings, education, and referrals,” says Ella Garner Jackson, RN, CHN, leader of the church’s Health and Wellness Ministry. Jackson and her team also provide a full calendar of other disease prevention programs, including exercise classes, kidney disease screenings, and HIV/AIDS education. On the advocacy front, the ministry helps increase access to health care for low-income church members by connecting them with community resources that provide affordable prescriptions.
Because Mississippi has some of the highest levels of poverty and African American health disparities in the nation—including disproportionately high morbidity and mortality rates from cancer, diabetes, and other chronic diseases—Jackson is especially focused on the FCN’s volunteer training role. In 2005, Jackson, who is also a cardiac case manager at Mississippi Baptist Medical Center, founded the Abundant Living Community Organization (ALCO), a nonprofit organization that has taught nearly 160 nurses and non-nurse volunteers to lead health ministries in African American churches throughout the state.
Same Roles, Different Needs
How faith community nurses carry out these roles is driven by the unique needs of the communities in which they serve. In some faith settings, for instance, FCNs must tailor their health promotion activities to accommodate specific religious requirements.
“In Islam, we don’t mix men and women together in the mosque,” says Hassan. “If we’re doing something like screenings or flu shots, we have to have it in two separate places for men and women. And the women’s space has to be covered, because they don’t want to [expose their bodies] in front of others.”
But in many minority faith communities, the biggest challenges for FCNs are more likely to revolve around cultural and socioeconomic needs than belief-based ones.
“Here in the Chicago metro area, Advocate’s parish nursing program includes two Latino congregations and two African American congregations,” says Durbin. “Our nurses who work with those communities are very focused on the needs of people who are disenfranchised, undocumented, and struggling with access to care. Some of our nurses are dealing with the problem of food deserts, and they’re trying to work with the communities to create sustainable vegetable gardens and increase access to quality foods.”
Littleton, a retired English teacher who became a church health advocate after taking the ALCO training in 2010, emphasizes that “in our Hispanic health ministry, we don’t ask about immigration status. If anybody comes to us in need of our services or a referral, we try to make them feel as comfortable with us as possible. It’s important for them to feel that we’re not going to pry into their status; we’re just providing health services that they need.”
One of the most empowering ways minority FCNs can lead their faith communities down the path to healthier living is by breaking down cultural barriers that exacerbate health inequities and impede access to care.
“In some African American communities, there is still enormous distrust of the health care system,” Durbin notes. “A black faith community nurse can become the entry point for many people to develop that trusting relationship. Someone may say, ‘I went to the public health clinic down the street and they were mean to me. So I’m not going back.’ And the nurse will say, ‘Well, how about if I go with you? Because that’s where you need to be to get your meds refilled.’ Then the nurse can physically take that person back to the clinic and help them [build a better relationship with those providers].”
Durbin also notes, “In our Latino communities, men’s health is a big issue. Many of the guys have traditional machismo cultural values, so they don’t take care of their health. And traditionally, it’s the women and the older men who are the churchgoers, but not the younger guys. Latino faith community nurses who know the culture can figure out creative ways to engage that core group of men, such as providing them with health information through the people who love these men and who do go to church.”
Enlisting the aid of lay community health promoters can also help FCNs connect with hard-to-reach populations. Daniels cites the example of a group of parish nurses in Portland, Oregon, who are partnering with local promotores to extend their health ministry outreach deeper into the Hispanic community. “Because the promotores had such good relationships with the people, and people trusted them so much, they were able to get many more community members to come to health events the nurses had organized than the nurses would have gotten by themselves,” she says.
Bridging Cultural Differences
Even if a nurse doesn’t share the same religious, ethnic, or cultural background as the faith community he or she works with, collaborating with leaders within the community can be an effective way to bridge those gaps. For example, the Faith Community Health Ministry (FCHM) program at Carolinas HealthCare System in Charlotte, North Carolina, uses a model that makes it possible for the hospital system to meet the needs of virtually any belief community.
“We form partnerships with faith communities through either a faith community nurse or a faith community health promoter,” explains Sheila Robinson, BSN, RN, the program’s health ministry coordinator for Mecklenburg County. “My role is to help each one of those individual communities promote health and wellness within their own particular faith. I provide the clinical guidance and oversight to the nurses and the health promoters.”
This approach enables Robinson, an African American Christian nurse, to work with such diverse faith communities as the Hindu Center of Charlotte, a temple that serves about 2,000 families. Her health promoter partner is Chidaabha Vyas, vice president of the Hindu Center’s executive committee. When they first teamed up in 2012, one of their key projects was to survey the temple’s members about their most important health concerns and then develop programs targeted to those needs.
“Heart disease, allergies, and weight loss were some of the top concerns the community identified for us,” Vyas says. “Diabetes is a very big concern. And it’s not specifically the Hindu community that’s so affected by this disease,” she points out. “It’s [Asian] Indian people in general. Diabetes is more of a concern for us as a race, I would say.”
Being able to work side by side with a community liaison like Vyas makes it easier for both Robinson and Carolinas HealthCare System to serve the local Hindu community in culturally sensitive ways. “When we formed the partnership, I told Chidaabha, ‘I’m of Christian faith, so you will have to help me to be able to meet the needs at the Hindu Center,’” Robinson says. One cultural lesson she learned early on is that some members of this community may be uncomfortable with the idea of placing a terminally ill family member in hospice care.
“Again, this is more of an Indian cultural issue than a religious one,” Vyas stresses. “Some of us do not believe in speeding up the process of death. We believe death will come when it will come. Having a connection between our temple and the hospital system through the FCHM program is very helpful, because we can let them know that when an Indian family is resisting hospice it’s because there is a real cultural dynamic going on.”
A Higher Power
Praying isn’t enough to make America’s health disparities crisis go away. But by educating, advocating, and integrating spirituality with health in all the diverse settings where people gather together to pray, faith community nurses have the power to bring about real change.
“Because of our partnership with Sheila and the FCHM, something is happening at the Hindu Center now that was never happening before,” Vyas reports. “It has helped us develop a culture that prioritizes health. Before, health was thought of as more of an individual responsibility. But now, we’re beginning to develop a connection with our members based on the idea that ‘you are responsible for your own health, but the temple is here to help you be responsible for your health.’”
Jackson adds: “My pastor has told me, ‘I know that you’ve saved some lives in this congregation. I know that I am a healthier person myself because of all the education you’ve provided in the church.’ I can look out into the pews and show you people who were not going to the doctor, who weren’t taking their medicine, and who are now routinely seeing a physician. That’s at the heart of what a faith community nurse can do.”
Among the many challenges of trying to promote cancer screening and early detection in American Indian and Alaska Native communities is the reluctance to speak about it. Some Native people consider cancer to be an automatic death sentence, and some believe talking about it could invite the disease into one’s body.
So when DeAnna Finifrock, MSN, RN, PHN, a trusted public health nurse who for many years has worked on the Fond du Lac Band of Lake Superior Chippewa Reservation in Cloquet, Minn., was diagnosed with breast cancer 11 years ago, she saw an opportunity.
She told people in the community how she had almost missed getting her annual mammogram that year because she was so busy with her job and family, but that fortunately she did make it to the appointment. She openly shared news of her diagnosis and treatment. And she talked about hope and gratitude.
“I said, ‘I want to be there to rock my great-grandbabies. If I had skipped the mammogram that year, I wouldn’t be here talking to you.'”
Her powerful story helped raise awareness about cancer screening and treatment in the community, and today it adds validity to her work managing a Centers for Disease Control and Prevention (CDC) cancer control and prevention grant for the reservation.
“I’ve traveled the cancer journey,” she says. “I know what it’s like.”
Finifrock is an example of how culturally competent nurses can make a major impact in eradicating cancer disparities in minority and medically underserved communities.
Disparities by the Numbers
Although scientific breakthroughs have led to better treatment and survival rates for many types of cancer, these advances haven’t brought equal hope for everyone. Racial and ethnic minorities bear a disproportionate share of pain, suffering and death from the disease compared to the U.S. population as a whole. Consider these statistics:
African Americans have the shortest survival and highest mortality rates from cancer than any other racial or ethnic group. In 2005, the death rate for all cancers was 33% higher in African American men and 16% higher in African American women than in white men and women, according to the American Cancer Society (ACS).
Although Hispanics get cancer at lower rates than non-Hispanic whites, they are more likely to be in the advanced stages of the disease when they are diagnosed. Even disregarding age and stage of the disease, the ACS says Hispanic men and women have lower survival rates for most cancers than Caucasian men and women.
For many years, research had showed lower rates of cancer among American Indians/Alaska Natives (AI/ANs) than in other ethnic groups, but incidence was vastly underreported. Newer figures show cancer incidence rising in this population, with AI/ANs carrying a disproportionate burden from the disease and facing many barriers to treatment. For instance, the average amount of time between cancer diagnosis and treatment is six months for AI/AN women and nine months for AI/AN men, according to Native American Cancer Research (NACR), a community-based non-profit organization headquartered in Colorado.
Asian Americans are the only minority group in which cancer is the leading cause of death. They experience a disproportionate share of cancers with an infectious origin and a growing number of cancers resulting from such factors as smoking and unhealthy diet, according to research published in the American Cancer Society’s journal, Cancer.
Efforts to end these disparities through culturally appropriate research, prevention programs, education and cancer care have increased in the last decade. But there’s obviously much more work to be done.
Making Community Connections
“You see the disparities and you ask why,” says Sandra Millon-Underwood, PhD, RN, FAAN, a professor at University of Wisconsin-Milwaukee College of Nursing. “That’s a good question to ask, but maybe the more important question to ask is: ‘What can we do about it?'”
Millon-Underwood, who was recently inducted into the National Black Nurses Association’s Institute of Excellence, has conducted many research projects on cancer education, prevention, early detection and cancer risk management for at-risk and underserved populations. Her focus for the last 30 years has been on getting the word out in plain language to people right where they live.
For instance, a program she designed to promote breast health among African American women addresses the misconceptions and fears that often prevent women from getting mammograms. In this intervention, nurses present culturally specific breast cancer screening, early detection and follow-up programs to groups of women in the places where they work and worship. Audiences have included housekeeping, custodial and dietary staff at hospitals and colleges; childcare attendants at daycare centers; alliances of ministers’ wives; and weekly Bible study and prayer groups at tiny storefront churches, halls and mosques. More than 6,000 women have benefited from the program to date.
A key to reaching people in communities of color is connecting with them at the grassroots level, Millon-Underwood emphasizes. She cites other successful cancer outreach programs in which nurses have presented information to customers at nail salons, barbershops and even laundromats.
To make true connections with people in the community, nurses must first establish trust. “You’ve got to be engaged before you can engage [others],” Millon-Underwood says. “You’re not there just to present a program. You’re there because you care.” She encourages nurses to structure cancer awareness presentations as participatory dialogs rather than one-way lectures, and to stay after group meetings so individuals can approach with questions they may be afraid to ask in front of everyone.
Opening Doors
Personal stories from the community can be powerful dialog openers. Cancer awareness increased substantially on the Fond du Lac Reservation after the community began to participate in the American Cancer Society’s Relay For Life, an annual overnight event that brings people together to celebrate cancer survivorship and raise money for ACS research and programs.
For More Information In addition to the Intercultural Cancer Council, here are some other online resources where nurses can learn more about reducing minority cancer disparities and providing culturally competent cancer care: Native American Cancer Research http://natamcancer.org Asian American Network for Cancer Awareness, Research and Training www.aancart.org Centers for Disease Control and Prevention, Cancer Disparities Page www.cdc.gov/cancer/healthdisparities/ National Cancer Institute Health Disparities Page www.cancer.gov/cancertopics/types/disparities American Cancer Society www.cancer.org
Six years ago, more than two dozen people from the reservation participated in Relay For Life for the first time, walking or running laps to raise funds. Others donated money for luminaria (small lanterns made by placing votive candles in paper bags and weighing them down with sand) to honor loved ones and friends who had experienced cancer.
“It was amazing to walk that path of lighted luminaria. It opened the door so people could start talking about [cancer],” Finifrock says. Today more than 100 Fond du Lac community members take part in the event.
Since then, Finifrock and her public health nursing team have expanded their cancer control activities on the reservation. Through its CDC grant, the reservation created the Wiidookaage Cancer Program. (Wiidookaage is the Ojibwe word for “they help each other.”) The program includes a wide variety of cancer education, screening and outreach activities, with a focus on one-on-one and small-group interventions developed by health professionals who are well known and trusted in the community.
Now Fond du Lac is advising the American Cancer Society on its revision of the national Circle of Life program, which is designed to decrease breast cancer incidence and mortality rates among Native American women through culturally sensitive early detection and screening strategies. The revision, based on the successful programs developed by the Fond du Lac reservation, also addresses other types of cancer in Native communities.
But early diagnosis can only help so much when so many barriers to treatment still remain. For many American Indians and Alaska Natives, obtaining access to the health care system is complicated, and the Indian Health Service suffers from a lack of funding.
“If I had to go through my tribe to get health care after a diagnosis of cancer, I’d first have to move back to Oklahoma and wait six months to establish residency,” says Linda Burhansstipanov, MSPH, DrPH, CHES, executive director of Native American Cancer Research and a member of the Cherokee Nation. “Then I’d have to get on a referral list.” She estimates that it could take as long as 18 months to get treatment under that scenario.
Access to anti-nausea and pain medications is limited, too, and sometimes patients don’t get any information about how to take the medications. A large percentage of patients in NACR’s database report unmanaged cancer pain.
These color-coded reference cards, developed by nurses at University of Texas M.D. Anderson Cancer Center, help palliative care nurses provide culturally competent spiritual care to cancer patients at the end of life.
Cultural barriers can also contribute to pain management disparities in AI/AN patients. For example, some Indian patients may have completely different ways of thinking about, describing and dealing with pain than their non-Indian health care providers. When doctor and patient aren’t on the same wavelength, communication becomes difficult, if not impossible.
“We don’t [like to talk about our pain],” Burhansstipanov says. “Indian patients feel they’re supposed to show stoicism.”
These cultural communication breakdowns can be a problem for other racial and ethnic minority populations as well. In some cultures, a patient may be reluctant to complain about pain because it might imply disrespect toward the health care provider, says Guadalupe Palos, RN, LSMW, DrPH, an oncology nurse and assistant professor at University of Texas M.D. Anderson Cancer Center in Houston, who has conducted cross-cultural research on cancer pain and symptom management.
Spiritually Competent Care
Nurses can also play an important role in providing culturally and spiritually competent care to minority cancer patients in the hospital setting. Nurses in the palliative care unit at M.D. Anderson Cancer Center, for instance, work with hospital administrators to accommodate patients’ cultural celebrations, such as quinceaneras, and honor religious observances, such as Ramadan.
Cancer researcher Jennifer Wenzel, PhD, RN, CCM
Earlier this year, a team of four palliative care nurses at M.D. Anderson, led by Teresa Smith, RN, MS, NP-C, CHPN, developed a set of color-coded reference cards to help nurses and nursing assistants in the medical center’s acute palliative care unit understand patients’ diverse religious and spiritual traditions, especially those involving death and dying. Because about 40% of patients on this unit are at the end of life, preparing patients and their families for death is a daily reality.
Years ago, the prevailing perception was that half of the medical center’s patients were Baptist and the other half were Catholic, Smith explains. But patients now come from all over the world. “I can count on one hand the number of patients I had who were Baptist or Catholic,” she says.
Smith began researching end-of-life spiritual practices for her master’s degree, and the cards developed from there, with input from community religious leaders. Each card covers a different religion, from Hinduism and Islam to Coptic Christianity, and includes details about that faith’s end-of-life rituals. Some Hindus, for instance, tie the dying person’s toes together with colored threads, which nurses should not cut or remove. Some members of the Buddhist faith may want the body left undisturbed for hours after their loved one has died, so they can chant and pray for the deceased person’s soul.
Nurses who lack understanding of a dying patient’s cultural and spiritual needs at this difficult time can make that person’s death an even more traumatic experience for his or her family members. Smith recalls one Hindu family who were deeply upset because a nurse read the 23rd Psalm to their dying family member. The nurse was only trying to help, but the good intentions didn’t erase the family’s pain.
Creating Support Systems
Research is still another area in which nurses can make significant contributions toward closing the gap of unequal cancer outcomes. There is a tremendous need for more minority nurse scientists who can join the ranks of those who are already investigating the causes of cancer disparities—including biological, genetic, socioeconomic, cultural and health care access issues—in order to develop interventions that will improve care for at-risk and vulnerable populations.
Meet the Intercultural Cancer Council Not long after the terms “health disparities” and “culturally competent care” came into the national vocabulary in the 1980s, a group of health care leaders formed the Intercultural Cancer Council (ICC) to focus attention on the disproportionate burden of cancer among racial and ethnic minorities and medically underserved populations in the United States and its territories. Today the ICC, based at the Baylor College of Medicine in Houston, promotes policies, programs, partnerships and research to eliminate cancer disparities. It also offers many resources to help nurses and other health care professionals provide culturally competent cancer care. These include publications such as the Cultural Competence in Cancer Care pocket guide for health care professionals and a series of fact sheets about cancer disparities in various minority populations. In addition, the council—which includes 3,000 individual and organizational members—provides funding for grassroots projects through its Voices of the Community program. The ICC also holds a biennial symposium attended by more than 1,000 people, making it one of the largest national conferences focusing solely on addressing minority health disparities. While the council’s focus is on cancer, its work has ramifications throughout the health care spectrum. According to ICC executive director Jay Silver, “If we can address disparities in cancer, it will trickle over to [other disparity areas, such as chronic diseases].” For more information about resources available from the International Cancer Council, visit http://iccnetwork.org.Many minority cancer caregivers are under severe financial and psychological stress.
For example, Jennifer Wenzel, PhD, RN, CCM, assistant professor at Johns Hopkins University School of Nursing in Baltimore, is currently conducting a mentored research study called “Developing Cancer Navigation Support for Rural African American Elders.” The five-year pilot study, funded by the American Cancer Society, the Robert Wood Johnson Foundation and the National Institute for Nursing Research, will test a community health worker/RN-led intervention designed to help older African American cancer patients in rural Virginia overcome barriers to obtaining quality care and accessing available support services.
Initial focus groups examined cancer survivors’ experiences with navigating diagnosis and treatment, including financial issues and strategies for support. The study is now recruiting African American elders undergoing cancer treatment and asking each of them to identify one support person/caregiver, such as a family member or friend. Community health workers will be trained to provide these caregivers with education and support to help them feel better equipped to deal with the challenges of their role.
This approach is innovative because it focuses not only on the patients but on their caregivers, too. “The health care system places a lot of burden on the person providing support for the patient,” Wenzel says. “The closer that person is to the patient, the harder the situation can be for helping [the patient make it] through cancer treatment.”
The study will look at stress measures and economic and social outcomes. In addition, half of the patient/caregiver pairs will be in a control group that will get survivorship support once cancer treatment is finished.
Palos, too, has conducted research on the impact of cancer on the caregivers of minority and medically underserved patients. Many of these caregivers are under severe financial stress, she says. Often they’re forced to choose which prescriptions to fill when co-pays outstrip their available cash. Psychological burdens take a toll, too, Palos adds. Many caregivers show symptoms of depression but avoid using the word. “They say, ‘I’m not [the one who’s] sick. I shouldn’t be depressed.'”
She has found many similarities across cultural groups in her research, such as the importance of spirituality and the commitment of family members to care for their loved ones going through cancer treatment. Understanding cultural differences is important, too, but Palos cautions nurses not to categorize or stereotype people on the basis of race, ethnicity, culture, religion or other factors. Cultural competence goes beyond broad categories and should include sensitivity to people’s individual values and circumstances, she emphasizes.
Underwood agrees that cancer care providers must never lose sight of the patient as a unique, individual human being. “Sometimes we can get so focused on the machines and monitors, we don’t see the person,” she says.
Twenty years ago, when a landmark American Cancer Society-funded study was released showing that poor people died needlessly from cancer, Cassandra Middleton, a low-income cancer patient, said the doctors who treated her for osteosarcoma of the leg made her feel unimportant because she was poor. At the news conference announcing the study’s results, Middleton told reporters: “They made me feel poor. I know I am, but they made me feel like I am.”
Those words haunt Underwood to this day. She says nurses should ask themselves: “Could that ever have been me?”
Imagine for a moment that you are a patient in a hospital that is unable to meet your special dietary needs. What are you going to do? Would you sign out against medical advice and go to another health care facility that can accommodate your requirements, even if its medical care is not known as the best?
The health care profession, like any other profession, has been forced to adopt customer-oriented service models. Logically, the best customer service model is to provide whatever is necessary to please every customer. In reality, of course, this model presents many challenges within the health care environment because of the many restrictions and contingencies, such as time, hospital policies, patient privacy and legal factors.
One of the biggest “customer service” challenges for nurses and other care providers is being able to meet the unique needs of patients from a wide variety of cultural, ethnic and religious backgrounds. Applying the adopted customer-oriented model within the context of nursing requires advanced assessment and validation skills whenever caring for our “customers” (patients). With this notion in mind, care providers are expected to be sensitive, open, flexible and able to meet these unique “customer” needs as appropriately as possible and at all times. Remember, cultural needs are not a luxury; they are a necessity and a part of the basic patient’s bill of rights.
Performing dietary assessments is one key area where nurses must develop cultural competency skills. Being knowledgeable about the dietary needs of different cultures and religions—including preferences, customs and restrictions—and how they may impact a patient’s care plan is essential to providing customer-oriented patient care. The following recommendations for conducting a dietary culturalassessment can guide nurses in reaching the desirable level of cultural sensitivity.
The art of asking the right questions—rather than making assumptions based on preconceived notions or stereotypes about various cultural, ethnic or religious groups—is the key to conducting a culturally competent dietary assessment. Here are some considerations to keep in mind.
Remember that each patient is a unique individual. Just because a certain culture, ethnicity or religion has dietary traditions or guidelines, that doesn’t necessarily mean that every person who is a member of that group adheres to them. Nurses must determine whether the patient follows his/her cultural guidelines, and if so, to what extent. E.g., does he/she follow the guidelines strictly or liberally? When dealing with immigrant populations, special attention must be paid to issues such as length of time the person has been living in the United States, whether the person is first or second generation, and degree of assimilation into the American and/or other cultures.
Understand the significance of patients’ personal food habits and preferences in relation to cultural norms. For example, just as buttering the bread is an essential habit for Americans, so is cooking with soy sauce—which is high in sodium—in many Asian cultures. Asking Asian renal or heart patients not to use soy sauce in cooking is like asking Americans not to butter their bread. However, asking them to switch from regular soy sauce to a low-sodium brand of soy sauce can decrease their total salt intake by half.
When asking about foods the patient eats, keep in mind that patients who are recent immigrants to the U.S. may not be familiar with American food names or dishes. This problem can be solved by using pictures of foods. I cite this example based on my own personal experience: When I first emigrated to the America from Egypt, I felt no need to learn the American names of food until I had to study them in order to pass my NCLEX-RN® examination!
Investigate whether the patient’s dietary restriction is a cultural norm, a personal preference or a religious mandate. This is a vital element when serving meals and different food items. For example: for Muslims, who religiously are not allowed to eat pork or any part of the pig cannot eat from any dish or food utensils used or touched pork and pork products. It is considered a contaminated item and they expect to eat from a new clean dish and utensils that are completely free from any pork or pig traces. This restriction is true for Muslims as well as other faiths such as Judaism, Hinduism, and vegetarians.
Being very specific when asking about a main belief system such as Christianity. This is not enough; investigate more about the uniqueness within this belief system such as Seven Day Adventist, Mormon, Jehovah’s Witness, etc. For Example; an insulin diabetic patient needs few snacks per day, which is quiet normal to many Christians. For some Seven Day Adventist believers; they are dominantly pure vegetarians, it may be more appropriate for the care provider to suggest dividing the three main meals into five or six small ones rather than suggesting eating snacks between meals. Eating between meals is not a favorable habit for some Seven Day Adventist believers.
Inquiring about special habits or religious practices desired to be performed before/after a meal and/or any food item. Facilitating such desires or practices can positively impact on the level of the patient’s compliance with the prescribed plan of care including any dietary restrictions and enhance health recovery.
Folk Practitioners or Corandero Practices
Asking about the prescribed pharmacological/herbal treatments and visits to the folk practitioners need to be an essential part of our assessments. Being aware of the existing combination is a safety issue for both the patient and the care providers. In fact, we need to acknowledge the hidden competition of the Folk Practitioners existence in almost every culture, including the US. He/she is an experienced person in prescribing effective herbal treatments, home remedies, dietary management, etc. that are easy to follow and are quite inexpensive. The folk practitioner has almost a treatment for every illness, sickness, and/or all different kinds of health problems. Their repeated home visits for the sick are one of their key strategies for gaining great success among the poor, elderly, lonely, and the disabled population.
For example, physicians prescribe expensive nitroglycerin sublingual tablets for Anginal pain that usually expires within 6 month contrasting the Corandero/Folk Practitioners who prescribe peppermint oil that never expires and costs only a few dollars. Applying a few peppermint oil drops in the mouth has a very close vasodilatation effect on the body. Of course the elderly, no insurance, and limited income populations will select the peppermint regime especially if it can manage their condition effectively. Another factor for the folk practitioner’s success is teaching their patients effective complementary dietary practices such as drinking very light tea with plenty of natural mint leaves. The constant effect of the mint leaves on the blood vessels may easily keep some patient populations free from chest pain.
Whenever discovering the mix of the non-traditional and pharmacological medications, that are widely spread lately, it is very serious to ask the patients to continue or stop taking this combination. Especially if we do not know that much about these practices for the following reasons:
Keeping in mind that the patient has already made a conscious decision to take such therapy or combination of therapies.
What is being used may be a placebo to sooth the emotional status with no medical significant effect.
The patient may already stop taking the traditional pharmacological medications and is currently only using something that has a very similar effect to the prescribed pharmacological medication.
The patient is combining both therapies because one of them is not enough or not effective for the current health condition.
The patient is experiencing current side effect of one or both therapies without realizing the significance of them.
Conducting further physical and psychological assessment evaluating the effect of each therapy on the current health condition is a must before altering or stopping any of these therapies. Logically and scientifically, if assessment reveals a healthy condition, regardless of what is being used currently, it means that it must be working right for that patient or illness and why not keeping it and wisely ask for more frequent assessment visits as needed.
The best approach in similar cases is to continue dietary/herbal cultural assessment focusing on the following issues to reach a safe, sound, and legal decision:
the current use, action, side effects, and the length of use.
any possible addiction effect whether physical or emotional, and assess the current addiction signs and/or symptoms if they exist.
the current combining: prescribed pharmacological medication, herbal, and the folk treatment.
the current health condition while using or not using this combination.
Because there is no equivalent of FDA approval for most of these folk remedies, ask the patients for any documents or sources of information to gain in depth of information for any unfamiliar herbs, un-known therapies, and/or non-traditional ones. If nothing is available in English, there are many herbal and non-traditional books available in the public libraries, different bookstores, and university’s libraries that teach cross cultural programs. Internet searches may also be performed to reach countless English websites. Also, we need to accept that the patient is a source of such information whether documented or not. He/she is the one who knows most about these therapies and why he/she decided to try it/them.
Editor’s Note: Minority Nurse’s cultural competence expert, Gihan ElGindy, RN, MSN, is an internationally recognized authority on cross-cultural issues in nursing. Her advice column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace.
