Studying Disparities: How Nursing Schools Cover Minority Populations and Health Care Inequality

Studying Disparities: How Nursing Schools Cover Minority Populations and Health Care Inequality

About 30% of Hispanic Americans and 20% of African Americans don’t have a usual source of health care, but less than 16% of white Americans lack a source.

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For women who have had an abnormal screening mammogram, the length of time before a follow-up test is conducted is twice as long in Asian American, Hispanic, and black women than it is in white women.

It’s no secret that there are racial and ethnic disparities in health care. These statistics, which come from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, highlight a major concern in the field of medicine. Not all patients receive the same level of high quality treatment—or in some cases, receive treatment at all.

This concern is important within nursing schools, because they are tasked with making sure our country’s future nurses fully understand racial disparities and what can be done to address them, says Mary Green, PhD, MN, RN, interim chair of the Dillard University School of Nursing in New Orleans.

Schools must show the latest research and best practices to the next generation of nurses, and take them into communities so they can see firsthand the effects of health inequality, argues Green. “Nurses need to get the broadest experiences they can.”

Learning in the Community

Many nursing schools have mandatory community health courses that expose students to inequalities among groups of people. Nursing students learn about the statistical differences in health care outcomes, and along with that, many of these institutions require nursing students to meet the people behind the statistics.

For example, at the University of Alabama-Birmingham (UAB) School of Nursing, undergraduate students, along with faculty, go into communities in the greater Birmingham area that have historically had less access to health care, says Linda Moneyham, PhD, RN, FAAN, senior associate dean for academic affairs at UAB. There, nursing students learn how to master their clinical work while partnering with neighbor representatives who are interested in improving the community’s health, she adds.

“These tend to be communities that are lower income, have high minority populations, and have a lot of health needs,” she says. “In fact, Alabama is often the epicenter for some of the major health problems the country faces.”

Moneyham explains that Alabama ranks near the top for prevalence of heart disease, obesity, and HIV—and minorities are disproportionately affected. “We have to focus on these populations because they are the populations nursing students are going to be caring for,” says Moneyham.

At the University of Washington School of Nursing in Seattle, there is a similar approach. “We have for years had a required course on community health nursing that addresses health disparities and inequities,” says C. June Strickland, PhD, RN, associate professor, psychosocial and community health nursing, at the school. “It’s [often] the very first course that students take when they come into our program to study,” she says. “Essentially, it focuses on health disparities, equities, and social justice.”

“In addition, we have clinical sites in multicultural environments that include American Indian, African American, Latino, and Asian populations,” explains Strickland.

“When faculty members take students to those clinical sites, they get a cultural immersion and opportunity to understand some of the issues people are facing. For instance, with Native people, some of what we experience is the impact of colonialization that continues on in our community.”

The School of Nursing also attracts other students that plan to work in related fields, such as social work, public health, and psychology, says Strickland. “I teach a core course in assessment and that course also draws students from all over campus, because certainly these issues come up [in those disciplines].”

There are also graduate level courses that dig deeper into problems associated with inequalities. Deborah Ward, PhD, RN, FAAN, is associate dean for academics at the Betty Irene School of Nursing at the University of California-Davis in Sacramento. “We have a course in health status that all of our masters and PhD students take. That course looks at health status around the world, and it certainly looks at disparities in the US,” says Ward.

“We also have another course called Community Connection. Our masters students in the leadership program take this course where pairs of students work with community agencies,” she continues. Examples of these agencies include the Sacramento Unified School District and the local food bank’s parent-child program to provide support for parents with a variety of special needs. “Students come face to face with the issues that community agencies are working on, which includes the health effects of disparities of all kinds,” says Ward.

For example, one pair of students working with the county health department looked at soft drink vending machines in certain schools. School districts that are strapped for funds—and often in minority neighborhoods—can get money by having vending machines for soft drinks in their schools, Ward explains. “But on the other hand, if you have vending machines in schools that deliver sugary drinks, you’re contributing to the obesity epidemic that places students at all kinds of risk.”

Students who are obese are at great risk for many health problems, such as diabetes, says Ward. So the nursing students learned how school pupils in minority neighborhoods are exposed to factors that contribute to the obesity epidemic.

In this particular course, nursing students wanted to address the question of whether or not it was good for a cash-strapped school system to get immediate money from vending machines, or if it was better to ban the vending machines and have students ingest fewer sugary drinks.

“The students did a sophisticated analysis of the cost and benefits to the community in having soda machines in the school,” says Ward. “Armed with that kind of data, you can come back to your community as a nurse leader and demonstrate the long-term advantages of not having soda machines in a school.” The students learned how to work at system-level changes that are going to help communities make decisions about important health issues in their community, Ward adds.

Filling in Gaps

With upcoming changes in health care laws, there are going to be thousands of people from different communities who are going to be seeking health care services they might not have sought in the past, says Moneyham. In many areas, especially rural areas, nurse practitioners will be called on to help fill in the gap between patients requiring care and available physicians, Moneyham explains. Nursing schools are teaching their students that this is something that can directly help reduce the inequalities that have historically existed in those communities, she adds.

In addition, nursing students will be called on to share information about programs that help disadvantaged patients. For example, there are pharmaceutical companies that may supply medication for patients for minimal charge, particularly if the shelf life of the medicine is short. “Sometimes they’ll distribute those to poorer patients,” says Moneyham, and a nurse can be the link between that patient and the pharmaceutical company.

Avoiding Stereotypes

In order to give quality care to people who are from different cultures and ethnicities, all nurses, including minority nurses, need to learn to overcome misconceptions and even prejudices they may have about the patients they serve, says Moneyham. “For example, one stereotype is that if someone is overweight or they have health problems, they don’t care about themselves, and you can’t help those people because if they wanted to lose weight they could.”

But the nursing school helps students understand that there are often external affairs that affect a person’s health, and health professionals should understand what those factors are in order to effectively help a patient, she says. “We provide the experiences to nursing students to help them walk in the [patient’s] shoes, and try to understand their perspective about their weight problem and their challenges.”

The methods used when approaching people should be appropriate and respectful. If nurses don’t understand someone’s situation, any recommendation will likely not be effective, says Moneyham. She conducts focus groups with women who may be classified as obese, and she finds that many may not see themselves as overweight. Students learn that in these cases, giving lectures on losing weight likely won’t work. “What we need to focus on are things that help these women feel healthier, such as getting enough exercise or watching the types of food they eat,” she argues. “We have to work where the person is ready to work.”

Even then, minority nursing students should learn that individual actions are only a small piece of what impacts health, argues Vicki Hines-Martin, PhD, CNS, RN, FAAN, director of the office of health disparities and community engagement at the University of Louisville School of Nursing. In fact, students are often surprised to learn that social factors outside of a person’s control have a very large influence on their health. These “social determinants of health,” as outlined by the World Health Organization, identify that a person’s health status, access to care, and health outcomes are all influenced by things that are not specifically health-related, says Hines-Martin. Those determinants include economic status, education, and even access to transportation. “If you have people who have lower income, less education, and who live in communities that are less friendly to activity [and exercise], their health by definition is going to be less,” explains Hines-Martin.

“Increasingly, students at both the undergraduate and graduate levels are expected to think critically about the context from which a person comes. And as a result of that, faculty are changing where they do their work clinically, how they do their classroom teaching, and the examples they use to help a nursing student make better decisions about the populations they work with,” says Hines-Martin.

“Not only do we need to teach our nurses what they should be doing directly with the patient, we also need to put them into the context of where that patient comes from. Then we realistically adjust, adapt, or support that person’s ability to maintain whatever wellness they can,” she continues.

At Dillard, nursing students learn to address disparities and overcome their own prejudices by looking at case studies, says Green. She gives the following example of a case study:

Let’s say we have JM, who is a 47-year-old African American male who is currently homeless, jobless, and suffers from schizophrenia, uncontrolled diabetes, and hypertension. Because of the behavior attributed to his mental illness, he may be in and out of jail and perceived as a threat to the community. As nurses, what do we do?

Green explains that nursing students learn how to deal with urgent problems, such as the uncontrolled diabetes, as well as seek out other resources, such as helping to locate a case manager who could help JM access mental services that may be available.

These case studies are then followed up by actually visiting similar neighborhoods. “Going into the community gives a more accurate picture of the racial and ethnic disparities that exist,” says Green.

School Diversity

Understanding disparities can occur with one-on-one teaching, but diversity initiatives should also occur on an administrative, school-wide level, says Strickland. This means having a nursing school that reflects and celebrates racial and ethnic diversity in addition to teaching it. “It’s important to have systems and structures in place that support these behaviors.”

Strickland states that the University of Washington has a diversity council and an office of minority affairs that’s very active. “There is also a diversity council within our School of Nursing, and some of the activities have included working with faculty to design an evaluation so faculty can evaluate how effectively they’re addressing disparities and diversity in their course content,” she says. Strickland adds that the school recently voted to include diversity in their promotion and tenure documentation for faculty.

At UC-Davis, Ward says the first area where the school practices the goal of cultural inclusiveness is with its faculty and staff. “We like to think of what we’re doing as a multi-faceted approach,” she says. “This means cultural inclusiveness, teaching cultural approaches to care, and working with all of our communities to improve care and health.”

At the UAB School of Nursing, Moneyham says that more than 26% of students are minorities. “This is high compared to the national average,” she explains. “A lot of that has to do with where we sit in the Deep South region of the United States.” Moneyham adds that cultural diversity in nursing schools is good because nurses are able to accurately reflect the communities they serve.

When nursing schools cover minority populations and health care inequality effectively, they produce nurses who are more competent at addressing those inequalities. This in turn produces better nurses who are more likely to take a leadership role in helping eliminate disparities, says Hines-Martin. “It is a strategy of engaged scholarship, engaged teaching, and engaged research that has evolved.”

Margarette Burnette is a freelance writer based in Georgia.


Nurses in Hospital Planning, Working with Administration

Nurses in Hospital Planning, Working with Administration

Good nurses are professionals who strive to make a positive impact in their organizations. Some are able to make this impact by working in planning with hospital administrators.

The minority nurse who works in planning is in a pivotal role for making sure patients are safe, says Evelina Echols-Sutton, BSN, RN, nursing director of Women and Children’s Services at Methodist Charlton Medical Center in Dallas, Texas.

These professionals often have leadership titles, such as nurse manager or nurse director. Or they may be in specialty roles, such as nurse statistician and nursing informatics, she says. But one common theme is that they are called on to share ideas with their organization’s leadership.

“They are in those key meetings where decisions are made on the policies that we adopt, the equipment that we eventually bring in to our facility, and the streamlined workflows that will make sure our patients and family are safe,” says Glenda Totten, RN, MSN, CNS, director of nursing services at Kaiser Permanente Los Angeles Medical Center in California.

On an average workday, a nurse who works in planning may interact with the director of pharmacy, information technology, environmental services, human resources, risk management, and legal departments, says Echols-Sutton. “My typical day is probably about four hours of meetings, four hours of office work, and then four hours of follow-up on all these activities.”

Kanoe Allen, RN, MSN-CNS, PHN, ONC, chief nursing offi cer at Hoag Orthopedic Institute in Irvine, California
“Meetings are also a constant variable in my day,” says Sylvia Williams, RN, MSN, director of education and inpatient nursing services at La Rabida Children’s Hospital in Chicago, Illinois. “They range from brainstorming meetings on quality initiatives to troubleshooting staffing concerns. On average, I would say I am in meetings a good five to six hours per day. They are important to keep morale high and ensure everyone works together harmoniously.”

Kanoe Allen, RN, MSN-CNS, PHN, ONC, is chief nursing officer at Hoag Orthopedic Institute in Irvine, California. She says that nurses who work in planning have to juggle meetings with idea generation. “One of the challenges is carving out time to sit quietly and think through the issues and to have time to develop solutions,” says Allen.

Unsurprisingly, nurse leaders are better compensated for their efforts. The median pay for a nurse manager is $77,988, while it’s only $55,447 for a registered nurse, according to

Hospitals in turn get someone who engages in positive relationships within nursing, and with managers, supervisors, staff nurses, and executive leaders, says Totten. “It takes all that to make it work and have a world-class facility.”


Managing Inside and Out

In addition to working with leadership, minority nurses in hospital planning also have to help manage their organizations’ external pressures, says Totten. There are numerous outside factors to consider, such as working to meet the standards established by the Joint Commission. As an example, Totten regularly conferences with a stroke performance improvement committee to help her facility earn a comprehensive designation from the Joint Commission.

“It’s ensuring that for any [stroke] patient that goes to our emergency room, or any that are inpatients, we react immediately. We get the neurology resident in there and get the team in there within seconds,” she says.

Kanoe Allen, RN, MSN-CNS, PHN, ONC, chief nursing offi cer at Hoag Orthopedic Institute in Irvine, California

Totten also works on a nursing quality improvement committee to assess nurse sensitive measures, such as interventions that help prevent falls in the hospital. Her teams are responsible for coming up with tools to communicate with nurses so that they are quickly informed about any relevant changes within the medical facility.

“We plan for our 1,200 or so nurses to make sure that everyone, including the per diem nurses, know what’s coming, what’s changing, how they can get more education, and the kinds of tools they need so that they’re up-to-date with the changes,” explains Totten.

Another planning team is responsible for providing constructive criticism to nurses on meeting patients. This involves communicating the best ways to exhibit caring behaviors, such as pulling up a chair and sitting eyeball to eyeball with those they serve, says Totten.

“It’s evidence-based and proven that you don’t want to stand over [patients]. You want to be as close to them as possible,” she notes. “We’re trying to standardize how we greet our patients when they come in on admission and also while they’re here.”

These issues are important because of the new value-based purchasing environment, says Shawana Burnette, OB-RNC, MSN, CLNC, a nurse manager in High Risk Post Partum and High Risk OB at Carolinas Medical Center in Charlotte, North Carolina.

A portion of reimbursements received from the Centers for Medicare and Medicaid Services will be based on the patient’s value perception of the care they receive, she explains. This means nurses in planning have to encourage their teams to not only help the patient heal, but to also have a good bedside manner.

Another area where nurses who work in planning are called on to help is to find ways to improve infection rates. The Centers for Disease Control and Prevention as well as the Institute for Healthcare Improvement review these rates, and of course, the goal is to have them as low as possible, says Totten. “You have to plan how you can show that you have a stellar place.”

Medical centers also compete with other health care centers in the community. “The consumer is more astute nowadays, and they are open to shop for the best medical facility, best health care facility, and the best insurance,” she notes.

This means nurses who work in planning often need to represent their medical centers to the community. “We have a foundation that does fundraising. In order to help them, I have to go out and speak,” says Echols-Sutton. “You want to talk to those that you serve, and find out what’s important to them.”

Improving Soft Skills, Leveraging Clinical Skills

First, health care is a highly regulated industry. Second, reimbursements are based upon the customers’ perceptions of “soft” skills, explains Allen. “Putting the two together is a change for this industry.”

Fortunately, nurses are usually well-prepared. “Nurses, by their calling, have a set of innate behaviors of putting people and solutions to the front,” says Allen. “It is a team spirit, not an individual-only spirit. That is key to the success of multidisciplinary patient care.”

People come to nursing with a big heart and a desire to help others, and it serves them well in collaborative environments where they have to work together to find the solutions, she adds.

Allen notes that being successful in nurse planning requires emotional intelligence, meaning the ability to understand and have a sense of another person’s views. To achieve success in planning means being a team player, using that emotional intelligence to understand the interplay between various personalities and departments, and working in a collaborative manner to solve regulatory and other issues, she says.

Minority nurses who work in planning can also help bridge multicultural gaps. Multicultural environments are a challenge to blend and the goal is to bring out the best attributes, says Allen.

“We serve patients from many backgrounds and having a diverse staff allows us to better anticipate and understand their cultural needs,” notes Williams.

Soft skills are necessary in higher levels of planning, but practical experience is also important, explains Totten. “One thing you can never take away from a nurse is her clinical skills. It’s handy when you’re working in a clinical setting. The more you move up in your career, [the more] those clinical skills are key.”

It all comes down to ensuring that staff members have the correct resources to care for patients, says Allen. Providing the right resources allows the staff to provide strong patient care. “Staff who do not have to worry about resources and administration support provide great customer service,” she adds.

The Career Path

Minority nurses who want to work with hospital administrators, or who want to be in administration themselves, have multiple options.

“The best thing about the profession of nursing is you can pretty much take any path. You can be in a clinical track and still move up to administration. There is also the education track, nurse practitioner track, and advanced practice nursing,” says Totten. “All these elements can secure you a good position in administration.”

Totten’s own background is as a clinical nurse specialist, but she emphasizes there are many ways to advance.

As a first step, Burnette suggests becoming a bachelor’s-prepared nurse. “They have the four-year preparation that includes handling more professional issues and critical thinking,” she explains. “The classes prepare you to be in a leadership role.”

But you should also have your sights set on earning a master’s degree. “Years of experience on the nursing unit are critical, but I would strongly recommend to anyone that is interested in this path to pursue an advanced degree in nursing,” says Williams.

“Nurses who work in planning need knowledge-based skills like budgeting and financials, experience you don’t necessarily receive on the floor,” she continues. The more educated you are regarding the area you’re going in, the more prepared you will be.


Another important means for having a successful career in hospital planning is to find a mentor who can show you the ropes in a real life environment, notes Williams.

“There are many ups and downs in nursing. There are plenty of wonderful days, and there are days in which nothing seems to go right. Being able to balance the good with the bad is essential to having a long career in nursing,” argues Williams. A good mentor can instill these lessons to their mentees and help them find their way, she adds.

Mentoring is intended to help nurses develop their skills and grow within the nursing profession. “The mentor accomplishes this by sharing their years of experiences—warts and all—to help them see nursing in its true light,” explains Williams.

Mentoring also helps a person explore who they are and how they can achieve more in their career, says Allen. In some cases, it opens doors for opportunity as well. “I have had a mentor who challenges my thoughts and plans, refocuses me when I am at a loss and then cheers me on,” she continues.

Having a mentor can also help nurses develop critical work skills, such as priority setting, stress management, people management, and good communication, says Echols-Sutton. She hasn’t had an “official” mentor, but she has had role models she patterned herself after. Other nurses who aren’t in employee-sponsored mentor programs can do the same, she notes.

“I didn’t have just one person. I tried to learn from everybody, including coworkers, bosses, and even people out in the community,” says Echols-Sutton. “They were available for me to pick their brains.”

Burnette advises nurses to find mentors who are not necessarily in their departments. If you talk to someone who works in another area of the hospital, they can give you a more global view of your organization. It’s important to surround yourself with people who have different perspectives but who are committed to achieving the same goal of providing patients with the best possible health care, she adds.

Whether a nurse joins a formal preceptor program or starts an informal mentoring friendship, anyone who wants to work in planning should reach out to a health care professional with more experience to help them along, argues Totten. “It’s not just enough to sit in your position.”

Working with Administration

Hospital administrators face many challenges from staffing to budgeting, and it is impossible to have a “go alone” mindset, says Williams. That’s why nurses who are in planning are a vital part of the team. Nurses who work with hospital administration report that their careers are fulfilling, and they have a large say in improving their hospitals.

“When you’re working in planning, you’re able to communicate with all the various staff as well as patients. It gives you a love for the ways you can improve the care that’s delivered to patients,” says Williams. “That’s where you can make the biggest impact.”

Helping AAPI Populations Address Health Disparities

Helping AAPI Populations Address Health Disparities

The Asian American and Pacific Islander (AAPI) population is often perceived as being one of the healthiest ethnic groups in the Unites States.   However, contrary to the “model minority” perception, many of the 16.6 million AAPIs in this country are disproportionately affected by certain health issues.  For example:  

  • Laotian, Samoan, and Vietnamese women have the highest cervical cancer rates in the United States.
  • AAPIs represent more than half of chronic Hepatitis B infections (and resulting deaths) in the country.
  • AAPIs in the state of Hawaii have more than twice the rate of diabetes as its White residents.

One of the reasons for such health disparities is likely “linguistic isolation.”  There are more than 100 languages prevalent in AAPI communities, and experts estimate that nearly a quarter of AAPIs live in isolated households, where adults and/or family members over age 14 are not proficient in English.

AAPIs who are linguistically isolated may be less likely to seek help if they have a medical concern. To help reduce these disparities, nurses who serve AAPI communities should know about available multilingual online resources.  Here are two to consider:

1. The Asian American Health Initiative (AAHI)

Based in Montgomery County, Maryland, the AAHI was created to meet the health care needs of its AAPI citizens in a culturally competent manner. The program sponsors a detailed website that provides educational health resources offered in English, Chinese, Hindi, Korean, and Vietnamese. 

Though the organization exists to help address health care needs in Montgomery County, Maryland, the website provides a good source of education for anyone who wants to learn more about health care issues affecting Asian Americans and Pacific Islanders. 

2. Asian Pacific Islander Cancer Education Materials (APICEM) Web Tool

Cancer is the leading cause of death for the AAPI population.  The American Cancer Society provides access to this web tool, which offers information on detection, treatment, pain management, and related topics for a number of different cancers. The materials have been screened to be culturally relevant and are available in several different languages.

Nurses play an important role in helping all patients and their families receive the health care services they need. These resources can assist nurses in addressing those issues that disproportionately affect the AAPI population.

 Margarette Burnette is a freelance writer based in Acworth, Georgia.

Understanding Lupus

Understanding Lupus

May is National Arthritis Awareness Month. There are many forms of arthritis, but one in particular disproportionately affects minority women: lupus.

More than 16,000 Americans will likely develop this autoimmune disease each year, according to the Lupus Foundation. Most of them will be women between the ages of 15 and 45. No one knows what causes lupus, but many experts believe that it involves a combination of genetics, hormones, and an environmental trigger.

Here are three actions you can take this month to help spread awareness of this often-misunderstood disease.

1. Get the facts. Learn how lupus is affecting people in your community. There are four recognized forms of the disease:

  • Systemic Lupus Erythematosus
  • Cutaneous (skin) Lupus Erythematosus
  • Drug-induced Erythematosus
  • Neonatal Lupus

When most people talk about “lupus,” they are usually talking about the most prevalent form, systemic lupus erythematosus, or SLE. It causes pain and swelling across the body.

Lupus occurs three times more often in women of color than in Caucasian women. African Americans have higher reported rates when compared to Hispanics. But of all cases, only 10% of people who have lupus have a close relative with the disease.

If there is a diagnosis for lupus, treatment consists primarily of immunosuppressive drugs such as hydroxychloroquine (Plaquenil) and corticosteroids (prednisone).

Organizations such as the Lupus Foundation and the Arthritis Foundation can provide a wealth of information online. They detail symptoms, describe which population groups are most likely to be diagnosed, and the types of treatments available.

2. Take the Lupus quiz. The website is dedicated to sharing information about this hard-to-diagnose disease. Take its interactive quiz to make sure you can separate fact from fiction when it comes to understanding this disease.

3. Support your local Arthritis Walk. The Arthritis Foundation hosts a nationwide event that raises awareness and money to fight arthritis. Find out if there is an Arthritis Walk in your neighborhood.

 Margarette Burnette is a freelance writer based in Georgia.

Six Facts about Prenatal Alcohol and Drug Use

Six Facts about Prenatal Alcohol and Drug Use






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The National Council on Alcoholism and Drug Dependence (NCADD) has designated May 12 -18, 2013, as NCADD Alcohol & Drug-Related Birth Defects Awareness Week.  It is designed to increase knowledge about the effects of drugs and alcohol in newborn babies.  We want every child to be healthy, so it’s important to understand how illicit substances can affect growth and development.  Here are six facts everyone should know.

  1. Fetal Alcohol Spectrum Disorders (FASDs) are used to describe a range of developmental problems in newborns that are caused by alcoholism or heavy drinking during pregnancy.  They may include behavioral problems and intellectual delays, but also physical issues, such as growth deficiency and changes in facial features.
  2. FASDs are 100% preventable.  If a woman does not drink alcohol during pregnancy, FASDs are not a factor.
  3. In the US, about 20% of pregnant women report that they smoke cigarettes, 18% drink alcohol, and 6% say they’ve used an illicit drug at least once while carrying their pregnancy to term.
  4. Many children who experience prenatal alcohol exposure may not meet the definition of FASDs, but still have neurodevelopment problems and birth defects.
  5. Pregnant women and women of childbearing age can get help if they believe they are suffering with alcoholism or drug use.  The Substance Abuse and Mental Health Services Administration (SAMHSA) has a treatment facility locator or you can contact the NCADD for additional resources.
  6. If you know a child that may have FASD, there are treatment options available.  The parent should ask for a referral to someone who specializes in FASDs, such as a clinical geneticist, developmental pediatrician, or child psychologist.  There is no “cure” for FASD, but some treatment options can reduce some of the effects.  Examples of treatment include behavior and education therapy, parent training, and medication.

Margarette Burnette is a freelance writer based in Acworth, Georgia.
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