In early December 2021, I was seeing a physical therapist for a shoulder injury. During one of my visits, the therapist was alternating between me and another patient on an adjacent bed, who had a knee replacement. While the therapist worked on the other patient’s leg, stretching it and bending the knee, I eavesdropped on their conversation.
The patient was in pain, anxious to complete the hard part of the therapy. The therapist was encouraging him to keep working. At one point the patient expressed a desire to quit. The therapist responded “Te queda una semanita más.” This translates to “You have a short week left.” The patient agreed to continue.
By adding the suffix “ita” to the word “semana,” – or week – the therapist offered the patient a perspective on how much therapy remained in a way that sounded shorter, even though it was still a full week.
This ability to minimize or exaggerate a situation by simply adding a suffix is one feature of the Spanish language that could contribute to a striking resilience in health that researchers have documented in Hispanic populations in the United States, called the “Hispanic Paradox.”
As a Hispanic quantitative psychologist, I have been involved in research on stress and cardiovascular health at the University of Miami since 1988. More recently, I joined the Hispanic Community Health Study/Study of Latinos as an investigator. This observational study of over 16,000 adults documents the health of Hispanics of various backgrounds in four urban communities in the U.S.
Stress also contributes to heart disease. How people react to that stress is important, too. The extent to which our language facilitates how we process our emotions in response to stress may therefore be important in heart disease. For that reason, the Spanish language may offer an advantage. Having lived a bilingual life, I believe this to be true.
Family ties alone can’t explain the Hispanic Paradox
I became intrigued by this phenomenon when I joined the Hispanic Community Health Study in 2008. My first attempt at finding an explanation for the Hispanic Paradox led me to investigate whether the family unit might offer some protection against early life stress.
In that work, I estimated the prevalence of adverse childhood experiences in Hispanics in the U.S. If the family was a source of resilience, I expected to find low rates of experiences of abuse, neglect or family dysfunction. But to my surprise, the prevalence of these adverse events was actually quite high in those populations. In fact, 77% of the target population reported experiencing at least one adverse childhood event, and about 29% reported experiencing four or more before the age of 18.
That led me to the realization that the source of the resilience seen in the Hispanic Paradox did not necessarily come from the safety net of family.
Exploring how culture could contribute
I next turned my attention to other cultural resources such as social support and optimism, factors that may buffer the impact of stress.
Is the Hispanic culture more optimistic than the American culture? Having an optimistic view can help people think about stress as being temporary and manageable. Optimism can make a person feel they can cope with stress.
I came across a paper on the positivity of human language. The researchers had developed a “happy index” that they applied to measure the number of positive words in a variety of sources from several different languages. They analyzed books, newspapers, music lyrics and tweets, for instance.
A figure in the paper showed the distribution of the happy index across sources and languages. The result was startling. The sources with the highest happy index ratings were those in Spanish!
In other words, the rich and positive emotion lexicon of the Spanish language may not only influence culture over time, but also influence our emotional reaction to stress.
The contribution of verbs
However, it may not only be the positive words that are contributing to better cardiovascular health in Hispanic populations. There are other features of the language that facilitate emotional expression.
Take, for example, the two forms of the verb “to be.” In English, we simply “are.” But in Spanish, we can be a certain way temporarily – “estar” – or more permanently, “ser.” This comes in handy when considering negative situations. In English I could be overweight. In Spanish I can be permanently overweight, which translates to “ser gorda,” or I could be temporarily overweight, or “estar gorda.” The latter is transient and entertains the possibility of change, which can itself encourage motivation towards change.
Spanish is one romance language that makes use of the subjunctive form of verbs. The subjunctive expresses hypothetical situations, wishes and possibilities. For instance, consider the “magical realism” of the Colombian author Gabriel García Márquez. His use of the subjunctive facilitated the possibility of alternative realities.
The Spanish language’s ability to minimize and exaggerate by the simple addition of a suffix also increases the range of emotions and perceptions. This is how the therapist in the example helped his patient persevere through a difficult phase of therapy.
While English is the language of science – precise and succinct – my hunch is that the flowery nature of Spanish contributes to a culture that supports emotional expression. In doing so, it can help its speakers manage the responses to stress.
Crooks has published a paper, titled “The Impact of COVID-19 Among Black Girls: A Social-Ecological Perspective,” in the Journal of Pediatric Psychology, reporting on the findings of a qualitative study that featured interviews with 25 Black girls—ages 9 to 18—from December 2020 to April 2021. Most participants reported significant psychological and physical consequences, including depression and anxiety, disrupted eating, distorted body image, and changes in self-esteem.
“Black girls are a very vulnerable and unprotected population, especially within the context of COVID,” Crooks says. “I thought it was a really critical question to be asking youth: How has this impacted their perceptions of self?”
Black girls are particularly vulnerable because they enter puberty and develop secondary sex characteristics earlier than their non-Black peers, according to the paper, causing them to suffer from “adultification” and “sexualization by society.” This can lead to elevated sexual and mental health risks.
Crooks found that only two of the girls in the study received any formal sexual education during the pandemic, as schools opted to delay teaching sex education during online learning due to the sensitive nature of the topic.
“Missing such a critical component of education was alarming to me,” she says. “This is a critical period in their life. Just because the world stops, doesn’t mean their bodies stop growing and evolving.”
Social media also played an outsized role in the girls’ lives as they found themselves isolated from peers during quarantine. Some girls struggled with body image issues and eating disorders, Crooks says.
“They were sitting in their houses watching TV, or they were on social media sites like Instagram or Tik Tok, so they were constantly exposed to overly-sexualized, unrealistic expectations for what their bodies are supposed to look like,” Crooks says.
Conversely, a majority of the participants said the isolation and reduction in peer interactions allowed them to engage in emotional healing and self-discovery, independent from peer pressure.
The pandemic also intersected with the Black Lives Matters movement. As the participants increasingly turned to media in lieu of social interactions, they saw mistreatment of Black people by police, including the murders of Breonna Taylor and George Floyd, nationally broadcasted. These messages led to mixed feelings among the participants.
“A lot of what the girls talked about was feeling empowered to be Black and having a sense of pride within their identities,” Crooks says. “On the other hand, there was fear that came with color of their skin – fear of being harmed themselves, or their fathers, brothers or other family members being hurt. There was this constant fear and threat to Black families.”
Crooks says her research shows the need for more school-based programming to bridge the gap in sexual health education in schools, as well as the need for family interventions to instill protective strategies in Black girls to help them be prepared to handle threatening situations.
After showering, applying deodorant twice, and cranking up her car’s air conditioning against the summer heat (“I will not be the sweaty, smelly fat girl,” she thinks), Eva arrives at the doctor’s office ready to get to the bottom of what ails her: a newly swollen, tender abdomen, growing breathlessness, and debilitating fatigue.
Given her previous interactions with healthcare providers, Eva practices what she’ll say when she reaches the clinic: “I know I am fat. But this is not because I am fat.”
But clinic staff presume she has diabetes and hypertension. They raise their eyebrows when she steps on the scale. And the waiting room chairs are as tight as the nurse practitioner’s smile and her degrading use of the word we.
As in, “Have we maybe been eating our feelings? Your BMI is 39.6. We don’t get to that size on accident.”
“I speak about weight bias as an actual factor that furthers these patients’ disease processes. Healthcare providers need to recognize that their weight bias actually hurts their patients.”
“We often talk about contributors to someone’s obesity—genetic factors, emotional factors, and personal factors,” explained University of Virginia DNP student Habibah Williams, NP, MSN, AGACNP-BC, the lead clinician at Virginia State University’s Student Health and a nurse practitioner who often treats patients with weight issues, “but I speak about weight bias as an actual factor that furthers these patients’ disease processes. Healthcare providers need to recognize that their weight bias actually hurts their patients.”
For her doctoral scholarly project, Williams created a seven-week intervention to educate healthcare staff—”from the physicians to nurses to receptionists”—to affect awareness and change. She’s deployed and is currently testing “We Matter” among 20 clinic staff to determine its impact. In addition to the intervention’s educational and self-assessment components, Williams, with University of Central Florida nurse and PhD student Aislinn Woody, also created a unique fictional narrative—Eva’s story, told in the first person—to build consciousness of the experiences obese and overweight patients face.
“Bias is slick and sneaky.”
After the seven-week intervention is administered, Williams will assess participants’ knowledge and weight biases. Her ultimate hope is to scale the intervention up so that, like other routinely certified healthcare competencies, such awareness is repeatedly built among those whose job it is to provide compassionate, non-discriminatory health care without regard to a patient’s weight status.
In mid-November, Williams and Woody earned the American Association of Colleges of Nursing’s 2021 “PhD-DNP Collaboration Excellence Award” for their work. The two will present the intervention—“Evaluation of an Educational Intervention to Effect Obesity Bias”—and their findings at AACN Doctoral Education Conference in Naples, Fla., in January 2022.
Williams is the first UVA student to earn the competitive national AACN collaboration award, which is bestowed annually and comes with a cash prize.
“DNPs are charged with identifying the best evidence, folding it into practice change, and improving outcomes,” said Beth Quatrara, assistant professor and DNP program director, “and Habibah is following the DNP path. We are incredibly proud of her work to trial strategies to reduce obesity bias with the goal of removing roadblocks so that all obese patients can receive compassionate care that enhances their health.”
Williams hopes to build healthcare staffers’ awareness and ownership of weight bias—and to affirm that living with obesity doesn’t reflect a personal moral failing. She also firmly believes biases can be intentionally unlearned.
“Bias is slick and sneaky,” she said. “Many of us say we don’t have weight bias, but in many cases, we’re not aware that it’s going on. And non-overweight people don’t understand just how much the person with obesity internalizes the behaviors, which has a snowball effect on their weight journey.”
In percentage terms, Asian Americans are the fastest-growing U.S. racial group for the past three censuses, yet data aggregation obscure distinctions within subgroups of the more than 24 million Asians living in the United States. The JNCI commentary illustrates the harmful impacts this is having on Asian American communities.
Chen said the neglect of Asian American cancer inequities stems from multiple factors. They include historical prejudices against Asian Americans and the myth of Asian Americans as the model healthy minority, compounded by language and cultural barriers as well as racism.
“Asian Americans are unique as the first U.S. population to experience cancer as the leading cause of death,” said Chen. “Bigotry against Asian Americans, pervasive since the 19th century, but especially during the COVID-19 pandemic, is only exacerbating the cancer disparities that are costing Asian Americans their lives.”
High rates of certain cancers in Asian Americans
The authors cite a disproportionate rate of certain cancers affecting Asian Americans including:
Cancers due to infectious origin such as the human papillomavirus (HPV). For example, Vietnamese American women experience the highest U.S rates of cervical cancer.
High rates of liver cancer caused by chronic hepatitis B virus (HBV) infection rates in Asian and Southeast Asian Americans, including Hmong Americans.
Nasopharyngeal cancers, occurring in the upper part of the throat behind the nose, affecting Chinese Americans at high rates.
Stomach cancers, which have the highest rates among Korean Americans.
Lung cancer among never-smokers that disproportionately affects Asian American women at a rate of more than twice that of non-Hispanic white women.
The authors note an “infinitesimal proportion” of the National Institutes of Health (NIH) budget funds Asian American research even though the population is experiencing the highest percentage increases of any U.S. racial population for the past three decades. Between 1992 and 2018, only 0.17% of the total budget of the NIH funded research on Asian Americans. A portfolio analysis of grants funded by the National Cancer Institute’s Division of Cancer Control and Population Sciences showed a very limited number of studies focused on Asian Americans, with none at the time addressing the causes of cancer.
Asian Americans are also underrepresented in clinical trials. According to the commentary, only 1% of clinical trials emphasize racial and ethnic minority participation as a primary focus. Only 5 such trials focus on Asian Americans as compared with 83 for African Americans and 32 for Hispanics.
“Classifying Black Americans and Hispanic Americans as underrepresented minorities in clinical trials is helpful, but it is regrettable that our national policy excludes designating Asian Americans as underrepresented minorities, as documented by data in this commentary,” said Chen. “There is a myth that Asian Americans don’t get cancer, but that is far from the truth.”
What needs to happen to equalize cancer inequities
To rectify inequities, the authors recommend a call to action:
Disaggregate data for Asian American subgroups (Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam). The commentary calls for a separate focus on Native Hawaiians and other Pacific Islanders.
Assess the impact of lived experiences and historical trauma. The authors state that culturally competent oncology care is required to improve access to health insurance/health care. They assert it is also needed to address language and cultural barriers that prevent Asian Americans from getting the medical help they need.
Listen to community voices. Rich diversity and unique experiences within Asian American communities are best understood and appreciated by listening to and partnering with patients and community advocates. Research must ensure community representation, buy-in and engagement.
“It is also important to focus on the impact of racism on cancer disparities and prioritize funding resources. Otherwise, we will not take the necessary steps forward for achieving health equity for Asian Americans,” Chen added.
Polly Sheppard has been on a mission since surviving the 2015 Emmanuel AME church massacre in South Carolina. If the killer spared the retired prison nurse in the hope that she would spread his message of gun-toting white supremacy, though, he must be grievously disappointed.In fact, the indefatigable septuagenarian has been delivering her own messages – and like many nurses, she is a very good communicator.
In the years following the notorious shooting, Sheppard crisscrossed the country to speak against gun violence. Then, once she accumulated enough speaker fees she poured her earnings into another passion and established her own Scholarship Foundation to support nursing students in Charleston. Now, as the seventh anniversary of the chilling church murders approaches, Sheppard is focusing on another initiative to reduce future bloodshed: this week she sent an eloquent appeal to South Carolina’s senate urging them to finally pass a hate crimes law.
“Being there, laying under the table with this gun to my head couldn’t be anything but hate.”
Like most hate crime laws, the proposed SC bill would add up to five years to prison sentences for any homicide or assault motivated by hatred of the victim’s race, sexual orientation, gender, religion, or disability. Aside from Wyoming, South Carolina is the only state that has failed to pass some form of law against hate crimes, but the current bill has faced a steep uphill battle. At present eight SC senators are determined to see it expire… which is a painful irony as Emmanuel pastor Clementa Pinckney, a victim of the massacre, had been a senator himself. If the bill ends up on the table as a code blue, though, it won’t be due to inactivity on Sheppard’s part.
In a powerful two-minute video viewed by the senate on April 27, Sheppard addressed the recalcitrant senators. She mused on other ironies, asking some acute questions: “I really can’t understand them standing against a [hate] law, but they can pass a law to kill somebody a firing squad. They can take that to the floor, but they can’t bring the hate crime law to the floor… What’s the problem?” Sheppard also wondered “why South Carolina has to be the last, almost the last to get a hate crime law? Because we didn’t have it. We had to go to the federal government for (the AME killer) to be charged with a hate crime. It makes no sense.”
Sheppard reminded her audience: “Eight members of the South Carolina Senate are giving a safe haven to hate. Every time you look at senator Pinckney’s photograph, you should be reminded that hate killed him.”
Having spent her career “truly on the front lines making a difference,” Gloria McNeal, PhD, MSN, ACNS-BC, FAAN, will receive an AACN Pioneering Spirit Award at the American Association of Critical-Care Nurses (AACN) 2022 National Teaching Institute & Critical Care Exposition in Houston, May 16-18.
McNeal’s award recognizes her efforts to bring healthcare directly to those most in need and introduce telehealth and remote monitoring to critical care. The AACN Pioneering Spirit Award, one of AACN’s Visionary Leadership awards, recognizes significant contributions that influence progressive and critical care nursing and relate to the association’s mission, vision and values.
The health equity trailblazer is associate vice president for community affairs in health at National University headquartered in San Diego, the flagship institution of the National University System, which comprises three nonprofit universities serving more than 45,000 students nationwide, both on-site and online. In this role, she leads the university’s comprehensive community and global outreach strategies efforts related to healthcare services and education. She previously served as dean for the university’s School of Health and Human Services for six years.
“Dr. McNeal has a passion for healthcare and serving those who are underserved,” said AACN President Beth Wathen. “Her community service efforts and nurse-led clinic model sponsored by the university bring healthcare directly to those most in need. She is truly on the front lines making a difference.”
At National University, McNeal has worked with community-based organizations to establish nurse-managed clinics at churches, community centers and shelters in South Los Angeles. The initiative was expanded to offer telehealth services for patient-provider interactions that do not require in-person visits.
Among her academic appointments, she has held the administrative positions of director, assistant dean, associate dean, dean and founding dean at various research-intensive public and private universities. As dean, McNeal has led several academic nursing programs on their journey to acquire national accreditation for both graduate and undergraduate curricula of study.
Her interprofessional, nurse-led and other projects, totaling more than $12 million in extramural funding, have been continuously funded for over 20 years. She currently serves as project director for the Health Resources and Services Administration Nurse Education, Practice, Quality and Retention (NEPQR) Simulation Education Training (SET) Program, a highly competitive grant-funded project initially awarded to a cohort of only five nursing programs nationwide. With this latest project, she is spearheading the use of virtual reality and immersive technologies to better prepare nursing students to practice in real-world settings through simulation.
Developing the protocols of care, she helped lead the transition of critical care nursing practice beyond the traditional walls of the intensive care unit, and was among the first to publish work on the remote monitoring and electronic transmission of ambulatory electrocardiographic data, revolutionizing the manner by which critical care nurses could remotely monitor their patients.
As a result of her work, she was invited to author “AACN Guide to Acute Care Procedures in the Home,” which describes over 100 complex nursing home-care procedures written in collaboration with 20 nursing expert contributors.
Her nursing career began as a critical care nurse in the U.S. Navy Nurse Corps at Philadelphia Naval Hospital, where she received two medals of commendation and three promotions leading to the rank of Lieutenant.
She obtained her bachelor’s degree from Villanova University Fitzpatrick College of Nursing, where she currently sits on the Board of Consultors, and her master’s degree at University of Pennsylvania (Penn) School of Nursing, later receiving the Outstanding Alumna Award. She returned to Penn for doctoral studies in the Graduate School of Education. For her PhD, which was awarded with meritorious distinction, she investigated the scholarly productivity of minority nurse academicians.
The American Academy of Nursing awarded her the coveted Media Award in 1994, inducted her into the Academy in 2006, and most recently named her a 2020 Edge Runner Award recipient.
She served as an invited co-contributor for the IOM (now National Academy of Medicine [NAM]) text on “The Future of Nursing: Leading Change Advancing Health” and is a featured speaker for the current NAM podcast on “The Future of Nursing 2020-2030,” Episode 2 – Health Equity.