Race is a socially constructed concept, and its boundaries frequently shift. Though racial categories have changed over time, a major distinction remains between blacks and whites.1 Race can be regarded as a proxy for class, and health care disparities are the products of social and economic inequality.2 Upon the request of the U.S. Congress, the Institute of Medicine (IOM) formed a committee to evaluate these disparities and provide recommendations concerning how to combat them.3 They released a report showing the depth of racial and ethnic inequalities in American health care in 2002.4
The IOM committee defined health care disparities “as racial or ethnic differences in the quality of health care that are not due to access related factors, clinical needs, preferences, and appropriateness of intervention.”3 They concluded the following:
Racial and ethnic disparities exist in the U.S. health care system.
Disparities are rooted in historic as well as contemporary inequality in social and economic aspects of American lives.
Ethnic discrimination is among historical factors leading to disparities.
There are numerous sources contributing factors, including health systems, utilization managers and health care providers, stereotyping, prejudice, and bias.
Clinical uncertainty amongst health care providers may affect equal health care as well.3
According to the Department of Health and Human Services, health care disparity can be linked with economic, social, and environmental disadvantages.5
Disparities in diabetes care
Many researchers have found racial and ethnic disparities in disease management, including diabetes.6 Other affected conditions include asthma, hepatitis, cancer, and HIV/AIDS.7 Associated with poor patient outcomes, disparities are deemed unacceptable.3 Findings in a majority of these studies show that regardless of cause, minorities’ experiences differ from whites in many disease categories. Most literary reports on diabetic disparities pertain to African Americans; data on Native Americans, Hispanics, and Asian Americans/Pacific Islanders were limited.3
According to Bal, projections estimate that by 2025, there will be about 300 million people with diabetes worldwide, with the biggest increase occurring in the developing countries.8 The effects of unmanaged diabetes can be life threatening. According to the Centers for Disease Control and Prevention (CDC), diabetes is the leading cause of many health problems, such as kidney failure, blindness, lower limb amputations, stroke, and heart disease; it is the seventh-leading cause of death in America.9 Reasons attributed to diabetes disparities include differences in income, barriers to health care (type and lack of insurance), and divergent medical needs. After accounting for these causative factors, racial and ethnic disparities in the delivery of health care still persist.10 The United States has made much progress in establishing fairness and justice in many aspects of its citizens’ lives. A barrier yet to be crossed is health care equity. One major economic effect of health inequality is overuse of urgent care centers or emergency rooms for routine care.11
African Americans have the highest rates of diabetes diagnosis; Hispanics, Asian Americans, and American Indians are affected by diabetes disparities as well.9 Chin et al. evaluated the care received by 1,376 diabetic patients aged 65 years or older. Compared to whites, African Americans’ health perception and quality of care were low; they had fewer physician visits per year than whites, higher rates of emergency visits, and poor health perceptions.6 Although African Americans are less likely to receive certain treatments, they are more likely to receive non-leg-sparing treatment (amputation) than whites.12 In 2005, diabetic blacks were over two times more likely to receive lower extremity amputation than diabetic whites.9 Amongst the elderly, diabetes was almost twice as prevalent in blacks as whites, and the frequency of amputations in blacks was almost four times the number with whites, with 62% of the principal diagnosis for amputation being diabetes.12
Chin et al. indicated that African Americans with diabetes might experience reduced use of the emergency department and improved perception of health if the access to preventive care is improved. They also recommend improving the quality of care for Medicare patients, many of whom are African Americans.6
Relevance to nursing
In many areas of practice, nurses provide the most direct patient care. In acute care, nurses assess patient glucose levels and treat as needed. They are also more likely to provide diabetic patients with disease education in collaboration with dieticians. Nurses must be aware of their own prejudices and biases that may interfere with the care they provide diabetic patients from different racial and/or ethnic backgrounds. In addition to nursing schools including cultural literacy in their curriculum, patient education must reflect cultural congruence with patient background to be effective. Brown et al. conducted a study to evaluate two different culturally sensitive interventions designed for Mexican Americans. Findings indicated the participants in both intervention groups had perceived improvements in sense of control over their diabetes.13
Piette et al. studied the effect of automated telephone disease management (ATDM), with nurses following up with patients via phone. After 12 months, researchers found the participants receiving the interventions had more frequent self blood sugar checks and foot inspections compared with patients receiving more standard care. In addition, the glycosylated hemoglobin level was lower in the intervention group, and overall, the glycemic control and the diabetic symptoms were improved. This result is significant for APNs who may be planning interventions for reducing diabetic care disparities in minorities. With proper monitoring, minority diabetic patients may have more successful diabetes management.14
In another study, Piette et al. reviewed automated telephone calls with a nurse’s follow-up of 280 Spanish-and English-speaking adults diabetics. Findings indicated that glycemic controls were better in patients receiving the interventions than those receiving the usual care; the treatment group also had better glucose, weight, and foot monitoring than the control group.15 The automated calling system was available in both Spanish and English language, providing culturally sensitive care to people who might not speak or understand English well.
Yeboah-Korang, Kleppinger, and Fortinsky studied variations in the use of home health services amongst participants from different racial and ethnic groups with type 2 diabetes. They found African Americans received fewer nurse visits and other clinical disciplines than whites. In addition, Hispanics were less likely to receive physical therapy or home health aide than whites as well.16
Jenkins et al. researched the efforts to decrease the number of amputations caused by diabetes in African Americans. The Racial and Ethnic Approaches to Community Health (REACH) program in South Carolina propelled the efforts toward reducing the number of amputations in African Americans. Data for South Carolina indicated foot amputation was a problem for African Americans, and Jenkins et al. evaluated how the Community Chronic Care Conceptual Model for REACH Charleston and Georgetown Diabetes Coalition addressed the issue. The coalition efforts involved racial and ethnic approaches, and they included education of health professionals, two days of nurse training on foot care, inclusion of podiatrist in staff membership, a foot examination by the nurses with a physician follow-up, a media campaign, volunteers and community health advocates, and diverse educational materials for patients. These REACH efforts have reduced the number of diabetes hospitalizations in both Charleston and Georgetown counties from about 38.7 per 1,000 diabetes patients in 1999 to about 21.7 per 1,000 in 2008. The numbers of amputations in both counties have also decreased significantly since 1999.17
Another study by Two Feathers et al. attempted to determine the effect of a community REACH program culturally tailored to address the diabetes care needs of African Americans and Latinos in Detroit, Michigan. Results showed significant improvement in dietary knowledge and glycosylated hemoglobin among participants.18 With these two reports, one can conclude that the REACH program has the potential to reduce disparities in diabetes care; hence, the need to adopt this program nationwide.
Chin, Walters, Cook, and Huang described many strategies to reduce health care disparities, such as interventions addressing multiple levels of change, culturally tailored quality improvement, and nurse-led interventions. Culturally tailored intervention has the potential to “enhance effectiveness of general quality improvement interventions among ethnic minority groups.” Additionally, nurse-led interventions can yield positive results because nurses are both cost effective, and may be able to spend more time with patients and provide culturally appropriate care.19 Using their training and experience, nurses can effectively collaborate with other health care workers to develop programs that reduce disparities in diabetic care. Peek et al. concluded there may be benefits to culturally tailored programs addressing disparities, and interventions should focus on not just patients but also providers and health systems, including nurse clinicians and case managers. They “found good evidence that nurses acting as clinicians (via treatment algorithms and physician support) can produce significant improvement in both process and outcome measures.”11
Prejudice and bias
Although a majority of health care practitioners may abhor prejudice, prejudicial approaches to health care exist among health care providers; in fact, they may not be able to recognize they are displaying such behaviors.3 In a study of 720 physicians, Schulman et al. found a patient’s race and sex influenced how physicians provided care. Physicians were less likely to recommend cardiac catheterization to black females when compared with a white male, white female, or a black male.20 In a study of 60 therapists primed with African American stereotypes or neutral words, African American stereotypes may lead to either positive or negative impressions in health care providers. Indeed, negative impressions may influence the way health care providers rate patients’ attributes.21
Forces behind health care disparities can be multifaceted. Balsa and McGuire identified three mechanisms, including bias against minorities, significant uncertainty when practitioners interact with minority patients, and health care providers’ beliefs or stereotypes regarding minority patients’ behaviors and health. Some practitioners have difficulty understanding the symptoms minority patients report; with the greater clinical uncertainty along with stereotypes identified at the base of patient data gathering, there is the need for a policy that can prevent further propagation of disparities. Balsa and McGuire, in addressing unfairness and discrimination in health care, “treated prejudice as a ‘psychological cost’ born by the doctor when treating a patient of a different race or ethnic group.” A white practitioner may experience a distaste or psychological cost when dealing with patients of a different race, which then influences the practitioner’s decision making.22
Pettigrew and Meertens presented two sides of prejudice in social research, including subtle and blatant prejudice. They called blatant prejudice “hot, close, and direct,” while subtle prejudice is the opposite. Prejudicial behaviors tend to lead to the formation of beliefs promoting discrimination and subtle prejudice. It often involves the defense of traditional values, which may include blaming victims and exaggerating cultural differences through gross stereotypes—although the differences may be genuine—and denial of positive responses toward the out-group.23
Demographic and fiscal data
In general, health care disparities are costly, and the magnitude of the cost burden should not be overlooked. Waidmann reports that in 2009, disparities among African Americans, non-Hispanic whites, and Hispanics cost an estimated $23.9 billion dollars, while the extra cost for Medicare and private insurers was an estimated $15.6 billion and $5.1 billion, respectively. Disparities in diabetes, hypertension, renal disease, and stroke in African Americans and Hispanics resulted in excess cost in 2009; disparity between blacks and whites alone cost an estimated $2+ billion. With Medicare and Medicaid combined, health disparities for both African Americans and Hispanics cost about $12 billion and $5 billion, respectively.24 According to Rastogi, Johnson, Hoeffel, and Drewery, 308,745,538 million people lived in the United States in 2010, and 42,020,743 (13.6%) were black.25
Many reasons have been attributed to health care disparities, but one discussed most commonly is insurance. Forty-nine percent of African Americans in 2007 had employer-sponsored insurance compared to 66% of whites. The average African American family earned $33,916; the average white family, $54,920.5
Between 2008–2009, 19% of all Americans, 23% of the black population, 14% of whites, and 34% Hispanics considered non-elderly were without health insurance.26 A different report by Cohen, Ward, and Schiller stated that in 2010, 48.6 million Americans (16%) did not have health insurance; whites were more likely to have health insurance than Hispanics, Asians, and African Americans.27 Minorities were also more likely to live in rural areas where there are fewer health care centers and hospitals. Even among those in urban areas, minorities were more likely to require multiple buses to reach health care facilities or hospitals. And, because minorities are more likely to be poor, they are less likely to receive adequate, quality health services.10
In a 2007–2009 national survey, of the Americans over 20 years old, about 7% of whites, 8% of Asian Americans, 12% of Hispanics, and 13% of blacks were diagnosed with diabetes. In 2010, diabetes affected 25.8 million people in the United States, or about 8.3% of the population; of that number, seven million went undiagnosed. In addition, 1.9 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010. Among people 65 or older living in the United States in 2010, 10.9 million people (26.9%) had diabetes. Lastly, in 2010, about 215,000 Americans younger than 20 years old had either type 1 or 2 diabetes.9
In 2010, among those aged 20 years or older, 4.9 million (18.7%) blacks, as opposed to 15.7 million (10.2%) whites, had diabetes. In 2006, the rate at which treatment was initiated for end-stage renal disease for diabetic blacks was about two and a half times the rate for diabetic whites. In 2006, diabetic African Americans were one and a half times more likely to be discharged from the hospital than diabetic whites.9 Lastly, in 2006, African Americans were over two times more likely to die from diabetes than whites.28 According to the 2008 National Healthcare Quality Report, the direct cost of diabetic care in 2007 was $116 billion, while the total cost was $174 billion.7
Moral and ethical issues
Concerns about moral and ethical issues surrounding these disparities call into question justice and fairness in the United States.10 Practitioners and policy makers alike must address disparities with a sense of urgency—projections show that by 2050, about 50% of the population will belong to a “minority” group.29 For practitioners, disparities “pose moral and ethical dilemmas that will be among the most significant challenges of today’s rapidly changing health systems.”3
Health care practitioners must follow certain ethical principles, including beneficence, nonmaleficence, fidelity, justice, and veracity. Nonmaleficence requires that health care providers not do any harm to patients; justice pertains to the morality that is involved in fairness, equity, and rightness of care of all patients.30 Many of the findings reviewed have shown disparities occur as a result of omission, commission, or inadequacy of action. According to Balsa and McGuire, information-based policies will “at least satisfy the medical creed, ‘first do no harm.’”22
According to Smedley, health care providers must choose between what is ethically right and what limited health care resources can address. Providers may then allocate more resources to a particular group of people over the other. However, public trust may be harmed if people perceive health care providers engaging in social triaging.3 According to Bal, in the next 25 years the burden of diabetes may make the ethical issue of access to primary care shaper in order to avoid the need for intensive diabetes complication care. There is an urgent moral need to attack diabetes at the primary care and public health levels to implement prevention strategies.8
Health policy issues pertaining to disparities in diabetes care
One can assume and hope that when and if prejudice is at the base of disparities, having a policy that mandates practitioners provide equal care may “result in an improvement of health care conditions for minorities and in a fair outcome.”22 The U.S. Department of Health and Human Services (USDHHS) has begun reviewing factors affecting discrimination against the health care environment. One federal initiative by the Agency for Healthcare Research and Quality (AHRQ) focuses on the development of a national report on ethnic and racial health care disparities.3 Smith proposed the use of report cards to assess ethnic and racial disparities.31
The Department of Health and Human Services (HHS) has set some health care goals and action plans concerning these disparity issues. Their first goal is health care transformation, where insurance coverage expands to include people that do not have it, along with increased access to health care through an innovative health care delivery approach. The second goal is to strengthen the health and human services workshop, and to achieve this, there is a plan to recruit undergraduates from underserved communities for biomedical and public health fields, as well as supporting community health worker training. The third goal of the HHS is to advance the health, well-being, and safety of Americans. To achieve this, new CDC grants will be implemented to achieve improved health care in many of the diseases affected by disparities. The fourth goal is to advance scientific knowledge and innovation by implementing a new strategy for data collection and analysis as authorized by the Affordable Care Act. The fifth goal is to increase the efficiency, accountability, and transparency of the HHS programs by taking into consideration the assessment of health care disparities programs and policies.5
In a study focused on the preferences of patients for same race health care providers, Malat and Hamilton found when black patients believed discrimination existed in the health care provider-patient dyads, they were more likely to prefer the same-race provider.1 Cooper and Roter in a study of 252 adults found patients may benefit from having race-concordant visits because the patients were more likely to rate their satisfaction with their physicians highly. Cooper and Roter recommended there be a policy concerning increased number of ethnic minority physicians; they also encouraged fostering trust between patients and providers.32 LaVeist and Nuru-Jeter examined the connection between the patient-doctor concordance and patient satisfaction using a sample that included African Americans, Caucasians, Hispanics, and Asian Americans. When patients had the choice of selecting their own physicians, the participants were more likely to select persons of their own race. There is then the need to increase the number of health care practitioners from diverse racial and ethnic backgrounds while at the same time increasing practitioners’ capacity to interact with patients in a culturally congruent way.33
A major deterrent to equality in health care is finance; factors such as capitation and incentives to providers who practice frugally can negatively affect the quality of care people from racial and ethnic minorities receive, and lessen the negative effects on the care of whites. Provider incentives may not necessarily lead to disparities in care if more finely crafted; an example might include rewarding providers for time spent engaging with patients and their families, which may help overcome cultural communication barriers and improve provider empathy.3
Balsa and McGuire advocated for information-based policies that may break stereotypical patterns or reduce the degree of uncertainty in health care; these are more likely to be effective when lack of information is the underlying cause of disparities. Balsa and McGuire also suggest using rule-based policies, which require patients be treated the same way.22 Beal reports a gap in the training of health care providers in cultural competence. In addition, there is a need for improved interpersonal care, improved cross-cultural relationships, and proper provider training regarding engaging patients from all backgrounds. There are currently some programs in place to increase the number of practitioners from underrepresented populations; however, interested stakeholders have to apply for the funds. Additionally, many of the programs are underfunded.34
Another policy issue is proximity of health care centers to where minorities live. Diabetic patients residing in remote areas should be able to reach their health care providers without undue stress. Nurse-managed clinics help reach people that otherwise would not have access to health services; however, there is a need for more nurse-managed facilities. Employing community health workers (CHW) can also reduce health disparities. Corkery et al. conducted a study to assess the effect of CHWs on diabetes education program completion among Hispanics. They found the assignment of a CHW had a robust effect on “program completion, controlling for financial status, and language spoken,” as well as “on knowledge, self-care behavior, or glycohemoglobin outcome variables was not statistically significant.” However, the researchers concluded that the ability of Hispanic patients to complete the diabetes education program led to improvement of patient knowledge, glycemic control, and the displayed self care behaviors.35 According to Smedley et al. in order for a CHW program to be successful, there is the need for a properly designed program that allows for adequate CHW training and supervision.3
After reviewing literature concerning disparities in diabetic care, White, Beech, and Miller concluded that in approaching diabetic disparities, the providers should consider patient and provider factors, including the use of nurse educators, case managers, algorithms, and diabetes self-management education. Other aspects of care, as recommended by White et al., include seeking patient colleague feedback, consideration of literacy and numeracy in designing educational materials, increasing the use of interpreters and language-specific reading materials, and use of patient-centered communication processes.36
In a promising report, Peek et al. found many interventions to reduce disparities in diabetes care already implemented, but the design and method of evaluation of the current interventions “leave us with many unanswered questions regarding the benefits of cultural tailoring, the impact of interventions on health disparities, and the ideal target of interventions (patient, provider, organization).”11
Summary, conclusions, and recommendations
There are three major issues surrounding disparity in diabetes care: the patient, the health care provider, and the system. The patient’s personal issues, including lack of trust in the system and/or health care providers, along with unhealthy habits, may serve as impediments to appropriate care. The provider issues may pertain to bias, stereotype, and care competency level, while the system concerns lack of access to health care services such as proximity of health care facility, insurance coverage, and education opportunity.
While the burden of diabetes is enormous, policies can be put in place to reduce the disparities in its care. Using trained volunteers and CHWs, such as the promotoras and curanderos (Latino/Hispanic community health care leaders), may help ease the burden of health care disparities in general. In order to improve the patient/health care provider interrelationship, there is the need for improved cultural literacy of health care. In addition, health care providers need to advocate for diabetic patients that are not getting adequate care so that the morbidity and mortality associated with diabetes can be minimized. All persons with diabetes deserve culturally appropriate care, tied to treatment and management success. Health policies are needed to address access and barriers to health care, and nurses have vital responsibilities in promoting system-wide positive change. Program initiatives like REACH need to be used in many more communities.
The work that needs to be done to reduce disparities in diabetes care may be challenging. There are scattered ongoing efforts to reduce diabetes disparities, but the efforts need to be present throughout the country. When such initiatives are widespread, there is the potential for greater improvement in diabetic care of minority patients. The multifaceted nature of the issues surrounding disparities in diabetic care requires careful assessment to employ appropriate strategies. Nurses are in a special position to make a difference in diabetes care and help reduce disparities.
There is the need for ongoing cultural competence training for health care providers, which should be standardized nationally, regionally, or by state. Just like health care practitioners are expected to have certain requirements for maintaining their license, cultural competence continuing education could be part of the requirements for license renewal. All health practitioner schools (medical, physical therapy, dental, etc.) should include cultural competence in the curriculum and not leave it to the individual student to find a way to attain the knowledge. Health care providers should work closely with local government on policies that improve health care equality. Nurses and other health providers should belong to professional organizations that enhance their capacity to lobby for policies and programs that reduce health care disparities.
References
J. Malat and M.A. Hamilton, “Preferences for same-race health care providers and perceptions of interpersonal discrimination in health care,” Journal of Health and Social Behavior, 47, 173-187. doi: 10.1177/002214650604700206.
W.F. Wong, “Confronting the uncomfortable: Health plans and health disparities: A moral dilemma in a morally driven industry,” The Permanente Journal, 12(1), 81-86.
B.D. Smedley, A.Y. Stith, and A.R. Nelson, “Unequal treatment. Confronting racial and ethnic disparities in healthcare,” Washington, D.C.: The National Academies Press.
T.A. LaVeist, “Minority populations and health. An introduction to health disparities in the Unites States.” San Francisco: Jossey-Bass.
United States Department of Health & Human Services. (n.d.), “The HHS action plan to reduce racial and ethnic health disparities,” Retrieved from: www.hhs.gov.
M.H. Chin, J.X. Zhang, and K. Merrell, “Diabetes in the African-American Medicare population: Morbidity, quality of care, and resource utilization,” Diabetes Care, 21, 1090–1095.
United States Department of Health & Human Services. (n.d.), “National health care quality report.” Retrieved from: www.ahrq.gov.
A. Bal, “Diabetes: Ethical, social and economic aspects,” Indian Journal of Medical Ethics. 8(3). Retrieved from: www.issuesinmedicalethics.org.
Center for Disease Control and Prevention (2011). “National diabetes fact sheet.” Retrieved from: www.cdc.gov/diabetes/pubs/factsheet11.htm.
G. K. Steel Fisher, “Addressing Unequal Treatment: Disparities in Health Care. The Commonwealth Fund.” Retrieved from: www.commonwealthfund.org.
M.E. Peek, A. Cargill, and E.S. Huang, “Diabetes health disparities: a systematic review of health care interventions,” Medicare Care Research and Review, 64, 101S–156S. doi: 10.1177/1077558707305409
M.E. Gornick, P.W. Egers, T.W. Reilly, R.M. Mentnech, L.K. Fitterman, L.E. Kucken, and B.C. Vladeck, “Effects of race and income on mortality and use of services among Medicare beneficiaries,” New England Journal of Medicine, 335, 791-799.
S. Brown, S.A. Blozis, K. Kouzekanani, A.A.Garcia, M. Winchell, & C.L. Hanis, “Health beliefs of Mexican Americans with Type 2 diabetes: The Starr county border health initiative,” The Diabetes Educator 33, 300-308. doi: 10.1177/0145721707299728.
J.D. Piette, M. Weinberger, F.B. Kraemer, and S.J. McPhee, “Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a department of Veterans affairs health care system,” Diabetes Care, 24, 202–208.
J.D. Piette, M. Weinberger, S.J. McPhee, C.A. Mah, F.B. Kraemer, and L.M. Crapo, “Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes?” American Journal of Medicine, 108, 20-27. Retrieved from http://ebn.bmj.com.
A. Yeboah-Koran, A. Kleppinger, and R.H. Fortinsky, “Racial and ethnic group variations in service use in a national sample of Medicare home health care patients with type 2 diabetes mellitus,” Journal of the American Geriatrics Society, 59, 1123-1129. doi: 10.1111/j.1532-5415.2011.03424.x.
C. Jenkins, P. Myers, K. Heidar, T. Kelechi, and J. Buckner-Brown, “Efforts to decrease diabetes-related amputations in African Americans by the racial and ethnic approaches to community health Charleston and Georgetown diabetes coalition,” Family & Community Health, 34(1), S63-S78.
J. Two Feathers, E.C. Kieffer, G. Palmisano, Anderson, B. Sinco, K. Janz, S.A. James, “Racial and Ethnic Approaches to Community Health (REACH) Detroit partnership: Improving diabetes-related outcomes among African American and Latino adults,” American Journal of Public Health, 95, 1552-15560.
M.H. Chin, A.E. Walters, S.C. Cook, and E.S. Huang, “Interventions to reduce racial and ethnic disparities in health care.” Medical Care Research and Review, 64(5), 7S-28S. doi: 10:1177/1077558707305413.
K.A. Schulman, J.A. Berlin, W. Harless, J.F. Kerner, S. Sistrunks, and Gersh, J.J. Escarce, “The effect of race and sex on physicians’ recommendations for cardiac catheterization,” New England Journal of Medicine, 340, 618-626. Retrieved from: http://psg-mac43.ucsf.edu/.
J.M. Abreu, “Conscious and non-conscious African American stereotypes: Impact on first impression and diagnostic ratings by therapists,” Journal of Consulting and Clinical Psychology, 67, 387-393. doi: 10.1037/0022-006X.67.3.387.
A.I. Balsa and T.G. McGuire, “Prejudice, clinical uncertainty and stereotyping as sources of health disparities,” Journal of Health Economics, 22, 89-116.
T.F. Pettigrew and R.W. Meertens, “Subtle and blatant prejudice in Western Europe,” European Journal of Social Psychology, 25, 57–75. doi: 10.1002/ejsp.2420250106.
T. Waidmann, “Estimating the cost of racial and ethnic health disparities.” Retrieved from: www.urban.org.
S. Rastogi, T.D. Johnson, E.M. Hoeffel, and M.P. Drewery, “The Black population: 2010. 2010 Census Briefs.” Retrieved from: www.census.gov.
Henry Kaiser Family Foundation. (n.d.), “Indianauninsured rates for the nonelderly by race and ethnicity, states (2008-2009).” Retrieved from www.statehealthfacts.org.
R.A. Cohen, B.W. Ward, and J.S. Schiller, “Health Insurance coverage: Early release from the National Health Interview Survey, 2010.” Centers for Disease Control and Prevention. Retrieved from: www.cdc.gov.
M. Heron, D.L. Hoyert, S.L. Murphy, K.D. Kochanek, and B. Tejada-Vera, “Deaths: Final data for 2006.” National Vital Statistics Reports, 57(14), 1-136. Retrieved from www.cdc.gov.
Henry Kaiser Family Foundation, “Key facts: race, ethnicity, and Medical care. Figure 2.” Retrieved from: www.kff.org.
H. Harkreader and M.A. Hogan, “Fundamentals of Nursing: Caring and clinical judgment. (2nd ed.).” Saint Louis: Missouri: Saunders.
D.B. Smith, “Addressing racial inequities in health care: Civil rights monitoring and report cards,” Journal of Health Politics, Policy, and the Law, 23, 75–105.
L.A. Cooper and D.L Roter, “Patient-centered communication, ratings of care, and concordance of patient and physician race,” Annals of Internal Medicine,139, 907-915.
T. LaVeist & Nuru-Jeter, “Is doctor-patient race concordance associated with greater satisfaction with care?” Journal of Health and Social Behavior, 43, 296-306. Retrieved from: www.jstor.org.
A.C. Beal, “Policies to reduce racial and ethnic disparities in child health and health care,” Health Affairs, 23(5), 171-179. doi: 10.1377/hlthaff.23.5.171.
E. Corkery, C. Palmer, M.E. Foley, C.B. Schechter, L. Frisher, & S.H. Roman, “Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population,” Diabetes Care, 20, 254-257.
R.O White, B.M Beech, and S. Miller, “Health care disparities and diabetes care: practical considerations for primary care providers,” Clinical Diabetes, 27(3), 105-112. doi: 10.2337/diaclin.27.3.105. United States Department of Health & Human Services. (n.d.). African American Profile. Retrieved from: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=23
Not only does diabetes run rampant among Native Americans, it has recently reached epidemic levels in third-world countries as well. In May 2008, a team from Ada, Oklahoma, comprised of East Central University (ECU) nursing program graduates and Chickasaw Nation employees, traveled to Belize in Central America to share their knowledge of diabetes prevention with the Punta Gorda community. This five-day trip is associated with an overall tribal project initiated to provide Chickasaw youth an opportunity for cultural exchange and participation in community services in a third-world country. Dr. Judy Goforth Parker, who at that time was a Chickasaw Nation Legislator and ECU community health professor, along with Jay Keel, administrator of Chickasaw Nation Youth and Family Services, led this team, including recent nursing graduates Tara Fall, Casey Greer, Macy Mitchell and Monica Winford along with other team members Stacie Carroll, Deanna Kendall and Chris Snowden.
The team was met by Global Outreach International missionary Bob Farley upon arriving in Punta Gorda, and they were invited to attend services the next morning at the Laguna Community Church. They were relieved to hear that the service was presented bilingually in both Kekchi Maya and English. (There are four languages prevalent in Punta Gorda. Most children spoke English as well as their native language.)
The team visited schools and provided teachers and students of all ages with valuable information concerning diabetes prevention. A skit was performed to demonstrate how the body’s insulin plays a vital role in regulating blood sugar, and pictures of food were dispersed to encourage students to choose healthier snacks with less carbohydrates and sugar. The children agreed to ask their parents to “get moving” and play catch or take a walk with them. Storybooks taught them that physical activity is important their entire life. Hand hygiene was emphasized with explanations of the various ways worms can invade the body. The children eagerly joined in singing, “If you’re happy and you know it, wash your hands.” This helps them remember to wash their hands for 30 seconds before meals and after bathroom breaks. Handouts were given to all, along with Georgia Perez’s The Eagle Books provided by Bobby Saunkeah, director of the Chickasaw Nation Diabetic Clinic.
Punta Gorda’s community hospital allowed the team’s registered nurses to administer diabetic screenings, take blood pressure readings and calculate each individual’s Body Mass Index. They were met by Dr. Garcia, who had been the chief physician for two years, and they discussed his overwhelming patient load. He greatly appreciated the team’s ability to instruct each patient. He saw teaching diabetes prevention and maintenance as a critical need, but his large patient load restricted the time he had to thoroughly educate each patient.
The ECU nurses were amazed at how many patients were not aware which foods contained carbohydrates. Many stated, “I do not drink pop; I drink fruit juice,” not realizing juice also has carbohydrates. Patients were in disbelief that half of a banana contained only 15 carbohydrates and a serving of rice was one-third of a cup. They previously thought they had to skip meals or starve themselves to maintain their weight as a method to control this horrible disease and were relieved to learn three balanced meals with a snack is much more efficient in maintaining a normal blood sugar level.
The Belizean Health Care System
Belize is a small country about the size of New Hampshire. It is bordered by Mexico on the northwest, Guatemala to the west and south and the Caribbean Sea on its eastern border. English is the official language of Belize, although Spanish is widely spoken as well. Known as British Honduras from the mid-1800s to 1973, Belize was home to the great Maya civilization, which flourished for hundreds of years, developed a very advanced civilization for its time and grew in size to approximately one million people at its height in the first millennium A.D. Descendants of this civilization are now few in number with the majority living in Toledo, the southernmost district.
A typical dwelling in Belize’s Toledo District, the country’s poorest region. Many of the communities in this district are remote rural villages with severely limited access to medical care.
The Belizean health care system serves 300,000 people living within six districts. Belize District is the largest, with a population of 75,000. Toledo is the smallest district, with 28,000, approximately 6,000 of which live in Punta Gorda. This community suffers basic problems like malnutrition and diarrhea, but diabetes has only recently become an issue and the rural areas are not yet very concerned or know much about the disease. The Toledo District is mainly affected by Type II, or adult-onset diabetes. However, once thought to only afflict the older population, diabetes is now occurring more in younger demographics. Its progress is gradual and effects are slow to present. As a result, it may take a back seat to more immediate or emergent health problems.
Of the 53 rural communities in the Toledo District, 80% are remote, some without roads and accessible only by foot, severely limiting education and access to medical care. The population is very diverse, especially in Punta Gorda. The Maya and Garifuna are considered indigenous, with a holistic way of viewing health, valuing the spiritual aspect as well as physical well-being. Mestizo, Creole, Mennonite, East Indian, Chinese and European make up the remainder of the population, with each ethnicity retaining its own traditions. This makes for a cultural melting pot and mixed influences on the community’s diet and health.
The Belizean Minister of Health is located in Belmopan, the capitol city, in the Cayo District. Regional health services control the allocation of resources to Belize, but sometimes become disconnected from the needs of the smaller, southern region of the Toledo District. This health care system is oriented toward primary health care, as conceptualized at the 1978 International Conference on Primary Health Care in Alma-Ata. This approach has proven to be very efficient and cost-effective.
Curative and preventive health care is an essential element of primary health care. Belizean programs with this focus include community outreach, public health, vector control and psychiatric programs, with an emphasis on maternal and child health. The public and rural nurses contribute to this by educating the community about the health problems specific to young children (0–5 years old) and pregnant mothers. These nurses also give immunizations, perform pre- and post-natal care and address malnutrition, tuberculosis and HIV/AIDS.
The vector control programs focus on preventing malaria, dengue and chagas disease. The public health division goes into restaurants, diners and grocery stores to check sanitation and proper food storage practices. Public health is also responsible for the animal rabies campaign. The Guatemalan and Mexican Boards of Health combine resources with Belize to combat its overwhelming poverty and malnutrition.
The author and her team of Eastern Central University nursing program graduates visited schools and a community hospital in Punta Gorda, Belize, to educate local children about diabetes prevention.
Community participation is key in an effective public health program. The director of public health in the Toledo District plans meetings, organizes reports, obtains supplies and coordinates and collaborates training programs designed to involve the community and increase active participation and interaction in its health care. Health care volunteers are encouraged and given a stipend for their efforts equal to $50 (USD) per month. The Toledo District is the country’s poorest region, with a 79% poverty rate per the 1996 census. The estimated average annual income in Belize varies from $1,000–$3,000 (USD), well below the U.S. average.
Many health problems facing Belizeans are related to the lack of an adequate supply of safe water and public sanitation. Illnesses are often transmitted through contaminated food and water. The Toledo District has the lowest levels of available safe water. Thirty percent use streams, rivers and creeks as a water source for bathing and laundry as well as drinking, cooking, washing and preparing food. Bodily wastes can potentially come in contact with water sources, compounding the prevalence of illnesses and disease.
Access to health care is a major problem, especially in remote, rural areas of Belize. Isolated villages suffer from inconsistent care and their most vulnerable populations, young children, endure high incidences of child mortality. A mobile health system, comprised primarily of public health nurses, tries to combat this by going out into these areas and giving immunization shots and other health care. Polyclinics, such as the one visited in Punta Gorda, are outpatient facilities aimed to improve primary care and represent an attempt to spread some of the concentrated health care from the bigger cities to rural areas. Patients requiring additional care and treatment are usually referred to a city hospital, but for most in Punta Gorda, transportation is a problem as well. The sole doctor for Punta Gorda’s polyclinic has days where up to 100 patients need his services. So given the heavy case load and frantic pace, patient health care education and disease prevention can easily go unaddressed.
Overall, there is a shortage of doctors and health care workers in Belize. Only a few medical schools exist and nurses seeking an advanced practice degree must travel outside the country to obtain one. The United States, as well as Nigeria and Cuba, aid in supplying doctors to Belize, but the growing population needs more doctors than are currently practicing. Due to the demand for health care personnel, educational requirements for health care positions are much lower. A large majority of the health care centers are not fully staffed, but even when they are, they still lack a complete range of health care services. Certified nursing assistants are utilized to a much higher degree in Belize compared to the United States and are in high demand. Dieticians are needed because of widespread hypertension, obesity and diabetes. Effective results are dependent on the dieticians’ ability to incorporate the cultural and traditional diet of the different ethnicities living in Belize.
With so many problems facing this health care system, it is a matter of deciding not only which improvements benefit the greatest number of people, but also determining which are realistically achievable. Yet, like the old saying goes, climbing a mountain starts with small steps.
Cultures Coming Together
Not only did diabetes education take place, but also a cultural exchange between the Chickasaw Nation and the Mayan and Garifuna tribes. This was a continuing practicum experience for the graduate nurses of ECU as well.
One of the main tasks given to the team of nurses was to serve as guest lecturers at the Belize Diabetes Association, the Toledo Chapter’s inaugural support group meeting. The seminar was coordinated by Cherry Mae Avilez, District Health Educator, and Rhoda Duncan, president of the local Diabetic Chapter. Also attending was the president of the National Diabetes Association of Belize, Anthony Castillo. The team of five ECU nurses presented an educational program that incorporated the history of diabetes mellitus in Chickasaw Native Americans, the pathophysiology of the disease and prevention techniques like exercise, carbohydrate control and portion size. Also included were blood sugar screenings, group exercises, skits, visual aides of portion sizes and local healthy snack choices. The blood sugar screenings showed several members of the audience having levels well into the 400s. With the help of Melissa Vavricka Conway, a Chickasaw Nation diabetic dietician, the indigenous community was educated on correct portion and proper food selection in relation to the local diet. Attendees enjoyed a “portion-correct” meal of local foods, prepared by “Miss Ruth,” a local diabetes success story. She was diagnosed with diabetes approximately six months before and had since lost 35 pounds through exercise and successfully controling her blood glucose levels.
When it comes to pediatrics, health professionals face a number of challenges in providing quality care for minority patients. According to the American Academy of Pediatrics, severe racial and ethnic disparities exist in pediatric health and health care, and minority patients tend to experience greater difficulty across a wide range of categories, including infant health, access to providers, prevention, and chronic diseases.
Despite the challenges, minority nurses make a difference working with pediatric patients, says Charlotta Marshall , R.N., M.S.N., a hematology/oncology clinical nurse specialist at Children’s Hospital of Michigan in Detroit. Nurses are proactively assembling teams of physicians, social workers, dieticians, family members, and other community advocates to provide excellent care, she says.
“You have all these health care disciplines around the patient, but as a nurse, you’re in the middle. The nurse is often the coordinator, pulling people into the circle to meet the needs of the patient and family. Good health care means bringing together many professionals to work together for the benefit of the patient,” she says.
Here’s a look at the state of minority pediatric health, and how minority nurses are working to overcome the challenges they face while providing better care for their patients.
A link to communities
Nurses serve as a vital link between the patients they serve and the communities where their patients live, says Gwenda Grant, R.N., a New Brunswick, New Jersey–based pediatric clinical liaison with Bayada Nurses, a national home care company. “We help parents become better advocates for their children,” she says. For example, Grant says many parents don’t know the right questions to ask, or how to find extra resources, and nurses have to help bridge those gaps.
Frederica Williams is the President and CEO of Whittier Street Health Center in Roxbury, Massachusetts. She says nurses need to not only reach out to their neighbors but also become more visible, especially in minority communities. “We have to get out there in the schools and churches to educate families about good health care.”
Whittier staffers implement education programs in the neighborhood, faith-based institutions, and even prisons to educate people about health topics. According to the center’s website, these efforts have reached 20,000 local residents in addition to their regular patients.
Professionals also go into the schools to talk about prevalent issues, including obesity, human papillomavirus (HPV), and mental health issues, Williams says. “We can’t just be a building in the community. Our focus has to be expanding our public health outreach in the community,” she says.
Though community efforts are helpful, minority pediatric nurses say cultural and linguistic barriers still exist in health care. “Many patients in minority communities come from different backgrounds and speak different languages,” says Williams.
According to Williams, these language barriers can lead to a lack of understanding and treatment problems, or even a misdiagnosis. For that reason, she says it’s important for health care professionals to be able to speak multiple languages and be familiar with the cultural backgrounds of the families they serve. If more minorities go into nursing, Williams says there is a greater likelihood that they’ll be able to linguistically and culturally connect with a more diverse set of patients.
Financial resources
With health care costs rising steadily, minority nurses are instrumental in helping patients find financial resources to pay for their children’s services, says Maria Arteaga, R.N., Director of Nursing at LaSalle Medical Associates in San Bernardino, California.
According to Arteaga, most of the families of pediatric patients in her community are concerned about how they’re going to be able to pay for health services. A majority of her patients have low incomes, so when their children are admitted, she says their first question is often, “What is this all going to cost?”
Nurses can respond by helping parents learn about governmental program that are offered to low-income families, says Arteaga. “We work hard to understand what’s available to them.”
Many patients also fear that their children’s treatment will be insufficient, because they don’t have the money to pay for expensive “high-quality” care, says Arteaga. LaSalle nurses help patients understand that they will be receiving quality medical care, no matter what their socioeconomic status is, she says. “We explain to the patient that, regardless, we treat them with respect and they can be confident with our services.”
Williams says that whether or not patients embrace that message is a matter of trust, and minority nurses are a crucial part of helping build such trust among minority communities.
Whittier provides cultural competency training for its entire staff, so that the center can better serve its community. “We’re serving populations that have had to deal with racism and classism,” says Williams. “Many times, patients have told us that [being at Whittier] is the first time they have been dealt with dignity and respect.” Williams says this is one of the best compliments she can receive.
Health challenges
Though minority nurses are making strides in serving their communities, many report that their minority pediatric patients face a disproportionate number of health problems when compared with other pediatric populations. It takes a dedicated staff to help patients eliminate or reduce these challenges, which range from childhood obesity to teen dating violence.
Obesity According to research published by the U.S. Department of Health and Human Services (HHS), African American children in 2007–2008 were 30% as likely to be overweight than non-Hispanic white children. Mexican American children were 1.4 times more likely to be overweight as non-Hispanic white children, according to a 2009 survey.
“In the African American community, there is a higher rate of obesity in pediatric patients,” says Dana G. Rader, R.N., M.S.N., C.N.M., a nurse practice leader with Women and Children’s Services for Kaiser Permanente’s Mid-Atlantic region. In fact, she says childhood obesity has been targeted as a “hot topic” for the nurses in her facility.
“We’re working together to expand the nurse’s role in following and educating patients regarding their BMI and nutrition,” Rader says. She and her colleagues are creating a resource packet for nurses who need to talk to parents of patients about BMI, pediatric standards, and teaching children how to exercise and eat better.
As a minority nurse, Rader advocates taking a proactive role in reaching these patients, which can help prevent future health problems when pediatric patients become adults. “A lot of our preventative diseases stem from poor nutrition,” says Rader. “We need to talk about managing and preventing these conditions and not waiting until that obese child becomes an obese adult with Type 2 diabetes.”
For some communities with high levels of crime, fighting obesity involves more than educating parents about exercise, says Williams; it means finding them a safe place to exercise. For instance, many parents and guardians that come to Whittier may feel that it’s safer to keep their children indoors, she says. And if kids stay inside, they could gain weight at a faster rate.
Charlotta Marshall , R.N., M.S.N.
With these concerns in mind, Whittier nurses help battle obesity with a free afterschool program called Race Around Roxbury (named for the neighborhood where the health center is located). It’s a year-round program that helps overweight and at-risk adolescents learn about healthy eating, exercise, and high self-esteem, says Williams.
Children work in groups and complete fun activities that help them reach nutrition and weight goals. As part of the program, nurses teach children how to make healthy dietary choices, but they also work with parents to show that everyone can eat healthy on a budget. Race around Roxbury also collaborates with a local gym that sponsors child-focused activities, such as karate. All of the children in the program also attend a healthy weight clinic at Whittier where nutritionists, case managers, and physicians work with the children to determine nutrition and weight loss or stabilization plans.
During the program, children can earn prizes such as MP3 players or inexpensive sports equipment as awards for participation. “We’re giving children incentives, but we’re also teaching them lifelong habits about nutritional habits and exercise,” Williams says. She adds that the program has been successful and 100% of the children enrolled have made some type of lifestyle improvement.
Teen dating violence According to Rader at Kaiser’s Women and Children’s Services, another important challenge for nurses is helping eliminate dating abuse. She says some studies have shown that as many as one in four teens report being physically, verbally, or emotionally abused every year.
Recognizing symptoms of abuse is especially important for minority pediatric patients, Rader says. “As we deal with minority communities, it’s something that’s not talked about a lot. Sometimes we have a culture that says [abuse] is what you should accept, but this is not acceptable.”
According to Rader, many teens don’t recognize the signs of an abusive relationship, such as verbal threats and insults or physical violence. Or if they do recognize the signs, they grow to accept it. “In pediatrics, [abuse symptoms] are not an obvious risk factor for professionals. But we should be sharing more patient material with teens,” she says.
Rader suggests nurses talk to teens more frequently about potential abuse symptoms and make sure their patients know about community resources should they find themselves in an abusive relationship. “We need to reach out to teens because this problem is becoming more prevalent,” she says.
Premature birth According to the Office of Minority Health, African American babies are four times as likely to die due to low birth weight complications and premature birth than non-Hispanic whites. In 2008, 12.3% of all U.S. births were premature, compared to 17.5% of African American births alone. The Office of Minority Health also reported in 2006that African Americans had an infant mortality rate 2.4 times higher than that of non-Hispanic whites.
Melissa Strachan, R.N.
Minority nurses can address this issue by helping pregnant women learn where to go for prenatal education and resources, Rader says. Nurses can also encourage moms to breastfeed “not just after birth, but also six months to a year later,” she says.
Some health care centers are advocating a group approach to prenatal care. Whittier has implemented an obstetrics program that focuses on grouping doctors, nurses, and midwives together with pregnant moms. A group of about 8–12 pregnant mothers, who are close to each other in gestational age, work with medical professionals to learn about proper prenatal care as a part of Whittier’s Prenatal Care clinic and the OB/GYN department.
“The results have been shown to help reduce low birth weight and premature birth,” Rader says. The education offered in such a supportive group setting has helped mothers give birth to healthier babies in Boston where, according to statistics published on Whittier’s website, black mothers have the highest infant mortality rate, and 75.8% of black pregnant women receive adequate prenatal care, compared to 86.7% of white pregnant women.
Chronic conditions
Melissa Strachan, R.N., a pediatric nurse at Whittier, says another issue minority pediatric patients face in large numbers is the management of chronic illnesses, such as asthma. She says many of her patients live in public housing, which includes old buildings that can aggravate asthma symptoms.
Asthma can interrupt classroom time and parent work schedules when the symptoms become severe. “Kids are missing school because of preventable asthma attacks,” Strachan says.
Health care facilities can address these challenges by going to the community and educating parents about prevention and treatment, Strachan says. “Whittier hosts an asthma focus twice a month with providers, a case manager, and an on-site pharmacy,” she says. Whittier also hosts an asthma clinic every Wednesday afternoon where pediatricians and pharmacists review medication management and asthma education.
Strachan says the clinic exists so patients receive prompt care and treatment. “We look at what’s happening with their home environment so we can help prevent them from being sick and missing school,” she says.
Immunizations
According to Arteaga, some parents skip vaccinations because they have a hard time adjusting to the idea of paying for care when their child is not sick. The cost of good medical care is always a concern, but in many cases, these parents don’t know about the programs that help cover the cost of child immunizations, she says. To help boost immunization rates in these situations, Arteaga says minority pediatric nurses can make sure parents are aware of any community programs that help pay for preventative medical care.
At LaSalle, Arteaga says she proactively reaches out to families in her community to make sure patients know what’s available. “I keep a record of every single child that’s being immunized. We call them [when it’s time for their next vaccination], send letters and send cards, and we do the best of whatever is possible, whatever it takes,” she says.
Labor of love
As nurses help their minority patients face a wide range of health challenges, they find the pediatric specialty a fulfilling way to give back to their communities. “I’ve always had a love of children and in caring for their welfare,” Rader says. In fact, she says it was a positive experience with a nurse practitioner when she was young that made her decide to go into the pediatric specialty. Rader recalls that the nurse took what could have been a scary health procedure and helped her feel at ease. She now hopes to provide similar experiences for her patients. “I want to give children as healthy a start as possible,” she says.
Rader says working in pediatric nursing helps her make a positive change in children’s lives, and by doing so she helps bring about a positive change in their families and their neighborhoods as well. “It’s rewarding to be able to change not only one person, but to change an entire community.”
Other minority pediatric nurses agree. “There are people who enter the nursing field because of financial reasons only, and not because of what’s in their heart,” says Marshall at Children’s Hospital of Michigan. “But I always tell students to make sure they want to be a nurse.” She considers her career to be more than a job. “You want pediatric nursing to be a calling.”
“Our center serves all ages, but I believe our kids are the future of our area,” Arteaga says. “Children are the door of the family. If the parents don’t have the education, the kids can provide information.” And nurses can share vital health care information with families via children, she says.
Gwenda Grant adds that pediatric nursing allows nurses to see great success in some of the smallest things, such as taking a patient off ventilator support. “We see children start to eat, and we see their progress,” she says. “You can see the joy and delight in the eyes of parents when a child reaches a simple milestone, such as being able to pick up a toy.”
Nursing sick kids back to health
Though pediatric nursing can be gratifying, some nurses may avoid the specialty because it can be emotionally draining to care for very sick children on a regular basis. “I used to feel that way,” says Rader, “but then I realized that it takes a special person to push through their own pain and discomfort in seeing children in pain, and knowing that the nurse’s work is for the greater good.” Minority nurses who stay in pediatrics can experience the benefits of helping kids get healthy, Rader says. “You get way more in return for your willingness to work with children and teens.”
Marshall, who works in hematology and oncology, agrees that it can be difficult dealing with children who face life-threatening health obstacles. “Some people have a fear of working with children who are sick and have a potential for dying,” she says. “But instead of crawling under a rock, I think about what I need to do to help, and do it.”
For Marshall, this means forming interest groups with other nurses who treat patients with similar diseases so they can advance best practices. She also participates in medical fundraising efforts. “It’s important to be able to reach out to help others in any way you can,” she says.
A future in nursing
Even though nurses primarily assist the medical needs of their patients, they also provide a secondary benefit—they show children that nursing is a good career choice, says Williams. Minority nurses can help minority children and teens picture themselves working in the medical field, she says. “A lot of our kids don’t have that example at home, so our patients look up to us as examples.”
Doctors and nurses should go to schools in their communities and let kids know that if working in health and medicine is what they aspire to do, they can do it, Williams says. Whittier health professionals often serve as mentors, and some high school students gain hands-on experience at Whittier through internships. “We want to teach kids about all the different opportunities in health care,” Williams says.
Educational advancement Minority pediatric nurses should also look for ways to further their own education whenever possible, Marshall says. This could include earning new credentials, joining affinity groups, and mentoring other nurses. “Show, demonstrate, and build your clinical skills to deliver excellent patient care,” she says.
Minority pediatric nurses may face a number of challenges in their communities, but they also have ample opportunities to create positive change, Williams says. It can be especially fulfilling to meet the needs of the youngest patients. “My message is, don’t be afraid of the pediatric nursing environment,” she says. “There are a lot of loving people.”
This article is the first in a two-part series concerning minority pediatric health. Part two, devoted specifically to the infant mortality epidemic, will appear in the fall 2011 edition of Minority Nurse.
When Reggie Brown of the Detroit Lions was tackled in a game against the New York Jets on December 21, 1997, it appeared to be just another good hit. That is until he didn’t get up. Immediately, Kent Falb, the team’s head athletic trainer, ran out onto the field to determine what was wrong. Unfortunately, the impact displaced Brown’s first and second vertebrae, but it was impossible diagnose that on the field. All Falb knew at the time was that Brown was struggling for every breath. But it was Falb’s quick-thinking reaction along with the help of team doctors that helped to stabilize Brown and prepare him for transport to the nearest trauma center.
While the public may automatically associate athletic trainers, also referred to as sports therapists, with professional athletic teams, their expertise reaches far beyond the playing fields of the NFL, NBA, NHL or MLB. It’s an allied health specialty that’s gaining respect among school districts, sporting clubs, hospitals, physicians, and even in the field of industrial manufacturing.
In fact, the profession has been experiencing significant growth for nearly 30 years. Membership in the National Athletic Trainer Association (NATA), the profession’s leading organization, has grown more than 520% since 1974. Its most recent statistics reveal that membership topped the 28,000 mark in 2001.
And it’s a specialty that continues to create new jobs for sports medicine graduates. In fact, NATA forecasts continued job growth of at least 2,600 more jobs by 2005, and another 7,000 jobs by 2010.
The Fundamentals
In some ways, athletic trainers assume many of the same responsibilities as triage nurses—they’re usually the first ones on the scene and in charge of making split-second assessments. “The trainer is the first-line soldier, working in the trenches with the athletes,” comments Dale Baker, the Smith and Nephew chair for director of education at the American Sports Medicine Institute, based in Birmingham, Ala.
As in Brown’s case, Falb was able to gauge the urgency of the situation and prioritize the initial treatment steps. In less traumatic cases, trainers determine whether or not an athlete’s injury is severe enough to warrant transportation to the hospital. If not, they treat the injury on site and follow up with a rehabilitation plan.
“We’re trained to splint a fracture, perform cardiopulmonary resuscitation (CPR), assess injuries and illnesses, and rehab an injury,” states Laura Harris, PhD, ATC, assistant professor of athletic training at Ohio State University, School of Allied Medical
Professionals in Columbus.
But trainers also work in preventative capacities, such as strength training, conditioning, exercise instruction and overall health maintenance. “Athletes are expected to do a job and the trainer is trying to get them back to work as soon as possible,” notes Michael Mandich, ATC, an independent consultant based in Lewisville, Texas.
Because their responsibilities cover such a wide spectrum of health care tasks, athletic trainers and sports therapists are typically required to have a four-year degree that includes classes in anatomy, physiology, psychology, nutrition and conditioning. Employers also require a variety of certifications, namely athletic trainer certified (ATC), CPR and first aid. Additional certifications focus on specific areas within the profession, and requirements vary depending on the needs of the job.
Of course, to practice at the professional sports level, trainers must have several years of experience and usually an advanced degree. Even at the collegiate level, the competition for positions is extremely stiff, and a master’s degree can be a deciding factor.
“Most trainers recognize the need for advanced education in order to be competitive. It’s difficult to make it to Division I, II or even III without a graduate degree, and it’s especially difficult to get into the professional level,” asserts Harris. “It doesn’t necessarily matter what your degree is in, but it proves you’re someone who has challenged your critical thinking skills.”
Unlike physical or occupational therapists (PTs and OTs, respectively), not all states mandate athletic trainers be licensed. However, 43 states currently demand some form of regulation, from licensure to registration, and the average starting salary hovers around $28,000.
Game Plan
Almost without fail, an individual’s introduction to sports medicine comes from sustaining an injury while playing a sport. “I would say about 98% of us in the profession were injured as an athlete and had to be treated by a trainer. We didn’t know about [the field] until a trainer took care of us,” says Harris, a former gymnast.
Of course, there is that small percentage that simply saw sports medicine as a way to stay directly connected to sports without becoming a professional athlete or coach. Mandich is one example: “Growing up in Green Bay, Wis., I always wanted to work for the Packers. I knew I was never going to play for the team, so I thought the closest I could get would be to become a trainer,” he says.
While Mandich hasn’t landed that dream job with an NFL team yet, he has been able to expand his skills through various positions. Since graduating from the University of Wisconsin at La Crosse in 1997, he has worked at PT clinics, hospitals, and with a number of school districts. “I especially like working with kids because it’s challenging work and always changing. You never do the same thing two days in a row,” he comments.
Little League
Many athletic trainers start off their careers treating high schools athletes, getting them in shape, and prepping them to compete at the more advanced collegiate level. Unfortunately, there are very few individual schools that can afford to hire a trainer to solely attend to students’ needs. Rather, school districts usually contract with local clinics or hospitals to have staff trainers work with the schools on a part-time basis. These specialists split their time between patients and students. “I like being part of the fast-paced environment during the day and working at a high school in the evenings,” Mandich says.
“In more rural environments, some of the education budgets are not as lucrative, and schools may have to hire a trainer to service the entire district instead of one trainer per school,” notes Harris. “At the high school level, trainers are more often used in the game settings for emergency medical situation rather than for their rehab or prevention skills.”
Yet another sport medicine career path is teaching. In this scenario, individuals are in the classroom during the day and on the field or court after school. “However, that’s a job with a high amount of burnout because they are there from early in the morning to late at night,” states Harris. “Typically after five to seven years, many trainers find a spouse or start a family and want better hours.”
Neither the health care nor the educational communities overlook the importance of having certified trainers to support young athletes. Recent studies have shown that too many children are insufficiently trained and, therefore, sustain unnecessary injuries. According to U.S. News & World Report, there is an alarming rise in the number of overuse injuries among children, such as persistent heel problems among young soccer players.
Complicating matters is the fact that many youth teams are coached by parents or sports enthusiasts who may know about the sport’s fundamentals but aren’t necessarily trained in the finer aspects of conditioning. Without a balanced approach to practices, weight training, and overall conditioning, children are at risk for injuring themselves or, at the extreme, causing permanent damage. Additionally, the medical community has expressed concerns about undiagnosed concussions, particularly among football and soccer players.
With more than 30 million children playing on school or recreation-league teams, it’s no wonder that there’s a growing call for change. More organizations and schools are recognizing the importance of appropriate training and, where budgets allow, are seeking the expertise of professional athletic trainers. Even the American Academy of Pediatricians has publicly advocated the use of ATCs for high school sports. Therefore, industry analysts believe this is a work setting that will continue to grow for entry-level sports medicine grads.
The Practice Arena
For those who prefer treating a broader range of people, doctors’ offices, PT clinics and hospitals also offer interesting career options. In these settings, the ATC works along side PTs, OTs, doctors and nurses as part of the health care team. Additionally, patients vary in age, race and socioeconomic backgrounds. Specialists may see professional and collegiate athletes, weekend enthusiasts, children, and even the elderly—all of whom may have suffered an injury or require additional training in order to avoid further complications. Says Mandich, “Athletic training is a very interdisciplinary approach. You’re still treating an active population, they’re just not all athletes.”
Regardless of the environment, sports therapists are required to function under the supervision of a physician and are often the link between patients and the rest of their health care team.
“We work with the primary health care team that consists of the patient, parents if a minor, coaches and physician. Then there is the secondary team, which consists of a rolodex of consultants, such as PTs, exercise physiologists, nutritionists, psychologists, social workers, school nurses and chiropractors,” explains Harris. “Our co-workers run the gamut of the health care professions.”
Additionally, trainers in the clinical setting assume more of a rehab perspective, including exercise prescriptions and patient education. In a time of heightened cost-consciousness, ATCs have proven to be a valuable asset. The NATA reports that physicians have indicated a higher rate of reimbursement when employing trainers. Additionally, ATCs free up doctors’ time to see more patients while continuing to cater to an individual’s needs.
As the population ages, industry analysts anticipate a significant increase in the need for sports therapists in the clinical arena. As people grow older, they become more susceptible to activity-related injuries. Therefore, there will be a greater demand for specialists who can help individuals return to their daily life, which includes instruction on how to prevent further injuries.
Another promising development for ATCs is the recent changes in insurance policies that now agree to reimburse providers for sports medicine treatments. “The list of companies that will reimburse trainers is growing, whereas PTs have been billing for their services forever. In terms of reimbursement, trainers have been undervalued and underutilized,” says Mandich.
“As we gain more progress toward reimbursement—and the number of potential services that are covered by reimbursements—we will also see salaries increase,” adds Harris.
The Professional Team
Perhaps the most promising employment environment for ATCs is nowhere near a football stadium, ice rink or hospital. Rather, it’s within the walls of high-rise office buildings and manufacturing plants. Corporate America has taken notice of the benefits of being physically fit, including the financial results. At its most basic, active employees are less likely to use up sick days and make fewer medical claims against insurance policies—they even add to high company morale.
Although most evidence is anecdotal, more and more companies are encouraging employees to exercise and maintain healthy lifestyles by providing workout facilities, discounts to private gyms, and even perks like free movie tickets to those who prove to be physically active. But back in 1985, Honda of America Manufacturing (HAM) simply wanted to give its employees and their families a place to exercise, get in shape and enjoy recreational activities. That’s when the automotive manufacturer opened its first Wellness Center in Marysville, Ohio.
Now, nearly 20 years later, HAM boasts three Wellness Centers, each with degreed professionals on staff to assist employees with their physical needs.
“Each center promotes wellness with education. There is nutrition information from a registered dietician, and associates can discuss their wellness concerns and have one-on-one consultations for issues like stress management. The centers’ program departments plan recreational activities, such as intramural leagues and holiday parties. The aquatics departments run the pools, swimming lessons and aqua aerobics. The fitness departments’ staff have the capabilities to help individuals with any from training—from a marathon to body building,” explains Dave Litzke, the coordinator for the Marysville center.
While the centers are designed to accommodate individual needs, their staffs also help HAM employees recuperate from injuries, whether suffered on the job or during their off time. “Injured athletes need to return to playing at the same level of competence in the shortest period of time—that is what the athletic trainer does. A lot of those same treatments also work on other workers and athletes, including the weekend warrior,” notes Baker.
“Nowadays, larger organizations are recognizing athletic trainers as entities that are viable options to help offset or deter health care costs,” adds Casey Kirk, coordinator at one of HAM’s Wellness Centers.
Athletic trainers are particularly valuable in the industrial environment where assembly workers are expected to do heavy, monotonous functions that can lead to workplace injuries, if the workers are not properly conditioned.
“When you look at the volume and repetition of movement an associate does in a fast-paced manufacturing environment, the amount of trauma on the body equates or supercedes that of an athlete. Upon their gaining employment at Honda, some people may not have the baseline physical condition that’s required,” explains Kirk. “Associates who work in these facilities need a high level of conditioning.”
Both Litzke and Kirk agree that it’s satisfying to help people not only obtain better performance on the job, but to also enhance their lives as a whole by becoming physically fit. “We work with a diverse group of people in very different ways. In the morning we could be working with a senior citizen, in the evening we could be working with mom who just had a child, and at night it could be helping a high school athlete,” explains Kirk.
Keeping Score
In order for athletic trainers to be effective with their clients, regardless of the setting, a holistic approach is required. Lifestyle, motivations and health care goals are all taken into consideration. “Most of the time, you’re not dealing with sick people but people with health care problems nonetheless. You have address the whole person in treatment,” advises Baker.
And it’s this complete approach that places sports therapists in a unique position within the allied health field. Their broad knowledge, multiple applications, and adaptability to numerous environments make them an asset.
Indeed, it was Kent Falb’s expertise that helped Detroit Lion Reggie Brown not only survive that tumultuous tackle, but allowed him to make a remarkable recovery. Less than a month later, Brown was jogging and doing other prescribed exercises on his way back to a fully functional life and a winning athletic career.
