Mental Health Is a Global Issue

Mental Health Is a Global Issue

October 10 is World Mental Health Day, and nurses are in an excellent position to notice when patients might be suffering from a mental health condition.

Nurses have the knowledge and authority to offer patients the facts about mental health, and they can normalize conditions like depression or anxiety. They can convey the important fact that, like any other medical condition that needs to be treated properly, mental health conditions are a physical and chemical imbalance and not a character flaw.

Although the general attitude toward mental health conditions is gaining more mainstream discussion and acceptance, the attitudes vary greatly. Factors like location or family culture can either normalize depression or obsessive-compulsive disorder make it a forbidden topic. Knowing a little about how your patient sees mental health conditions can help you adapt your approach.

On World Mental Health Day, nurses worldwide can spread the word by offering access to online screening tools through places like Mental Health America or the Anxiety and Depression Association of America. They can offer referrals to area mental health providers if appropriate. This year’s theme focuses on mental health in the workplace, so it’s also a good time to open up discussions in your workplace about paying attention to our own mental health and how it impacts job performance.

But nurses can also just talk about mental health issues in a nonjudgmental manner to put patients at ease. If someone is struggling with something like racing or unusual thoughts, severe anxiety in public places or about specific topics, or experiencing significant impacts to daily life because of sadness, they want to know they are not alone. Nurses can fill that role with care, compassion, and expertise. They are also there to offer hope that with treatment, the person can feel better and can begin to resume a life they are happier with.

Of course, some patients are reluctant to talk about their mental health directly, but they might bring it up in ways that are less obvious. Nurses can ask direct questions or they can listen for clues in conversations. What are your patients saying? Are they gaining or losing weight? Having trouble sleeping? Becoming more argumentative or less engaged with their family and community? Are they missing work or getting in trouble at work for being late or making errors? Are they drinking more or using recreational drugs?

It’s good to remind patients that a mental health condition doesn’t always require medication, although that is often a good option, and it isn’t always a lifelong condition. Other treatments like therapy, stress reduction, and healthy living basics like exercise, quality sleep, and a good diet also help lesson some symptoms. Sometimes problems are a result of a different condition or a side effect of a medication—factors many people don’t know. Getting to the root of the problems will help a patient find the right treatment plan.

The important message is that help is available, treatment works, and that first step can bring them enormous relief. Your positive attitude and compassion can make a big impression and can influence how people see their condition and think about treatment.

On World Mental Health Day, remain alert to what your patients are telling you. You may be able to help change their lives in a way you didn’t expect.

Use Men’s Health Month as a Springboard for Good Choices

Use Men’s Health Month as a Springboard for Good Choices

There are lots of health tips that men and women can both benefit from. Getting enough sleep and exercise and eating a well-balanced diet are some good all-around health tips everyone can use. But the genders have some pretty diverse health challenges. For example, did you know men die, on average, five years sooner than women?

Whether you are a man looking into your own health concerns or a woman with men in her life, Men’s Health Week (June 12 to 18) is celebrating its 23rd anniversary this year and comes right in the middle of Men’s Health Month. If you’re a nurse and a man, use this opportunity to talk to your male patients about the specific health problems men face and what to do to help prevent them or cope with them.

How can men make sure they are doing the best they can for their own health? Here are some pointers from the Centers for Disease Control and Prevention and

Get Screenings

One of the best ways to stay healthy is to get regular screenings for diseases and conditions that can be detected and therefore treated, early. Get an annual checkup so you can stay on top of your blood sugar levels, your weight, your cholesterol, and your blood pressure. Get a colonoscopy if you’re past age 50— earlier if you have a family history of colon cancer or if you have certain conditions that could increase your risk. Be sure a prostate screening is part of your annual exam and examine your testicles at least every month to notice any changes or lumps and bumps. Check your skin regularly for new moles or those that seem to have changed size, shape, or color. If you notice any unusual changes on your body, bring it to the attention of your physician.

Play Hard, But Play Safe

Whatever your interest—biking, running, flying, rock climbing—make sure you practice basic safety rules. Use proper protective gear and equipment. If you’re swimming, go with someone. If you’re hiking or camping, let people know where you’ll be. Bring along extra provisions and proper weather gear. Basic safety considerations can go a long way toward keeping you healthy.

Be Social

Men tend to let their social relationships slide when life gets busy. With work and family obligations, it’s tough to carve out time with friends. But social connections and solid friendships can help ward off many health problems including depression, heart disease, and even dementia.

Make Healthy Choices

All the basic health tips hold true because they work. Eat a diet rich in fruits, vegetables, and plant proteins. Ease up on meats, cheeses, butter, fried foods, and treats like full-fat ice cream. Get daily or near-daily exercise. Get enough sleep. Keep your vaccines up to date. Use protection during sex. Don’t smoke anything, ever. Drink alcohol in moderation. Wear sunscreen. Protect your heart health (and keep inflammation down) by keeping your stress under control. Find help for your stress if you can’t manage it on your own.

Wear Blue to Start the Conversation

The Friday before Father’s Day is traditionally a Wear Blue Day, when anyone concerned about men’s health can wear blue clothing or blue ribbon pins to show support of Men’s Health Month. You can also give a shout out on social media with #MensHealthMonth or #ShowUsYourBlue.

Spread the word about men’s health during the month of June. You never know what kind of lasting impact a few words of wisdom might have,

Breast Cancer Treatment Options: Do Minority Women Have a Choice?

Over the years, a multitude of research data has confirmed that occurrence rates for breast cancer are lower for minority women than for Caucasian women. In fact, Native American women have a lower incidence rate for this disease than most other racial and ethnic groups. [INSERT STATISTICS FROM OMHC] These statistics would seem to indicate that minority women have an advantage over white women in terms of reduced breast cancer risk.

But a look at survival rates for this disease reveals a starkly different picture. Recent studies by Gulattee1, Fulton, Rakowski and Jones2 and others have shown that women from racial and ethnic minority groups have a substantially higher relative breast cancer mortality rate than white women. Skinner and associates3 cite data from the National Cancer Institute demonstrating that the five-year survival rate for breast cancer is 81% for Caucasian women, compared to only 64% for African-American women. Furthermore, other research has shown that the five-year survival rate for Hispanic women is 4% lower than for non-Hispanic white women2 and that Native American women have only a 53% five-year survival rate compared to Caucasian women.4

These statistics paint a bleak picture. Minority women are less likely to contract breast cancer than white women—yet they are far more likely to die from the disease. Ironically, one reason for this disparity is the fact that, because the occurrence rates for women of color are lower, health providers often do not consider breast cancer an important issue for minority populations. Therefore, breast cancer in minority women is less likely to be diagnosed in the disease’s earlier, more treatable stage.

For example, in 1993 the National Cancer Institute noted that “[because of low occurrence rates], it may not [italics mine] be a high priority baseline mammograms. Referrals for breast lumps are sometimes prioritized as low as a ‘seven’ on the Indian Health Service’s priority list, which can result in a year’s delay for referrals for clinical breast examination.”5

Not an Option?

While a number of different treatments for breast cancer exist, the options most frequently offered to patients are either a lumpectomy with radiation therapy to the breast and lymph node area, or a mastectomy. (Chemotherapy may be prescribed along with either treatment.) Although studies have found both treatments to be equally effective6, removing the entire breast is a far more radical and disfiguring procedure that can be extremely traumatic for many patients.

In 1999, I conducted a study examining the life patterns of Native American women who had experienced breast cancer. For this project, which was the basis of my doctoral dissertation at the University of Minnesota in Minneapolis, I conducted in-depth interviews with 10 Native American women, on an average of three times each. First, the unique life pattern of each individual woman was chronicled; then I looked for commonalities among the group’s life experiences.

The participants were not initially asked about their breast cancer experience. The primary interview question was simply: “Tell me about the most meaningful people and events in your life.” Nevertheless, each of the women reported that her breast cancer was one of the most important events in her life.

One of the most surprising findings was that all 10 of these minority women had undergone either single or double mastectomies. None had been treated with a combination of lumpectomy and radiation therapy, which would have allowed them to keep their breasts.


Moreover, not only did each of these 10 women have a mastectomy but, when they spoke of relatives and [Native American] friends who had experienced breast cancer, all of these people except one had also had mastectomies.

While the study was qualitative, and therefore not intended to be statistically valid, this finding was disturbing. Moreover, it could not be attributed to a local phenomenon. These women did not come from just one or two communities. I deliberately sought participants from different parts of the country, to protect their anonymity. Because I chose participants from within a radius of up to 260 miles from me, some of them lived as far away as 520 miles from each other.

The results of this study raise some troubling questions about breast cancer treatment options for minority women. Do health care providers recommend mastectomy as the treatment of choice more often for women of color than they do for Caucasian women? If so, why? What are some of the factors contributing to minority women’s decision to have a mastectomy even though this treatment method is much more mutilating than a lumpectomy with a lymph node dissection and radiation therapy? Are minority women offered enough of a choice between these two procedures? Do they have enough information about the different treatment options available to them?

In Mourning

As the 10 Native American women I interviewed shared their feelings about having had mastectomies, it became clear that several of the participants were indeed traumatized by the experience. “Sarah” (not her real name) found a lump in her breast and had a mastectomy several weeks later. Within a year, cancer appeared in her other breast, resulting in a second mastectomy. Sarah related how she mourned the loss of her breasts. She also suffered from depression after the mastectomies.

“Cheryl” discovered a lump in her breast about the size of the end of her finger. The biopsy revealed a “multifocal carcinoma.” She was referred to an oncologist in a larger town who told her she had a 95% chance of eventually having cancer in her other breast as well. Cheryl had a mastectomy in her right breast and, after being pressured by family members, also had her left breast removed as a preventive measure. Nearly five years later, she continues to mourn the loss of her breasts. Cheryl regretted not getting “a second and possibly third medical opinion.” She still views her breastless body as repulsive.

At age 46, “Martha” was diagnosed with breast cancer when she had a physical examination after being hired for a job working for the federal government. Martha feels “unbalanced” without the breast that was removed. She continues to grieve over her loss.

“Callie” had her first mammogram when a friend suggested that the two of them go together to have breast cancer screening. Callie’s mammogram looked suspicious, and a biopsy confirmed a malignancy. Although Callie was given the option of either a mastectomy or a lumpectomy with chemotherapy and radiation, she chose the mastectomy because she felt “it would be easier on the whole family” and because a close friend had recently had several lumpectomies and within a few months had to have both breasts removed. After the mastectomy, Callie was unhappy with wearing the breast prosthesis and the special bra to accommodate the prosthesis. She said it was uncomfortable and very hot in summer, but she felt that people stared at her if she didn’t wear it.

Unanswered Questions

These accounts suggest that minority women and their families may not be receiving enough information about what the mastectomy procedure involves, and about the effectiveness of alternative methods, to make well-informed decisions about which breast cancer treatment option to choose—if they are indeed presented with a choice of options in the first place.

Clearly, more research is needed in this area. The most critical questions are: Do minority women diagnosed with breast cancer receive a greater proportion of mastectomies than breast cancer patients in the general population? Are Caucasian women more likely to be treated with lumpectomies and lymph node dissections than women of color? And if so, what are the reasons for these treatment disparities?

Beyond this, however, we also need to examine broader issues. Who makes or strongly influences minority women’s treatment decisions? What information do women have prior to the crisis time when a decision needs to be made? What role do nurses play in this scenario—and what role should they be playing? Is more intervention by nurses needed to increase minority patients’ chances of being fully informed and treated fairly? These are questions to which we, as professional nurses, must search for answers.


1. Gullattee, M. (1999). “Breast Health and Culture: Issues for Nursing Practice.” Georgia Nurse, 59 (1), 18-20.

2. Fulton, J., Rakowski, W. and Jones, A. (1995). “Determinants of Breast Cancer Screening Among Inner-City Hispanic Women in Comparison with Other Inner-City Women.” Public Health Reports, 110 (4), 476-482.

3. Skinner, C., Sykes, R., Monsees, B. and Andriole, D. (1998). “Learn, Share and Live: Breast Cancer Education for Older, Urban Minority Women.” Health, Education and Behavior, 25 (1), 60-78.

4. Palos, G. (1994). “Cultural Heritage: Cancer Screening and Early Detection.” Seminars in Oncology Nursing, 10 (2), 104-113.

5. National Cancer Institute (1993). What You Need to Know About Cancer. National Institutes of Health Publication No. 94-1563. Revised April 1993.

6. Thomas, S. and Greifzu, S. (2000). “Breast Cancer.” RN, 63 (4), 41-47.

One Name, Many Faces

The next time you read a statistic such as “there are 2 million Asian Americans and Pacific Islanders in the U.S. with no health insurance” or “visits to the emergency room represent 18.8% of total visits to health care facilities by Asian Americans and Pacific Islanders, compared with 11.7% for whites,” stop and think for a moment. What exactly does the term “Asian Americans and Pacific Islanders” really mean?

Did you know, for example, that this simple-sounding classification actually encompasses more than 30 different countries and 100 languages? Are you aware that there are very few links connecting these different ethnicities other than the government-assigned label? How much do you really know about the people, their cultures and their health?

“The majority of Asian American and Pacific Islander subgroups each have their own distinct language, history, culture and migration pattern [to the U.S.],” explains Kem Louie, RN, PhD, FAAN, associate professor in the Department of Nursing at William Paterson University, Wayne, N.J., and president of the Asian American/Pacific Islander Nurses Association (APINA). “Even though there seems to be a clustering of Asian immigrant groups in larger cities, especially on the East and West Coasts, there is no common thread among them.”

That said, it should come as no surprise to learn that health beliefs, behaviors and risks can vary substantially between the different Asian American and Pacific Islander (API) populations in this country–including Chinese, Japanese, Filipinos, Koreans, Vietnamese, Native Hawaiians, Samoans and many more. Unfortunately, medical researchers traditionally have classified Asian Americans and Pacific Islanders as one broad umbrella group with similar, if not identical, health care concerns. Few, if any, research studies have bothered to make distinctions between Native Hawaiians and Hmong, for example, despite the fact that the people are dramatically different in their diets, languages and traditional beliefs.

But today, in response to federal mandates for increasing cultural competence in health care and eliminating racial and ethnic disparities in health outcomes, this oversimplified view of the nation’s API populations is finally changing. Recent culturally sensitive research studies have begun to uncover groundbreaking information about how the multiple subgroups differ from one another. Here’s an in-depth look at some of the initial findings that are helping to paint a more definitive picture of the health needs of Asian Americans and Pacific Islanders–and the implications of those findings for the nurses who provide them with care.

The Past

According to Census 2000 figures, there are approximately 11.2 million people of Asian and Pacific Islander descent living in the U.S.–up from 9 million in 1990. This increase reveals a significant immigration movement. In fact, 24% of foreign-born U.S. residents in 1997 were Asians or Pacific Islanders. In other words, six out of 10 API persons living in the United States at the time were born elsewhere. That diversity–and varying degrees of acculturation–creates an interesting and complex situation for health care providers.

“There is a changing of demographics for the Asian-American population in general and there are so many nuances and variations from one [API] culture to another,” says Daisy Rodriguez, RN, MN, MPA, an administrative nursing supervisor at San Ramon Regional Medical Center in San Ramon, Calif., and coauthor of a recent study on the health status of Filipino immigrants in the San Francisco Bay area.

Each API subgroup possesses its own cultural characteristics that are just now being examined in terms of how they impact the overall health of the people. The lack of focus on such differences in the past, say some practitioners, may have resulted from a long-held stereotype of Asians as the healthy “model minority.”
“Asians are often seen as a self-sufficient minority group, but that might simply mean that the issues are hidden,” asserts Rodriguez.

Adds Louie, “Many Asian Americans, like those of Chinese and Japanese descent, have been here for generations and have done very well through the acculturation process. But perhaps because they have done so well, the government hasn’t taken seriously the thought of examining [population-specific] health care issues.”

To fill these information gaps, API health care professionals like Rodriguez are initiating their own research to gain insight into the specific health issues affecting their communities. In addition, several federal agencies, such as the Office of Minority Health, have begun investigating health differences between API populations. The 1999 White House Initiative on Asian Americans and Pacific Islanders and the more recent Initiative to Eliminate Racial and Ethnic Disparities in Health are two such endeavors that have dispelled the misconception that Asian Americans have few major health care worries compared to other racial and ethnic groups.


The Present

Although much of the current research data on minority health disparities suggests that Asian Americans and Pacific Islanders generally fare better than African Americans and Hispanics when it comes to health outcomes, this does not mean that API communities don’t suffer from their share of disproportionately high health risks and mortality rates. In fact, recent reports have raised a number of red flags indicating serious API health concerns that physicians, nurses and other health professionals urgently need to address. Some of the most critical areas of concern include:

This deadly disease appears to be a prevalent health problem for Asian Americans and Pacific Islanders in general, regardless of differences between specific subgroups. There is overwhelming evidence that many types of cancer are more common among Asians and Pacific Islanders than even heart disease, which still ranks as the leading cause of death for the U.S. population as a whole. “This is the first time that cancer is the leading cause of death among any [racial or ethnic] group,” Louie points out.

More Asian Americans and Pacific Islanders suffer from liver, stomach and nasopharyngeal cancer than Caucasians, according to the Asian/Pacific Islander National Cancer Survivors Network. More specifically, Vietnamese Americans are 11 times more likely to develop liver cancer than whites, and Chinese Americans report the highest rate of nasopharyngeal cancer among all racial or ethnic groups, according to The Health Care Challenge: Acknowledging Disparity, Confronting Discrimination and Ensuring Equality, a 1999 report ordered by the U.S. Commission on Civil Rights.

But what has many caregivers particularly worried is the growing numbers of API women diagnosed with breast and cervical cancer. Again, incidence rates vary among subpopulations, but Native Hawaiians top the list of breast cancer sufferers, with 106 cases occurring per 100,000 people. Vietnamese women are 2.5 times more likely to develop cervical cancer than women in any other racial or ethnic population. Both anecdotal and qualitative research suggests that these disparities are linked to cultural issues that may be creating barriers to early diagnosis and preventive care.

For example, says Rodriguez, “Some Filipino women who feel lumps in their breasts may not be reporting them to their physicians because it involves a sensitive part of their bodies and they don’t want to be examined.”

Dorothy E. Schmidt-Vaivao, coordinator of the Samoan National Nurses Association (SNNA)’s cervical cancer program, based in Carson, Calif., has encountered similar resistance to cancer screening among Samoan women. “We have had women comment that they don’t want anyone other than their husbands touching them.”

Statistics from the API Cancer Survivor Network further confirm the prevalence of these attitudes. A study of Vietnamese women living in California revealed that 34% had never had a mammogram and 54% had never had a Pap test. The Network also notes that Asian American and Pacific Islander women, as a whole, have the lowest screening rates for breast and cervical cancer among all ethnic groups.

Recognizing the immediate need for interventions in their community, SNNA has initiated two outreach programs in Southern California: the Pacific Islander Women’s Breast Health and Breast Cancer Early Detection Program, and Breast Cancer Awareness–The Fa’a Samoa Way Project. “We go to community churches where we talk to the women members,” explains Schmidt-Vaivao. “Afterwards, the women tell us that they now know why they have to follow up [and get breast exams].”

Although these programs are relatively young, Schmidt-Vaivao believes the grassroots effort is making an impact. “Our goal is to create a prevention awareness in the Samoan community,” she emphasizes.

Tuberculosis and Hepatitis
More than a decade ago, researchers discovered a worldwide resurgence of tuberculosis (TB). This time, however, the airborne, infectious disease had mutated into a new, drug-resistant strain. Even though health experts in various countries had hoped to curtail its spread by developing more aggressive medications and treatment programs, TB remains a serious public health issue, especially in API communities.

The World Health Organization (WHO) estimates that, under current conditions, nearly 1 billion people will become newly infected with TB by 2020, and 35 million will die from it. Many of these victims will be from Southeast Asia, which is already recording 3 million new TB cases per year. These predictions worry U.S. public health officials because of the increased immigration from that part of the world. According to WHO, nearly half of all TB cases in industrialized countries occur in foreign-born people. In the United States, 40% of TB patients are immigrants, many of them from Southeast Asia.


In fact, the American Lung Association reports that Asian Americans and Pacific Islanders are 15 times more likely to contract an active case of TB than Caucasian Americans. As with cancer, this disparity is often exacerbated by cultural taboos that can prevent Southeast Asian immigrants from seeking treatment.

“In some Asian cultures, TB is a stigma,” notes Louie. “And if patients perceive they are being chastised by health care providers, they may not come back for follow-up care or take the treatment at all.” Such behaviors can result in a significant public health risk, experts warn, because untreated or half-treated TB can evolve into a drug-resistant form of the disease.

Similarly, hepatitis B seems to be hitting the API population harder than other racial or ethnic groups. Again, the concern in the public health arena is the effects that can develop if the disease isn’t identified and treated early enough. While not an airborne contaminant like TB, hepatitis B is the leading cause of liver cancer–and as noted earlier, Asian Americans and Pacific Islanders, especially those of Vietnamese descent, have a higher incidence of this cancer than whites.

“The rate of hepatitis B [among Asian Americans] is on the rise, and we weren’t looking in that direction,” says Louie. “Children who contract it are especially at risk for developing cancer later in life.”


Obesity, Diabetes and Kidney Disease
Interestingly, many Asian Americans, and especially Pacific Islanders, are following in the footsteps of other minority groups when it comes to problems with obesity and sedentary lifestyles–unhealthy behaviors that can increase the risk of developing diabetes. In fact, type 2 diabetes has become so prevalent among Americans of all races that health experts have virtually declared it a national epidemic.

Diet, of course, plays a huge role in the both the cause and the treatment of diabetes. While Pacific Islanders have traditionally been known for their healthy eating habits, Schmidt-Vaivao is concerned that this pattern is changing as the people become more acculturated to the American “burgers and fries” lifestyle.

“We [Samoans] have the highest incidence of obesity among the Pacific Islander community,” she says, adding that it’s a problem both in the U.S. and on the island of American Samoa. “There are a lot of fast food places over there now. The people on the island are turning to that eating habit versus the fresh fish and fruit that’s been traditional. It’s scary to see that happening, because it can create problems with diabetes and hypertension.”

Diet is also a leading suspect behind the unprecedented number of renal problems among API subgroups. “I’ve noticed a lot of Samoan people on the island, young and old, on dialysis,” Schmidt-Vaivao reports. “We need to find out why. Is it because of our diet? Is it hereditary? Has this always been going on but we weren’t testing for it before?”

Southeast Asians in the U.S. are also on dialysis in record numbers, says Ana Schaper, RN, MSN, PhD, an epidemiologist at Gundersen Lutheran Medical Center in La Crosse, Wisconsin. Currently there is no conclusive research available to shed light on why so many Asians and Pacific Islander are requiring this complicated treatment.

Generally speaking, America’s API population has some of the lowest numbers of HIV and AIDS cases compared to other minority groups. The Civil Rights Commission report states that Asian Americans accounted for eight AIDS cases per 100,000 people in 1996, which is extremely low compared with the 111 and 52 cases for African Americans and Hispanics, respectively. But within the Asian community, Filipinos lead the subgroups in known AIDS cases, with 45 cases per 100,000.

Furthermore, both Louie and Rodriguez suggest that these statistics may be misleading. “We believe there are more API people who are infected but are not reporting it because of the cultural barriers in their communities,” explains Rodriguez.

In addition to cultural mores, factors such as language barriers and lack of education about the disease may also be clouding statistical findings and preventing people from seeking care. Some research suggests that awareness and understanding of AIDS and its risk factors among the more recently immigrated Asians lags behind that of their counterparts who have lived in America for some time. For example, a 1992-94 National Health Interview Survey found that 21.2% of Vietnamese adults in the U.S. admitted knowing nothing about AIDS and its transmission, compared to only 5.1% of Japanese-American adults.

As more research among API subgroups is conducted, and as community education efforts broaden, the number of reported HIV/AIDS cases among Asian Americans and Pacific Islanders could start to inch upward as more people come forward for testing and treatment.

The Future

Because there has historically been so little definitive research into differences between API subgroups, the current body of knowledge about their health care needs is all relatively recent and preliminary. But now, nurse researchers who are concerned about providing better care to Asian American communities are hoping to make up for lost time–and Asian American/Pacific Islander nurses are leading the way.

“There has been more printed about Asians in the medical literature in the past five years compared with the previous 25 years,” Louie comments. “Still, we need to do a better job in specific data collection if we are really to get a handle on health care concerns among Asian Americans and Pacific Islanders. Currently, we’re dependent on government-gathered data. So much depends on how well the Health Department and other agencies define their categories.”

Adds Rodriguez, “There may be many differences between the various API groups, but the only way to know is to do the research.” That’s exactly why she, along with colleagues from the Philippine Nurses Association of Northern California, initiated their in-depth study of Filipino Americans’ health status, risk behaviors and health promotion practices.

What started as a local survey of older Filipino adults in the Bay Area has expanded into a comprehensive national project, Rodriguez reports. “We realized our focus needed to extend beyond just the elderly because there were so many health care issues in the Filipino community that needed to be addressed.” The study’s initial findings will be presented this summer at the 2002 Philippine Nurses Association of America national conference in Philadelphia.

Schaper recently concluded a project examining the existence of postpartum depression in Hmong women. Wisconsin is home to a large Hmong population and state officials had done some initial research on this issue. Their report concluded that this condition was not prevalent in the Hmong community. However, translators working with Hmong maternity patients at Gundersen Lutheran told Schaper and her colleagues they believed this conclusion was incorrect.

“Because of those initial research results, we weren’t screening Hmong women for postpartum depression like we did with other patients,” she says. As a result, Schaper and several local midwives embarked on a two-year project to clarify the issue. Her findings proved that there was indeed a growing presence of postpartum depression in young Hmong mothers, but because of cultural and linguistic misunderstandings, it had been overlooked by the previous research.

“We didn’t realize how difficult it was to become trusted within the Hmong community,” Schaper adds. “Confidentiality is a big part of their lives. Issues surrounding childbirth are not usually talked about with people outside the family for fear of starting rumors.”

Through her research, Schaper determined that a more symptomatic-oriented screening tool was able to better identify postpartum depression in Hmong women. “Now we screen all our patients for postpartum depression,” she says. “We’ve also developed [educational] materials for Hmong families to help them prepare for the birth of their babies.”

Schaper also discovered some interesting generational and acculturation issues impacting the women in her focus groups. Generally speaking, the younger women who were either born in the U.S. or had lived here since childhood had more “Americanized” expectations about motherhood. It was often the clash between these views and the traditional Hmong philosophies that caused much of the anxiety and depression.

“There was a difference in how the young women saw their world compared with their mothers who had given birth in Laos,” Schaper explains.

The Providers

Other recent studies have confirmed that the degree of acculturation in Asians and Pacific Islanders who have migrated to the U.S. has both direct and indirect connections with their health and their use of health care providers. For example, the Civil Right Commission’s research found that the longer Korean women had lived in the United States, the greater their risk was for developing breast cancer. Furthermore, it’s often the newly immigrated who lack access to health care services the most, in part because of such factors as poverty, language barriers, lack of insurance and unfamiliarity with the American health system.

But that’s also why it’s important for nurses and other health care professionals to approach Asian and Pacific Islanders with cultural sensitivity and an open mind. “While we may not know all the specifics about health care issues in API communities, we do know what makes for good health. Now we have to look at these factors within the framework of their culture,” Schaper advises.

For nurses, that process must begin with taking the time to listen as well as learning to ask the “right” questions. “Samoans don’t believe in saying much,” comments Schmidt-Vaivao. “As health care providers, you have to dig because they won’t volunteer information.”

Such cultural barriers to communication are common among many API subgroups, Louie agrees. For instance, there’s often an attitude of “automatic” respect assigned to health care professionals that can actually be counterproductive. “Asians don’t want to offend a care provider, even if they don’t agree with him or her,” she explains. “Nevertheless, nurses have to find a way to get an accurate assessment. You have to take the time to listen and ask many questions. It seems like a simple philosophy, but when you do it, they’ll respond.”

Nurse researchers who have studied health issues affecting Asians and Pacific Islanders advise nurses in clinical practice who care for API patients to seek out as much information about Asian cultures as possible, whether it’s from published research or simply talking with colleagues who have firsthand knowledge in this area. After all, most hospital staffs are a microcosm of the communities they serve. Don’t hesitate to ask for translation assistance, or for information on traditional diet, religious beliefs or anything else that can help you provide more culturally competent care.

Above all, cautions Louie, avoid the stereotype that all Asians and Pacific Islanders are alike. “The API population is a diverse group,” she says, “and I can’t stress enough the importance of not generalizing.”

Multicultural Internet Resources for Pediatric Nurses

The number of nurses who search for health information on the World Wide Web is increasing every year. Whether you need the information for patient care or for personal reasons, it is important to be able to find reliable and current information resources.

Sometimes the information you get from searching the Internet is just what you need. But very often nurses may end up feeling frustrated and overwhelmed because they get lost in enormous amounts of information, fail to locate what they need or are not sure whether the retrieved information is accurate and unbiased. Choosing a favorite search engine such as Google or Yahoo! and entering a disease or medical condition can often result in hundreds, even thousands, of “hits.” Sorting through it all to find information that is trustworthy can be time-consuming and even discouraging.


Nurses who work with pediatric patients are involved in patient and parent education on a daily basis. In today’s racially, ethnically and culturally diverse America–where, according to the U.S. Census, one out of every four people is non-Caucasian–it is essential for pediatric nurses to be aware of high-quality, multicultural Internet resources they can search for credible health information or recommend to patients and families from a wide diversity of backgrounds.

As nurses know, written patient education materials can be used to support or supplement any oral instruction given to patients. Patients and families whose native language is not English need to receive easy-to-understand reading materials, preferably in their native language, because they are more likely to experience difficulty in understanding verbal instructions delivered to them for the care of their child.

Health literacy is defined as the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions. Studies have shown that racial and ethnic minority patients are disproportionately affected by health literacy problems. Parents who are challenged by their low level of health literacy can face many barriers to getting reliable, up-to-date information related to their child’s health. For example, they may be unaware of existing resources or tools, or lack skills in locating and evaluating health information on the Internet. Or, as a result of the “digital divide,” they may lack access to a computer altogether. This is why it is so important for pediatric nurses to be familiar with quality online health resources they can recommend or download for these families.

The following is a list of selected pediatric health resources on the Web that nurses may find useful. The Web sites are listed in alphabetical order. While not all of them are multicultural, many do offer bilingual or multilingual patient education materials, information on health conditions that disproportionately affect children of color, research data on minority children’s health or links to other culturally competent resources.

American Academy of Pediatrics
The official Web site of the AAP offers a wealth of information on pediatric health topics, including pages created specifically for families and for health care providers. On the Parenting Corner page, parents can learn what different pediatric subspecialists are, find out where to locate a pediatrician or pediatric specialist, order titles from the parenting bookstore and read articles about featured health topics such as immunizations and car safety seats. The Health Topics section features valuable information resources related to health promotion, community health, violence prevention, literacy, and Native American children’s health.

Children First for Health
This attractive Web site from the United Kingdom contains more than 1,000 pages of health information for children, teenagers and parents in 10 different languages, including English, Spanish, French, Arabic and Turkish. While much of the material on the site is geared toward residents of the UK, the information provided can help fill the gap of multilingual pediatric health education materials.

Children’s Health Environmental Coalition
The Children’s Health Environmental Coalition (CHEC) is a national nonprofit organization dedicated to educating the public–specifically, parents and caregivers–about environmental toxins that affect children’s health. Interactive features in the Web site’s HealtheHouse section include Virtual House (a virtual tour of common home environmental health risks) and My Home Quiz, which enables users to receive personalized assistance in identifying and eliminating their household risks.

The Children’s Heart Institute
This award-winning site, created by pediatric cardiologist Hasan Abdallah, MD, presents pediatric cardiology in simple language so that kids with heart problems and their families can understand how the heart works. The site’s excellent Patient Education page includes The Heart House, a simplified illustration of the structure and inner workings of the heart. There is also a Medications page with information for doctors and nurses on pediatric cardiology drugs and their recommended doses.
Sponsored by the Federal Interagency Forum on Child and Family Statistics, this Web site offers easy access to statistics and reports on children’s and family health topics as well as socioeconomic issues affecting children’s health. A key feature of the site is the America’s Children: Key National Indicators of Children’s Well-Being report, which contains extensive information relating to minority children’s health and health disparities. ChildStats also offers links to tables and databases comparing the well-being of children in the U.S. with those in other countries.

FirstGov for Kids: Health Page
Maintained by the Federal Citizen Information Center, FirstGov for Kids is a kid-friendly gateway to a wealth of annotated Web resources from governmental, educational and commercial sites. On the Health page, kids can find answers to questions about healthy eating and exercise, living with a disability, smoking, drug abuse, girls’ health issues and much more.
This site, produced by a physician and partially supported by the Robert Wood Johnson Foundation, provides an extensive collection of links to pediatric health information resources selected from over 400 Web sites.’s central feature is a pair of easily searchable A-to-Z guides to common pediatric health problems–one for health professionals, the other for patients and families. Topics covered include asthma, diabetes, Sudden Infant Death Syndrome (SIDS), suicide prevention and many more. The section for patients includes a link to an excellent selection of Multilingual Patient Education Resources in many different languages.

Health Information Sheets
Here you’ll find downloadable information sheets on various children’s health topics–such as childhood obesity, asthma, depression and child passenger safety–created by medical experts at Children’s Hospital Boston. Parents can also search the site for information about a wide variety of other pediatric health conditions. This Web site is part of a partnership with Yahoo! in which Children’s provides pediatric content to Yahoo! Health. Additional pediatric health information can be found at

Health Topics: Infants and Children
A collection of informational resources on pediatric health issues from the Centers for Disease Control and Prevention (CDC). Topics include immunizations, fetal alcohol syndrome, disabilities, lead poisoning, SIDS and Kawasaki Syndrome, a disease that disproportionately affects Asian children. Detailed information on each topic is provided along with links to other related health resources.

Indian Health Service Kids Page
Created by the IHS especially for kids, this site is enhanced with multimedia features and a variety of attention-grabbing tools–such as word-finds, a comic book and interactive quizzes–to teach young people about health and safety while exploring their Native American cultural heritage. The site includes many resources designed to teach kids decision-making skills about alcohol, tobacco, drugs, gangs, bullying and domestic abuse. While not all of the health information is specific to American Indians and Alaska Natives, the extensive collection of links relating to Native American history, culture, art and story-telling make this site a valuable educational resource.

A project of the Nemours Foundation, KidsHealth provides doctor-approved health information in English and Spanish about children ranging in age from before birth through adolescence. Separate sections of age-appropriate content for kids, teens and parents include original articles, videos, games and expert resources that are accurate, up-to-date and easily understood. Examples of topics covered include prenatal care, nutrition and fitness, asthma, diabetes, sickle cell disease, teen suicide prevention and teen sexual health.

MedlinePlus: Children’s Health Page
MedlinePlus, from the National Library of Medicine and the National Institutes of Health, has a special collection of reliable, up-to-date child health information resources that health professionals and health consumers will both find helpful. The links are organized into categories such as diagnosis/symptoms, treatment, prevention/screening, research, statistics and financial issues. Many resource links under each topic have a Spanish-language version. Nurses who work with low-income, uninsured and immigrant families should be sure to check out the link to the Department of Health and Human Services’ Insure Kids Now program.

National Institute of Child Health & Human Development
The NICHD, one of the National Institutes of Health, offers information on its site for parents, health care professionals and health educators. Many NICHD publications, research studies and patient education materials (some in Spanish) can be found in the Health Information & Media section. Culturally competent resources available here include “Back to Sleep” SIDS prevention campaign materials designed specifically for African American and Hispanic families. Most of the publications are available online in PDF and/or HTML formats; in many cases, paper copies can be ordered free of charge.

NOAH Children’s Health Page
NOAH (New York Online Access to Health), a collaborative project developed by a partnership of several libraries in the New York City area, is a bilingual English/Spanish Web resource dedicated to providing consumer health information that is timely, accurate, unbiased and easily understood by laypersons. The Children’s Health page provides access to high-quality, full-text information on a wide variety of pediatric topics, including asthma, eating disorders, children and AIDS, environmental health, accident prevention, dental care and childhood obesity.

PedsCCM: The Pediatric Critical Care Website
PedsCCM contains a collection of information resources and communication tools for health care professionals who care for critically ill and injured infants and children. All materials submitted to the Web site are peer reviewed. The site is supported in part by the Section on Critical Care of the American Academy of Pediatrics, the Pediatric Section of the Society of Critical Care Medicine, and the Pediatric Critical Care Colloquium.

The Pocket Guide to Good Health for Children (English), (Spanish)
The Agency for Healthcare Research and Quality (AHRQ) offers this online guide to help parents keep track of the immunizations, tests, checkups and other types of health care their children will need. Parents and families from different cultural backgrounds, especially those who are recent immigrants to the U.S., may have had different experiences with immunizations and other types of pediatric preventive care when they were growing up. The information in this guide can educate them and help them make well-informed decisions about what care their children should receive to maintain good health.

Your Child’s Health
This well-organized site, created and maintained by Cincinnati Children’s Hospital Medical Center, contains an extensive collection of patient education materials on a wide range of pediatric health topics. Many of the materials are available in both English and Spanish. Some topics relating specifically to minority health issues include immunizations, sickle cell anemia, lupus, asthma and diabetes.