New federal grants help minority infants in Utah

Every newborn enters the world with the unlimited promise and potential of a life yet to be lived. However, alarming research conducted in Utah has revealed that all babies may not have the same chances, particularly those born to African Americans and Pacific Islanders. According to the Utah Department of Health’s Center for Multicultural Health, Pacific Islander infants (those under 12 months) experience about 8.8 deaths out of every 1,000 births, compared to about 4.5 deaths out of every 1,000 births statewide. Utah’s infant mortality rate hasn’t exceeded eight deaths per 1,000 births in over 20 years. In light of these facts, the U.S. Department of Health and Human Services recently decided to provide over $130,000 over a three-year period to help specialists study mortality rates within various populations in Utah.

Center specialist April Bennett says the information gathered from this process will be used to implement many interventions and outreach programs for minority women. Surveys will be conducted to help expecting mothers identify obstacles that they may experience during pregnancy, such as maternal obesity, smoking, poverty, etc. The ultimate goal is to help them lead better lifestyles.

The number of uninsured in the state has risen in the past 10 years, with Hispanics holding the highest number at 35.7%, compared with only 11.1% of all Utahans. In 2001, 25.8% of Hispanics were uninsured. For uninsured mothers, this means inadequate prenatal care, which can lead to premature labor and put the lives of their infants at risk. Various health department surveys have shown that African Americans have the highest rates of pre-term births of all infants in Utah, one of the underlying issues contributing to a higher infant mortality rate in the state. But, the U.S. Department of Health and Human Services is determined to make an impact on this issue immediately, starting with studying the contributing factors, such as insufficient insurance and a lack of access to care.

An Open Book

Medical terminology can be overwhelming, and despite the best efforts of nurses and doctors, a lot can get lost in translation. Now, for the first time, patients will have access to the notes doctors have made in their medical records through OpenNotes. The initiative, designed to improve communications between medical professionals and patients, is currently being tested in Massachusetts, Pennsylvania, and Washington State. Over 100 doctors and 25,000 patients across the three states are currently testing the project.

“People remember precious little of what goes on in a doctor’s office,” Dr. Tom Delbanco, M.D., at the Beth Israel Deaconess Medical Center in Boston, Massachusetts, notes during a video tour on the project’s website ( “It’s a high-stress situation for everyone, whether healthy or whether sick, and there’s lots of data that shows the memory for what happens in the doctor’s office or in the nurse clinician’s office is not very good.” Delbanco stresses the relaxed approach that home access brings. Via a secure website, patients can browse doctors’ notes at their own leisure.

But what does this newfound access to information mean? OpenNotes is more than just a digital record of physicians’ notes; it provides a streamlined way for patients to interact with their prescribing doctor. Doctors can update their notes after follow-up visits, phone calls, and e-mail correspondence and keep a cohesive record of everything the patient is experiencing. Notes can be presented in a variety of forms, including recorded sound bytes created by the doctor after the visit. It also gives patients the chance to double-check accuracy of notes in their file and correct errors more quickly.

However, many patients don’t even know that they have the legal right to view their doctor’s notes, the result of 1996 legislation under the federal Health Insurance Portability and Accountability Act (HIPAA). As the project continues its test run, there is a clear goal in mind: “The bottom-line evaluation of OpenNotes, to be assessed primarily through Web-based surveys, is straightforward: will patients and providers want to continue online access to notes when the year-long study ends?” says a perspective compiled by all participating doctors published in Annals of Internal Medicine.

“I think this may be a real step in transforming the patient and provider relation,” Delbianco says. “There’s lots of talk about shared decision making, there’s lots of talk about leveling the playing field, there’s lots of talk about not talking down to those whom we serve…My own hypothesis is that we’ll make for better health care and for healthier patients and a healthier citizenry.” Hypothesis, noted.

Health Care Reform One Year Later

President Obama signed the historic Patient Protection and Affordable Care Act into law on March 23, 2010, and its first changes went into effect on July 1 of the same year. But signing that bill was just the beginning of a passionate national health care debate. Even one year later, the dust is far from settling.

One of the most politically divisive issues in the United States’ history, the Patient Protection and Affordable Care Act has been at the forefront of public and Congressional discourse practically from the moment it was written. Reforming the health care laws of the early 20th century has been a topic of discussion since the 1970s.

Yet, revisiting the Patient Protection and Affordable Care Act today is really just rehashing what was signed into law a year ago. Not much has actually changed, though those opposing the Act in the deeply divided Congress say it will change, and soon.

“Reforms under the Affordable Care Act have brought an end to some of the worst abuses of the insurance industry,” says the White House on its health care reform website,

Some of the more prominent facets of the reform include ending lifetime and some annual limits on care, allowing adults under age 26 to stay on their parents’ insurance plans, and forbidding insurance agents from denying care to children with preexisting conditions.

Regarding Medicare, almost 48 million of those receiving aid are eligible for free preventive care, including mammograms and colonoscopies, among other Medicare-specific reforms like prescription drug discounts.

The Act also takes into special consideration the disparities surrounding health care and minority populations. Minority Nursefrequently covers the lack of access to care and disproportionate incidences of disease, and the Patient Protection and Affordable Care Act outlines several initiatives to combat those inequalities.

Especially pertinent to low-income patients, the Act calls for subsidized preventive health care services like annual exams, immunizations, and cancer screenings for those falling into certain eligibility groups. It also invests in cultural competency and language training, chronic condition management teams, and community clinics, with a goal of doubling the number of patients those clinics can serve. The Act also provides funds for home care visits for pregnant women and new mothers, in an effort to stem the low birth weight and infant mortality epidemic affecting minorities.

Finally, by 2014, the Act will establish State-based Health Insurance Exchanges that will create a competitive health insurance marketplace and “guarantee that all people have a choice for quality, affordable health insurance even if a job loss, job switch, move, or illness occurs,” according to the U.S. Department of Health & Human Services.

Multiple parties have already questioned the Patient Protection and Affordable Care Act’s constitutionality, saying Congress does not have the power to require individuals to buy health insurance. The Obama administration has countered these claims, pointing to Congress’s Constitutional right to regulate interstate economic activity. The crux of the Act is fostering those State-based Health Insurance Exchanges, giving states flexibility in their implementation and giving individuals a choice that spans state borders. Surveys conducted by third parties, such as the Harvard School of Public Health, showed many Americans support the Act and many of its provisions, and that there is no swell of people hoping to have it repealed. Obama’s Congressional Budget Office also estimates the Act will eventually save money, reducing the deficit by $138 billion.

The White House, for its part, has tried to tout those functions of the Act that are already helping people, like the Medicare discounts and continued insurance coverage for young adults. However, though millions have already benefited from the law, most of the country has yet to feel its effects, making the continuation of these costly and sweeping changes seem pointless. The Act calls for more drastic health care overhauls through 2014, including many of the provisions directed toward reducing health disparities, but for the uninsured and underinsured, that can be a long wait. 

Of course, speeding up the implementation of the Act isn’t an option, but voting during the 2012 election is. Nurses can support these changes (or refute them) with their vote. In the meantime, nurses can educate themselves, as the repercussions of the Act—whether it endures or is repealed—will be felt in communities and clinics, in juggernaut HMOs and small businesses, for years to come.

California hospital ER overcrowding affects area minorities

A University of California, San Francisco study found that California hospitals in areas with large minority populations are more likely to be overcrowded and divert ambulances, delaying timely emergency care.

The study, published in the August issue of Health Affairs, examined ambulance drivers in hospitals around the state to assess whether overcrowding in emergency rooms disproportionately affects racial and ethnic minorities. Researchers say this is the first study using hospital-level data to show how diversion affects minorities, and research found minorities are more at risk of being impacted by ER crowding and by diversion than non-minorities.

Ambulance diversion takes place when hospital emergency rooms are too busy to accept new patients, so they’re rerouted to the closest available ER. This is especially common in urban areas.

Researchers looked at 2007 data from 202 hospitals around the state, which showed hospitals that served the greatest percentage of minority patients turned away ambulances because of overcrowding far more than those that served the smallest number of minorities.

Researchers found that 92% of the hospitals experienced a median diversion of 374 hours over the course of the year. Those serving high numbers of minorities experienced ambulance diversion for 306 hours, compared to 75 hours with fewer minority patients.

Lead author Renee Y. Hsia, M.D., assistant professor of emergency medicine at University of California, San Francisco, notes that these diversions put patients suffering from conditions like heart attack or stroke at a much higher risk. “Minutes could mean the difference between life and death,” she says in a press release.

There are several reasons that cause emergency rooms to become overcrowded. First, many patients—especially those who are uninsured and don’t have access to primary care services—end up there for less urgent reasons or serious conditions that could have been treated earlier. Additionally, hospitals lack the proper staffi ng to admit patients into the hospital, so patients are stuck waiting. Lastly, hospitals sometimes don’t have the equipment or services needed to treat specifi c medical problems.

The study authors say their research points to the need for systemic reform, including better management of hospital flow and statewide criteria regulating diversion policies.

Minority Mental Health: Shining a Light on Unique Needs and Situations

A recent Institute of Medicine report documented evidence that minorities in the United States received lower levels of mental health care, even when variables such as insurance status and income were controlled, says Debbie Stevens, P.M.H.C.N.S.-B.C., a doctoral student at Emory University’s School of Nursing in Atlanta, Georgia. That’s because nurses play a major role in helping reduce these disparities by educating patients, families, and their communities, Stevens says.

Overcoming cultural barriers

Finding treatment for an illness, such as depression, can be difficult for members of minority groups because they may face stumbling blocks to care, says Vicki Hines-Martin, Ph.D., R.N., F.A.A.N., a professor in the University of Louisville School of Nursing in Louisville, Kentucky.

A major barrier is a perceived cultural stigma of mental health issues. Hines-Martin says some minority populations don’t talk about suicide or depression because it’s seen as shameful. “You may have people who say, ‘I know about suicide, but it has nothing to do with my family or my group,'” she says.

Another problem is that many people may not understand the seriousness of their needs, says Harriett Knight, R.N., a nurse at Sinai Hospital in Baltimore, Maryland. Some people may initially seek an appointment with a specialist, but if treatment involves ongoing medication for an illness, such as depression or schizophrenia, the patient may be resistant to taking the drug as prescribed, or they don’t fully accept that they should continue to take it, says Knight.

Sylvia Hayes R.N., M.S.N., is a nurse in the mental health unit of Peninsula Regional Medical Center in Salisbury, Maryland. She says many patients she sees also don’t accept that mental health is a specific medical science. “They tend to believe their issues are caused by a physical problem,” she says. So they may seek help for a persistent headache, when the real issue may be anxiety related, she says.

In many cases, if a patient realizes that his or her medical issue does involve mental health, they may face another barrier—the fear of being stigmatized. Hayes says she’s seen many African American patients who are afraid that they’ll be “labeled” if they admit to having mental health issues.

“They don’t want to be considered ‘crazy,’ and their family doesn’t want them to be considered ‘crazy,'” says Hayes. “They may be afraid their family will isolate them if they seek help, because then they’ll become an embarrassment.”

Of course, many families support their loved ones suffering from mental illness, regardless of any perceived social stigma. In fact, when relatives are accepting of their loved ones and are willing to help them find care, they can be a vital part of the recovery plan. Many patients will even turn to family members for help before they turn to the medical system, says Hayes. This is good, as long as well-meaning relatives encourage patients to seek professional help when necessary. “It can be a negative if the family delays the patient from receiving the treatment they need,” she says.

Many families actually hold the key to helping patients understand their medical histories, Hayes says. “I’ve seen people with family secrets. They had an uncle or aunt who may have dealt with the same mental health issue,” she says. But if the family shunned that aunt or uncle, the patient may not be as open to finding help.

Family cooperation is also important in treating children and teens. Hayes says many mental illnesses are present at a young age. “I’ve worked with kids as young as two years old,” she says.

However, it may be difficult for well-meaning families to receive satisfactory care. A recent press release from the National Alliance on Mental Illness (NAMI) reports “63% of families reported their child first exhibited behavioral or emotional problems at seven years or younger,” but at the same time, “only 34% of families said their primary care doctors were knowledgeable about mental illness.”

Language and cultural obstacles present another challenge for mental health patients. If a person can’t find a medical professional they can simply talk to, they are less likely to seek medical care, says Patricia Lazalde, Ph.D., Director of Behavioral Health at San Ysidro Health Center in San Diego, California.

San Ysidro serves many Spanish-speaking Latino clients, so it’s important for minority nurses to be able to speak Spanish too, she says. “Minority clients may come in with a variety of stressors, but due to language issues they often don’t seek help until it reaches a crisis,” says Lazalde.

Immigrants of various backgrounds encounter similar stressors. In Louisville, Kentucky, there are increasing numbers of members in immigrant and refugee communities, particularly form Somalia and Myanmar, says Hines-Martin. “They’re newcomers, and they’re dealing with the stressors of changing from one environment to another,” she says. “How they deal with these stressors and whether they want to talk about them is important.”

Members of minority populations may also postpone or avoid seeking care for mental health issues, Hines-Martin says. It’s not so much related to an ethnicity or racial group, but it’s associated with people who hold more traditional values related to their culture, and are less likely to follow mainstream care, she says. “People who are less acculturated into the general population may be less likely to seek help if their culture says it’s not something they should do.”

Financial stress and mental health

The slow economy is also creating a barrier to care for some people, even as it’s identified as a stressor for many. Patients are dealing with the stress of lost jobs, eviction, and foreclosure, says Hines-Martin. She recently completed a study of 127 people in a low-income area and found that poorer residents had almost double the rate of depression as the general public.

“When you look at the economic factors they have to deal with, it makes perfect sense,” Hines-Martin says. The stress of constantly figuring out how to survive can wear down a person, and those factors are associated with depressive systems, she says. “If you have problems in several areas of your life, it can affect your mental health.”

Obviously, financial setbacks don’t always cause mental illness, but they can exacerbate problems in people who are vulnerable, says Knight. “A lot of patients don’t know they’re getting sick until there’s a trigger,” she says. For example, a person may get a call from their mortgage company informing them that they’re being foreclosed on, and they can’t handle their emotions, she says.

Lazalde agrees that whenever there is a loss of financial status within the family, nurses tend to see people with increased levels of depression and anxiety, particularly with wage earners.

“Traditionally, Latino males are the primary breadwinners for families, so the loss of a job and the inability to properly care for the family can really create an additional sense of anxiety, depression, and worry. It’s because they can’t live up to the more traditional roles that they would typically fulfill for the Latino family,” Lazalde says. As a result, there’s an increase of male Latinos coming to seek help for depression and anxiety, she says. The issues affect the entire family. “It creates marital problems. Parents are fighting, and we see the kids coming in with levels of anxiety as well,” Lazalde says.

Residents often have to move out of their homes and move in with relatives and extended family because of financial problems, she says. “Family members have to change schools and meet new friends, and there are not a lot of places they know to go to in terms of seeking resources and finding a shoulder to cry on,” Lazalde says.

Financial problems can also limit access to health care, including treatment for mental health needs. “Many clients are losing medical or health insurance coverage,” says Lazalde. This means fewer people can afford their doctor visits, and they have a more difficult time paying for their prescriptions.

Immigration issues are another stressor in many minority communities. There’s a lot of anxiety and depression when people hear about immigration reform on the news, and they’re worrying about what the outcomes and changes will be, says Lazalde.

“Many of our families are being impacted. A number are split up, with half the family living in the United States and the other half in the native country,” Lazalde says. As a result, wage earners have to support two homes, while they’re responsible for the cost of attorneys and other fees. “They have the stress of keeping the family together.”

Getting involved

One way nurses can help patients deal with their stresses, and improve mental health care overall, is to become active in the communities they serve. This helps build trust between residents and medical professionals, says Hines-Martin.

She says that’s a goal of the Office of Disparities within the University of Louisville’s School of Nursing, where she serves as the center’s Director. The office was started because the school of nursing identified a need to focus on how nursing education, practice, and research could help populations that experience disparities in health, Hines-Martin says.

The Office of Disparities sponsors a variety of programs, including faculty and student activities. Hines-Martin’s most recent project involves working with an entire low-income public housing community. “There are about 700 people in a one-block area,” she says. “It’s a way for us for us to see how economics, food, and trans-generational housing affect how people cope.”

Hines-Martin and her nursing students have found they don’t necessarily see people who are actively engaged in behaviors that are detrimental, such as self-inflicted violence or substance abuse. “But I do see people taking risky behaviors because they don’t care anymore,” Hines-Martin says. These people put themselves in dangerous situations, such as drinking excessively, and the drinking is actually related to depression or a depressed state of mind, she says.

There are many challenges, but the program is yielding results for patients who receive care, says Hines-Martin. She says she’s seen people who received help for psychological conditions and didn’t need to be readmitted to a medical facility after receiving treatment.

There’s also been a decrease in the number of people who have been evicted from their homes because of problems that could be tied to mental illness, such as drug use, says Hines-Martin.

“The community is in partnership with us,” Hines-Martin says. “We’ve learned that people are really invested in having a better understanding of their lives and mental health. It makes it easy to partner with them and invest in them.”

Another way to help build trust is to work with other professionals and community leaders to help educate the population about mental health topics. “Many Latino families aren’t likely to go to a behavioral health specialist initially. Instead, they’re more likely to seek help from clergy or a medical doctor,” Lazalde says. With regards to minority nurses, if they are connected to these influencers, they can help patients find needed behavioral care more quickly, she says.

Identifying red flags

Finding good mental health care is not simply a task reserved for nurses who specialize in behavioral health. Minority nurses in all specialties can help identify red flags that a patient may need a referral for a behavioral health specialist, Lazalde says.

When a nurse in any practice area sees a patient, he or she should look for issues such as a high frequency of usage, she says. The primary care doctor is usually the first person a potential mental health patient will visit, Lazalde says. If a patient has historically only visited the doctor’s office once or twice a year, but now they’re visiting two or three times a month, that’s a red flag, she says. These patients tend to have physical complaints with no apparent cause, so the real issue could be stress or anxiety related, she says.

Minority nurses also need to pay attention to comments patients make during their visits. “They may see a doctor and complain about a headache, or pain in the chest or back, but at the end of the session they bring up family problems,” Lazalde says.

Another red flag could be visits from multiple family members. “If you’re seeing a mom, dad, and siblings for physical problems, all within the space of a month, it could be a sign that there’s some sort of turmoil in the family,” Lazalde says.

And nurses shouldn’t wait until the visit is nearly over before addressing mental health issues. “I think it’s really important for nurses to ask questions early on,” says Lazalde. “Ask how things are going in the family and at home. If the questions are addressed by the medical provider or nurse, it normalizes the situation and allows the family to speak more freely,” she says.

When nurses are rushed for time, sometimes really important pieces of information fall through the cracks. This can be prevented by having a patient fill out a survey at the start of their visit, Lazalde says. She encourages the use of a questionnaire, such as the Generalized Anxiety Disorder 7-item scale (GAD7), to help assess a patient’s mental health needs. “It only takes a few minutes and can be completed in the waiting room, and it doesn’t take away the nurse’s time,” she says.

If it’s determined that a patient should receive specialized care, Lazalde recommends that referrals be “normalized.” For example, when nurses make a referral to a provider who’s an oncologist, it’s normal because the oncologist is simply a member of the health care team, she says.

“So we have to find a way to make the behavioral health provider a member of a team. Instead of making the client feel as if there’s something wrong with them when they receive a referral, they’ll know that they’re just meeting another member of the team,” she says.

Lazalde also has another important piece of advice for minority nurses: don’t give up on your patients. “It often takes more than one referral to be successful. Sometimes we have to refer the patient three, four, and five times,” she says. If nurses approach their roles knowing that it takes multiple referrals before they reach a successful linkage to the other provider, then nurses may be less likely to get discouraged, she says. “We’ll know that the family hears the referral more times and there’s a higher likelihood the patient will go and complete the referral and receive the services they actually need.”

Erasing stereotypes

Perhaps the most disappointing barrier minorities face are the ones caused by the attitudes of medical professionals. Minority nurses can exhibit the same biases about their patients as anyone else, and if they’re not careful, they may start to form negative opinions that could affect their levels of care, says Stevens. “Just because a nurse is a minority doesn’t mean they’re immune to stereotyping,” she says.

Some nurses, particularly those who serve low-income communities, fall into the trap of assuming that some poorer patients check into medical facilities to access prescription drugs, three square meals, or a warm bed, she says. “I’ve heard people say ‘the patients are looking for three hots and a cot,'” Stevens says.

These biases are often reinforced when patients have high rates of repeat visits, she says. But despite the challenges, many minority patients who do receive appropriate care become better and are able to function in society, she says. Minority nurses must provide the best service possible by making a sincere effort to view each patient as deserving of quality medical attention, Stevens says. “Nurses have to fight to eliminate negative stereotypes they see, even if they may have had those same stereotypes themselves,” Stevens says.

Translating policy into practice can be difficult because of how pervasive some biases are, but it can be fought the way any ethnic or cultural stereotype is fought, says Stevens. “It starts with education and awareness.”

Some patients will be difficult, Stevens concedes. But if mental health care is your specialty, you should remain confident that you are helping your patients. Standards of care have to be the same, regardless of who the patient is or where he or she comes from, Stevens says.

Minority nurses are specially suited to help break down barriers and stigmas, build trust among their communities, and help their patients live the best lives possible.