The inclusion of cardiovascular disease as one of the six target areas of the Department of Health and Human Services’ Initiative to Eliminate Racial and Ethnic Disparities in Health has created a heightened need for more culturally sensitive nurse researchers who can investigate the causes of unequal heart disease outcomes between Caucasian Americans and the nation’s rapidly growing minority populations.
[ads:career]
One academic institution that is taking an aggressive approach to filling this research gap is the School of Nursing at the University of Mississippi Medical Center (UMC) in Jackson. Each year, in conjunction with the Jackson Heart Study, the school conducts the Jackson Heart TRAIN (Training for Research Awareness in Nursing), a nine-week summer program for minority nursing students enrolled in historically black colleges and universities (HBCUs).
Funded by a grant from the National Institutes of Health and the National Heart, Lung and Blood Institute, the TRAIN Program is designed to increase the pool of minority nurse researchers by providing theoretical and practical learning activities related to the research process and to minority cardiovascular health concerns. Perhaps even more important, the program also focuses on providing students with special instruction and training to facilitate their entry into graduate nursing study.
Students selected for Jackson Heart TRAIN participate in an intensive, structured learning experience designed to develop their knowledge of research issues, clinical trials, clinical care and methodologies affecting ethnic minority communities. The program provides students with financial support, including a stipend, a housing allowance and travel reimbursement for domestic travel to and from Jackson.
Who is eligible to apply to the program? You must be an undergraduate ethnic minority nursing student enrolled at UMC or at an HBCU anywhere in the country, and must be in your junior year at the time of application to TRAIN. Students are selected on the basis of their GPA, academic transcript, three letters of reference and an essay on “Why I am Interested in Cardiovascular Research and How I Will Use the Experience Gained in the Future.”
Next summer’s Jackson Heart TRAIN Program will be held June 2 to August 1, 2003. The deadline for submitting applications and support documentation is March 15. To obtain an application, or for more information, contact Dr. Rosie Lee Calvin, principal investigator and director, UMC School of Nursing, at (601) 984-6222 or [email protected].
The United States is in the midst of an epidemic. Obesity rates across the country are staggering, having increased dramatically over the last 25 years. Research suggests that more than one third of adults, or over 72 million people, were obese in 2005–2006.1
Though there was no significant change in obesity numbers between 2003–2004 and 2005–2006 for men or women, this does not negate the need to direct attention and intervention efforts into mitigating the effects of obesity and addressing the underlying reasons for its high prevalence.2 And while this problem runs rampant among adults, it has been steadily encroaching upon children and is particularly disproportionate among minorities.
Defining obesity: a refresher
According to the Centers for Disease Control and Prevention (CDC), the body mass index (BMI), which correlates with body fat, determines overweight and obesity ranges using weight and height. An adult with a BMI of 25–29 is considered overweight; a BMI of 30 or higher is considered obese.3 BMI is calculated by weight in kilograms and height in meters squared (kg/m2); for English measurements, use lb/in2 x 703. BMI charts are also widely available on the Web, including at the CDC website (www.cdc.gov).
Obesity has been linked to a number of chronic health conditions, including diabetes, cardiovascular disease, and some forms of cancer, as well as increased health care expenditures—it simply costs more to be obese.4 In particular, an obese person spends $1,429 more in medical bills compared to a person of a healthy weight. The annual obesity expenditure in the United States is an estimated $147 billion dollars.5
While the pervasiveness of obesity is troubling in and of itself, some of the more shocking statistics are found amongst minority populations. A 2009 CDC Morbidity & Mortality Weekly Report revealed that from 2006–2008 African Americans had 51% higher prevalence of obesity compared to Caucasians, with Hispanics having a 21% higher prevalence.6 African American and Hispanic women seem to be particularly vulnerable and representative among these numbers. Recent data show racial and ethnic obesity disparities for women, but not for men. Non-Hispanic black and Mexican American women were more likely to be obese than non-Hispanic white women. For men in general, obesity prevalence rose from 27.5% in 1999–2000 to 32.2% in 2007–2008.2
The disproportionate instances of obesity within minority populations may have roots in a number of factors. However, none can be addressed without examining the effects of U.S. health disparities, as well as the impact of social determinants of health. Two overarching national public health goals in the United States are to increase healthy life expectancy at all ages and to eliminate health inequalities according to gender, race or ethnicity, education or income, disability status, geographic location, and sexual orientation.7 But persistent health disparities—inequalities in health outcomes because of social disadvantages—have been an ongoing challenge within minority communities, hindering those national goals.4 According to Carter-Pokras & Baquet (2002), any health disparity should be viewed as a chain of events signified by a difference in environment; access to, utilization of, and quality of care; health status; or a particular health outcome that deserves scrutiny.8 Education and income levels contribute to disparities, but living conditions and behavioral risk factors also impact health.
These disparities become more notable considerations as the minority population increases. A U.S. Census Bureau population profile of 2010 indicates that over the past decade America’s population has grown by 9.7%, accounting minorities for 92% of that growth. The number of Hispanics grew approximately 43%, with the Asian population at the same rate, and the African American population increased in number by 11%. The total minority population increased 29% over the past decade, and now comprises approximately one-third of the American population.9,10
Evidence also suggests a relationship between socioeconomic status, income, education, and higher rates of overweight and obesity.1 Members of minority communities often reside in more urban areas, and these areas may provide limited or no access to healthy options for food, physical activity, or security. Residents in low-income urban areas are more likely to report greater neighborhood barriers to physical activity, such as limited opportunities for daily walking or exercise and reduced access to stores that sell healthy foods, especially large supermarkets.11
Nurses in the fight against obesity
Public health nurses are effective in responding not just to the needs of the majority population, but also allowing for, even ensuring, the inclusion of minority segments. Aware of the unique challenges these populations face, nurses can educate—and advocate—for change where they work and live. After all, isn’t the term “public” indicative of representation of diversity among the population?
Obesity is a complex problem, and finding the root causes will help to inform possible solutions. Contributing to the problem is a lack of income and education, cultural differences, environmental changes, learned behaviors for coping, and food advertisements. From an economic perspective, people purchase foods they can afford; they are not necessarily thinking about the future consequences of those choices. And with lower-income populations—also consistently disproportionately composed of minorities—affordable healthy food alternatives should be strongly advocated, (i.e., farm cooperatives, farmers’ markets, free community nutrition workshops, etc.). Safety concerns might also make it hard for people to walk about their neighborhoods and for children to go out and play; nurses can inform their patients of known safe exercise areas and other community resources, like high school gymnasiums or free athletics classes at a public park or YMCA.
The influence of social factors, access to quality food and exercise, and individual factors around maintaining a healthy weight must be addressed. Each has an indirect and direct influence on behavioral choices and may ultimately impact weight. Individual-level characteristics (including income, cultural preferences, and genetic predisposition) contribute to macro-level considerations (neighborhood services, government health initiatives, education, etc.). These all feed the obesity epidemic, the significance of which public health nurses cannot overlook. Structures that affect physical activity behaviors and dietary choices are emerging as important and are potentially amenable to public health intervention efforts.
Yet, nurses cannot fight alone. A collaborative effort must be sought to help sustain community programs, which means establishing dialogue and partnerships between all stakeholders. Key legislative offi cials, health care providers, local businesses, community residents, journalists, educational administrators, nursing organizations—all must rally to address the problem of obesity systemically. The CDC’s Division of Nutrition, Physical Activity, and Obesity and the American Obesity Society (www.obesity.org) have online resources to help nurses and other health care professionals combat obesity. On an individual level, nurses can assess their own living, working, social, and other environments. They can engage and advocate for their immediate community and, ultimately, their state and country. Nurses working in public health facilities can be especially influential, as they may treat patients with the fewest resources. Educating one’s patients—whether through simple instructions during an exam, dispersing informational brochures, or even volunteering to speak at local schools and community centers—is the fi rst step in prevention.
Though health care is not yet available to all at this moment in history, public health nurses can reduce the impact of obesity on the nation’s most vulnerable populations.
References
C.L. Ogden, M.D. Carroll, M.A. McDowell, and K.M. Flegal, “Obesity among adults in the United States—No Statistically Significant Change Since 2003–2004,” NCHS Data Brief No 1, National Center for Health Statistics (2007). Accessed 2011. www.cdc.gov/nchs/data/databriefs/db01.pdf.
K.M. Flegal, M.D. Carroll, C.L. Ogden, and L.R. Curtin. “Prevalence and Trends in Obesity Among US Adults, 1999-2008,” The Journal of the American Medical Association, 303, no. 3 (2010): 235–241. Accessed 2011. doi:10.1001/jama.2009.2014.
Centers for Disease Control and Prevention, “Defining Overweight and Obesity,” (2010). Accessed 2011. www.cdc.gov/obesity/defining.html.
A. Stratton, M.M. Hynes, and A.N. Nepaul. “The 2009 Connecticut Health Disparities Report,” Connecticut Department of Public Health (2009). Accessed 2011. www.ct.gov/dph/cwp/view.asp?a=3132&q=433794.
Diana Holden. Fact Check: The Cost of Obesity. “Fit Nation” coverage, February 2010. CNN. com, accessed 2011. www.cnn.com/2010/HEALTH/02/09/fact.check.obesity/index.html.
L. Pan, D.A. Galuska, B. Sherry, A.S. Hunter, G.E. Rutledge, W.H. Dietz, and L.S. Balluz. “Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006–2008.” Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report 58, no. 27 (2009): 740–744. Accessed 2011. www.cdc.gov
Sam Harper and John Lynch. “Trends in Socioeconomic Inequalities in Adult Health Behaviors Among U.S. States, 1990–2004.” Public Health Reports 122 (2007): 177–189.
Olivia Carter-Pokras and Claudia Baquet. “What is a ‘Health Disparity’?” Public Health Reports 117 (2002): 426–434.
“The Census: Minority report,” The Economist, Accessed March 31, 2011. www.economist.com/node/18488452.
“Population Profi le of the United States.” U.S. Census Bureau. Accessed 2011.
J.L. Black and James Macinko. “Neighborhoods and Obesity.” Nutrition Reviews 66, no. 1 (2008): 2–20.
The smell of burning sagebrush, sweetgrass and cedar perfumes the air. A drum keeps time softly as voices quaver in song and prayer. A traditional American Indian smudging ceremony is in progress at Deaconess Billings Clinic (DBC) in Billings, Montana–a routine procedure per clinic policy, thanks to DBC’s Native American Patient Advocate, Lanette Perkins, BSN, RN.
For many Native peoples of Montana, Wyoming and the Dakotas, the mingling of smoke, breath and prayer in a smudging ceremony is believed to create more integrated spiritual and physical health or a more peaceful transition to death. “It gives them a chance to express their religious beliefs and center themselves for hope,” Perkins explains.
Many hospitals are reluctant to allow ceremonial smudging at their facilities, citing fire safety and other concerns. But the Native American Patient Advocate Program at DBC is demonstrating how, with thoughtful planning and a little extra effort, modern medicine can make room for traditional healing practices and cultural beliefs.
The smudging policy that Perkins developed for the clinic is “worded so that it’s not locked into just one culture,” she says. “At this time it might benefit one group of people, and one culture might be utilizing the policy, but it’s not exclusive to [Native American] culture.” Certain Asian cultures also perform similar ceremonies, Perkins explains. She has filled requests for copies of the policy from other hospitals, colleges and even an Aboriginal group in Ottawa, Canada.
It’s a Family Affair
Billings stands on the banks of the Yellowstone River, surrounded by forests, mountains and the Crow Indian Reservation. Deaconess Billings Clinic, which is the largest health care facility in the region, serves not only the usual mix of townspeople, ranchers and tourists but also Hutterites [a religious group whose beliefs are similar to the Amish] and Native people representing more than 40 different tribes.
Determined to serve all patients effectively, DBC received grant funding from the Rocky Mountain Technology Foundation to establish the Native American Patient Advocate Program, believed to be the first of its kind in the United States. Perkins was hired to implement the program and has been on the job for three years now. She works with patients, their families, hospital staff and tribal leaders to eliminate cultural barriers that could affect the quality of care Indian patients receive.
More About the “Getting to the Heart of It” Video “Getting to the Heart of It: Bridging Culture & Health Care,” the video that Native American Patient Advocate Lanette Perkins, BSN, RN, uses in her cultural competence training sessions, is an excellent resource for nurses and other health care professionals who work with American Indian patients and their families. Developed by the University of Minnesota School of Nursing in Minneapolis, in partnership with Indian community representatives and health care providers from the Ho-Chunk, Chippewa and other tribes, the 18-minute video focuses on what health care providers need to know about Indian culture and how to translate that knowledge into culturally appropriate care.Featuring expert advice from Indian physicians, nurses and patients, “Getting to the Heart of It” covers such important issues as:
• learning about a tribe’s history and culture;
• establishing trust and respect with the tribal community;
• learning how to communicate with patients about their cultural, religious and health- related beliefs; and
• the importance of respecting traditional tribal healers and partnering with them in the health care process.
For more information about this award-winning video, contact Ann Garwick, PhD, RN, at the University of Minnesota School of Nursing, (612) 624-1141, [email protected]
“When I go into a room [to meet with patients and family], I hope I can be helpful,” Perkins says. “The first thing they want to know is, who’s your mother–or in my case, who’s your dad. My dad is Crow and my mother was German, and I also have Chippewa and Cherokee ancestry. [The nursing profession frowns on nurses discussing their personal lives with patients], but there are no big secrets in my family and this the only way I can get my patients to trust me and start to work with me. The trust part is the biggest issue.”
Establishing that trust starts with introducing yourself, she continues. “I usually go around the room and introduce myself [to everyone], and they will usually tell me their name and how they are related. Some of them like a light handshake–not a heavy handshake, which may seem like a sign of aggression, but a light handshake.”
In North Plains tribes, according to Perkins, “anyone in your generation could be considered your brother or sister, even if they may actually be a very distant cousin.” Similarly, anyone in the parents’ generation may be considered a father or mother, and so on. Most hospitals are not used to accommodating such large extended family groups, but for Perkins it’s another vital function of her job as patient advocate.
For each patient, she says, “I find the family spokesperson, usually a lady about my age, because most Montana tribes are matriarchal. I talk with her and find out who is in the family and make a list. This helps the clinic staff recognize who is family to be contacted in case there is an emergency, and who will be visiting the patient. I also sort out who are the biological parents, siblings and spouse, because when it comes time for health care decisions, we need to make sure that we speak with what would be recognized in Western culture as the core family.”
Mediating and Educating
Perkins estimates that about 60% of the staff at Deaconess Billings Clinic like the way her program seeks to adapt hospital routines to meet the cultural needs of Native American patients, but about 40% see her as an obstacle that makes it harder to do their jobs.
“I tell them, I’m not the ‘Indian Police,’” she says with a chuckle. More seriously, she adds, “I tell them, if you see me walk into your area, don’t get nervous. If I ask to have you reassigned to another patient [because of problems in establishing an effective relationship with an Indian patient], don’t think of it as a negative. Think of it as a positive: Something’s not working out well and we have to make a change [in order to provide the best possible care for that patient].”
Indeed, some of her nurse colleagues are more than willing to ask Perkins to intervene when such problems occur. “They’ll call me if there’s something that’s not going right,” she explains. “They’ll say, ‘Lanette, can you come up and see what you can do to help?’ And if there are people [who may feel threatened by] what I do, that’s an issue that they’ll have to get past.”
In addition to acting as a mediator and resolving cultural misunderstandings that may arise between Indian patients, families and staff, Perkins’ job functions also include providing cultural competency training for clinic staff. “Every two weeks, I do a portion of our new staff orientation program and we talk about culture,” she says. “[I explain that] culture can be nurses to nurses, department to department, and then we get into the [ethnic cultural differences]. We talk about respect, listening and communication. I use the University of Minnesota video ‘Getting to the Heart of It: Bridging Culture & Health Care’ to get the staff thinking about their communication style.”
Many experts agree that communicating with respect is an essential element of cultural competence. “[In a busy health care setting,] we get wrapped up in what we’re doing, we get into a hurry and forget to take time to be respectful,” Perkins observes. But she emphasizes that “it doesn’t matter whether it’s a patient or a co-worker, we need to be respectful.”
While her official title is Native American Patient Advocate, Perkins says she’s available to advocate for anyone who needs cultural assistance. “For example, we had an Aboriginal lady from Australia in our mental health facility,” she recalls. “They had her there for three or four days and couldn’t figure out [how to communicate] with her, so they decided, ‘Why don’t we call Lanette and see if she can help?’
“I went over and just did the listening strategy. I asked questions, letting her be the teacher. It was one of my most interesting and rewarding experiences, because I learned a lot about Aboriginals. We found out what the patient’s issues were and we were able to discharge her in three or four more days.”
A Personal Cultural Journey
Recognizing that historically the North Plains tribes were often at war with each other, Perkins invests time and energy in developing relationships with various tribal leaders. She visits reservations and last year she organized a multi-tribal conference at the clinic. “If I’ve had personal, face-to-face interactions with people, the next time I call them on the phone it goes a hundred times better,” she observes. “I never take those relationships for granted. I feel blessed when I go and talk with the tribal leaders and we work together as a team.”
Perkins’ nursing career reflects aspects of her own heritage that are meaningful to her. “My German grandmother was a teacher,” she remembers, “and my Indian grandmother was a certified nurse’s aide. She kept talking to me about nursing. In high school I worked as a nurse’s aide and I wanted to be a nurse.”
She enrolled in Montana State University, but her Indian scholarship was revoked on a technicality. She worked two jobs to pay her own way but was able to struggle through only five quarters of college. Though she never completely gave up on her dream of becoming a nurse, she did have to put it on hold for a while.
“I started my family and for 12 years I had a courier business,” Perkins says. “Mine was the only woman-owned, minority-owned transportation business in the state of Montana. I had contracts with the city, the county, Montana Power. I learned about business, customer service, how to write contracts and how to do a lot of things under state and federal regulations.
“Then, unfortunately, my husband became disabled and couldn’t work, so I had the opportunity to go back to school on scholarship,” she continues. “I went to Salish Kootenai College in Pablo, Montana, and got my ADN. But partway though I realized that for some of the things I wanted to do as a nurse, I should at least have my bachelor’s. So I took extra classes as part of my ADN program. I graduated in May, took my state boards in July and in August started the bachelor’s program at Missoula. I got my BSN in three more semesters. I didn’t want to move my family again, so I stayed in Missoula and worked for the Indian Health Service till my son graduated from high school.”
In many respects, Perkins’ current role of patient advocate is a logical progression in her personal cultural journey. She admits that “I took a chance when I came to Deaconess, because they didn’t have the program all developed,” but she’s glad about how everything has worked out. “For me it has been a real opportunity to learn and to build,” she says.
In addition to her work at the clinic, Perkins mentors students in the Caring for Our Own Project (CO-OP) at the Montana State University College of Nursing. This nationally recognized program is designed to increase Native Americans’ access to culturally competent health care by recruiting, retaining and graduating Native nursing students.
Perkins also serves on the board of directors of the National Alaska Native American Indian Nurses Association (NANAINA). She values the opportunity of getting to know other Indian nurses through NANAINA and hearing their success stories.
As for where her own story will eventually lead, Perkins speculates that “one of these days, I’ll go back to school and get my master’s in nursing education. I want to teach. One of my grandmothers was a teacher and one was a nurse, so I’d be combining both of their vocations. Both are important components of me.”
While studying for an American Nurse Association Commission on Nurse Certification examination, I was surprised to read a question regarding an African American male diagnosed with lung cancer. The question inquired how a master’s-prepared nurse would respond when the patient said he would have a better prognosis if his doctor listened to his symptom complaints. Interestingly, the “correct response” did not strike me as a response at all; it was an acknowledgement of his statement, given that statistically, despite his education or economic level, he would likely still receive substandard health care treatment as an ethnic minority.
I shared this scenario with my colleague Maria Krol, a fellow Bridgeport Hospital School of Nursing faculty member. Ms. Krol, Peruvian by familial origin, and myself, a Jamaican American, began to discuss the unfortunate state of health care if this has to be a question on a certification exam. Ms. Krol shared her own personal experience of witnessing Latino patients, who spoke minimal or no English, unable to have their health care needs explained to them despite the availability of translator phones, an electronic translator, and trained health care translators. She noted the problem was often the infrequency of translator device usage and the lack of availability, specifically during the evening and nighttime hours, of trained health care translators. Ms. Krol also noted that in outpatient settings like clinics and physician offices, translator devices and health care translators are often unavailable. How do we begin to bridge the gap imposed upon segments of our society in America—the land founded upon opportunity for all?
Examining the case for the existence of vulnerable populations
As the American Heart Association noted in Health Day News, “wide differences in the care of people who’ve had a stroke still exist between whites and ethnic minorities in the United States.”1 Dr. Salvador Cruz-Flores, the study’s author and Director of the Souers Stroke Institute at Saint Louis University, says, “We see disparities in every aspect of stroke care, from lack of awareness to stroke risk factors and symptoms to delayed arrival to the emergency room and increased waiting time.” Even after the stroke has occurred, disparities continue throughout the treatment and rehabilitation stages of care, he says.
The American Heart Association suggested that the varied medical risk factors of diabetes, obesity, and high blood pressure contribute to the disparities among ethnic minority groups in stroke care. It was noted that amongst African Americans and Hispanic Americans, the risk of metabolic syndrome and diabetes is significant, placing both ethnic minority groups at increased risk for stroke.
In her article “Vulnerability in Research and Health Care: Describing the Elephant in the Room,” Dr. Samia A. Hurst discusses how although the medical and science communities recognize vulnerable populations, historically, figuring out ways to protect them has proven difficult. Hurst provides a comprehensive list consisting of cited examples of vulnerability in human subjects research, including the following:
International Conference on Harmonisation (ICH) of Tripartite Guidelines: Those incapable of giving consent, minors, refugees, nomads, homeless persons, ethnic minority groups, patients in emergency situations, unemployed or impoverished persons, persons in nursing homes, patients with incurable diseases, and more
Council for International Organizations of Medical Sciences (CIOMS): The unemployed, members of communities unfamiliar with modern medical concepts, individuals who are politically powerless, patients with incurable disease, prisoners, refugees or displaced persons, nomads, homeless persons, some ethnic and racial minority groups, patients in emergency rooms, people receiving welfare benefits or social assistance and other poor people, residents of nursing homes, elderly persons, and more
Declaration of Helsinki: Persons susceptible to coercion, persons who will not derive direct benefits from participation, persons for whom research is mixed with clinical care, and incompetent persons
Belmont Report. The very sick, the institutionalized, economically disadvantaged, and racial minorities
45 Code of Federal Regulations (CFR): Pregnant women and fetuses, children and prisoners2
The variation among organizations regarding what populations are considered vulnerable is significant in itself, it contributes to a narrowed view of who should be protected and why. Persons can become vulnerable through injustices, their own fault, and misfortune; nevertheless, the goal of all health care organizations, as well as organizations conducting research with vulnerable populations, is to ensure equality of services rendered.
Disparities in ethnic populations across the socioeconomic spectrum
D’Anna, Ponce, and Siegel, in their article “Racial and ethnic health disparities: evidence of discrimination’s effects across the SEP spectrum,” discuss how discrimination, from a psychosocial perspective, can be a stressor for affected populations. Ultimately, the discrimination ethnic/racial groups experience could contribute to having physical and mental health problems. The purpose of their research was to investigate the association between perceived discrimination in receiving health care and racial/ethnic disparities in self-rated health status, physical, and emotional functional limitations among a diverse sample of California adults; to assess whether discrimination effects vary by racial/ethnic group and gender; and to evaluate how the effects of discrimination on health are manifest across the socioeconomic position (SEP) spectrum.”3
The diverse racial/ethnic group data was collected from a 55,428-participant California Health Interview Survey in 2001. The researchers noted two types in their study that qualitatively identified discrimination: “discrimination due to race/ethnicity, language, or accent and other discrimination.”3 The California Health Interview Survey included such topics as alcohol and cigarette use, diet, exercise, dental health, mental health, medical care/advice, physical health conditions, the utilization of health care services, compliance with recommended tests and treatment, prescriptions, perception of discrimination in health care settings, immigrant status, gun access, sexual orientation, education, employment, income, age, sex, race/ethnicity, and self-reported physical and mental health status. The survey frame included only Californian households that had listed landline telephone numbers. Interviews were conducted in Korean, Vietnamese, Spanish, Chinese (Cantonese and Mandarin dialects), Khmer, and English.
D’Anna, Ponce, and Siegel found discrimination due to race/ethnicity and language/accent, as well as other discrimination, had a negative effect on how ethnic minorities self-rated their emotional and physical health. And, while researchers observed variations between racial/ethnic groups and even gender, the effect of discrimination on physical health was noted as attenuated among participants of higher socioeconomic position. For example, Latinos reported discrimination when it came to emotional health; however, for physical health, minimal discrimination was noted.3 The Latino population encompasses a broad mix of persons from different countries that from a linguistic, migratory, and cultural perspective vary greatly. This alone may prompt the need for further studies in health care discrimination for similar yet distinct racial/ethnic groups.
Historically, discrimination and racial harassment have been linked to poor health and health outcomes as self-reported by ethnic minority patients.4 Researchers noted that prolonged exposure to inferior health care treatment invalidated patients’ self-worth, blocked aspirations, and damaged their self-esteem. The ethnic minority patients’ initial psychological response may eventually develop into the physiological problems that lead to deterioration in health manifesting in the form of such conditions as cardiovascular disease, mental illness, and hypertension.4,5
Exploring the direct socioeconomic effects of physical illness in an ethnic minority group with education and income being factors, Jackson researched the inverse association existing between hypertension and income for African American men and women.6 Roux et al. noted that in New York City’s Harlem, African American women had a decreased risk of hypertension that correlated with the achievement of a higher level of education and income, whereas African American men had a higher risk for hypertension with the achievement of a college education.7 Researchers recommend further exploration on how education and income in other ethnic minority groups affect psychological and physiological health outcomes.
How do we repair a system that doesn’t seem to empower the education of underrepresented ethnic minority groups on their risk factors for poor health outcomes? And when do we actually use current research to not only acknowledge that disparities exist, but hold health care facilities and professionals accountable for the delivery of quality health care to all of their patients regardless of their ethnic origin?
As nurses, we are patient advocates who assist in navigating the health care system. Our goal is to ensure our patients obtain optimum wellness by educating them on such topics as safe medication administration, exercise, self-injections of prescribed medications, daily weights, and various signs and symptoms of bodily and emotional illnesses. Therefore, when we see patients that are not given thorough or accurate medical, surgical, rehabilitation, or psychiatric treatment, are we not obligated as health care professionals to ensure equitable treatment is provided?
The Department of Health and Human Services released a plan in 2011 to reduce racial and ethnic disparities in the United States. The plan has five major goals: “transform the health care system by expanding the health care coverage of persons and thereby increase access to health care; strengthen the health care workforce by recruiting more minorities for medical and public medical careers, supporting of the training of community health workers such as promotoras (Spanish-speaking community health workers), and improving health care interpreting services; improving the health of minority communities through community transformation grants to target health disease, tobacco-related illnesses, flu, asthma, maternal child health, and childhood obesity; the improvement of research and data collection involving racial and ethnic minorities; and, lastly, an increase accountability and transparency of the Department of Health and Human Services’ programs that are working toward the goal of the reduction of minority health disparities.”8,9
As nurse educators responsible for preparing the minds of future nurses for direct patient care in a variety of clinical settings, we feel obligated to train our students understand and respect the rights of all people, as they deserve the opportunity—through the conveying of nursing and medical knowledge—to make informed decisions about their health care and to receive quality care. Skin color and language differences should never be a consideration that clouds our judgment.
References
Health Day News, retrieved on May 26, 2011, American Heart Association, (2011): 1-2.
Samia A. Hurst, “Vulnerability in Research and Health Care: Describing the Elephant in the Room,” Bioethics 22 (2008): 193.
Laura Hoyt D’Anna, Ninez A. Ponce, and Judith M. Siegel, “Racial and ethnic health disparities: evidence of discrimination’s effects across the SEP spectrum,” Ethnicity and Health 5 (2010):
121-143.
S. Karlsen and J.Y. Nazroo, “Relation between racial discrimination, social class, and health among ethnic minority groups,” American Journal of Public Health 92 (2002): 624-631.
B.K. Finch, et al., “The Role of Discrimination and Acculturative Stress and the Physical Health of Mexican Origin Adults,” Hispanic Journal of Behavioral Sciences 23 (2001): 399-429.
P. Jackson, “Health and inequalities among minority populations,” The Journals of Gerontology: Series B 60 (2005): S63-S67
A. Diez-Roux, et al., “Prevalence and social correlates of cardiovascular disease, risk factors in Harlem,” American Journal of Public Health 89 (1999): 302-307.
Sherry A. Gilead, Garth Graham, and Howard K. Koh, “Reducing racial and ethnic disparities: the action plan from the Department of Health and Human Services,” Health Affairs 30 (2011): 1822-1829. doi: 10.1377/hlthaff.2011.0673.
J. Warner, “New United States plan to improve health care for minorities,” WebMD Health News, April 12, 2011: 1-2, http://www.medscape.com/viewarticle/740906_print
Alexander, G. Caleb, Gadon, Margaret, Vanderbilt, Susanne K. and Wynia, Matthew K.(2007). A qualitative study of physicians’ engagement in reducing healthcare disparities. Journal of the National Medical Association, December 99 (2007): 1315-1322.
Espinosa, M. Cristina. (2009). Ethnic spirituality, gender and health care in the Peruvian Amazon. Ethnicity and Health, October 14(5): 423-437.
Tirado, Miguel. (2011). Role of mobile health in the care of culturally and linguistically diverse United States populations. Perspectives in Health Information Management, Winter 2011: 1-7.
Among the many electrolytes, potassium stands out. It is perhaps the most prescribed electrolyte, followed by magnesium and phosphorous. In cardiac units, it is one of the staple drugs twinned with digoxin. Brand-name orange juice and milk products are now advertised as “potassium rich” to lure not only consumers concerned with heart health, but also the general public.
The health benefits of potassium
When patients ask why they are given potassium, the standard reply is “it’s good for your heart.” But there is more to it than that. According to the National Council on Potassium in Clinical Practice, evidence supports high-potassium diets can reduce the risk of stroke by combating the effects of sodium.1
When teaching patients about dietary sources of potassium, most nurses stop at bananas. The New England Journal of Medicine published the following categories of excellent potassium sources: Highest Content (>1000 mg [25 mmol] per gram) • Dried figs • Molasses Very High Content (>500 mg [12.5 mmol] per gram) • Dried fruits, nuts • Avocados • Bran cereals, wheat germ • Lima beans High Content (>250 mg [6.2 mmol] per gram) • Vegetables: spinach, tomatoes, broccoli, winter squash, beets, carrots, cauliflower, potatoes • Fruits: bananas, cantaloupe, kiwis, oranges, mangos • Meats: ground beef, steak, pork, veal, lamb
Studies also show reduction in blood pressure after potassium supplementation is three times higher in African Americans than in Caucasians.2 Research suggests that when one’s potassium level is below 3.5 mmol/L, supplementation is essential, even in asymptomatic patients with mild-tomoderate hypertension.3 For patients with a history of arrhythmias, the threshold for potassium replacements is higher: 4.0 mmol/L. The Journal of the American Medical Association reports the risk for ventricular fibrillation in acute myocardial infarction is significantly higher in patients with a potassium deficiency (less than 3.9 mmol/L).
The effect of digoxin is enhanced in the presence of hypokalemia. Hypokalemia predisposes a patient to digoxin toxicity by reducing renal clearance and promoting myocardial binding of the drug.4 Maintaining a normal potassium level is important in preventing digoxin toxicity and minimizing the potential side effects.
The daily minimum requirement for potassium in the average adult is 1600–2000 mg (40–50 mEq). It is interesting to note that across racial lines, it is reported that urban whites consume approximately 2500 mg of potassium per day while African Americans take in only 1000 mg per day on average.5
So what can your patients (and you) eat or drink to get an adequate amount of potassium? For starters, eight ounces of orange juice supplies 450 mg of potassium. Milk and vegetable juice (such as V8) are also rich in potassium but, unfortunately, can be loaded with sodium. Additionally, some of these potassium-rich foods can be costly and potentially cause weight gain. But don’t limit yourself to bananas; seek diverse foods to supplement your potassium intake.
Potassium replacement
In the hospital setting, compliance with potassium replacements or therapy can be a challenge. Tablets are better tolerated than the liquid form for patients who do not have any difficulty swallowing. Compliance is also enhanced by the dosing schedule; the more infrequently the patient takes the pill, the better the compliance. Instead of giving 20 mEq BID, you can ask the doctor to order it as 40 mEq once a day as clinical condition allows. In patients taking diuretics, dietary consumption of potassium-rich food is not enough and must be coupled with a potassium supplement.
Mixing potassium liquid with juice or ice makes it easier to swallow. To prevent the occlusion of feeding tubes, give the liquid form to the patient instead of crushing the pills. Lastly, it is important to note that magnesium is an essential cofactor for potassium uptake and maintenance of intracellular potassium level.1 Potassium supplementation works best when the magnesium level is within a normal range (1.5–2.5 mEq/L).
Nurses must be particularly keen on improving potassium intake in vulnerable groups such as the elderly, those who live alone, and persons with disabilities or functional limitations—they are most at risk for low potassium intake.
Resources
J. Cohn, P. Kowey, P. Whelton, et al., “New guidelines for potassium replacement in clinical practice,” Archive of Internal Medicine 160 (2000): 2429-2436.
P.K. Whelton, J. He, J.A. Cutler, et al., “Effects of oral potassium on blood pressure: meta-analysis of randomized controlled clinical trials,” Journal of the American Medical Association 277 (1997):1624-1632.
P.V. Caralis, B.J. Matterson, E. Perez-Stable, “Potassium and diuretic-induced ventricular arrhythmia in ambulatory hypertensive patients,” Miner Electrolyte Metabolism 10 (1984): 148-154.
A, Bielecka-Dabrowa, D.P. Mikhailidis, L. Jones, et al., “The meaning of hypokalemia in heart failure,” International Journal of Cardiology (2011) doi:10.1016/j.ijcard.2011.06.121
A.K. Mandal, “Hypokalemia and hyperkalemia,” Medical Clinics of North America 81 (1997):611-639.
