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.
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.
“Before we were Westernized, Native Hawaiians were very healthy, lean people,” says Suzette Kaho’ohanohano, RN, health educator and clinical supervisor at Hui No Ke Ola Pono, a health care center for Native Hawaiians on the island of Maui. “We were fishers, we had land.”
Today, few Native Hawaiians own land, much less cultivate crops or catch fish offshore. Often unable to afford fresh vegetables or fish, they eat an Americanized diet of fast food and are the world’s number one consumers of Spam, the canned meat product high in saturated fat, sodium and cholesterol.
Unhealthy eating and a sedentary lifestyle have translated into big health problems for Native Hawaiians. Three-quarters of them are overweight, according to the Hawaii Department of Health. While Hawaii has the third lowest overall obesity rate in the nation (20.6%), the rate for the state’s Native Hawaiian population is 39%—much higher than Mississippi, the most obese state, at 31.4%.
The outlook is similarly grim for other Pacific Islanders living in Hawaii, most of whom are immigrants from Samoa, Guam and Micronesia. Nafanua S. Braginsky, MSN, RN, a Samoan American nurse who is a lecturer at the University of Hawaii at Manoa School of Nursing, treats many Samoan patients at a clinic in Honolulu.
“We see a lot of big women,” she says. “When we ask them to work on losing some weight, they say: ‘But I don’t want to lose weight.’ It’s a culture where [you’re not supposed to] be too skinny.”
Too Little, Too Late
Obesity is only one of the many serious health problems Native Hawaiians and Pacific Islanders (NHPIs) are grappling with. They have high incidences of diabetes, hypertension, infant mortality and mental illness, to name just a few. Pacific Islanders also have high rates of tuberculosis and Hansen’s disease (leprosy).
In contrast, NHPI women have comparatively low rates of breast and cervical cancer. But because they are much more likely to be diagnosed late, when the disease is already in an advanced stage, they have disproportionately high mortality rates, according to the American Cancer Society.
Lack of early detection and preventive care is a problem across the health spectrum for Native Hawaiians and Pacific Islanders. They have unusually low rates of cancer screening, immunizations and visits for prenatal care. A variety of studies has found that they visit the doctor less frequently than their Caucasian counterparts, seek care late in the course of a disease and are more likely to accept a serious disease as fatal, rather than try to fight it.
Yet in most cases, this low utilization of health care services is not due to lack of access. With the state’s mandate that employers provide health insurance for all full-time workers, only 4.1% of Native Hawaiians are uninsured—lower than the rate for Hawaiians as a whole, the state health department reports. Unemployed Hawaiians can qualify for the state’s Medicaid managed care program, Hawaii QUEST. But many do not apply and application processing can take months.
This long list of health disparities breaks the hearts of veteran Native Hawaiian nurses like Mary Frances Oneha, PhD, APRN, director of quality and performance at the Waianae Coast Comprehensive Health Center. The center provides health care services and outreach primarily to disadvantaged Native Hawaiians on the west coast of the island of Oahu. In her 17 years at the center, she says, “there has been an increase in screenings and more outreach, but I’m not sure they have resulted in better outcomes. I can’t think of a significant health care indicator that has gotten better.”
But Oneha has by no means given up hope. She is currently working on several research projects to improve Native Hawaiian health, including one that focuses on infant mortality risk reduction factors among pregnant women.
Asked to explain the poor health outcomes and underutilization of medical services, Native Hawaiian nurses at the front lines point to cultural trauma. Every Native Hawaiian is familiar with the events of 1893, when American and European plantation owners and missionaries, assisted by the U.S. Marines, invaded the palace of Queen Liliuokalani and seized control of the Hawaiian government. Hawaii was annexed by the United States five years later.
Mary Frances Oneha, APRN, PhD
Like most Native Hawaiians, Kaho’ohanohano’s ancestry comprises a mixture of races and ethnicities. Her background includes German, Polish, Irish and Russian heritage, but she feels the closest affinity with her Native Hawaiians roots. She says the near-destruction of the traditional Hawaiian culture has thrown Native Hawaiians off balance and had a devastating effect on their emotional and physical health, a process called “cultural wounding.”
“Native Hawaiians [sank into a collective] depression when we lost our land, our culture and our language,” she explains. “We turned to alcohol and tobacco. To me, it’s a lot like what happened to the American Indians.”
Now Native Hawaiians are a minority in their own land, unnoticed by tourists in the beachfront hotels. According to the most recent U.S. Census, there are only about 260,000 Native Hawaiians in the state, or about 15% of the population. That’s fewer than the number of Japanese Americans living in Hawaii and only slightly more than Hawaiians of Filipino descent.
Oneha, whose ethnic background reflects successive migrations to Hawaii (English, Scottish and Chinese), agrees that Native Hawaiians’ poor health “has to do with the history, the historical trauma that we’ve been through. There is a cumulative experience that people bring with them [from generation to generation].”
A Patchwork of Cultures
Pacific Islanders have also experienced the impact of Western influences on their traditional way of life. But unlike Native Hawaiians, their small island societies have managed to hold on to their languages and much of their culture.
Thanks to wide-open borders between these islands and the United States, some 28,000 Pacific Islanders have migrated to Hawaii. So have thousands of people from the U.S. territories of Guam and American Samoa, who have no entry restrictions because they are U.S. citizens. There are currently 16,000 Samoans and 4,000 Guamanians living in Hawaii, the Census Bureau reports.
Suzette Kaho’ohanohano, RN, screens a patient for hypertension.
America’s borders are also open to people from the former U.S. trust territory of Micronesia, some 8,000 of whom now live in Hawaii. While one part of this territory, the Commonwealth of the Northern Mariana Islands, remains American, the rest has spun off into three independent nations: the Federated States of Micronesia, the Republic of Palau and the Republic of the Marshall Islands, where the U.S. conducted extensive nuclear weapons testing from 1946 to 1958. Under treaties with these nations, called the Compacts of Free Association, their citizens can enter the United States without visas or time limits.
Unlike Native Hawaiians, who share a common language and culture, Pacific Islanders in Hawaii are a fragmented population who speak many languages and come from many different islands with totally different customs and cultural beliefs. As many as 20 different languages are spoken at health centers in Hawaii.
All of this adds up to frustrating challenges for Hawaiian health professionals trying to provide care to Pacific Islander patients. In an article published in the California Journal of Health Promotion, researchers from the Hawaii Department of Health and the University of Hawaii noted that “health care providers [in Hawaii] almost universally regard Micronesians as ‘difficult’ patients.” Not only are there cultural barriers, they wrote, but many of these patients change residences frequently and go back to their homelands, making screening and follow-up “problematic.”
Under the Compacts, Micronesians are eligible for Hawaiian Medicaid, which has spent an estimated $100 million on health care for them over the years. Prodded by state health officials, the federal government finally agreed in 2004 to pay the Hawaii Medicaid program $10.5 million for Micronesian care, but the contribution falls short of the full $18 million their care actually cost.
Not surprisingly, Native Hawaiian and Pacific Islander nurses are at the forefront of the state’s efforts to improve health outcomes for NHPI patients and communities. Many of these nurses are involved in interventions that tap into Native Hawaiian cultural traditions—traditions that patients are in many cases reconnecting with.
For More Information About Native Hawaiian and Pacific Islander Health Hawaii State Department of Health http://hawaii.gov/health Native Hawaiian Health Office of Minority Health–Native Hawaiians/Other Pacific Islanders Profile Papa Ola Lokahi www.papaolalokahi.org Asian and Pacific Islander Health Forum www.apiahf.org Nutrition and Well-Being A to Z–Diet of Pacific Islander Americans www.faqs.org/nutrition/Ome-Pop/Pacific-Islander-Americans-Diet-of.html National Minority AIDS Education and Training Center–Native Hawaiian Fact Sheet CDC National Center for Health Statistics—Health of Asian or Pacific Islander Population www.cdc.gov/nchs/fastats/asian_health.htm
To break down barriers and establish trust, nurses take advantage of Native Hawaiian concepts like ohana (close connections to family and friends). Patients are encouraged to bring family members into examination rooms, which actually improves compliance. Similarly, patients are urged to draw on their shared cultural values to help each other stay healthy. A study conducted in the 1990s found that when groups of Native Hawaiian women used traditional Hawaiian values like kokua (proactive helping), aloha (compassion) and pili (bonding as family), more of them sought screening for breast and cervical cancer.
This emphasis on providing culturally competent care is epitomized by the Native Hawaiian Health Care Systems, a group of wellness and outreach centers created under the Native Hawaiian Health Care Act of 1988 and partly funded by a grant from the federal Health Resources and Services Administration (HRSA).
“Native Hawaiians have often felt that the Western health system did not understand or value their beliefs and practices,” says Dianne Ishida, PhD, MA, MSN, RN, an associate professor at the University of Hawaii at Manoa School of Nursing. “That’s why it was important to create a Native Hawaiian health system.”
Each of the five main Hawaiian islands has a separate system. Hui No Ke Ola Pono, the system for Maui, offers disease prevention and health promotion programs, nutritional education and counseling, wellness classes and community health screenings.
Janice Fernandez, RN, a Native Hawaiian nurse who runs a hypertension and stroke program at the center, says some patients do not readily accept her recommendations. “Sometimes Native Hawaiians are really hard-headed,” she explains. “If they are not ready [to make the necessary lifestyle changes], they’re not going to accept it.” Some patients, she adds, have dropped out of the program, then reappeared a year or two later.
Hui No Ke Ola Pono also offers traditional Hawaiian healing methods, including lomilomi, a form of massage, and hooponopono, family conferences in which relationships are set right through prayer, discussion, confession and forgiveness.
Kaho’ohanohano, the lead clinical supervisor for the Maui system, says the nutrition courses try to accommodate Native Hawaiian tastes. “For example, they should not be eating Spam, but if they insist, we show them how to cook it healthier. Instead of frying it, they can steam it.” Participants are also given opportunities to taste healthy foods and are taken on shopping trips to grocery stores.
Given Native Hawaiians’ distrust of Western medicine, it makes sense to take small steps. Rather than impose a strict diet, Ke Ola Mamo, the Native Hawaiian Health Care System for Oahu, helped middle-aged and elderly patients lose 5% of their body weight through lifestyle modifications, such as taking walks. Participants wanted “to do things their way,” says Donna Palakiko, RN, MS, programs administrator for the Oahu system. “We [Native Hawaiians] don’t really take well to being told what to do.”
She adds that Native Hawaiians often keep their opinions to themselves, so nurses need to pick up non-verbal cues, such as a patient making a face.
Nurses Reaching Out
Pacific Islanders are also eligible to receive care from the Native Hawaiian Health Care Systems, but many of them don’t take advantage of this opportunity. So the Maui system is reaching out to them by partnering with local churches and other trusted organizations in the PI community. When Fernandez provided health screenings to 125 Micronesians at a church-sponsored outreach event, she found that more than half of them had high blood pressure or diabetes and most had not signed up for Medicaid. Even by NHPI standards, “it was very disheartening,” she says.
Church-based outreach programs have been very successful in raising community awareness about health issues, Hawaiian nurses report. For example, Samoan pastors have been trained to present cancer as a palagi (white man’s illness) to differentiate it from a Samoan spiritual illness, which cannot be cured.
At the Waianae Coast Comprehensive Health Center, nurses are reaching out to homeless Native Hawaiians living on the beaches. Partly due to a lack of affordable housing, an estimated 2,000 people live on beaches and other unsheltered areas on Oahu alone.
The nurses bring hygiene products, blankets and donated clothes. “We try to meet their needs and their goals,” says Yvette Budoit-Alop, RN. “In the short term, that means food, shelter and clothing. In the long term, it means being ready to get off the beach.”
Being Native Hawaiian herself helps her establish rapport with them—at least to some extent. She uses “talk story,” an informal way of conversing using Hawaiian pidgin slang. One person will share a story, and the others corroborate or add to it. But the homeless people are still wary. “It takes a while for them to trust us,” Budoit-Alop says. “We saw one mother with kids out on the beach for a year before she requested shelter.”
Even though there is a great need for more nurses like Budoit-Alop who can provide culturally knowledgeable care to the NHPI population, very few Native Hawaiians enter nursing. To try to increase Native Hawaiian enrollments, nursing schools like the University of Hawaii at Manoa on Oahu are doing their own community outreach, sending representatives into local high schools to develop students’ interest in nursing, help students become academically prepared for nursing school and find financial aid for them.
Outside of Oahu, it is difficult for Native Hawaiians to pursue their education. Kaho’ohanohano says she earned her associate’s degree in nursing from Maui Community College, but then had to get her BSN degree online through the University of Phoenix, because there were no such programs on Maui.
She believes Native Hawaiian nurses can make an important contribution to improving the health outlook for her people, because “we are actually the bridges between the traditional Hawaiian culture and the Americanized world. We are trying to incorporate the Hawaiian culture into Western medicine.”
When Asian and Pacific Islander (API) patients visit medical facilities complaining of physical problems, they usually receive physical treatments. However, Shih-Yu (Sylvia) Lee, PhD, RNC, a postdoctoral fellow at Emory University in Atlanta, knows that asking these patients a few extra questions may mean the difference between curing a minor physical ailment and treating a major mental illness.
“[API patients] tend to express their feelings through physical complaints like a headache or upset stomach,” she explains. This practice is known in psychiatry as somatization.
ShihYu (Sylvia) Lee, PhD, RNC
Research suggests that health care providers’ failure to look at non-physical causes of ailments in Asian Americans and Pacific Islanders, combined with other cultural and linguistic barriers, may mean that this population is receiving inadequate mental health care. Lee encourages nurses to actively help eliminate these barriers by adopting a culturally competent approach to assessing API patients’ symptoms. Cultural sensitivity to these patients’ unique mental health needs is also a must for communicating treatment options to API individuals, who represent the fastest-growing minority population in the United States.
According to A Provider’s Handbook on Culturally Competent Care: Asian and Pacific Islander Population, 2nd Edition, published by Kaiser Permanente, little is known about the frequency of mental disorders in APIs. Because they represent a relatively small number of patients admitted to psychiatric hospitals compared with other racial and ethnic groups, this has led to the misconception that Asian Americans simply have fewer mental health problems than other Americans.
Gayle Tang, MSN, RN
However, the research data that is available contradicts this stereotype. The Centers for Disease Control and Prevention’s National Center for Health Statistics reports that API males and females between the ages of 15-24 consistently have the highest suicide rate of all ethnic groups in that age range. Elderly Asian Americans exhibit more instances of dementia than the general population, according to the National Asian American Pacific Islander Mental Health Association (NAAPIMHA). The association also reports higher than average suicide rates among some elderly Asian groups.
Many immigrants from Southeast Asian countries, particularly those from Vietnam, Laos and Cambodia, have survived traumatic refugee experiences. According to NAAPIMHA, 40% of these refugees suffer from depression, 35% from anxiety and 14% from post-traumatic stress disorder. And a study cited in Kaiser Permanente’s Provider’s Handbook reveals that while API patients are less likely to be admitted to psychiatric hospitals than their Caucasian counterparts, those who are admitted have a longer median length of stay than white patients.
These disturbing statistics suggest that Asian Americans and Pacific Islanders may not be receiving adequate mental health care early on and that by the time they do obtain treatment, their problems are more severe and harder to treat.
Behavior, Culture and Language
While mental illness is not an easy topic for most Americans to discuss, there is an especially strong stigma in the Asian American culture that discourages potential patients from seeking mental health services. “We tend to suppress our feelings,” says Lee, who is from Taiwan. “What happens in the family stays in the family.”
This is where the somatization comes in. Instead of seeking a mental health referral, many API patients will choose to see their primary care physician about a physical problem. Even if primary care providers are aware that their patient’s physical complaints may have an underlying emotional cause, lack of familiarity with Asian cultural norms can make it difficult for providers to determine whether a particular behavior is a common practice or a cause for concern.
For example, Lee says, in Chinese, Japanese and Korean cultures, women who have given birth take the post-partum healing period so seriously that they often remain at home on bed rest for up to a month after delivering their baby. Even if the newborn needs to be placed in the NICU, the mother might send other family members to visit the baby, while she continues to rest. If she were to visit the baby, her family may request a wheelchair for her to help conserve her energy. Nurses who are not familiar with this cultural practice may be unnecessarily alarmed that the mother is showing signs of post-partum depression.
If a nurse does have a concern about a patient’s behavior, Lee’s advice is to simply ask for more information. “You really need to talk to a family member,” she emphasizes.
Linda S. Beeber, PhD, APRN, BC, a professor of nursing at the University of North Carolina at Chapel Hill, agrees that nurses should look at each patient individually, even if they are Asian American nurses who share the patient’s ethnic background and are familiar with the culture. This is because familiarity could lead to labeling and making assumptions. “It could perpetuate biases. It is a step away from stereotyping,” says Beeber, who has studied depression in Korean, Chinese, Taiwanese and Native Hawaiian graduate students. “It does not take into account the powerful process of acculturation.”
In addition to barriers caused by cultural differences, there are often obvious language barriers that can prevent Asians and Pacific Islanders from receiving adequate mental health treatment. “New immigrants might not be able to speak English well,” says Lee.
According to the Kaiser Permanente Provider’s Handbook, about 38% of Asian Americans do not speak English fluently. The same holds true for a very large proportion of APIs over 65 years of age. And unlike most Hispanic subgroups, who all speak Spanish, API subgroups encompass a wide range of different languages, from Chinese, Japanese and Vietnamese to Tagalog, Hindi and Hmong.
While nurses are not expected to provide interpretive services, patients will rely on nurses to find well-trained translators to help communicate with them. Lee advises nurses to get to know the network of translators in their geographic area and to only recommend the professionals who have proper training. “In addition to linguistic training, they need to know the medical terms,” she says, citing an instance where a patient misunderstood a diagnosis because one of the medical terms was not communicated effectively.
Gayle Tang, MSN, RN, director of national linguistic and cultural programs at Kaiser Permanente in San Francisco, believes that linguistic competence is an important component of a health care facility’s ability to provide culturally competent care. This goes beyond simply providing translation services, she adds. “Language and culture are interchangeable,” Tang argues. “[If you can’t] speak the right words, in the right tones and with the right expressions, you’re not linguistically competent.”
Communication for Compliance
Once it has been determined that an Asian American or Pacific Islander patient is in need of mental health care, the next challenge for the nurse to overcome is often recommending treatment in a way that encourages the patient to complete his or her therapy successfully. Typically, a care provider would gather data on the symptoms of the problem, determine the cause, recommend a treatment and assume that the patient accepts the counsel.
However, an API patient might have a different explanation for the problem, based on his/her cultural beliefs. According to Tang, some patients may feel that their problem is primarily a spiritual one, or is a consequence of past behavior. If the recommended therapy does not address what the patient believes is causing the problem, the patient may choose to forego treatment.
Raising Awareness: Resources for Patients and FamiliesThere are a number of support groups, education programs and other consumer-focused resources available nationwide to help Asian and Pacific Islander patients, families and communities become better educated about the mental health system. By referring patients to these resources, nurses can help remove some of the cultural stigma associated with treatment. • The National Alliance for the Mentally Ill (NAMI) is an organization dedicated to providing support for mental health consumers and their families. “[NAMI] has local grassroots support groups in every state,” says Maggie Luo, whose Chinese American Mental Health Outreach Project (CAMHOP) is an initiative of the NAMI New Jersey chapter. NAMI’s national Web site is www.nami.org. • The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) is committed to enhancing appropriate and accurate research data, identifying best practices for treating the API population, increasing mental health care training, and engaging consumers and their families. The consumer section of its Web site, www.naapimha.org, offers resources such as fact sheets on depression, bipolar disorder and schizophrenia in English, Chinese, Korean, Vietnamese, Khmer and Hmong.• “Healing the Spirit: Treating Depression Among the Asian Elderly” is a 19-minute educational video produced by the Asian Pacific Fund in partnership with the Stanford Geriatric Education Center (SGEC) and the American Association of Retired Persons (AARP). An excellent resource for both health care professionals and health consumers, the video discusses the symptoms of depression, its effects and treatment options. The project leader is an Asian American nurse, Melen McBride, PhD, RN, associate director of curriculum, technology and research at SGEC. To order the video, which costs $30, contact her at (650) 494-3986 or [email protected].• The National Asian Women’s Health Organization (NAWHO) is partnering with several community organizations on an outreach campaign called Empowering Avenues for Community Action in Mental Health: The National Collaborative for Asian American Women’s Health. The campaign’s mission is to “lower rates of depression and suicide in Asian-American women aged 18-34; remove stigma surrounding mental health issues through education and outreach; build the mental health information and referral capacity of community-based organizations; and empower Asian American women to serve as leaders and advocates for mental health.” More information about this initiative is available at www.nawho.org/mentalhealth.html.
Tang recommends using one of two culturally sensitive communication methods to increase the chances of successful treatment: the Kleinman model or the LEARN model. These methods can help nurses determine their patient’s level of acculturation and minimize the use of broad cultural stereotypes and prejudicial biases.
The Kleinman model, developed by noted psychiatrist Arthur Kleinman, is a general tool for cross-cultural communication. According to Tang, this model involves asking patients a series of questions about their complaint. “[It helps] assess a patient’s beliefs about their condition,” she says.
What do you call your problem? What name does it have? Why has it happened to you? Why now? are examples of questions Tang may ask. She would also ask patients what they believe will help make the problem go away. Using this model helps nurses understand whether or not they are seeing an issue in the same way their patient sees it.
The LEARN model, published in 1983 by E.A. Berlin and W.C. Fowkes, Jr., is geared toward letting the patient lead the discussion of his/her symptoms. It is an acronym for listen, explain, acknowledge, recommend and negotiate.
“It is an easy-to-remember model that reminds nurses to not only explain a situation but to also take time to understand how their patient sees a problem,” says Tang. “The nurse will listen to how the patient sees their own problem, then the nurse will explain his or her own perception of the problem. At that point the nurse acknowledges the differences and similarities between the two viewpoints while being nonjudgmental. The nurse would then recommend treatment or behavior change and then try to negotiate the best way to get the patient to follow through.”
Encouragement is a good way to successfully negotiate a treatment plan. “Find out what the patient is doing to help himself,” Beeber suggests. Even if a nurse has to advise a patient to stop using his current remedy in favor of a more medically effective option, the nurse can still use negotiation techniques to encourage the patient to try the recommended treatment.
For example, if a patient is treating her ailment with a traditional remedy such as a blend of herbal plants, Tang recommends saying something along the lines of: “We would like you to stop taking the herbal remedy for two weeks [and use the medicine that the doctor prescribed for you], just to make sure we know what is working and what is not working.” The patient is probably more likely to take the prescribed medicine if this approach is used–as opposed to the nurse saying, “That’s not going to work. There’s no scientific basis for [the herbal remedy].”
Even if patients accept a specific treatment regimen, they may not know how to follow it once they get home. “Ask for a return demonstration to help ensure that the information was communicated successfully,” says Tang.
If an API patient needs to be referred to an outpatient or inpatient psychiatric care facility, it is once again important for the nurse to be a strong encourager. “[Patients] need assurance that this is the right thing to do,” says Maggie Luo, program coordinator for the Chinese American Mental Health Outreach Project (CAMHOP) in New Jersey. This may mean encouraging family members to encourage the patient. Luo suggests that nurses identify the relative who may have the most influence in the family and try to win that person’s support for the referral.
She also recommends using the term “mental health consumer” instead of “mentally ill” when referring to patients. This simple title change may help reduce the level of stigma associated with the referral.
Being a patient advocate also means proactively locating other supportive health care providers. “Try to help patients find a physician who knows about their culture,” says Lee. “You could actively make the referral for the patient, or you could just follow up with the other physician.”
Tang agrees that nurses should take a proactive approach to making sure the patient’s cultural and linguistic needs are met. “Every single nurse needs to make sure the system is in place,” she urges. “Make sure there are no gaps. Take that extra step. Make sure the interpreter is pre-scheduled for the next visit and the referral is made.”
The federal Office of Minority Health (OMH) calls it one of the most serious but frequently neglected minority health disparities in the United States: Asian Americans, Native Hawaiians and other Pacific Islanders (APIs) have the highest rates of chronic hepatitis B and liver cancer caused by hepatitis B of all racial and ethnic groups. The Centers for Disease Control and Prevention (CDC) estimates that as many as two million people in this country are living with chronic hepatitis B, and over half of them are APIs.
The OMH and CDC aren’t just talking about this problem, they’re taking major steps to address it. The two agencies have teamed up to launch a national initiative aimed at closing the gap of chronic hepatitis B virus (HBV) disparities in API communities. In December 2008, the agencies published a report, based on the recommendations of a National Task Force on Hepatitis B Expert Panel convened by OMH, outlining an aggressive action agenda to reduce and eventually eliminate Asian Americans’ disproportionately high rates of this deadly disease.
The report, Goals and Strategies to Address Chronic Hepatitis B in Asian American, Native Hawaiian and Other Pacific Islander Populations, calls for increasing HBV education, public awareness, screening, early detection, immunizations and research, as well as improving access to care and treatment. Specific strategies include, among others, improving HBV-related public health prevention infrastructure and providing culturally competent HBV training for health care professionals.
“The fight against hepatitis B and associated liver cancer is critical to protect the health of Asian Americans and Pacific Islanders, who bear the brunt of the disease burden,” says John Ward, MD, director of the CDC’s division of viral hepatitis. “With a new strategic plan developed directly in partnership with communities most affected, we now have a clear roadmap to move forward in recognizing hepatitis B prevention as a national priority and protecting Asian Americans from the ravages of the disease.”
Rosemarie Jeanpierre remembers the cruel comments as if she heard them yesterday. She was riding a crowded bus to work in Los Angeles when a perfect stranger got on and said, “move over, fatso,” as they all jostled for more standing room. Feeling ashamed, she wanted to get off the bus immediately, but kept riding, all the way to her job as a treatment nurse at Western Convalescent Hospital.
At the time, Jeanpierre weighed 220 pounds, and at 5’2″, she was considered obese. In 2003, her doctor told her she had pre-diabetes, a condition of elevated blood sugar and a harbinger for a diabetes diagnosis down the road. She had been overweight her whole life. As a girl in the Philippines, she learned the habit of overeating for emotional comfort. She had the classic symptoms: her blood sugar was “out of control,” yet she felt hungry all the time. She felt short of breath, propping up pillows at night to breathe while sleeping. And her co-workers told her she looked stressed.
“My doctor got upset with me,” Jeanpierre, L.V.N., recalls. “She said, ‘You’re only 39 and you’re a nurse!'” Being scolded by her physician was upsetting, but not nearly as traumatic as dealing with her father’s death of a massive heart attack a few years before. He had been a diabetic and suffered from high cholesterol and high blood pressure as well.,
“That gave me a big realization that I needed to do something about my health,” Jeanpierre says. “I said to myself, ‘I’m a nurse, and I want to set a good example for my patients.'”
In a dramatic reversal of fate, Jeanpierre lost half her body weight in 18 months through a disciplined regimen of exercise and dietary changes. She forced herself to reduce her daily caloric intake from 6,000 to 1,800. The trips to McDonald’s and a local bakery stopped. What began with 45-minute walks on the treadmill gradually morphed into an abiding passion for running. Jeanpierre ran her first marathon in 2005 at the urging of her nephew. Now, she routinely wins shorter distance races in her age division and plans to run the Nanny Goat 100-mile race this year.
Jeanpierre’s story is exceptional, yet could have turned out much differently if she hadn’t found the willpower to change her behavior. Diabetes, heart disease, and hypertension are chronic diseases and are among the leading causes of death in all populations, but more acutely strike minority groups: African Americans, Latinos, Native Americans, and certain Asian ethnicities. They also happen to be diseases where behavioral changes can reverse—or at least mitigate— their impact.
Nurses possess greater knowledge of these illnesses than the average person, but are no exception. In addition, researchers have recently discovered nurses may be particularly vulnerable to developing key risk factors.
Diabetes: bad for our blood vessels
If not properly managed, diabetes sets the stage for poor heart health. Grim statistics prove cardiovascular disease is the leading cause of death among people with diabetes. Two out of three people with diabetes die of heart disease or stroke; a middle-aged person with type 2 diabetes has as much of a chance of having a heart attack as someone without diabetes who has already had one heart attack, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
“Diabetes is a risk factor for cardiovascular disease, and any diabetes education program must include information about heart disease,” says Cristina Rabadán-Diehl, Ph.D., M.P.H., Deputy Director of the Office of Global Health at the National Heart, Lung, and Blood Institute.
In fact, researchers have come up with a special name for the cluster of traits that make a person prone to both diabetes and heart disease: metabolic syndrome, meaning he or she has three out of the following five conditions.
Excessive abdominal fat
High levels of triglycerides
Low amounts of HDL, or “good,” cholesterol
Fasting blood sugar level of 100 milligrams per deciliter
So how exactly does diabetes compromise cardiovascular health? By adding stress to our circulatory system, which carries blood and oxygen to vital organs and tissues.
In type 2 diabetes, cells become resistant to insulin, the hormone needed to extract sugar from the blood and metabolize it into energy. Having excess sugar, or glucose, in the blood contributes to the deterioration of blood vessels, but researchers have yet to pin down glucose’s specific role in this process.
“Glucose exacerbates the action of other risk factors, [and] the process of atherosclerosis gets accelerated,” says Rabadán-Diehl. Atherosclerosis is the process by which arteries become clogged and hardened by plaque, a waxy substance made of cholesterol, fat, calcium, and cellular waste, thereby narrowing the channel through which blood can flow.
According to Rabadán-Diehl, excess blood sugar could also “stimulate the production of fatty acids, and makes plaque a bit vulnerable.” By producing fatty acids, glucose potentially destabilizes pieces of plaque, moving them through our arteries to potentially form blood clots.
“Glucose likely contributes to the formation of plaque and might also contribute to the instability of plaque, causing particles to drift,” she says.
The narrowing and blockage of blood vessels is the root cause of all major cardiovascular problems, from stroke (caused by blockage of arteries leading to the brain) to coronary heart disease (blockage of arteries leading to the heart) to peripheral arterial disease (blockage of arteries leading to the legs). In addition, more pressure is felt by the arterial walls because of the constricted space through which blood can flow, giving rise to hypertension.
Why nurses are vulnerable
Nurses shoulder a unique burden among health care providers. Not only are they the primary caregivers and conveyers of health information to their patients, but they are often expected to be role models of healthy behaviors. Among nurses who care for diabetic or cardiac patients, the burden is greater since risks for both can be mitigated by behavioral changes like weight loss, dietary modifications, and exercise.
Key Statistics 18.8 million people have been diagnosed with diabetes.* A 2007–2009 survey showed among people 20 years or older, 7.1% of whites, 8.4% of Asian Americans, 11.8% of Hispanics/Latinos, and 12.6% of African Americans/blacks were diagnosed with diabetes. Compared to whites, the risk for a diabetes diagnosis was 18% higher for Asian Americans, 66% higher for Hispanics/Latinos, and 77% higher for African Americans/blacks. * Among Latinos, Mexican Americans and Puerto Ricans run the highest risk of developing diabetes. * 26.7% of African American women are overweight, and another 51% of African American women are obese; 64% of African American women are sedentary and get no leisure time for exercise. ** Latina women suffer from heart disease 10 years earlier than other ethnic groups. *** Sources * National Diabetes Fact Sheet 2011, published by the Centers for Disease Control and the U.S. Department of Health and Human Services ** The National Coalition for Women and Heart Disease *** Interview with Marleny Ramirez-Wood, communications manager, Go Red Por Tu Corazón, American Heart Association
Sally K. Miller, Ph.D., F.N.P.-B.C., and clinical professor of nursing at Drexel University, has studied obesity rates among nurses and their ability to provide weight management counseling to their patients. She links a nurse’s own health status to her credibility among those in her care: “‘Do as I say and not as I do’ is not very effective. People in general put more weight on advice from someone who is modeling that behavior and has been successful in that behavior.”
Yet how easy is it for nurses to maintain a healthy weight and avoid chronic metabolic disorders? Not terribly, according to two studies published last year.
At the University of Maryland School of Nursing, postdoctoral fellow Kihye Han, Ph.D., R.N., and professor Alison M. Trinkoff, Sc.D., M.P., B.S.N., R.N., F.A.A.N., found that nurses who worked long shifts were more likely to be obese than underweight or at a normal weight. Their results, published in the November 2011 issue of Journal of Nursing Administration, show that among the 2,103 female nurses surveyed, 55% were obese and reported less physical exertion and movement in their jobs.
“Long hours affect circadian rhythms,” Han and Trinkoff wrote in an e-mail interview. “Disrupted day/night cycles have detrimental effects on sleep quality and quantity, which are important independent risk factors for obesity, more important than even physical inactivity and high fat intake.”
Han and Trinkoff conclude that nurses who work long shifts might not have the time and energy to participate in regular exercise and that sleep deprivation also stimulates the appetite, forcing nurses to snack during shifts when healthy food choices might not be available.
Nutrition researcher An Pan, Ph.D., goes a step further by solidifying the connection between nurse’s shift work, obesity, and a dispensation towards type 2 diabetes in a study published in the December 2011 issue of PLoS (Public Library of Science) Medicine.
Pan and his colleagues at the Harvard School of Public Health analyzed responses from 177,184 nurses surveyed over a span of two decades. They discovered that a nurse’s risk of developing type 2 diabetes grew in direct proportion to the number of years she worked night shifts. A nurse working night shifts for three to nine years had a 20% chance of becoming diabetic, while that risk jumped to 58% if a nurse worked night shifts for over 20 years.
Weight gain became inevitable after years of working nights, says Pan in an interview: “Women who worked rotating night shifts gained more weight and were more likely to become obese during the follow-up.”
Nurses also say they have a tendency to turn a deaf ear to warnings about their own health, opting to take care of everyone else—patients, spouses, children—first. Eva Gómez, M.S.N., R.N., C.P.N., and a staff development specialist at Children’s Hospital in Boston, waited 13 years before following up on a diagnosis of a heart murmur she received in her 20s. In 2010, she found out she had a misshapen aortic valve, causing her aorta to bulge with backed-up blood. She scheduled valve replacement surgery for later that year and says if she had waited any longer, her aorta could have burst.
“At one point, I said, ‘That cannot be me; that’s something that happens to patients. I take care of people who have this,'” says Gómez, a national spokeswoman for the American Heart Association’s Go Red Por Tu Corazón campaign. “It never occurs to you that it could happen to me.”
Why certain races and ethnicities are at risk
Nurses face serious occupational challenges when it comes to managing their weight and stress level, and those who belong to certain racial and ethnic groups face even steeper barriers.
Latinos, African Americans, and Native Americans are at particular risk for becoming diabetic, while cardiovascular disease remains the #1 killer of all populations, despite race. While genes play a role that researchers are only beginning to understand, lifestyle, socioeconomic, and environmental factors have been the focus of most public health campaigns.
Relying on staples like rice, beans, and bread products and cooking techniques like deep frying, many Latin American cultures eat “diets that are richer in carbs and fats,” says Maria Koen, F.N.P., C.D.E., a bilingual nurse practitioner and diabetes educator at the Joslin Diabetes Latino Initiative in Boston. In addition, “they’re not necessarily having regular exercise as part of their lifestyle [or] making it a priority.”
Getting patients to eat more fruits and non-starchy vegetables remains a challenge, and fast food is perceived as a reward in certain communities. “Going to a fast food restaurant is considered to be aspirational; it’s a treat” among Latinos, says Marleny Ramirez-Wood, Communication Manager of the AHA’s Go Red Por Tu Corazón campaign. “We want to focus our message…in terms of cooking traditional meals, how they can make them healthier, [and] how they can incorporate physical activity into what they’re doing.”
For many ethnic groups, questions about access and affordability arise in conversations about eating healthier, since the corner markets in their neighborhoods may offer nothing more than liquor, cigarettes, and lottery tickets.
“Access to fresh fruits and vegetables is not available in certain communities we’re talking about,” says Lurelean B. Gaines, R.N., M.S.N., Chair of the Department of Nursing at East Los Angeles College and President-elect, Health Care & Education, of the American Diabetes Association. “If it’s not there and you don’t have the means, and with gas prices what they are, you’re not going to drive out of your community to get better food.”
A diabetes educator at the Mattapan Community Health clinic in Boston, Sharon Jackson counsels Haitian immigrants and African Americans from the neighborhood, many of whom work multiple jobs, have no time for exercise, and struggle to manage their disease.
“There isn’t a two-hour stretch where a person who is conscientious isn’t trying to take care of their diabetes,” says Jackson, M.S., R.D., C.D.E., a clinical research program manager at the Joslin Diabetes Center. “Taking care of diabetes is a full-time task…[it] becomes a luxury when you’re in a lower socioeconomic level.”
Managing the deadly three
A nurse’s hectic schedule is often beyond his or her control, especially early on in the career. Scarfing down meals on the go, never getting a decent night’s sleep, working crazy hours to make ends meet, and juggling the demands of work and family life is the norm for many.
These habits take their toll, yet are not simply a matter of individual nurses making bad choices. Institutions play their part in either discouraging or promoting a culture of health for nurses.
One hospital is taking an aggressive approach in helping nurses and other hospital staff get control over chronic diseases like diabetes, heart disease, and hypertension. For the past decade, the Cleveland Clinic has offered its staff disease management programs as part of its employee health plan. Employees are assigned case managers who help them set and reach specific goals related to their condition, says Patricia Zirm, B.S.N., R.N., M.P.H., Senior Director of Employee Health Plans at the clinic.
The clinic is known for its culture of wellness, with nine different fitness areas scattered among its 12 hospitals, reimbursement of gym memberships, a ban on regular soda in vending machines, and healthy food choices in its cafeterias.
Of more than 30,000 employees enrolled in the health plan, approximately 18,000 have one of the diagnoses for which the clinic has a disease management program, and roughly 8,000 are already enrolled in a disease management program.
In 2010, the clinic started to incentivize employee health through a program called Healthy Choice, which ties participation in one of six disease management programs to lower monthly premiums. The six programs are focused on diseases, including diabetes and hypertension, where behavioral changes in diet and exercise deliver a huge impact.
Healthy Choice is a three-tiered system of insurance premiums where the highest level of discount (gold) is awarded to employees who are complying with their disease management goals. In the case of a diabetic, one goal is to maintain a blood sugar level of less than 7%. The silver rate is for employees participating in disease management, but aren’t completely meeting their goals; the bronze rate is the standard rate, where an employee is insured but not enrolled in disease management.
Attaching health outcomes to an employee’s paycheck seems to be a smart strategy. Since 2010, Healthy Choice participation among the staff has tripled. Over the past year, 17% of clinic employees went from the standard rate to the gold rate, and employees are making fewer trips to the ER and are being admitted less frequently to inpatient care, says Zirm. These are all signs of progress, yet work remains to be done.
“Anybody who is doing shift work is more prone to stress, diabetes, and heart disease,” says Zirm. “The clinic tries to do a [favor] of addressing these issues related to shift work…we’re trying to remove barriers, but the fact remains, because of the nature of the job, we can’t fix it for everybody.”