When she was working with American Indian communities in the Pacific Northwest to identify and build support for adolescents at risk for suicide, June Strickland, PhD, RN, did not call the endeavor a “suicide prevention project” or refer to the young people as “troubled.” Instead, she and her colleagues called the effort a “youth wellness program,” and when she met with parents, she spoke of their children’s “gifts”–special qualities that happened to make them more sensitive and more susceptible to absorbing pain. These carefully chosen words carried meaning because American Indian cultures emphasize positive concepts to promote healing. A negative approach focusing on brokenness would have failed.
This reframing of the issue was just one of the many ways the program was tailored to fit the tribal communities. Strickland, who is a member of the Cherokee tribe, bonded with the youths through traditional cultural activities, such as making baskets and working with clay, and she became part of the communities, visiting the hospital when a mother delivered a baby or someone was sick. She gave each of the young people a little pottery flower she made with her phone number on the back, so they could call her whenever they wished. She shared wisdom from her people, but also encouraged the teens to talk to their elders to learn about their own tribe’s traditions. The effort involved the whole community. Tribal leaders helped develop protocols and held celebrations to honor the youngsters.
The results were dramatic: Suicide risk and ideation decreased after just one year. Ten years later, Strickland, an associate professor of psychosocial and community health at the University of Washington School of Nursing, still gets calls from the young people, and she remains involved in the communities through other projects, including cancer prevention.
Her work, which was part of a larger suicide prevention project in the Seattle area in the 1990s, is an example of a culturally appropriate approach to suicide prevention and of the key role minority nurses can play in helping to restore hope in high-risk communities of color.
In recent years, racial and ethnic disparities in suicide rates–especially among young people–have become an urgent public health crisis. Statistics paint a grim picture:
• American Indian and Alaska Native (AI/AN) people have the highest suicide rates of any minority population in the country. Suicide is the second leading cause of death for young AI/AN people ages 15 to 24, with a rate 2.4 times that of the overall U.S. population.
• Asian American and Pacific Islander (AAPI) women ages 15 to 24 kill themselves at a higher rate than other women of the same age group, and AAPI women over age 65 have the highest suicide rates among seniors of all races.
• In 2005, a greater percentage of Hispanic high school girls reported thinking about, planning or attempting suicide than white or African American girls.
• Suicides among young African American men have risen alarmingly. The suicide rate for black men in general is almost seven times higher than for black women.
Preventing suicide is a task for every nurse, not just those who specialize in mental health. Because they spend so much time with patients, nurses are in a unique position to recognize when people are in trouble and to intervene, according to the Suicide Prevention Resource Center (SPRC), a joint project of the Substance Abuse & Mental Health Services Administration (SAMHSA) and the Education Development Center (EDC).
“Community nurses, public health nurses, school nurses and home health nurses are in the best position of any discipline to intervene, because they’re naturalists in those environments,” says Faye Gary, EdD, RN, FAAN, Medical Mutual of Ohio Professor of Nursing for the Care of Vulnerable and At-Risk Populations at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland. “They’re not strangers.”
Understanding the Risk Factors
A variety of complex factors put Americans of color at risk for suicide. Nurses who understand the cultural and community contexts of their patients’ lives are better equipped to recognize warning signs and introduce interventions.
The dissolution of the family support system is among the risk factors for Hispanic adolescents after their families immigrate to the United States, says Mary Lou de Leon Siantz, PhD, RN, FAAN, assistant dean for diversity and cultural affairs at the University of Pennsylvania School of Nursing and director of the Migrant Health Program at the university’s Center for Health Disparities Research. Hispanic culture emphasizes group cooperation for the good of the family, while the majority American culture emphasizes working hard to get ahead as an individual, she explains. Adolescents break away from their parents sooner here than in countries such as Mexico, and the cultural clash can be hard on both teens and their families.
Today’s anti-immigration sentiment also takes a toll, says Siantz, who is a past president of the National Association of Hispanic Nurses. “It doesn’t matter how long you’ve been here,” she maintains. “There’s so much animosity [against Hispanics] that teens are almost embarrassed to speak Spanish. Through school and friends, they further break ties from heir families.”
Cultural stigma about mental illness can be still another risk factor for this population, because it can prevent depressed people from seeking the help they need. “[Mental illness] is thought of as the curse of the devil and comes with great guilt,” Siantz notes. “A person [suffering from depression] might tell himself, ‘Obviously I did something terrible and it’s my fault.”
Because of this stigma, which is also very strong in the Asian community, patients are unlikely to say they’re depressed but instead will complain of physical ailments, such as stomach pains and headaches, or symptoms such as nervousness and sleeplessness. Even if patients at risk for suicide do reach out for help, health care providers can miss the warning signs if they don’t speak the patient’s language or lack cultural sensitivity.
Culture clash, high expectations and the pressures of being perceived as “the model minority” all help explain the high rates of suicide among young Asian American women, says Linda Beeber, PhD, RN, CS, a professor of psychiatric nursing at the University of North Carolina at Chapel Hill. Earlier in her career, she worked at a psychiatric clinic where she provided care to young immigrant women from Korea, Japan and China who struggled with depression and contemplated suicide. Many of them came to the U.S. to study or be with their spouses and found themselves torn between two cultures without support from their families, all the while under great pressure to succeed. Some, for instance, worked all day in a laboratory doing graduate work, then had to assume the traditional female role at home. “They had difficulty bringing those two worlds together,” Beeber explains.
Asian Americans and Pacific Islanders are much less likely than Caucasians to talk about their mental health concerns to friends, family or health care providers, according to the SPRC. They tend to view emotional problems as shameful and are less likely to seek mental health treatment than other racial and ethnic groups.
American Indian and Alaska Native youth have the highest suicide rates of any young people, although rates vary from tribe to tribe. Extreme poverty, lack of job opportunities, substandard housing and substance abuse are all significant risk factors. In many AI/AN communities, cultural destruction and forced assimilation to the majority culture have weakened traditional bonds of tribal unity and parental influence–important support systems that can help safeguard kids from depression and suicide.
Meanwhile, suicide among young African American men does not get enough attention from researchers, Gary believes. In 2005 the suicide rate for black Americans of all ages was 5.25 per 100,000 people–about half the overall U.S. rate of 10.75 per 100,000, according to the Centers for Disease Control and Prevention. However, the suicide rate for young black men between the ages of 20 and 24 was 18.2 per 100,000–almost twice the rate for the overall U.S. population and more than three times the rate for black Americans as a whole.
Some researchers believe that suicide rates for both African American and AI/AN young people are actually undercounted, theorizing that some young men living in despair and poverty deliberately put themselves in harm’s way to get themselves killed. For example, they may abuse drugs and alcohol, drive recklessly or even provoke police into shooting them. This is sometimes referred to as “hidden suicide.”
Community-Based Prevention
According to the U.S. Department of Health and Human Services’ Office of Minority Health (OMH), reversing the trend of rising suicide rates in communities of color “will require a renewed and revitalized approach, one that involves the courage to switch gears.” Addressing the problem will require multiple resources and a willingness to form partnerships that extend beyond the health care profession.
“We need to look at suicide in minority communities through the context of socioeconomic factors, such as acute poverty, joblessness, deindustrialization and drug abuse,” says Roberta Waite, EdD, MSN, RN, CS, assistant professor of nursing at Drexel University in Philadelphia.
There are no easy answers and a one-size-fits-all approach won’t work. The OMH emphasizes the importance of culturally and linguistically competent suicide prevention programs, early interventions and the involvement of families and entire communities. And this is exactly where minority nurses can make their most important contributions–through culturally sensitive research, clinical care and, especially, community outreach.
“We need to make the general public aware and alert individuals about [the problem], but the efforts must be specific to communities rather than something designed for everybody,” Gary says.
“You’ve got to spend time with folks in the community,” Beeber agrees. “You have to become a known entity.”
Beeber is currently the principal investigator of a community-focused research study that is testing in-home interventions to reduce depression in low-income mothers of infants and toddlers and improve young children’s mental health. The study has two components: The HILDA Project serves primarily low-income African American and Caucasian mothers in several North Carolina communities and in Syracuse, N.Y., while the Alas (Spanish for “wings”) Project targets Spanish-speaking mothers in four North Carolina counties. In both programs, psychiatric nurses visit the mothers weekly for five months, helping them develop coping skills to face difficult issues, improve their parenting skills and increase their use of social support resources.
“We’ve seen that through the interventions, the moms can reduce their depressive symptoms,” Beeber reports. “The programs reach mothers who probably would not be reached by traditional mental health [services].”
This would not happen, though, without strong community partnerships. The researchers work hand-in-hand with Early Head Start, a federally funded program for low-income families with infants and toddlers. Early Head Start staff, who have already established relationships with the families, screen mothers for symptoms of depression and encourage them to participate in the HILDA and Alas projects. The research team also works with Latino and African American community organizations, and through the years Beeber has established trust through many hours of community volunteer work.
Nurses must get involved in the community to reach people where they live their daily lives. For example, Ruby Murphy, RN, MS, a case manager for mental health emergency services at Jackson Memorial Hospital’s Mental Health Hospital Center in Miami, educates people in the local black community about depression through church health fairs. This is an ideal venue because many African Americans rely on prayer and spiritual support to deal with emotional problems and because the church is a hub of the community. Through this outreach work, Murphy teaches individuals and families how to recognize signs of depression and what to do if they think they or someone else is suffering from this illness.
Gary advises nurses to learn about the conditions and resources in the communities in which they work. “How do people feel about the resources, and do they use them? Who are the natural caregivers and community brokers? What is the rhythm of the community?”
By forming partnerships with these community resources, nurses can make information about mental health care and suicide prevention available at housing projects, day care centers, schools, barbershops and beauty salons, neighborhood youth centers–wherever people go in the course of their day-to-day activities.
Above all, community-based suicide prevention initiatives must be ongoing and consistent, Gary says. “You don’t go in and do it for a year, and then leave.”
Individual Interventions
On the individual patient care level, being culturally knowledgeable can give nurses an advantage in recognizing minority patients who may be at risk for suicide and in intervening early enough to save their lives.
In her research on depression among African American women, Waite found that understanding the cultural context of patients’ lives could lead to earlier detection of the disease. She studied how African American women articulate, conceptualize and cope with depression. Because of cultural and social norms, many of the women hid their depression from family and friends. The study reported one participant saying, “Being strong is seen as good. If I said I was depressed, people would say, ‘You’re a better person than that.’ You are labeled, and if you are perceived as ‘crazy,’ they do not want any part of you.”
Strickland’s Cherokee cultural background helped her connect with youth in the Pacific Northwest tribal communities, but she also delved deeper to learn more about the stressors and protective factors in the young people’s lives. One girl, for instance, reported deep anger over the rape of the land and the historical trauma her people had suffered for generations. The teens also spoke of the healing power of going to water, spending time in the mountains and talking to their grandmothers.
Of course, it is unrealistic to expect nurses to have a thorough understanding of every culture. But treating patients with cultural sensitivity and respect can do a lot to help fill in the gaps.
“There are so many nuances in culture,” Gary says. “You can’t know it all, but if you respect yourself and what you have to offer and also respect the individual and family, then you’ll manage.”
Any nurse, not just those specializing in mental health, can refer depressed patients for help, and should do if there is even a hint that a patient is at risk for harming himself or herself, says Murphy. Nurses must be familiar with the warning signs for suicide and sharpen their assessment and interviewing skills so that they know how to ask the right questions. “Good communication skills are imperative, because they can be life-saving,” she stresses.
Nurses should not shy away from broaching the subject of suicide if they think a patient might be at risk–even if suicide is a taboo subject in the patient’s culture, experts say. In focus groups for Beeber’s Alas Project, Latina mothers said they would confide in nurses about feelings they would not share with family members or friends.
“It takes courage on the part of nurses to bring up the subject of suicide, but you have to ask the questions in the context of a relationship,” Beeber says. “I can’t emphasize enough that you have to have a relationship with people because that’s the only way you’re going to hear how they really feel.”
A patient-centered approach is critical, Waite believes. Too often, health care providers approach problems with an “I know what’s best for you” attitude, instead of taking time to listen to the patient’s perspective.
“You need to connect with patients where they are,” she says. “If the patient thinks praying for 15 minutes a day helps, then you start working from there.”
Suicide Prevention Resources on the World Wide Web
National Strategy for Suicide Prevention http://mentalhealth.samhsa.gov/suicideprevention
Suicide Prevention Resource Center www.sprc.org
National Institute of Mental Health www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml
National Organization for People of Color Against Suicide www.nopcas.com
Indian Health Service Community Suicide Prevention Website www.ihs.gov/NonMedicalPrograms/nspn
American Association of Suicidology www.suicidology.org
Suicide Prevention Action Network USA www.spanusa.org
American Foundation for Suicide Prevention www.afsp.org
Threatening suicide or expressing a strong wish to die
Making a plan: • Giving away prized possessions • Sudden or impulsive purchase of a firearm • Obtaining other means of killing oneself, such as poisons or medications
Unexpected rage or anger
Source: American Foundation for Suicide Prevention
Teen suicide is a hidden epidemic in the United States. It is often overlooked by health care providers, parents and teachers because of the belief that suicide is something that happens to other people’s patients or children. No one wants to believe that adolescents are capable of taking their own lives. The statistics, however, reveal a different story. According to the Centers for Disease Control and Prevention (CDC), the suicide rate in young people has increased dramatically over the past several decades. Overall, suicide is the third leading cause of death for young people aged 10 to 24.
Suicide, as a potentially preventable public health issue, is an area where nurses can play a critical role. Because nurses are positioned on the front lines of hospitals, public health facilities and schools, they often are the first people to come in contact with depressed or suicidal teens. And because adolescents are more likely to open up to a person of their own racial or ethnic group about their depression, dysfunctional family, substance abuse or suicidal thoughts, minority nurses can play a crucial role in slowing this alarming trend.
As the racial and ethnic makeup of our country continues to diversify, and as the rates of minority teen suicides continue to grow, America currently needs culturally competent nurses who can be on the look out for at-risk minority adolescents.
A Growing Threat for Minority Teens
It is often assumed that suicide is mainly an issue for white male teens. In reality, it affects both genders and all racial and ethnic groups. While more than four times as many men than women die from suicide, women are at a substantial risk—they attempt suicide about two to three times as often as men. And although white males commit suicide in the largest numbers overall, minority teen suicide numbers are climbing.
From 1979 to 1992, suicide rates for American Indians/Alaskan Natives (AI/ANs) were about 1.5 times higher than the national rate. There was a disproportionate number of suicides among young male AI/ANs during this period as well—male teens accounted for 64% of all suicides by AI/ANs, according to the CDC.
Suicide rates are also on the rise for African-American teens: From 1980 through 1996, suicide increased most rapidly (105%) among young black males ages 15 to 19.
According to in a survey of 151 high schools around the country by the Children’s Safety Network National Injury and Violence Prevention Resource Center (CSN), Hispanic students (10.7%) were more likely than white students (6.3%) to have made a prior suicide attempt.
Suicide and depression rates are increasing for Asian-American adolescents as well. Asian-American girls have the highest rates of depressive symptoms of all racial, ethnic and gender groups. Among women 15 to 24, Asian Americans have the second highest suicide mortality rates, according to the National Asian Women’s Health Organization.
It has also been widely reported that gay and lesbian youths are two to three times more likely to commit suicide than other teens and that 30% of all teen suicides or suicide attempts are related to issues of sexual identity. Although there is currently no empirical data to support these claims, the CSN feels there is a growing concern about the connection between suicide risk and bisexual or homosexual youth.
The Loss of Hope
“Back in the ‘60s, there was no such thing as suicide among black people,” states Faye A. Gary, RN, EdD, FAAN, distinguished professor at the University of Florida School of Nursing in Gainesville and a leading expert in the field of mental health nursing. “[There are more black suicides today] because of the deterioration of communities, the invasion of drugs, the weakening of the family structure and the decline of one’s sense of identity. Overall, there is a loss of hope,” says Gary, who is African American. This loss of hope, she asserts, stems from social issues like “poor education, limited job opportunities, poor health care and a distrust of the institutions that are designed to take care of us, like the police and schools.”
Bette Keltner, RN, PhD, dean of Georgetown University’s School of Nursing in Washington, D.C., and a past president of the National Alaskan Native/American Indian Nurses Association, believes similar issues are causing depression in AI/AN teens. The lack of jobs and recreational activities on the reservation, coupled with a general feeling of disenfranchisement, leads to depression and despair, she explains.
“Although the U.S. went through an economic boom in the ‘90s,” Keltner says, “people on the reservation are still living with an 80% unemployment rate. That is even more demoralizing than it was a few generations ago, when many Americans were unemployed. Native American youths are looking around at their community and realizing that their future doesn’t look very good.”
“The heart of the issue is the fracturing of the family, cultural values and sense of community, and that isn’t unique to any one [ethnic or racial] group—it could be said for everyone,” states June Strickland, RN, PhD, associate professor of Psychosocial Community Health at the University of Washington School of Nursing in Seattle.
According to the American Academy of Child & Adolescent Psychiatry (AACAP), all teens deal with feelings of stress, confusion, self-doubt, financial uncertainty and pressure to succeed, regardless of race or ethnicity.
On the Front Lines
For some adolescents, a stressful living environment, coupled with typical teenage pressures, can result in clinical depression, other mental disorders or substance abuse, all of which can lead to suicide. According to the Surgeon General’s mental health report, over 90% of children and adolescents who kill themselves are suffering from depression or another mental or substance abuse disorder. However, these psychiatric conditions are highly treatable. More than 80% of people with clinical depression can be successfully treated with medication, psychotherapy or a combination of both according to the National Mental Health Association (NMHA).
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Early recognition of depression in teens is vitally important in preventing the onset of serious depression or suicide. Minority nurses who come in contact with teens during emergencies, routine check-ups or in schools, are in the perfect position to recognize signs and symptoms of depression early on and alert parents to the need for immediate intervention.
“Nurses are close to the people most at risk; whether we are in the emergency room, public health clinics or schools, we are on the front lines, which is very important,” Keltner says. “And as a minority nurse, you have a greater opportunity for connection and communication [with teens who are not part of the major population].”
This is particularly important because in many cultures, mental illness and depression are viewed as signs of weakness, especially among males. The stigma attached to depression, coupled with the general lethargy many depressed patients experience, may lead suicidal teens to avoid seeking treatment.
Dorothy Marks, RN Med, a school nurse in the Chicago area, believes her position makes her more accessible to both students and parents. “I am fortunate because nurses are seen in a different light [than teachers and social workers],” she says. “We’re seen as someone who is there to help, someone who is approachable.” As an African-American nurse who grew up in the community in which she works, Marks is even more accessible. “I think it helps that I grew up in the community; I can relate to many of the young people,” she explains. “I used to work at the elementary school as well, so I have [been their school nurse] from the cradle to high school. I always tell the student that we’re family.”
Depression and suicide are difficult issues for most people to discuss, making it harder to diagnose and treat. Strickland advocates a more positive approach. “I never use the word ‘suicide’ when talking to a depressed teen or their parents,” she says. “What kid wants to be labeled as a ‘suicide risk’?”
But that is not to say Strickland, who is Native American, isn’t actively addressing the issue of suicide in the reservation communities where she works. “When I talk to parents, I tell them their child is at risk for ending their life because they have a special gift—they are able to feel with more passion and depth than most people,” she explains. “I stress the need to support this young person, and I try to bring a spirit of wellness, not sickness, into the community.”
[Nan: please make the following section a sidebar.]
How to Spot a High-Risk Teen
As a school or clinical nurse, it’s important to look for telltale signs of seriously depressed or potentially suicidal teens. These can include:
• adolescents who are suddenly not interested in things they used to be interested in, such as sports or music;
• a reported change in eating or sleeping habits;
• drug or alcohol use;
• unusual neglect of personal appearance;
• complaints of physical symptoms that are often linked to emotions, such as stomachaches, headaches or fatigue.
Suicidal teens often display a sense of resignation about life. They begin to tie up loose ends, as if preparing for death, by giving away or discarding important possessions. “Often, adolescents do not display the typical outward signs of despair you might assume someone considering suicide would display,” Keltner says. She stresses that any teen who talks about suicide should be taken extremely seriously.
According to the NMHA, other issues for nurses to be aware of when assessing a patient’s risk for suicide are:
• a background of substance abuse or depression,
• family dysfunction or violence,
• delinquency at a young age and
• psychiatric disorders.
Teaching Nurses How to Care
Although it is certainly ideal for a depressed adolescent to receive health care from a nurse of their same racial or ethnic background, this is not always possible. During the current shortage of nurses, and even greater shortage of minority nurses, at-risk teens will often come in contact with nurses of racial or ethnic groups other than their own. To provide culturally competent care to all patients, including depressed or suicidal teens, Gary advocates in-depth diversity training for nurses.
Strickland agrees, “We need to prepare all nurses to work with diverse populations. We are currently not doing enough. [Diversity training classes] should not be electives; they should be integrated throughout all course work.”
Nurses who are planning to specialize in providing health care to a specific population need comprehensive training to gain experience with the particular culture’s health care beliefs and practices. Rosalyn Harris-Offutt, CRNA, BS, LPC, LNC, ADS-UNA, who is African American and a First Nation Person (her preferred term for Native American), concurs that there is a need for more educated and open-minded nurses. “First Nation People need health care providers who are willing to work with non-Western healers and who are willing to learn about our methods of healing,” she says.
Not only do typically underserved populations need nurses who are willing to learn about and embrace cultures other than their own, they also need nurses who are willing to relocate to areas were health care services are limited. Native American communities, Harris-Offutt explains, are in desperate need of nurses willing to work in the isolated areas where reservations are often located. “In more remote places, teens who are in need of help can be very far apart,” she states. AI/AN adolescents may be unable to receive the mental health care they need because they are unable to get to a health care facility.
Keltner agrees that there is not enough access to mental health care in areas where typically underserved minority populations reside. “The question of access is really three questions,” she says. “First, is [mental health care] present at all? Is it of good quality? And is it accessible to the community?”
In addition to cultural competency training, nurses interested in working specifically with adolescents in the area of suicide prevention or depression treatment should also gain experience in mental health nursing, substance abuse programs, crisis management and adolescent development. Keltner believes nurses must have comprehensive educational preparation to be ready to handle the challenges of this at-risk population.
“If your nursing career focus will be with at-risk adolescents, you need professional preparation,” Strickland says. “It’s serious work. If you’re interested in it, you should follow that track in your education.”
Making a Difference in Your Community
Even though working in suicide prevention may not be the perfect career fit for every nurse, Strickland says there are many different ways nurses can help high-risk teens. By always remaining on the lookout for teens at risk for serious depression or suicide, you can also make a difference in saving young lives.
“We need community focused, broad-based prevention work in mental health to combat adolescent suicide,” explains Strickland. “You need to ask yourself, as a concerned member of your community, what can I do to support local young people? They need recreation and fun things to do to lift their spirits.”
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Keltner adds, “Preventive, proactive programs that provide activities for kids where they can be successful, productive, valued and affirmed can make all the difference in the world.”
A Call To Action
Based on the startling statistics of increased suicide rates among minority teens, Surgeon General David Satcher, who is African American, recently issued a Call to Action to Prevent Suicide, which identifies suicide as a major public health issue. As part of the Healthy People 2010 Objectives, it sets a goal to significantly reduce suicide and suicide attempts among adolescents in grades 9 through 12 by the year 2010.
Satcher’s Call to Action recommends the following three steps to reduce suicide rates:
• Awareness—Public health professionals are encouraged to broaden the public’s awareness of suicide and its risk factors.
• Intervention—Services and programs aimed at preventing suicide must be enhanced.
• Methodology—The science and research behind suicide prevention must also be increased.
Minority nurses can play a vital role in accomplishing Satcher’s objectives. According to Mental Health: A Report of the Surgeon General, racial and ethnic backgrounds need to be considered when treating teens who are depressed or suicidal. “Cultural differences exacerbate the general problems of access to appropriate mental health services,” the report states.
“Just being born American Indian brought me into the legacy of harm and poor health,” asserts Roxanne Struthers, RN, PhD, CTN, assistant professor at the University of Minnesota School of Nursing in Minneapolis and president-elect of the National Alaska Native American Indian Nurses Association (NANAINA). “I have seen in my family the effects of disease–TB and other epidemics with no resistance and little or no treatment. And not only disease [but also cultural loss]. My mother’s first language was Ojibwe; she was beaten when she spoke it, then her only language, at a rural reservation school. Later, she would not allow us to speak it at home. Now as a nurse, all the diseases I encounter every day [in Indian patients]–alcoholism, drug dependence, diabetes, overeating–I see as parallel to my own life. Some younger nurses may not be as aware of this at first, but it will resonate when they hear the history.”
“That’s when I started to see–and later I started to hear more,” recollects Lillian Rice, a Forest County Potawotami Tribe Native practitioner and alcohol/drug counselor, born in backwoods Star Lake, Wisc., and now living in Minneapolis. Then only 17 years old (in 1949), she linked the negative behavior of a close family member sinking into alcoholism with what she had heard earlier as a child from her grandmother. The grandmother had told of TB epidemics and children’s deaths, of scarlet fever quarantining with confiscation of Native ceremonial paraphernalia, of relocation without treatment or recompense, of going back home and finding the old estate burnt down by the U.S. government. Other family members brought forth painful memories from boarding school days of horsewhipping and humiliation.
“That’s when I decided to become a healer,” says Rice, who leads women’s sweat lodges and women’s spiritual gatherings. “After raising my five children and getting into chemical dependency work, I made a decision with a promise to the Great Spirit to be there for [Indian] women in honor of my grandmother.”
Lea Warrington, RN, BSN, gives a presentation on historical trauma to nursing students at the University of Wisconsin-Milwaukee.
“If you are Native and born into a Native family, your community’s past is a part of who you are,” attests John Lowe, RN, PhD, a faculty member at Florida Atlantic University’s College of Nursing in Boca Raton and a researcher/designer of Native American teen interventions to prevent and reverse substance abuse and reduce HIV/AIDS risk. “I was raised in a Cherokee farming community in the Southeast and went to school there,” he says. “My father, now 80, would have had to go to boarding school, so he didn’t go to any school. He was needed on the farm and his parents did not want their kids taken away. [I used to wonder,] why didn’t my father have the problems we see so often [in Indian communities], such as alcoholism and diabetes? Why was he OK? When I went away to attend a college nursing program in the 1970s, I took with me that vision of my father. He knew who he was: Cherokee, with traditions, values and beliefs. He faced many barriers, but something within him was very grounded and centered, and that kept him OK. If we [as nurses] could understand it, that is what we should promote.”
These Native American health practitioners are describing historical trauma. Although of recent coinage as a term, its devastating effects on the physical and mental health of American Indians and Alaska Natives have been documented for decades. Native healers, with their feeling for root causes, have tapped traditional spiritual resources to help put their families and communities back on a path to recovery. Now, working right in the mainstream of Western health science, leading Indian health professionals and researchers have given the concept a scientific name and a place for testing in their disciplines. The literature is now packed with empirical clinical evidence and qualitative data. Promising new models of care are emerging.
And today at the front lines, strategically positioned to put these models into practice, are Indian nurses. Their recognition of who they are and what they do has inspired a call to action for Native nurses: to recognize the critical role they can play in helping their people begin the process of healing from the harms of historical trauma.
Connecting, Listening, Empowering
John Lowe, RN, PhD
How does the healing start? For Native nurses, it begins with knowing yourself, your community and your common past.
“First, heal yourself,” urges Struthers. “The healing of one is the healing of all. Then you can share [with patients]. It does ripple out. You can reassure your patients by saying, ‘You are not unusual, you are not alone.’ History lessons are OK, too.”
Rachel Wright, RN, BSN, a master’s student in the nurse practitioner program at the University of Oklahoma College of Nursing in Oklahoma City, talks in terms of empowering patients.
“In fact, I think that’s the main thing nurses can do,” says Wright, whose father is Cherokee. “I agree that I see many Native American patients with social problems associated with physiological problems, but I believe that some of those are related to the self-esteem issue, lack of knowledge and lack of confidence to make lifestyle/behavioral changes that impact their health status. Any patient who feels like a failure and does not understand the problem most likely will not comply with the treatment plan. The nurse or nurse practitioner must help patients learn appropriate knowledge and skills to help themselves.”
To get compliance and accurate information from your patients, make sure the communication connection is two way, advises Lea Warrington, RN, BSN, manager of the Gerald L. Ignace Indian Health Center, an urban Indian Health Service facility in Milwaukee. Warrington, who is of Menominee Indian heritage and visits the reservation frequently, often finds out what’s really going on with her patients–as opposed to what’s in the clinic record–when she encounters them on their own “turf.”
Communication failure may come from passivity or not wanting to cause conflict, Warrington warns. Take the case of a 72-year-old patient whose daughter found all his medication bottles unopened in his medicine cabinet. The patient’s record at the clinic showed that he had very literally answered “yes” when asked whether he had filled his prescriptions and “no” as to whether he “had any problems with them.”
Often, after patients leave the facility, Warrington hears complaints about the way the clinic works, or about problems with service, that never showed up on the returned patient satisfaction surveys (usually checked off as “excellent”). “Outside the clinic, even though I work there, patients open up because we are in our own common setting, such as the elderly center, the school or on the street,” she explains.
Native nurses who work within the mainstream Western health care system face a paradoxical challenge, Warrington adds. “I believe that Native patients appreciate that Natives work in health care centers,” she says. “But I think, though, that sometimes we end up having to prove that we can provide as good service as non-Natives. It’s an odd situation to be in, because of the way Native people perceive the overall health care system as not being Native-friendly.”
Reducing Suicide Risks
“Start off with questions checking for traditionality and family connectedness,” suggests Dan Edwards, DSW, director of the University of Utah School of Social Work and Native American Studies in Salt Lake City. This information is essential for effective assessment, particularly in the mental health area, such as evaluating suicide risk.
Three first questions, suggests Edwards, might be: Where do you live? Do you know the [tribal] language? Have you ever been to your own tribal ceremonies? (For example, a female patient could be asked, “Have you ever been to a kinaalda [a Navajo coming-of-age ceremony for girls]?”) Then, he says, “as you establish rapport and if the patient seems open to it, you can begin talking about spirituality and religion.”
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Edwards is of Yurok heritage, with pre-1970s personal experience with foster care, adoption, boarding schools and assimilation pressures. He has observed the links for bad parenting and high divorce rates, heavy drinking patterns, vulnerability to negative peer pressures and suicide clusters.
Alaska Natives and American Indians rank first among all ethnic groups in suicide rates. While the particulars vary for subgroups–e.g., Indian people living in cities versus rural areas and reservations–the causes can be traced to historical trauma.
“The lost birds–Native Americans who were adopted out or in foster care and have completely lost their culture–are at high risk for suicide and/or risk-taking behavior if they have not successfully taken on their new family’s ways to a level of comfort that will offset these problems or if they have not sought their own culture later in life,” explains Margaret P. Moss, RN, DSN, assistant professor at the University of Minnesota School of Nursing and a Native Investigator (Hidatsa/Lakota background) in research.
Getting the complete family and lifestyle picture is also critical for suicide prevention in Indian teens and young adults, a particularly high-risk group, adds Faye Annette Gary, RN, EdD, the Medical Mutual of Ohio Professor of Nursing for Vulnerable and At-Risk Populations at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland.
Gary, who gave a presentation on Native adolescent health and preventive education at NANAINA’s ninth annual Summit in Park City, Utah, last September, urges Native nurses to recognize the profile: male, between 15 and 24; single; likely to be under the influence of alcohol before suicide attempt; lived with a number of ineffective/inappropriate parental substitutes. Familiar historical trauma issues include “once a resident in boarding schools with frequent moves,” “in confinement centers at early age” and “experienced a loss of a significant other through violence.”
Healing Through Reconnecting
Defining Historical TraumaMaria Yellow Horse Brave Heart, MSSW, LCSW, PhD, research professor at the University of Denver Graduate School of Social Work, is the initiator and primary developer of historical trauma theory, intervention models and curricula. She defines historical trauma as “cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma.”Brave Heart introduced historical trauma theory and applications in the late 1980s when she started to see her Lakota Indian community’s past as a linked sequence of “unresolved grief.” She defined the concept and developed grief resolution interventions to deal with specific phases in the historical trauma and responses to it. Her pioneering research has been disseminated in numerous publications and through workshops and community education she provides through The Takini Network, Inc., in Rapid City, S.D. ([email protected]).Brave Heart’s definition has been adapted by Native nurse researchers Roxanne Struthers and John Lowe in their work on nursing interventions for healing historical trauma in Native Americans.1-5
To get ideas for meeting the toughest health care challenges, such as diabetes, periodically review the Native American nursing literature–especially the articles published by Struthers, Lowe and other Native nurse researchers as part of the ongoing Nursing in Native American Culture project (see “References” and “The Conceptual Framework of Nursing in Native American Culture” sidebar).
Diabetes, suggests Struthers, can be looked at in a current community context along with a racial memory of the past–the taking of Indians’ land, with no more hunting and fishing; forced relocation interfering with diet and exercise; and the poor food choices that come with poverty.
Talking circles–community sharing groups based on Indian tradition–are being tried in many places to help patients deal with diabetes self-management and emotions. In two circles (for diabetes and domestic violence) at the urban clinic where Warrington works, patients learn to listen as well as talk, taking turns with “the talking stick.” The groups start by smoking cedar or sage in a shell (sometimes called smudging), which has a calming effect, and then close down the circle the same way.
Lowe offers a scenario, summarized below, showing how the conceptual nursing framework’s connectedness dimension might work for an Indian patient with diabetes:
► The nurse listens to a patient describe how he has been managing his diabetes. She is seated next to him about one foot away. There may be long periods of silence, but the nurse appears comfortable and does not ask demanding or threatening questions.
► Conversation ensues, centered around who the patient’s family members are and his everyday life and activities. The nurse talks about the community the patient lives in and resources available.
Solving the “Indian Problem” by Breaking the Tribal Bond: Federal Policy on Indian Health, 1850-1950Assimilation was forced through:Illness/murder (reservations; laws restricting free movement; food withheld or stockpiled and no hunting/fishing allowed; disease with no medical treatment; resistors sent to prison, murdered)Boarding schools (kidnapping; personal humiliation; renaming and little to no contact with families; abuse; survivor syndrome, failure to fit in, intergenerational family bond breakdown)Urbanization/relocation (promised jobs, housing and financial support did not materialize; those returning home no longer fit in)Termination/allotments (61 Indian tribes terminated in late 1950s to early 1960s; large tracts of land signed over without consent of the population; created internal war and conflict; damage from destroying land base of people who saw themselves as part of the land)Genealogy–Dawes Act of 1887 (identify Indian by blood quantum; can claim only one tribe; those less than ¼ of any tribe not “Indian”; disruption of Indian identity, family, clan ties)
► As the patient talks about the foods he eats, the nurse does not act condescending in her reply about foods he should be avoiding. Instead, she talks about alternatives and options available to the patient. The nurse knows that family and community must be involved and that the patient may need to be encouraged to use them as a resource and to allow them to help him.
► The nurse remains nonjudgmental by respecting what the patient shares. He is encouraged to talk and holistically express who he is in his everyday life and activities, his beliefs, his strengths, his management of his diabetes, and who he is connected to, such as family, community and other elements of the creation/universe. There may be storytelling and the nurse may share similar experiences.
► Native American nurses sometimes connect at a deep indigenous “oneness” level when caring for another Native American, especially in talking about how the past, present and future have affected them in similar ways.3
And finally, for a tested model of customizing interventions for a specific tribe, review Lowe’s ongoing work on Cherokee self-reliance and its application to substance abuse and other nursing interventions for teens.4 On a lifelong quest to understand what kept his own Cherokee father “OK” in the midst of cultural devastation, Lowe has analyzed the historical trauma dealt repeatedly to Cherokee men and the misguided policies and health concepts imposing non-Cherokee notions of independence.
Revealing the true Cherokee conception of self-reliance, which rests on being responsible, being disciplined and being confident, has produced a model that will work for holistic nursing assessment of Cherokee patients. Promotion of the core Cherokee value of interdependence promises to help overcome many of the ills that have come from disconnection and non-Native concepts of self.
References
1. Struthers, R. and Littlejohn, S. (1999). “The Essence of Native American Nursing.” Journal of Transcultural Nursing, Vol. 10, No. 2, pp. 131-35.
2. Lowe, J. and Struthers, R. (2001). “A Conceptual Framework of Nursing in Native American Culture.” Journal of Nursing Scholarship, Vol. 33, No. 3, pp. 279-83.
3. Lowe, J. (2002). “Balance and Harmony Through Connectedness: The Intentionality of Native American Nurses.” Holistic Nursing Practice, Vol. 16, No. 4, pp. 4-11.
4. Lowe, J. (2002). “Cherokee Self-Reliance.” Journal of Transcultural Nursing, Vol. 13, No. 4, pp. 287-95.
5. Struthers, R. and Lowe, J. (2003). “Nursing in the Native American Culture and Historical Trauma.” Issues in Mental Health Nursing, Vol. 24, No. 3, pp. 257-72.
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program”
Majestic mountain peaks, abundant wildlife and unlimited natural beauty have made Alaska a vacation dreamland for millions of people from all over the world. But while tourists come and go, America’s northernmost state is also home to thousands of indigenous peoples, including Aleuts (people native to the Aleutian Islands), Eskimos (natives who live primarily in Alaska’s coastal regions) and many smaller tribal groups. Collectively, Alaska Natives constitute one of the smallest ethnic minority populations in the U.S.—only about 2 million people in the entire country.
According to the 2000 U.S. Census, there are nearly 100,000 Alaska Native and American Indian (AN/AI) people living in Alaska. By no means a homogeneous population, this group breaks down into numerous subgroups, each with its own distinct culture and, in many cases, its own language or dialect. In fact, the Women of Color Health Data Book, published by the Department of Health and Human Services’ Office of Women’s Health, estimates that there are more than 300 languages spoken among American Indians and Alaska Natives.
Unfortunately, awareness of Alaska Natives and their health care needs is extremely limited outside their home state. Down in the “lower 48,” as Alaska residents call the continental U.S., medical researchers and health care providers have traditionally lumped Alaskan Natives together with American Indian tribes from other parts of the country, even though they live thousands of miles apart and have different cultures and living environments.
The good news is that as researchers delve deeper into investigating the disparities in health outcomes between Americans of color and the white majority, Alaska Natives are finally being addressed as a group with its own identity. The bad news is that this research clearly indicates that Alaska Natives face many of the same serious health problems, in varying degrees, as minority populations in the rest of the nation.
“Overall, [the health issues here] are very much like those for people of color in the rest of the United States—they just differ in magnitude,” says Kathleen Kinsey, RN, BSN, MPA. “For example, Alaskan Natives’ smoking and obesity problems are greater.” Kinsey, an American Indian nurse originally from Washington state, is administrator of nursing services for Mt. Edgecumbe hospital in Sitka, Alaska, part of the Southeast Alaska Regional Health Consortium (SEARHC).
Here’s a closer look at what nurses interested in working in Alaska need to know about the major health care issues affecting Alaskan Native communities, both historically and in the context of current initiatives to close the minority health gap in the 21st century.
Alaska Native Health 101
Heart Disease [N Elia – These headings under the main subhed are sub-subheds. Please format this section the same way you did the section called “The Present” in the “One Name, Many Faces” article in the previous issue.]
For decades, the number one cause of death for Alaska Natives was infectious diseases. But as medical advances brought these illnesses increasingly under control, the mortality picture shifted toward chronic conditions. Today, one of the leading killers of Alaska Natives is heart disease, as it is for the rest of the U.S. population. According to the American Heart Association (AHA), 25.2% of all American Indian and Alaska Native males who died in 1999 suffered from heart disease or stroke. Women fared even worse, with 27% of all deaths attributed to these causes.
Interestingly, even though the Centers for Disease Control and Prevention (CDC) still rank it as the number one cause of death for Americans as a whole, the mortality rate for cardiovascular disease (CVD) in the United States has dropped by more than 50% during the past 40 years. Experts say much of this decrease is a direct result of improved medical technology and earlier diagnosis. But during this same period, according to the Indian Health Service, the incidence of CVD among Alaska Natives and American Indians rose dramatically.
In fact, Indians and Alaska Natives between the ages of 35 and 44 have a CVD risk at least two times higher than that of their Caucasian counterparts. Even though this gap diminishes with age, it doesn’t disappear: AN/AI people in the 55-64 age group are still 1.5 times more likely to suffer from heart disease than whites of the same age.
Researchers and health professionals alike point to increased tobacco use as one of the key factors contributing to this disparity. Both the AHA and the American Lung Association (ALA) report that nearly 40% of all American Indian and Alaska Native men and women over the age of 18 smoke regularly, compared with only about 26% of Caucasians in the same age bracket.
Obesity
Why the rising occurrence of heart disease among young Alaska Natives? Is smoking the lone contributing element? Health experts who work in Alaska Native communities believe changing dietary habits are also to blame.
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In recent years, many Alaska Natives have moved away from their traditional diet of seafood and game to embrace fast food and prepackaged meals, especially in the state’s more urban areas. (According to 1990 figures, 69% of Aleuts and 50% of Eskimos in Alaska live in cities.) As the food choices increased, so did Alaska Natives’ weight. Just two or three generations ago, malnutrition had been a pressing concern. But as AN communities became more urbanized, or as native people left their villages for larger cities, their diets began to include more saturated fats and processed foods.
Former U.S. Surgeon General Dr. David Satcher declared obesity a national epidemic in 2001 when research revealed that 60% of all Americans were overweight or obese. But the Alaska Native population has been hit especially hard. SEARHC routinely conducts a health survey of the various AN communities and tribes it serves. Its most recent survey (April 1998) found that 46% of adult participants were overweight. For such a small sample, that’s a staggering statistic. Additionally, SEARHC found that one in three youths in Alaska qualify as overweight, compared with one in five for the country as a whole.
“I grew up in an Aleut community in Kodiak, Alaska, on what was basically a subsistence diet of fish and venison,” says Kathy Belanger, RN, BSN, CNOR, nurse manager of surgical supply services at the Alaska Native Medical Center in Anchorage. “I didn’t eat beef until I was in the sixth grade. Our eating habits have gotten much worse and as that changed, so did the health of our people.”
Diabetes
Not only does obesity increase people’s risk of developing cardiovascular disease, it can also increase their likelihood of suffering from diabetes—the sixth leading cause of death in the U.S. Most racial and ethnic minority groups have been disproportionately affected by this serious chronic disease and its related conditions, such as renal failure, amputations and blindness. However, the disparity gap for Alaska Natives is narrower than for other Americans of color. For example, Hispanics and American Indians have two to six times the incidence rate of diabetes compared to Caucasians. Alaska Natives, on the other hand, are also more likely to have diabetes than whites, but their incidence rate is less than twice as high.
Still, the number of cases diagnosed each year in AN communities continues to climb. According to the Women of Color Health Data Book, the rate of diabetes mellitus in Alaska Natives has grown tenfold in the past 30 years. Not surprisingly, the disease is less common in the more remote villages where people maintain their subsistence-like diets.
Tuberculosis
While obesity and diabetes are relatively recent health problems for Alaska Natives, AN communities have been battling tuberculosis for generations. Indeed, TB was once called “the scourge of Alaska.” According to a report recently published on http://www.tribalnews.com/, an online AN/AI news source, when the state first started recording the number of TB cases in 1952, officials were stunned to learn that there were nearly 400 cases per 100,000 Alaskans. But the epidemic was far worse for Alaska Natives, with more than 1,800 cases per 100,000. Throughout the past 50 years, Alaska’s health care providers have struggled to treat and prevent the spread of this highly infectious disease.
Although never completely eradicated, up until the 1990s health experts believed the disease was on the decline. Unfortunately, it rebounded with mutated, drug-resistant forms, and Alaska is once again the hardest-hit state. In 2000, the CDC reports, there were 17.2 TB cases per 100,000 people in Alaska—the highest incidence in the nation. The 108 new cases reported that year represented a 75% increase over 1999 statistics.
“As a nursing student working in public health, I was surprised at the number of TB cases, especially among children,” Belanger remembers. “Today, I still see the isolation signs when I walk through the hospital.”
The threat of tuberculosis is greatest for Alaska Natives who live in the farthest reaches of the state. A full 90% of adults age 60 and older in remote Alaskan territories have had positive TB skin tests. Of those positives, approximately 10% develop active cases, which can pose a significant public health risk if left untreated or partially treated.
Cancer
A new study published this year in the journal Alaska Medicine confirms that cancer has moved up from second place to become the leading cause of death for the Alaska Native population. In particular, Alaska Natives are now 40% more likely to die of lung cancer than white Americans, and their risk of colorectal cancer is also greater. Breast cancer rates are also high among Alaska Native women, especially those who live in remote areas with limited access to health care facilities that can provide screening and early detection. Again, doctors and nurses point their fingers at the high rate of tobacco use in AN communities and the steady movement away from traditional foods as key factors behind the rise in this once-rare disease.
In the 1950s, cancer was hardly found among the aboriginal peoples of Alaska, according to TribalNews.com. But in 1988, former Alaska Native Medical Center Director Robert Fortuine drew statewide attention to the fact that rising rates of cancer and heart disease were directly linked to a drastic change of diet and lifestyle among Alaska Natives. Low-income people were especially at risk, he noted, because “they tend to eat more inexpensive meats like bologna and hot dogs.” These types of foods lack the healthier, unsaturated oils found in such traditional staples of the Alaskan Native diet as fish, seal, whale and walrus.
However, the results of the Alaska Medicine study did contain some good news: Alaska Natives are less likely to die from prostate cancer, leukemia, lymphoma and uterine cancer than members of other racial and ethnic groups.
HIV/AIDS
Although this deadly infectious disease is on the rise among Alaska Natives, the actual number of cases reported throughout the past 20 years is still quite low when compared with the rest of the U.S. population. According to the ALA, which tracks AIDS-related respiratory diseases, Native Americans as a whole represent less than 1% of all AIDS cases in the nation.
Culturally sensitive cancer prevention brochures from the Southcentral Foundation Alaska Native Women’s Program
“The low incidence of AIDS [in Alaska Natives] might be because of our lifestyle,” suggests Belanger. “The village setting with its small group of people is not necessarily exposed to the risk behaviors associated with the big cities. But that is changing as well.”
Much of this change has occurred rapidly over the past ten years. From 1992 to 1993, the CDC recorded a nearly double jump in the total number of AIDS cases in American Indian and Alaska Native communities—from 445 to 818. Just two years later, that figure hiked to 1,333 cases, of which less than 400 were reported in Alaska. By June 2001, the number of cases had again nearly doubled, reaching a total of 2,433. Additionally, at least 25% of new AIDS cases in Alaska are reported by young people.
Alaskan health officials remain uncertain as to how any future spread of the immune-attacking disease will develop, but they do acknowledge that at-risk behaviors appear to be on the rise. For example, alcohol and drug use is abundant among Alaska Natives. In fact, the SEARHC survey respondents listed alcohol and drugs as their leading health care concerns.
While alcohol abuse is disproportionately high among American Indians, the SEARHC survey concluded that the drinking habits of Alaska Native teens do not differ significantly from those of their counterparts in the majority population. But Alaska Native youths use marijuana at nearly twice the rate of whites. Moreover, suicide rates among Alaska Natives are four times higher than in the rest of the United States, with AN males between the ages of 15 and 34 at the higher risk.
Access Issues
As serious as these illnesses all are, one of the most critical health crises facing Alaska Natives is not a disease at all—it’s lack of access to health care services. While the larger cities, such as Anchorage and Juneau, offer a reasonable choice of health care options, native people who live in outlying areas and remote villages are often cut off from even the most basic care. Transportation can become a formidable obstacle when emergencies or acute care issues arise, especially during the winter.
“Our facility is located in a region where the only way to get into town is by plane or boat, which can take several hours,” explains Kinsey. “For many people, they’re only making the trip to the hospital because they have an acute health care need.”
The state government, however, is taking steps to bridge these access gaps. One solution has been to provide outlying areas with community health aides, who work under the guidance of physician consultants. While they’re not nurses, the aides are trained in a wide range of health care assessment skills, from baby wellness to trauma.
In addition, new advances in telecommunications technology are enabling more hospitals and clinics to reach out across the miles and bring their services directly to remote communities. Although it’s still a relatively new option, Kinsey says SEARHC has begun to use telemedicine as a means to help villages maintain their health. Doctors and nurses can now provide patients with one-on-one consultations via telephone, videoconferencing and even cyberspace, as more villages gain computer access.
“We need to ask how we can keep health care delivery in the villages and support them in real time,” Kinsey emphasizes. “I think telemedicine is an important issue for this region, especially because I don’t see transportation improving significantly.”
But geographical isolation is not the only problem that can limit Alaska Natives’ access to quality health care. Cultural differences can also be a significant barrier, especially when Alaska Native patients are hospitalized. Because the state’s health facilities typically have many staff interpreters or bilingual providers, language isn’t usually an obstacle per se. However, the way in which Alaska Natives speak is different from what most Americans are used to, which can often lead to communication breakdowns.
For example, says Kinsey, Alaska Natives often talk slowly with pauses, and they communicate through storytelling with the most important elements at the end of the speech. “Nurses should expect to sit and listen to patients and not talk over them. That’s probably the biggest cultural difference,” she advises. Belanger adds that nurses should look beyond the surface response to make sure Alaska Native patients truly comprehend their instructions for treatment and follow-up care. “Natives are trusting people and they may say they understand, but that isn’t always the case,” she says. “In training new nurses, we tell them what clues to look for to see if the native patient is really understanding what they say.”
Wanted: Alaska Native Nurses
This need for cultural competence training is extremely important given the fact that the majority of Alaskan hospitals’ nursing staff comes from outside the state. Furthermore, the University of Alaska Anchorage School of Nursing estimates that American Indians and Alaska Natives make up more than 15% of the state’s total population but only 2% of Alaska’s registered nurses.
The school hopes to change this situation through its Recruitment and Retention of Alaska Natives into Nursing (RRANN) Program, launched in 1999. RRANN offers Alaska Native students in associate and baccalaureate degree programs a variety of resources, including tutoring, mentoring, support groups and “student success facilitators,” to aid them in completing their nursing studies and transitioning into the workforce.
Kinsey, too, has been working to increase the number of Alaska Natives in SEARHC’s nursing rosters. She helped establish an LPN program to assist Alaska Natives’ entry into the profession. From there, the nurses are encouraged to pursue a degree leading to RN status. “Right now, we have eight employees signed up for the LPN program and we expect all of them to move on to the RN program,” she notes. “Of those eight, half are Alaska Natives.”
Women of color account for approximately one-third of all adult women in the U.S. Yet compared to women who are members of the white majority, minority women continue to bear a disproportionate burden of morbidity and mortality from a wide range of health problems–from heart disease, lung cancer, breast cancer and HIV/AIDS to suicide and lack of adequate medical insurance.
This is a key finding of the new third edition of The Women’s Health Data Book: A Profile of Women’s Health in the United States, published jointly by the Jacobs Institute of Women’s Health (JIWH) and the Henry J. Kaiser Family Foundation (KFF). The book draws on a variety of federal studies and independent medical research to measure the nation’s progress in addressing women’s health issues and reducing racial and ethnic health disparities.
The report emphasizes that women of color generally continue to be more economically disadvantaged than white women–a key factor associated with poorer health status and barriers to care. More than one fourth of African-American women and Hispanic women, as well as 21% of Native American women and 13% of Asian/Pacific Islander women, currently live in poverty, compared to only 9% of white females.
Furthermore, more than one third of Hispanic women (37%) and nearly one quarter of black and Asian/Pacific Islander women (23% and 24%, respectively) lack health insurance coverage. In contrast, only 13% of Caucasian women are uninsured. Compared to those with health coverage, uninsured women are four times less likely to see a medical specialist when needed and are three times less likely to fill a prescription because of the cost.
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Other minority health disparities revealed in the book include:
• African-American women are at particularly high risk of developing cardiovascular disease, in part due to a high proportion of such factors as hypertension and obesity. • Women now account for 23% of all new AIDS cases–up from only 7% in 1986– with black and Hispanic women at the highest risk (see chart). Among women 25 to 44 years old, AIDS is the third leading cause of death for African Americans, the fourth leading cause for Hispanics and the tenth for white women. • Hispanic teenage girls in grades 9 through 12 report high rates of attempted suicide (18.9%), compared to 9% for white female teens and 7.5% for black high school-age girls.
For more detailed data from the new Women’s Health Data Book, read the complete report available online at www.kff.org/women or www.jiwh.org. Bound copies of the book can also be purchased from either of these Web sites.
