A Culturally Competent Model Of Care For African Americans
A Culturally Competent ModelOf Care for African AmericansJosepha Campinha-BacoteAfrican Americans arelargely the descendantsof Africans who werebrought forcibly to theUnited States as slaves between1619 and 1860. The literature contains conflicting reports of theexact number of slaves that arrivedin the U.S., with varying estimatesrevealing that anywhere from 3.5to 24 million slaves landed in theAmericas during the slave tradeera. African-American slaves generally settled in Southern states,and currently, over 50% of AfricanAmericans still live in the South;19% live in the North andNortheast, 9% live in the West,and 19% live in the Midwest(Campinha-Bacote, 2008). Thehighest concentration of AfricanAmericans can be found in metropolitan areas, with over 2 millionresiding in New York City andover 1 million living in Chicago(U.S. Department of Commerce,Bureau of the Census, 2001). Watts(2003) asserts that race is an issuefor African Americans, and “theBlack experience” in America ismarkedly different from that ofother immigrants, specifically interms of the extended period ofthe institution of slavery and theissue of skin color as a means fordehumanization of Black persons.Josepha Campinha-Bacote, PhD, MAR,PMHCNS-BC, CTN, FAAN, is President,Transcultural C.A.R.E. Associates, Cincinnati,OH.Author’s Note: Tra n s c u l t u ral C.A.R.E. Ass ociates is an organization that providesclinical, administra t i ve, research, and ed ucational services related to transculturalhealth care and mental health issues.African Americans are one of the largest ethnic groups in the UnitedStates. Data from the U.S. Department of Commerc e, Bureau of theCensus (2001) reveal that there are approximately 34,333,000 AfricanAmericans residing in the United States, representing 12.1% of thetotal population. The African-American population is expected toincrease to 40.2 million by 2010 (American Demographics, Inc., 1991).Health disparities among the African-American population includelife expectancy, heart disease, hy p e rtension, infant morality and mor bidity rates, cancer, HIV/AIDS, violence, type 2 diabetes mellitus, andasthma. The purpose of this article is to address the issue of healthdisparities among African Americans by providing nu rses with apractice model of cultural competence. 2009 Society of Urologic Nurses and AssociatesUrologIc Nursing, pp. 49-54.Key Words: African Americans, health disparities, culturalassessment, cultural competence, culture, diversity,inequality, cultural awareness, racism.A Model of Cultural CompetenceCultural DesireThe Process of CulturalCompetence in the Delivery ofHealthcare Services is a practicemodel of cultural competencethat defines cultural competenceas the ongoing process in whichthe nurse continuously strives toachieve the ability and availability to work effectively within thecultural context of the patient(individual, family, community)(Campinha-Bacote, 2007). Thispractice model requires nurses tosee themselves as becoming culturally competent rather thanbeing culturally competent, andit involves the integration of cultural desire, cultural awareness,cultural knowledge, culturalskill, and cultural encounters(see Figure 1). Each of these constructs will be applied to caringfor the African-American patient.Cultural desire is defined as themotivation of the nurse to “wantto” engage in the process ofbecoming culturally competentwith African-American patients;not the “have to” (CampinhaBacote, 1998). Cultural desire isthe pivotal construct of culturalcompetence that provides thee n e rgy source and foundation forone’s journey toward culturalcompetence. Humility is a keyfactor in addressing one’s culturald e s i re. Nurses who are humblehave a genuine desire to discoverhow their patients think and feeldiff e rently from them. Culturalhumility is a quality of seeing theg reatness in others and cominginto the realization of the dignityand worth of others. As healthcare professionals, nurses do nothave to accept the patient’s beliefUROLOGIC NURSING / January-February 2009 / Volume 29 Number 149
Figure 1.The Process of Cultural Competence in the Delivery ofHealth Care Serv i c e sCULTURALAWARENESSThe Processof CulturalCompetenceCULTURALENCOUNTERSCopy right Campinha-Bacote, 1998. P rinted with permission from TranscultureC.A.R.E. Associates.system; however, nurses mustt reat each person as a uniquehuman being worthy and deserving of love and care. In this sense,cultural desire is expressed interms of human dignity, humanrights, social justice, and equity(Campinha-Bacote, 2005). Researchcontinues to demonstrate a directcorrelation between inequalityand negative health outcomes,and it is because of this link thatnurses must consciously connectcultural competence with socialjustice. Stacks, Salgado, andHolmes (2004) contend that whencultural competence partnerswith social justice, equality inhealth outcomes can finally beachieved for all, re g a rdless ofrace/ethnicity, language, gender,religion, or sexual orientation.Cultural AwarenessCultural awareness is the conscious self-examination and in-50depth exploration of our personal biases, stereotypes, pre j u d i c e s ,and assumptions that we holdabout individuals who are diff e rent from us. In addressing cultural awareness, nurses must ask thequestion, “Am I aware of anybiases or prejudices that I mayhave toward African-Americanpatients?” An example of oneunconscious area of bias may bethe African-American dialect.Although the dominant language spoken among AfricanAmericans is English, there is away of speaking among someAfrican Americans that sociolinguists refer to as African AmericanEnglish (AAE). These term sinclude Black English, Ebonics,Black Vernacular English (BEV),and African American VernacularEnglish (AAVE) (Bland-Stewart,2005). The major problem thatAAE speakers face is prejudice.Most people believe that AAE isinferior to Standard AmericanEnglish. At times, AfricanAmericans who use AAE aremisinterpreted as being uneducated.A nurse’s personal beliefs andbiases about African Americansmay lead to unequal treatment,misdiagnosis, and over-medication (Levy, 1993; Smedley, Stith,& Nelson, 2002). For example,African Americans are at a higher risk of misdiagnosis for psychiatric disorders, and therefore,may be treated inappro p r i a t e l ywith drugs. Studies have foundthat African Americas are morelikely to be over-diagnosed withhaving a psychotic disorder andm o re liable to be treated withantipsychotic drugs, re g a rdless ofdiagnosis (DelBello, Soutullo, &Strakowski, 2000; Lawson, 1999;Strakowski, McElro y, Keck, &West, 1996; Strickland, Lin, Fu,Anderson, & Zheng,1995). Whilet h e re are several possible explanations, DelBello et al. (2000)contend that one plausible explanation is that clinicians perceived African Americans to bem o re aggressive and more psychotic, and as a result, were prescribed the antipsychotics.In examining the construct ofcultural awareness, nurses mustalso examine the possibility ofracism and ask the question, “Isthere racism in health care?” Whileprevious research attributed thep roblem of health disparitiesamong African Americans andother minority groups to accessrelated factors, income, age, comorbid conditions, insurance coverage,socioeconomic status, and expressions of symptoms; the Institute ofMedicine (IOM) cites racial prejudice and differences in the qualityof health as possible reasons forincreased disparities (Burroughs,Maxey, & Levy, 2002; Smedley etal., 2002; Stolberg, 2001).Cultural KnowledgeCultural knowledge is thep rocess of seeking and obtaininga sound educational base aboutAfrican Americans (CampinhaBacote, 2007). In acquiring thisknowledge, nurses must focus onthe integration of three specificUROLOGIC NURSING / January-February 2009 / Volume 29 Number 1
issues: health-related beliefsabout practices and cultural values, disease incidence and pre v alence, and treatment eff i c a c y(Lavizzo-Mourey, 1996). Becausemost African Americans tend tobe suspicious of health care professionals, they tend to see aphysician or nurse only whenabsolutely necessary and may usehome remedies to maintain theirhealth and treat specific healthconditions. Some African Americans, particularly of Haitian background, may believe in sympathetic magic. Sympathetic magicassumes everything is interconnected and includes the practiceof imitative and contagious magic.Contagious magic entails thebelief that once an entity is physically connected to another, it cannever be separated; what is doneto a specific part is also done tothe whole. This type of belief isseen in the practice of voodoo,when an individual will take apiece of the victim’s hair or fing e rnail and place a hex, whichthey believe will cause the personto become ill (voodoo illness)(Campinha-Bacote, 1992).Imitative magic assumes thebelief that “like follows like.” Forexample, a pregnant woman maysleep with a knife under her pillow to “cut” the pains of labor.African Americans considerthemselves spiritual beings, andGod is thought to be the supremehealer. Spiritual beliefs stronglydirect many African Americans asthey cope with illness and the endof life. In a review of the literatureon spiritual beliefs and practicesof African Americans, Johnson,Elbert-Avila, and Tulsky (2005)noted that “spiritual beliefs andpractices are a source of comfort ,coping, and support, and are themost effective way to influencehealing; God is responsible forphysical and spiritual health,and the doctor is God’s instrument” (p. 711).In regard to disease incidenceand prevalence, Underwood andcolleagues (2005) assert thatAfrican Americans experience an“excessive burden of disease.”When examining the relationshipof social characteristics, such aseducation, income, and occupation to health indicators, AfricanAmericans have worse indicatorswhen compared to Caucasians(Navarro, 1997). African Americans are at greater risk for manydiseases, especially those associated with low income, stressfullife conditions, lack of access top r i m a ry health care, and negatinghealth behaviors.Hypertension is the single greatest risk factor for cardiovasculardisease and heart attacks amongAfrican Americans. Comparedwith hypertension in other ethnicg roups, hypertension amongAfrican Americans is more severe,more resistant to treatment, andbegins at a younger age, and theconsequence is significantly worse,including organ damage (Brewster,van Montfrans, & Kleijnen, 2004;Moore, 2005). African Americansalso experience higher overall cancer incidence and mortality rates,and less than 5-year survival rateswhen compared to non-HispanicCaucasian, Native American,Hispanic, Alaskan Native, AsianAmerican, and Pacific Islanderpopulation groups (Underwood &Powell, 2006). Because AfricanAmericans are concentrated inlarge inner cities, they are at risk forbeing victims of violence. Deathdue to violence is the sixth leadingcause of death among AfricanAmericans (National Center forHealth Statistics, 2002). It is alsonoted that African Americans havea disproportionally higher rate ofpoor asthma outcomes, includinghospitalizations and deaths.Deaths due to asthma are threetimes more common amongAfrican Americans than amongCaucasians (Asthma and AllergyFoundation of America and theNational Pharmaceutical Council,2006).African Americans suffer fromc e rtain genetic conditions. Sicklecell disease is the most commongenetic disorder among theAfrican-American population,affecting one in every 500African Americans. In additionto sickle cell disease, glucose-6phosphate dehydrogenase deficiency, which interf e res with glucose metabolism, is anotherUROLOGIC NURSING / January-February 2009 / Volume 29 Number 1genetic disease found amongAfrican Americans. Finally, AIDScontributes to the lower lifeexpectancy of African Americanscompared to European Americans.In 2003, African Americans, whomake up approximately 12% ofthe U.S. population, accounted forhalf of the HIV/AIDS cases diagnosed. Treatment efficacy, especially the field of ethnic pharmacology, is important to addresswhen obtaining cultural knowledge. Examples of drugs thatAfrican Americans respond to ormetabolize diff e rently are psychotropic drugs, immunosuppressants, antihypertensives, cardiovascular drugs, and antiretroviralmedications (Burroughs et al.,2002; Campinha-Bacote, 20 0 7 ;Dirks, Huth, Yates, & Melbohm,2004; Glazer, Morg a n s t e rn, &Doucette, 1993). For example,Dirks et al. (2004) found that theoral bioavailability of specifici m m u n o s u p p ressants in AfricanAmericans was 20 and 50%lower than in non-AfricanAmericans.In obtaining cultural knowledge of health-related beliefspractices and cultural values,disease incidence and pre v alence, and treatment eff i c a c yamong African Americans, it iscritical for nurses to rememberthe concept of intra-cultural variation. There are marked diff e rences within as well as acro s scultural groups (CampinhaBacote, 2007). African Americans are not a homogenousgroup, but rather, reflect a veryh e t e rogeneous group composedof a gene pool of over 100 racialstrains. Therefore, nurses mustdevelop the skill to conduct acultural assessment with eachAfrican-American patient.Cultural SkillCultural skill is the ability tocollect relevant cultural dataregarding the patient’s presentingproblem, as well as accuratelyperform a culturally based, physical assessment in a culturally sensitive manner (Campinha-Bacote,2007). The goal of a culturalassessment is to explore the51
patient’s explanation of his or herillness. Kleinman (1980, p. 106)finds it useful to ask the followingopen-ended questions in elicitingthe details of the patient’sexplanatory model: What do you call your pro blem? What name does ithave? What do you think hascaused your pro b l e m ? Why do you think it start e dwhen it did? What do you think your sickness does to you? How doesit work? How severe is it? Will it havea short or long course? What do you fear the mostabout your sickness? What are the chief pro b l e m syour sickness has caused foryou? What kind of treatment doyou think you should receive?What are the most importantresults you hope to receivefrom this treatment?Nurses also need to develop cultural skill when performing a physical assessment with AfricanAmerican patients. In performing aculturally based physical assessment, Bloch (1983) encouragesnurses to internally ask questionssuch as, “How does skin color variation influence assessment of skincolor changes and its relationshipto the disease process?” This question raises important concerns forthe African-American patient.Nurses are trained in the art ofusing alterations in skin color anddeviations from an individual’snormal skin tone to aid with diagnoses. For example, yellow jaundice is a sign of a liver disorder;pink and blue skin changes areassociated with pulmonary disease; and ashen or gray color signals cardiac disease (Salcido,2002). However, these acquire dassessment skills are based on aEurocentric rather than a melanocentric approach to skin assessment. Assessing the skin of mostAfrican-American clients requiresdifferent clinical skills from thosefor assessing people with whiteskin (Campinha-Bacote, 2008). Forexample, pallor in dark-skinnedAfrican Americans can be observed52by the absence of the underlyingred tones that give the brown andblack skin its “glow” or “livingcolor.” Lighter-skinned AfricanAmericans appear more yellowishbrown, whereas darker-skinnedAfrican Americans appear ashen.Cyanosis and blood oxygenationlevels may present differently indark-skinned clients than in lightskinned clients. For example, somedark-skinned African-Americanpatients may have very blue lips,which may give a false impressionof cyanosis. In striving toward amelanocentric approach to assessing the skin of culturally diversepatients, Purnell and Paulanka(2003) offer the following guidelines for assessing skin variations:1) establish a baseline color (ask afamily member), 2) use dire c tsunlight, if possible, 3) observ ea reas with the least amount ofpigment, 4) palpate for rashes,and 5) compare skin in corresponding areas.Cultural EncountersCultural encounter is the deliberate seeking of face-to-face interactions with African-Americanpatients. Ting-Toomey (1999) contends that effective cultural encounters should consist of “mindful intercultural communications”and argues that the opposite ofmindful cross-cultural communication is “mindless stereotyping”(p. 16), which is a closed-ended,exaggerated over-generalization ofa group of people based on little orno external validity. Negativeencounters from health care professionals can greatly affectAfrican Americans’ decision toseek medical attention (McNeil,Campinha-Bacote, Tapscott, &Vample, 2002). One study reportedthat 12% of African Americans,compared to 1% of Caucasians, feltthat health care practitioners treated them unfairly or with disrespectbecause of their race (Kaiser FamilyFoundation, 2001). Because mostAfrican Americans tend to be suspicious of health care professionals, effective cultural encountersare key in establishing a trustingrelationship. The case study inFigure 2 presents a communica-tion gap between the nurse and anAfrican-American patient.When interacting with AfricanAfricans, it is important to knowthat most prefer to be greeted formally, such as Doctor, Reverend,Pastor, Mr., Mrs., Ms., or Miss.They prefer their surnamebecause the “family name” ishighly respected and connotespride in their family heritage.African-American communication has been described as highcontext (Cokley, Cooke, &Nobles, 2005). They tend to re l yon fewer words and use morenon-verbal messages than what isactually spoken. The volume ofAfrican Americans’ voices isoften louder than those in someother cultures; therefore, nursesmust not misunderstand thisattribute and automatically assume this increase in tonereflects anger. African-Americanspeech is dynamic and expre ssive. They are also re p o rted to bec o m f o rtable with a closer personal space than other culturalgroups.Health literacy must also bea d d ressed during the culturalencounter with African Americans; re s e a rch shows that healthliteracy is the single best pre d i ctor of health status. HealthyPeople 2010 defines health literacy as “the degree to which individuals have the capacity toobtain, process, and understandbasic health information andservices needed to make appropriate health decisions” (U.S.Department of Health andHuman Resources, 2002). Lowhealth literacy affects 40% ofAfrican Americans and is considered a barrier to receiving optimal health care.ConclusionThe Process of CulturalCompetence in the Delivery ofHealthcare Servicesmodel(Campinha-Bacote, 2007) provides nurses with a model ofpractice to render culturallycompetent and culturally re s p o nsive health care to AfricanAmericans. In applying this practice model of cultural compe-UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1
Figure 2.Case StudyThe patient presents at a local urologic group as a refe r ral from a commu n ity clinic. The nurse reviews the chart prior to entering the examination room. Thenurse notes that the next patient is LaShawn, a 24-year-old African-Americanfemale with a chief complaint of low pelvic pain and bu rning during voiding for 2to 3 weeks. The nurse sees that the chart has been flagged, noting thatLaShawn is not employed, has no insurance, and lives in subsidized incomehousing. The nurse sighs and rolls her eye s, and enters the room to collect theinitial assessment information.Nurse: (enters the room, looking through the chart) “ W hy are you here”?LaShawn: (sitting on the end of the examination table) “I told the other nurse,why she didn’t tell you?”Nurse: (rolls eyes) “ Well, just tell me again.”LaShawn: “It hurts to go to the bathroom.”Nurse: (sighs) “How long have you had this problem?”LaShawn: “About 2 weeks. It got better because I drank baking soda like myGrandma to
The Process of Cultural Competence in the mDelivery of H e a l t h c a re Services is a practice model of cultural competence that defines cultural competence as the ongoing process in which the nurse continuously strives to achieve the ability and availabili-ty to work effectively within the cultural context of the patient
American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Two or more races EL 53% 16% 20% 4% . culturally responsive standards. Invest. Invest in state and local programs that recruit and retain culturally . Encourage culturally responsive
culturally responsive teachers Establish a shared language and vision for culturally affirming practices Use data to identify disparities and challenge exclusionary policies, practices, and beliefs Identify and plan for systemic, sustainable, affirming changes that center and respect the identities of culturally, linguistically, and .
"Culturally deprived children" -1960s We are dealing, it would seem, not so much with culturally deprived children as with culturally depriving schools. And the task to be accomplished is not to revise, amend, and repair deficient children, but to alter and transform the atmosphere and operations of the schools to which we commit these .
Multicultural Issues in Counseling: New Approaches to Diversity. The three previous editions, with their focus on culturally competent counseling practice, have become important books in the counseling profession. They have provided professional counselors with strategies for culturally competent intervention with many client groups.
resources provide guidance on evaluation approaches and methods, relevant examples, and additional resources. The guides are intended to aid in skill building on a wide range of evaluation topics. Practical Strategies for Culturally Competent Evaluation. is designed to complement
UK mental health nursing students are being prepared to learn not just about compassion but about ‘culturally competent compassion’ [1] by reviewing the key text- . An extraction table, with the textbook references, th
A culturally competent person is aware and respectful of beliefs, values, traditions, customs, and parenting styles from other cultures. Culturally competent people:File Size: 1MB
Related to Translation and Subtitling 7 2.1.2 Review of Theoretical Literature Related to Translating Culturally-bound Expressions 15 2.2 . Culturally-Bound Expressions from English into Arabic By Saleh Majed Al Abwaini Supervisor Professor Riyad Fayez Hussein Abstract This study aimed at investigating the problems that translators face when they subtitle culturally-bound expressions from .
