Increasing the cultural competence of health care providers serving diverse populations
In order to provide equitable and effective health care, clinicians need to be able to
function effectively within the context of the cultural beliefs, behaviors, and needs of
consumers and their communities. According to the 2002 Institute of Medicine report
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and
ethnic minorities tend to receive lower quality health care than non-minorities even
when access to insurance and income is accounted for. Failing to support and foster
culturally competent health care for racial and ethnic minorities can increase costs for
individuals and society through increased hospitalizations and complications.
In 2000, the US Census recorded approximately
34.7 million African Americans in the nation (12 percent of the total population).
According to the Minnesota State
Demographic Center, Minnesota’s African American population was 218,400 as of
2005. Cities with the largest percentage of
African Americans include Minneapolis (18%), St. Paul (12%), Brooklyn Park (14%), and Brooklyn Center (14%). This population
is projected to double by 2035. Substantial
growth is expected in all areas of the state,
although, growth will be greater in Minneapolis, St. Paul, and some suburban counties.
The following cultural patterns may represent many African Americans, but do not represent all people in a community. Each person is an individual, as well as a community member. The term African American generally refers to people descended
from Africans who did not come to the US voluntarily—descendents of the four million
slaves brought to the US between 1600 and 1800.
Social structure
According to the University of California School of Nursing, in Culture and Clinical Care, many aspects of African American culture today reflect
the culture of the general US population. The structure in African American families is often nuclear and extended with non-related “family” members. The family may be
matriarchal, although father or mother may take on the decision-making role. For
African Americans, women more than men tend to remain unmarried, and more women have been educated at the college level.
In general, the older generation is more conservative, may
have a more traditional view of gender roles, and may shun
interracial dating and marriage. Elders are respected and
often provide care for their grandchildren. Institutionalization
of elders has historically been avoided, with sons and
daughters taking on the family caretaker role.
Diet
Many African Americans like hearty meals that
may include meat, fish, greens, rice, grits, white and sweet
potatoes, corn, turnips, eggplant, peanuts, and homemade
desserts. Leafy greens may include spinach, collards,
mustard, kale, and cabbage. Traditionally, many elders eat a
large noon meal on Sunday after church.
Traditional African-American food—sometimes referred to as “soul food”—is diverse and flavorful with origins in
Africa, the West Indies, and American southern states. The idea of what soul food is differs greatly among African
Americans. Soul food may refer to meals made with fried
chicken, pork chops, chitterlings, grits, cornbread, macaroni
and cheese, and hushpuppies. Dishes such as hoppin’ John
(rice, black-eyed peas, and salt pork), gumbos, jambalyas,
fried porgies, and potlikker may all be considered soul food.
Okra is the principal ingredient in gumbo, a Creole stew,
and is believed to have spiritual and healthful properties.
Many of these foods found their way from the south to
the north via the Mississippi River. Cajun and Creole
cooking, which originated from the French and Spanish in
Louisiana, was changed in character and composition by
the influence of African cooks.
In 1965, African Americans were more than twice as likely
as whites to eat a recommended diet of fruit, vegetables, fat,
fiber, and calcium. By 1996, 28 percent of this population
was reported to have a poor-quality diet, compared to
16 percent of whites. A poor quality diet often can be
attributed to greater access to packaged, processed, and
fast foods; the common practice of using fats in cooking;
and the high cost of fresh produce and lean meat. And fast
foot companies have specifically targeted African American
communities as a growing market for their products.
Although many African Americans eat foods such as greens, beans, and rice, which are rich in nutrients, economic issues and deep-rooted dietary habits create challenges for changing behaviors and lowering disease risk
in this population. However, through health education and
increased awareness of healthy eating practices, African
Americans are replacing traditional pork products with
turkey, fried foods with baked foods, and starchy vegetables with tomatoes and green vegetables. National programs
to improve diet quality and the overall health of African
Americans and other minority groups have been initiated.
Body and Soul: A Celebration of Health Eating and Living
for African Americans offers information targeted to African Americans on eating
a health diet rich in fruits and vegetables.
Religion
African Americans often have strong
religious affiliations. Many are affiliated with Christian
denominations—notably Baptist and Church of God in
Christ. Many follow Islam. Maintaining good health is
associated with good religious practice. Many churches
maintain a health ministry, through which congregations
and parish nurses support good health with flu shots, blood
pressure checks, and health education. Before the advent of
health ministries, African American churches had mission
volunteers who attended services and administered to
parishioners.
Medical care
African Americans are becoming
increasingly health conscious, seeking health screenings and treatments, although health literacy in this population
tends to vary by generation. Older African Americans may
be suspicious of clinicians, believing their health is personal
and up to God’s will. Because they may be reluctant to share personal or family issues, building a trusting relationship is key.
African Americans are affected disproportionately by the leading causes of death in the US, with more morbidity and mortality from premature births, cancer, HIV/AIDS, obesity, and diseases related to obesity, including heart
disease, hypertension, stroke, and type 2 diabetes.
- African American men have higher rates of getting and
dying from prostate cancer than other men.
- Forty-five percent of African American adults in the US
are obese.
- African Americans are more likely to die from asthma
than other populations.
- Nearly half of those infected with HIV/AIDS are
African American.
Sickle cell anemia is the most common genetically inherited
condition in African Americans. They also exhibit a higher
incidence of lactose intolerance, periodontal disease, and have common skin problems such as melasma (discoloration
of the face) and other pigment disorders.
Death and dying
Many older African Americans
believe that death is at God’s will, but tend to believe that
life support should be continued as long as necessary. A
family-centered approach is recommended for conveying
serious medical information, seeking consents, and
explaining issues such as autopsy and organ donation.
Cremation is generally avoided in this community and
organ donation may be viewed by some as a desecration
of the body. Because of the importance of family in the
African American culture, the family should be informed of
an impending death so that extended family members who
live out of state can be notified.
In the African American community, death is an important
aspect of culture, with unique traditions, mourning
practices, burial rites, and even the structure of cemeteries.
Rather than a time of sadness, death is a time to celebrate
that the deceased no longer has to endure the trials of the
earthly world. Some present day customs associated with
death can be traced back to African roots. Customs have
been passed down in the form of expressions, superstitions,
religious practices, and music. At the time of death, old
beliefs and superstitions are remembered and may be acted
upon, such as not burying the deceased on a rainy day or
burying the deceased with feet facing east to allow rising on
Judgment Day. Coins may be placed on the eyes or in the
hands of the deceased, or placed around the grave site as
the deceased’s contribution to the community of ancestors.
Culture in context
Culture is essential in assessing a person’s health and
well-being. Understanding a patient’s practice of cultural
norms can allow providers to quickly build rapport and
ensure effective patient-provider communication. Efforts
to reduce health disparities must be holistic, addressing
the physical, emotional, and spiritual health of individuals
and families. Also important is making connections
with community members and recognizing conditions in
the community.
Get to know your patients on an individual level. Not all
patients from diverse populations conform to commonly
known culture-specific behaviors, beliefs, and actions.
Generalizations in this material may not apply to your
patients.
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