Vol. 17 •Issue 2 • Page 14
Allergy and Asthma
Providing Culturally Competent Care
Asthma educators must first understand their patients.
Health disparities are an unfortunate reality in asthma management.
Blacks are hospitalized at three times the rate of whites. In addition, their age-adjusted death rate for asthma is three times that of whites. Puerto Ricans have higher asthma prevalence rates than other Hispanic subgroups and non-Hispanic whites. And Native Americans and Alaskan Natives may have equal if not greater rates of asthma than other racial groups.1
Several potential reasons lay behind why health disparities exist in asthma. First, people of lower socioeconomic status or those who live in urban settings may come into contact with more indoor and outdoor allergens like cigarette smoke, cockroaches, mice, dust, mold, and poor air quality.
Second, these groups may have decreased access to health care due to lack of transportation and insufficient funds for medications and office visits.
Lastly, cultural influences that arise from an individual’s beliefs, language, and home remedies may pose barriers to the successful implementation of an evidence-based plan of care.2,3
Asthma educators are in a key position to positively influence asthma-related health disparities. By forming a partnership with the patient and family and practicing culturally competent care, asthma educators can help decrease morbidity and mortality and ultimately make a difference.
Components of cultural competency
The first step requires knowing what cultural competency is. It is defined as “a developmental process that is developed over time in order to increase understanding and knowledge of cultural differences that affect the health care experience.”4 Components of cultural competence include cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.
Cultural awareness requires a self-assessment of one’s own prejudices and preconceptions toward other cultures.5 Asthma educators must ask themselves questions such as how they feel about patients who believe in the use of foods or herbal products to control asthma symptoms.
Cultural knowledge is the process of obtaining education regarding various cultures.5 One of the best ways to gain knowledge is from the patients themselves. Attending conferences, reading articles, and browsing the internet also can be helpful.
Cultural skill is the ability to obtain appropriate cultural information about the patient’s clinical history and current problem. It also involves accurately performing a culturally specific physical examination.5
Cultural encounters involve asthma educators interacting directly with patients from different cultural backgrounds.5 This component is a lifelong process that builds on cultural knowledge.
Cultural desire is the asthma educator’s motivation to want to engage in cultural competence.5 Without motivation, cultural competence cannot be realized.
Disease causality
When approaching education in a culturally diverse population, the asthma educator must create a trusting environment that allows for open communication. Once this is achieved and cultural beliefs and differences are identified, education can commence.
This can be accomplished by asking patients about their health practices and beliefs in a non-threatening and non-judgmental manner. Essential assessment topics include religious preference, communication needs, diet, medicinal use of foods and herbs, complementary alternative medication use, and identification of the decision-makers.
In addition, the asthma educator should discuss with the patient and family what they think caused the asthma. There are four categories of disease causality:
- Individual cause: failure of the individual to follow a code of behavior determined by their culture, religion, or society
- Natural world cause: lack of harmony in the body
- Social world cause: result of a spell casting or stress
- Supernatural world cause: a test of religious faith.6Patients’ reaction to an illness depends on their belief of disease causality. As a result, patients may feel powerless and submissive to the illness, while others may take action. For example, some Hispanics believe asthma is caused by a surplus of coldness, and they treat it with “warm therapies” like drinking hot teas, dressing warmly, and keeping the home warm.6
Home remedies
It is wise to ask about home remedies, which can differ among ethnic groups. Some examples of culture-specific home remedies include the following:
- Puerto Rican: teas (chamomile, eucalyptus), aloe vera juice, garlic, seven syrups, cod liver oil, wonder water, and maguey syrup
- East Indian: spices, frankincense, Indian gooseberry, Malabar nuts, and other plant products
- European: mustard, horseradish, elderberry, primrose, rose hips, pine, and thyme
- Chinese: ginkgo biloba, peony, orange peel, cinnamon, yam, ginger, dates, and ma huang (ephedra).6Although there is no strong evidence for the use of herbal products, it is important to be sensitive to the fact that some remedies may have mucolytic, bronchodilating, and anti-inflammatory properties that could interact with traditional therapies. Therefore, the asthma educator must be aware of what home remedies are being used in conjunction with prescription medications.6
As a rule, it also is good practice to accommodate the patient and family’s beliefs and wishes regarding home remedies if no contraindications exist. Asthma educators who respect and incorporate patients’ cultural practices into asthma care will establish an enduring partnership.
In a study conducted to examine practice site policies and features associated with quality of care for Medicaid-insured children with asthma, researchers found patients of practices with the highest cultural competence scores were less likely to underuse long-term control asthma medications.8 This demonstrates culturally competent care can be an integral part of asthma management.
References
1. American Lung Association. Lung disease data in culturally diverse communities: 2005. New York: American Lung Association. 2005.
2. Mangan JM, Wittich AR, Gerald LB. The potential for reducing asthma disparities through improved family and social function and modified health behaviors. Chest. 2007;132(5 Suppl): 789-801.
3.Pask EG. Culture: caring and curing in the changing health scene. In: Morgan JD, editor.
Meeting the needs of our clients creatively: the impact of art and culture on caregiving. Amityville, N.Y.: Baywood Publishing Co.; 2000.
4.Obermeyer MV. Cultural competency: the building blocks. Available from: www.culture-advantage.com/etraining/courses.php
5.Campinha-Bacote J, Curry Narayan M. Culturally competent health care in the home. Home Care Provider. 2000;5(6):213-9.
6.George M. The challenge of culturally competent health care: applications for asthma. Heart Lung. 2001;30(5):392-400.
7.Kemper KJ, Singla M, Gardiner P. Herbs and dietary supplements for asthma. Clinical Pulmonary Medicine. 2005;12(2):67-75.
8.Lieu TA, et al. Cultural competence policies and other predictors of asthma care quality for Medicaid-insured children. Pediatrics. 2004;114(1):e102-10.
Concettina “Tina” Tolomeo, MSN, APRN, AE-C, is a nurse practitioner and director of program development at the Yale School of Medicine, section of pediatric respiratory medicine, New Haven, Conn. Patricia Goncalves, MSN, APRN, is a nurse coordinator at the same facility. <p>The LEARN model is a strategy for addressing asthma education and interacting with a culturally diverse population:
L:Listen to your patients.
E:Explain the information you have.
A:Acknowledge the differences and similarities in the patients’ and your beliefs.
R:Recommend a plan.
N:Negotiate an agreement with the patient.
Available from: URL: www.ahcpub.com/hot_topics/?htid=1&httid=1404