I was very excited to attend the 45th Annual Transcultural Nursing Society Conference in Richmond, Virginia, October 16-19, 2019. The Transcultural Nursing Society was founded in 1974 under the leadership of Madeleine Leininger, RN, PhD. Dr. Leininger, who was the first nurse to earn a PhD in anthropology, developed the Theory of Culture Care Diversity and Universality or The Culture Care Theory in the 1960’s. Subsequently, much research has taken place and many nurses have followed in her footsteps furthering our understanding of the importance of cultural awareness and cultural competence in all aspects of healthcare. The research has shown that when patient care aligns with the patients’ values and beliefs, overall health outcomes are improved (Betancourt, Corbett, & Bondaryk, 2014). Cultural Understanding of patients is key to improving health outcomes.
Dr. Powell Discusses Health Equity and Health Equality
Dr.Lauren Powell, Director of the Office of Health Equity, Virginia Department Public Health, opened the conference with a compelling keynote address. She discussed various aspects of health equity. One topic she delved into deeply explained that everyone experiences implicit bias even though we may think we do not.
Several years ago, I discovered this research into implicit bias. It came as quite a shock to learn that we all have some degree of unconscious bias. Research shows our brains are wired this way in
order to make sense of our daily interactions. Furthermore, this mental categorizing of people occurs more frequently when we are under stress, time pressure, or have the need to make quick decisions. In reality, this takes place in most of our clinical environments. The concept of health equity requires that we directly address implicit bias. Transcultural nursing concepts help us to do this. As we
focus on learning and understanding the history, cultural beliefs, and lifeways of the people to whom we provide care, it helps dispel even the most unconscious negative stereotypes we carry in our minds. Therefore, if we improve cultural understanding of our patients, it is one of the keys to improving health outcomes.
Dr. Powell also discussed the difference between health equity and health equality. She presented a strong example of how to appreciate this subtle yet crucial difference. Dr. Powell advised the audience to think about health equality as if we gave everyone a random pair of shoes, whereas health equity would mean giving everyone a pair of shoes that fit! Moreover, she emphasized the importance of building trust with the people and communities that we serve. One of the first steps in trust-building is asking communities what they think will help them be healthy and then listening carefully to their responses.
Dr. Marianne Jeffreys, TCNS Scholar Presentation
Throughout the conference, we had the opportunity to hear many wonderful presentations. Various scholars presented their research. Dr. Marianne Jeffreys, author of Teaching Cultural Competence in Nursing and Healthcare, gave the TCNS scholar presentation. She discussed the past 25 years of her research concerning teaching cultural competence and measuring the results. This presentation was especially meaningful to me since I had taken her graduate nursing course, Transcultural Concepts and Issues in Health Care at CUNY. She stated, “cultural competency involves every human being- it involves all of our human-to- human interactions.” She encouraged us to “get out there and make a difference!” I am always so encouraged each time I attend this conference. I learn many new things about providing culturally congruent care to patients or clients and how to make a difference in their health outcomes.
Appalachia and High Health Disparities
According to a report released by the Appalachian Regional Commission (ARC) in 2017, Appalachia has the highest level of health disparities of any region in the nation. Diabetes, obesity, cardiac disease,
COPD, cancer, substance abuse, and mental health issues, are all higher in Appalachia. There are many reasons for this enormous measure of inequity. The effect various social determinants of health such as poverty, educational levels, and joblessness have on health disparities have been studied for decades. Unfortunately, in the Appalachian region, little improvement has taken place compared to the rest of the country. One area of causes of health disparities that has received little attention in Appalachia is the cultural disconnect between healthcare providers and patients. The shortage of providers in this area has led to assertive recruitment of healthcare providers from all parts of the United States. Frequently, providers who move into Appalachia experience challenges in establishing trusting relationships with patients.
Appalachia and Negative Stereotypes
Negative stereotypes have plagued Appalachia for over 150 years. Unfortunately, many healthcare providers who relocate to the area have been unduly influenced by the media in this regard. Television shows and movies such as The Beverly Hillbillies, the movie Deliverance, and many books, magazines, and newspaper articles portray Appalachian people as illiterate, dangerous, moonshiners, lawbreakers, and snake handlers, to mention just a few. These stereotypes may indeed contribute to implicit or unconscious bias.
Distrust of Outsiders
In addition, there is a long history of exploitation by “outsiders” in timbering and coal mining. For years, well-meaning individuals and organizations have come to Appalachia in an attempt to solve the many socioeconomic factors that have plagued the area for more than a century. Unfortunately, these well-meaning people have consistently attempted to help by telling the people of Appalachia what they must do to fix their problems, with little regard for native Appalachians’ opinions on the matter. This has created a strong distrust of outsiders, including in the healthcare realm. The reality is that a large proportion of Appalachian people will first consult their family members when initially experiencing symptoms of illness. They will next ask church members and neighbors for advice. The end result of this dynamic is that healthcare providers are usually the last source of advice to be sought out. Often by this time a disease has progressed to a much later stage. Consequently, early risk factors and lifestyle modifications which may have prevented the progression of disease are not addressed in a timely enough fashion to have an appreciable impact.
Providing Culturally Congruent Care
Even though there is a great deal of diversity in the Appalachian region, many natives of this large multi-state area share similar worldviews, cultural values, beliefs, and communication patterns. Much research conducted in the United States and other countries has clearly shown that providing culturally congruent care inevitably leads to improved health outcomes. Unfortunately, little research has been conducted in the Appalachian region to see if providing culturally congruent care would improve outcomes and lessen the disparities which occur in Appalachia.
In order to be the most effective in providing healthcare and human services to the disparate communities of the Appalachian region, the history, values, beliefs, and lifeways of patients must
be understood by providers in order to have the most chance at gaining the trust and facilitating adherence to treatment. This is a significant overarching approach that must be addressed in order to improve health and decrease disparities in this fascinating, multifaceted, and historically significant region of the United States. Improving cultural understanding of patients in Appalachia is key to improving health outcomes.