March 29, 2006
Definitions of Health: Comparison of Hispanic and African-American Elders
By Collins, Cathleen A; Decker, Sharon I; Esquibel, Karen A
OBJECTIVE(S): The purpose of the study was to describe definitions of health in Hispanic and African American elders. METHOD(S): This study employed a qualitative framework conducted through a doctoral-level multicultural nursing course. Quasi- statistics and a semi-structured interview format tabulated a frequency in themes in the sample. Hispanic and African American clients at senior citizen centers comprised the convenience sample. Data collection occurred concurrently and the raw data was then shared throughout the class, which led to the study's major limitation. RESULT(S): Eight reoccurring themes were identified: spirituality, without pain/feeling good, positive attitude with good mentality, high priority, independent/active, health promotion/ maintenance, socialization, and helping others. CONCLUSION(S): Consistency was found between the existing literature and the results of the study. Differences were discovered between the groups, however more similarities were identified. The study results serve as a reminder to the importance in avoiding stereotypes when caring for individuals from any cultural background.KEY WORD(S): Culture; Cultural Competence; Cultural Competency Care Model; Definition of Health; Perception; Transcultural Nursing.
The United States is a nation rich in cultural diversity. According to the department of Health and Human Services Administration on Aging (2004), minorities currently comprise 16.1 percent of all Americans 65 years and older. By 2030 the older minority American population is projected to increase by 217 percent compared with 81 percent for the older white population (2004). This increase in the population diversity challenges nurses to explore how culture influences an individual's definition of health. The purpose of this study was to describe definitions of health in Hispanic and African-American elders.
The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (2003). Purnell and Paulanka (2003) expand on this by defining health as a state of wellness that includes physical, mental, and spiritual states and is defined by individuals within their ethnocultural group. Bonder, Martin, and Miracle (2001) recognize perception of health is influenced by an individual's culture and can be similar to or different from others from other cultures. Spector (2000) identifies that individuals define health through the use of specific descriptions that can be seen, felt, or touched and are linked to self-care practices. Culture is a learned paradigm of beliefs, values, and behaviors shared by a population or group. These values, beliefs, and behaviors are reflected in the language, dress, food, and in social institutions (Burchum, 2002; Mutha, Alien, & Welch, 2002). Purnell and Paulanka (2003) enhance this definition by stating culture is "the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life-ways, and all other products of human work and thought characteristics of a population of people that guide their world view and decision making" (p. 3).
Multiple factors that influence culture include nationality, ethnicity, religion, age, gender, education, occupation, life experiences, and religious affiliation (Purnell & Paulanka). Acknowledging that these multiple factors impact cultural beliefs and thus an individual's definition of health, nurses need to recognize individuals often embrace more than one culture. Therefore, nurses need to acknowledge each person as an individual who experiences different input and life experiences. This recognition requires nurses to be culturally competent. Leininger (2000) states becoming culturally competent requires commitment, a pursuit of knowledge about others, selfawareness and an open and humble attitude. This self exploration includes acknowledging personal values and beliefs, accepting that one's culture is not superior to others only unique, and recognizing how personal beliefs can influence relationships with others.
Cultural competence as described by Burchum (2002) is a "nonlinear dynamic process that is never ending and ever expanding" (p. 5). As a dynamic process, cultural awareness integrates an understanding and sensitivity to others with excellent interpersonal skills and knowledge from the humanities, and the physical, biologic and social sciences while avoiding stereotyping (Burchum, 2002; Purnell & Paulanka, 2003). Maintaining cultural competence is a daunting task. It requires life-long learning and unlearning, continuous self-awareness, open discussion with others, and personal and organizational accountability toward achieving identified cultural competence goals. Research conducted by Chevannes (2002) demonstrates that "sustainability of learning to care for ethnic minority patients ...is best undertaken in the environment where professionals and patients interact on an on-going basis" (p. 297).
Culturally competent nurses not only need to appreciate the culture of the patient, but need to develop a self awareness of their personal culture. The American Nurses' Association (ANA) Council on Cultural Diversity in Nursing Practice (1991) states, "It is important the nurse consider specific cultural factors impacting on individual clients and recognize that intra cultural variation means that each client must be assessed for individual cultural differences"( 5). Furthermore, the ANA position statement recognizes that nurse-patient encounters include the interaction of "the culture of the nurse, the culture of the client and the culture of the setting" (U 5). Purnell and Paulanka (2003) challenges that to provide culturally competent health care the provider needs to develop an understanding of "his or her existence, sensations, thoughts, and environment without letting these factors have an undue effect on those for whom care is provided" (p. 193).
This study used the Cultural Competency Community Care Model (CCCC) as a theoretical framework (Kirn-Godwin, Clarke, & Leslie, 2001). The CCCC (Figure 1) describes the need for culturally competent nursing to bring about positive health outcomes for clients. Cultural competence encompasses the dimensions of cultural sensitivity (being respectful of another's culture), cultural knowledge (cognitive understanding of another's culture), cultural skills (methods, such as cultural assessments and communicating in other languages), and caring (Kirn-Godwin, Clarke, & Leslie, 2001). To effectively influence positive outcomes, the nurse should demonstrate all dimensions of cultural competency to ensure that individuals entering the health care system are cared for appropriately. Utilizing this framework, it was the intention of the team that this study would assist us in becoming more culturally knowledgeable and sensitive to the views of health among African- American and Hispanic individuals.
Participants in the study were convenience samples of clients at senior citizen centers located in a large metropolitan area of Texas. Subjects were male and female and ranged in age from 65 to 92. Subjects were asked if they would be interested in participating in an interview, and signed informed consent was obtained. Subjects were assured of confidentiality.
Data Collection and Analysis
Subjects were interviewed by students in a doctorallevel multicultural nursing course. Students used a semistructured interview format using questions agreed upon prior to the interviews. Subjects were interviewed one time for approximately 30 minutes. Students then shared their raw data with classmates. Raw data was to be presented in the form of direct quotations to avoid interviewer bias.
This team chose to focus on multicultural definitions of health, and pooled answers to the following questions from the interview tool:
Figure 1 A model for the delivery of culturally competent community care
* "What does health mean to you?"
* "What does a healthy person look like to you?"
* "What makes you a healthy or unhealthy person?"
* "What means you are healthy, or when a person says you are healthy, what does that mean?"
Content analysis was used to analyze answers to the questions. This refers to the process of analyzing the content of the data for recurring themes and patterns (Polit & Hungler, 1993). Themes were identified in terms of recurring descriptions of health from the participants. Quasistatistics, which "involve a tabulation of the frequency with which certain themes, relationships, or insights are supported by the data" (Polit & Hungler, 1993, p. 331), were used to determine the frequency of responses within the themes. This assisted the team in determining differences or similarities of health definitions between Hispanics and African-Americans.
Obviously the major limitations of this study were the sharing of raw data among students and interviewing the subjects only once. The team was not able to interview all subjects and relied on others to share exact quotations wit\h the team. Therefore, the true intent and meaning of the quotations had to be taken at face value without the ability to go back and ask further questions of the subject.
Other limitations included the use of a conveniece sample which may not reflect the viewpoints of elders who do not attend senior citizen centers. The setting was not conducive to open communication because there were multiple interruptions and interviews taking place simultaneously in the same room.
Responses from a total of 45 subjects, 25 Hispanics and 20 African-Americans, were sorted into eight themes: spirituality, without pain/feeling good, positive attitude with good mentality, high priority, independent/active, health promotion/maintenance, socialization, and helping others. Table 1 lists the total number of responses, as well as the frequencies of quotes within the themes from Hispanics and African-Americans.
Health Promotion/Health Maintenance
Thirty two subjects reported health promotion or health maintenance activities as an important way to maintain good health, with a striking 90% of AfricanAmericans mentioning this theme as compared to 56% of Hispanics. Activities included seeing the doctor regularly for checkups (many reported seeing the doctor up to twice a month for checkups) or if they feel sick, eating and sleeping well, exercising, not smoking, and taking prescribed medications (especially those used for chronic illnesses such as hypertension and diabetes).
Table 1 Frequencies of Recurring Theme
Positive Attitude/Good Mentality
Many subjects (N=29, 64%) reported having a positive attitude or a keeping positive outlook or mental state as an important way to maintain good health. Hispanics and African-Americans reported this theme with equal frequency (64% and 65%, respectively). Most statements dealt with happiness and an overall enjoyment of life.
Statements from Hispanics included:
"(Healthy people are) always in a good mood, " and "happy and active. "
"As long as you are happy and enjoying life (you are healthy)."
While African-Americans stated:
"(Health is) being joyful with a good attitude," and "being happy daily."
Maintaining low levels of stress was also reported by both groups as being important.
Statements to this effect included:
"Don't let things bother you. " (Hispanic)
"Keep on going, do not give up; everyone has problems." (Hispanic)
"Take time for yourself; don't get too tired. " (AfricanAmerican)
"(Healthy people have) no kinda problems." (African-American)
"Don't bemoan fate. " (African-American)
The groups disagreed, however, as to whether one could tell what a healthy person looked like. Hispanics were more likely to report they could tell if someone was healthy from their outward appearance. One subject commented, "Being healthy shows on your face," while another stated, "You can see from a person's complexion they are healthy."
African-Americans, however, overwhelmingly stated the opposite: "You can't tell if someone is healthy just by looking. Some people are healthy even if they aren't walking around."
Maintaining independence and activity was considered an important aspect of health to both groups (62% of the total subjects); although the African-American group reported this theme slightly more than the Hispanic group (70% to 56%, respectively).
Independence was verbalized by both groups in the form of being able to do for themselves or not depending on others. Similar statements between groups were noted:
"A person is healthy if they are able to take care of themselves." (Hispanic)
"Health is being independent and being myself; not what someone else wants me to be or do." (African-American)
Staying active and being able to get around were often mentioned as an example of one's independence. Hispanics and African- Americans equally commented that being able to walk, dance, drive, come to the center, or work in the yard defined health.
Without Pain/Feeling Good
Fourteen total subjects (31%), with 40% of the Hispanics and 20% of the African-Americans stated having no pain and feeling good were indicators of good health.
Belief in God
Eleven subjects (24%) reported belief in God as a determination for health. This included 28% of the Hispanics and 20% of the African Americans.
"I go to church everyday. That's the best medicine." (Hispanic)
"Prayer and belief in the Lord (make you a healthy person)." (African-American)
Health as a High Priority
Eight subjects (an equal number from each group) reported health as being a high priority in their lives, with Hispanics comprising 16% and African Americans 20%. A common answer to the question "what does health mean to you?" included, "It means everything," and "Life is not important without it."
Being able to socialize at the senior citizens' center was important to a small number of subjects (N=6), particularly to the African-American group. One particular subject stated, "This center is a Godsend to me. I can be with these people, play cards, visit, and do whatever."
Although only a small number of subjects (N=6) reported that being able to help others defined health for them, it was interesting to identify this was a priority for some. Statements to this effect included, "It makes me feel good to know I have helped somebody," and "(Being healthy means) I can do extra for other people."
There is consistency in the results of this qualitative study with research in the existing literature. Hahn (2003), when exploring the definition of health among minority women from Hispanic, Indochinese, and African American heritage, identified similarities between groups were more striking than different. The theme that emerged in the study conducted by Hahn when the individuals' definitions of health were analyzed was health is "being able to do activities which have meaning" with the most repeated phrase being "staying active" (p. 8-9). According to Spector (2000) and Zoucha (1998), Mexican Americans identify health as a gift from God, a general feeling of well being, to be free of pain, able to work, and spend time with the family.
Other studies exploring definitions of health in the elderly have described the importance of socialization and caring for others as priority. Burbank (1992) found that older adults are more likely to correlate being healthy with maintaining meaningful relationships and helping others. Higgins and Learn (1999) described Hispanic women's views of health as putting others before themselves.
Additionally, Barrett and Victor (1997) reviewed several health surveys which interestingly enough, appeared to support the major themes identified in this study. Blaxters's Health and Life Style Survey (as cited in Barrett and Victor, 1997) identified several common perceptions of health: freedom from illness, ability to function, physical fitness, energy or vitality, psychosocial well- being, health as a 'reserve', health as an aspect of a healthy lifestyle, and the understanding that health could be present despite a major illness. Another health measurement tool known as the SF36 identified eight dimensions of health: physical functioning, social functioning, role limitations (physical problems), role limitations (emotional problems), mental health, vitality, pain, and overall evaluation of health (Barrett and Victor, 1997). It would seem this study modestly validates these tools' themes for identifying health.
This study sought to describe the definitions of health for African-American and Hispanic elders. While there were some differences among the groups, there were more similarities in the identified themes. This serves as a reminder to practitioners of the importance in avoiding stereotypes when caring for individuals from any cultural background. This study could also assist nurses to promote health promotion programs based on people's definitions of health (for example, the centers could include religious or health education programs into their activities for the clients).
Leininger (2000) stresses that a "self and others discovery process" is critical for effective and meaningful transcultural nursing practice (p.313). All practitioners are challenged to provide culturally competent care that is sensitive to differences. In order to provide holistic care, it is important for nurses to recognize everyone has his or her own personal definition of health. Recognizing differences in definitions of health between and within cultures will increase nurses' cultural knowledge thereby impacting the health care system and promoting positive health outcomes for all individuals, families, and communities.
American Nurses Association: Nursing World. (1991). Position statement: Cultural diversify in nursing practice. Retrieved January 20, 2004, from http://nursingworld.org/readromoom/position/ethics/ etcldv.htm
Bonder, B., Martin, L. & Miracle, A. (2001). Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Workforce Issues in a Changing Society, 35- 42.
Burbank, R M. (1992). An exploratory study: Assessing meaning of life among older adult clients. Journal of Gerontological Nursing, 18(9), 19-28.
Burchum, J.L. (2002). Cultural competence: An evolutionary perspective. Nursing Forum, 37(4), 5-15.
Chevannes, M. (2002). Issues in educating health professionals to meet the diverse needs f patients and other service users from ethnic minority groups. Journal of Advanced Nursing, 39(3), 290- 298.
Department of Health and Human Services Administration on Health. (2004). Addressing diversity. Retrieved February 8, 2004, from http:/ /www.aoa.gov/prof/adddiv/adddiv.asp
Hahn, K. (2003, July). Older ethnic women of faith communities: Culturally appropriate program planning. Journal of Gerontological Nursing, 5-12.
Higgins, R G., & Learn, C. D. (1999). Health practices of adult Hispanic women. Journal \of Advanced Nursing, 29(5), 1105-1112.
Kim-Godwin, Y. S., Clarke, R N., & Barton, L. (2001). A model for the delivery of culturally competent community care. Journal of Advanced Nursing, 35(6), pp. 918-925.
Leininger, M. (2000). Founder's focus: Transcultural nursing is discovery of self and the world of others. Journal of Transcultural Nursing, 11(4), 312-313.
Meleis, A.I. (1999). Culturally competent care. Journal of Transcultural Nursing, 10(1), 12.
Mutha, S., Alien, C, and Welch, M. (2002). Toward culturally competent care: A toolbox for teaching communication strategies. San Francisco: Center for the Health Professions, University of California.
Polit, D. F, & Hungler, B. P (1993). Essentials of nursing research: Methods, appraisal, and utilization, (3rd ed.). Philadelphia: J. B. Lippincott Company.
Preamble to the Constitution of the World Health Organization. (2003). WHO defines health. Retrieved January 25, 2004, from http:// www. who. int/about/definitions/en I
Purnell, L.D. and Paulanka, B.J. (2003J. Transcultural health care: A culturally competent approach (2nd ed). Philadelphia: E.A. Davis Company.
Spector, R.E. (2000). Cultural diversity in health and illness (5th ed). Upper Saddle River: Prentice Hall Health.
Zoucha, R.D. (1998). The experience of Mexican Americans receiving professional nursing care: An ethnonursing study. Journal of Transcultural Nursing, 9(2), 34-44.
Reprinted with minor modifications from the Journal of Multicultural Nursing & Health Volume 10, Number 3, Fall 2004
Cathleen A. Collins, RN, MSN, CHPN
Sharon I. Decker, RN, CS, MSN, CCRN
Karen A. Esquibel, RN, MSN
ACKNOWLEDGMENT(S): We acknowledge the assistance of Shirley Hutchinson, RN, DrPH of Texas Woman's University for her contributions toward the development of this article and study. We are especially thankful to all of the elders who participated in the study. Thank you for sharing your lives with us.
Cathleen A. Collins, RN, MSN, CHPN, Sharon I. Decker, RN, CS, MSN, CCRN and Karen A. Esquibel, RN, MSN. All are doctoral students at Texas Woman's University, Houston, Texas; and teach at Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas.
Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2006