REDUCING RISKY BEHAVIOR FOR African-American TEENS An Intervention for Reducing Risky Behavior Among African-American Female Adolescents: Provider Cultural Competency Training

The Office of Minority Health in the U.S. Department of Health and Human Services (2013) quotes Dr. Martin Luther King, Jr. As a way to introduce the topic of updating and enhancing the National CLAS (Culturally and Linguistically Appropriate Services) Standards. The quote is "Of all forms of inequality, injustice in health care is the most shocking and inhumane" (p. 14). Long recognized as a significant problem in the United States, health inequity along social, economic, racial, and ethnic boundaries has become a central focus of health care policy in this country. Although health care providers have little control over the historical determinants of discrimination in the U.S. they can work towards eliminating health disparities that exist through cultural competency. In addition to the ethical and moral rationale for attaining this goal, the Office of Minority Health (2013) listed legislative mandates, marketplace competition, and legal liability as other reasons for fostering cultural competency among health care workers.

The health disparities suffered by minority groups in the United States are significant. In addition to having reduced access to care, lower rates of insurance coverage, less financial resources, and less utilization of preventive services, the prevalence of obesity, smoking, and sedentary lifestyle is much higher (Liao et al., 2011). Self-reports of health status revealed a higher prevalence of chronic health conditions, including hypertension, cardiovascular disease, and diabetes. If the ideal of zero health inequities were ever to be achieved within the United States, researchers predict that the economy would benefit from an estimated $1.24 trillion in healthcare savings (as cited by Office of Minority Health, 2013, p. 14).

Twenty international experts on culture and cultural competency in health care were asked about their experiences and opinions on cultural competency during a qualitative study (Soule, 2014). The main elements that emerged were awareness, engagement, and application, which interacted with the four domains of intrapersonal, interpersonal, organizational/systemic, and global. At the most fundamental level a clinician needs to be aware of cultural differences and systemic discrimination before they can engage clients in a culturally sensitive way and apply an appropriate intervention. Awareness also implies being aware of personal, social, and organizational patterns of discrimination that may be contributing to disparities in health. These findings suggest that providers can play a crucial role in helping to eliminate health disparities through cultural competency training.

If provider cultural competence is viewed through the lens of Hildegard Peplau's interpersonal theory of nursing (Coury, Martsolf, Drauker, & Strickland, 2008) then the original six roles would contribute to lowering disparities in the quality of care provided. When a client first seeks health care services the nurse's stranger role may determine whether a transcultural client will be trusting enough to accept the care offered, let alone return for follow-ups or additional services. Cultural competence may also influence the quality of the health information provided to the client, as the nurse takes on the resource person role. In the teacher role, the nurse could ensure that information or training sessions are culturally sensitive, thereby increasing the health efficacy of the information and skills being taught. Once the information and skills have been acquired by the client, the nurse as leader can help ensure that the information and skills are implemented, retained, and become the responsibility of the client. As a surrogate, a nurse can temporarily stand in for someone close to the client or become an advocate. Cultural competency training could mean the difference between success and failure in this role. This is also true for the counselor role, which involves active listening, therapeutic communications, and guidance as the client develops their own plan for achieving their personal health goals. The seventh role, technical expert, was not included in Peplau's original model and is the least relevant to cultural competency.

By viewing cultural competency through the lens of Peplau's interpersonal theory of nursing it becomes clear that care efficacy depends on the attainment of transcultural knowledge and communication skills, which in turn fosters cultural awareness, culturally-sensitive engagement, and culturally-appropriate application. A recent statement by members of the American Academy of Nursing Expert Panel on Global Nursing and Health, Transcultural Nursing Society, and the American Academy of Nursing Expert Panel on Cultural Competence has suggested that a set of standards be adopted to promote culturally-competent care (Douglas et al., 2009). At the top of the list is social justice, followed by critical reflection, transcultural nursing knowledge, cross-cultural practice, systems and organizations, multicultural workforce, education...

While all of these are important, the last one defines the purpose of this research proposal. The panelist who formulated these standards believed that nurses should implement evidence-based interventions that provide the greatest benefit for a culturally-diverse patient population. Whenever culturally-sensitive, evidence-based interventions are lacking they recommend nurses take the initiative to conduct research into interventions that reduce or eliminate health disparities.
In the spirit of this recommendation, a proposed research study into the health disparities suffered by African-American female adolescents is described here. In contrast to previous studies, which have almost exclusively studied cultural competency evaluation efficacy for providers, this research proposal will test the relationship between cultural competency training and patient outcomes (Douglas et al., 2009). For example, a recent study found a significant correlation between self-reports of cultural competency and the likelihood that an HIV patient would receive anti-retroviral therapy, attain self-efficacy, and obtain viral suppression (Saha et al., 2013). Minority providers were more likely to rate themselves higher in cultural competency and also provide the highest quality care. Such studies are rare in the literature, especially in the nursing research literature (Douglas et al., 2009). What follows is a literature review discussing the health disparities suffered by African-American female adolescents and how provider cultural competency training may represent an effective intervention worthy of empirical study.

Literature Review

Syndemic theory proposes that a single independent variable contributes significantly to multiple health conditions (reviewed by Gonzalez-Guarda, McCabe, Florom-Smith, Cianelli, & Peragallo, 2011). An obvious example of a syndemic would be obesity and how it contributes to the prevalence of type 2 diabetes mellitus, cardiovascular disease, and metabolic disorders. Gonzalez-Guarda et al. (2011) were interested in whether a syndemic factor was contributing to health disparities experienced by sexually-active Hispanic women living in South Florida between the ages of 18 and 50. Of primary interest was risky behavior, as measured by substance abuse, exposure to violence, condom use, sexually-transmitted infections (STIs), and partner's risky behavior. They were also interested in the relationship between risky behavior and depressive symptoms.

In contrast to expectations, poverty and employment history were not significant predictors of risky behavior, but academic achievement and length of residency were (Gonzalez-Guarda, McCabe, Florom-Smith, Cianelli, & Peragallo, 2011). These results were interpreted by the authors as suggesting acculturation to American society tends to increase the isolation immigrants experience as they become less connected to their own ethnic community, thereby increasing the risk of risky behavior and depressive symptoms. This risk can be moderated significantly through the pursuit of a college education, which suggests that acculturation is more successful with academic achievement.

The study by Gonzalez-Guarda et al. (2011) revealed that a single variable, length of stay in America, was a significant predictor of risky behavior for immigrant, sexually-active, Hispanic women living in South Florida. Syndemic theory therefore seems to be a valid predictor of health disparities related to socioeconomic and racial variables. A widely accepted indicator of risky behavior is HIV risk, which Gonzalez-Guarda et al. (2011) employed in their study. HIV risk among African-Americans is also of primary interest to health policymakers because the incidence of infections in this group is significantly higher than the rest of the population (CDC, 2013). Even though African-Americans represent just 12 to 14% of the American population, 44% of new HIV infections occur within this demographic. If syndemic theory were to be invoked to explain this statistic, then it might predict that substance abuse, STI history, exposure to violence, and depressive symptoms would also be higher.

Even more troubling is the rate of HIV infections among U.S. adolescents and young adults between the ages of 13 and 29, who account for 38% of all new infections (CDC, 2012). When female adolescents between the ages of 13 and 19 are considered as a group then African-Americans represent 70% of all new HIV infections (as cited by Aronowitz & Eche, 2013). Compared to their White and Hispanic counterparts African-American females between the ages of 13 and 29 are eleven and four times more likely to become infected with HIV, respectively (CDC, 2012). To make matters worse, disparities in access to quality care has contributed to more African-American youth between the ages of 13 and 24 dying from AIDS (63%) compared to their non-African-American peers. As a result of these health disparities, AIDS is now the third leading cause of death for African-American women and men between the ages of 25 and 34, and…