Research proposal development and structure

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 and training, cross-cultural communications, cross-cultural leadership, policy development, and evidence-based practice and research. 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 35 and 44, respectively.

The disproportionately high HIV incidence among African-American female teens convincingly defines the term 'health disparity.' A possible intervention has been explored by Aronowitz and Agbeshie (2012) and Aronowitz and Eche (2013) using qualitative study designs. Working under the assumption that mothers are the primary sex educators for daughters, they investigated the interactions that took place between inner-city African-American mother-daughter dyads during discussions about intimate sexual issues. The goal of these studies were to define the main communication and parenting strategies employed, thereby providing valuable, culturally-sensitive information that could help clinicians reduce health disparities for African-American female youth.

Aronowitze and Agbeshie (2012) used a focus group strategy within a grounded theory study design. They limited the daughter's age to between 11- and 14-years of age, under the assumption that initiating discussion about sex before sexual debut is the most effective way to delay the age of sexual debut and related risky behaviors. The age range of the mothers was between 32- and 78-years of age, since a few daughters were being raised by their grandmothers. The main themes that emerged from these focus group sessions were level of disclosure, mixed messages, emotional tone, and knowing. The level of disclosure pertains to the amount of intimate information that the daughter and mother are willing to discuss, while mixed messages are the domain of how mothers communicate the topic of sex to their daughters. The emotional tone describes the extent to which discussions about sex are mostly reactive and therefore unproductive. Knowing describes how confident the daughter or mother is in understanding the non-verbal communications that take place during discussions about sex.

The findings from the study by Aronowitz and Agbeshie (2012) apparently informed a follow-up study examining the parenting styles used by African-American inner-city mothers during discussions of sex with their daughters (Aronowitz and Eche, 2013). Of the four parenting styles extensively covered in the research literature, including laissez-faire and permissive, authoritarian and authoritative parenting styles dominated. The researchers discovered that authoritarian mothers tended to rely on psychological control methods, such as scaring, to control the social behavior of their daughters. By comparison, authoritative mothers tended to rely more heavily on setting rules for behavior, monitoring the whereabouts of the daughter through social connections, communicating unconditional love, and fostering an ethnic identity. The daughters almost uniformly agreed that scare tactics and intrusive monitoring techniques tended to be counterproductive, even to the point that it might have the opposite effect on a daughters social choices concerning sex.

Aronowitz and Eche (2013) discussed their findings from the perspective of nursing interventions. A nurse could encourage mothers who tend to rely on an authoritarian parenting style to increase the amount of time spent communicating unconditional love and fostering a positive ethnic identity. With time, the mother may also become convinced that scare tactics may be counterproductive and that better approaches to controlling her daughter's social choices concerning sex are available.

Theoretical Framework

The theoretical framework for the proposed study is based on the work of Peplau (Coury, Martsolf, Drauker, & Strickland, 2008), Gonzalez-Guarda et al. (2011), Aronowitz and Agbeshie (2012), and Aronowitz and Eche (2013), in addition to the substantial policy shift that has taken place in the United States by federal health agencies (Office of Minority Health, 2013) and professional medical organizations (Douglas et al., 2009) in support of cultural competency training for health care providers. Currently, very little empirical support exists for the efficacy of cultural competency training for reducing health disparities. Best practice recommendations have been published by a number of organizations, but evidence-based practice recommendations are almost non-existent. Peplau's interpersonal theory of nursing seems to support such an intervention, since care efficacy would depend on transcultural knowledge and communication skills. There is thus a great need to begin the process of investigating the efficacy of cultural competency training in relation to health disparities.

Based on the findings and interpretations of Gonzalez-Guarda et al. (2011) the syndemic factor 'acculturation to American society' contributes to risky behavior in sexually-active Hispanic women between the ages of 18 and 50 living in South Florida. The main categories of risky behavior examined were substance abuse, exposure to violence, condom use, sexually-transmitted infections (STIs), and partner risky behavior. An additional, related category of depressive symptoms was also correlated with length of time spent in America.

It seems to naturally follow from these findings that the sexual choices being made by African-American female teens could be modified significantly by syndemic factors. The work of Aronowitz and Agbeshie (2012) and Aronowitz and Eche (2013) suggest that the parenting style of mothers of these teens could represent a syndemic factor, in part because mothers tend to be the primary sex educator for children. The findings of Aronowitz and Eche (2013) suggest that an authoritative parenting style, compared to an authoritarian parenting style, would more likely result in better health outcomes for daughters in terms of risky behavior.

Based on this theoretical framework, cultural competency training for providers would be predicted to improve the health outcomes of inner-city African-American female adolescents because of the positive impact the intervention would have on the mother's parenting styles.

Methods

Sample and Setting -- Nurse practitioners (NPs) meeting the inclusion criteria of primary care provider, inner-city practice setting, non-African-American identity, and African-American clients will be identified by cross-referencing contact information obtained from the American Association of Nurse Practitioners with low-income (SBA, n.d.)/African-American neighborhoods (SSDAN, n.d.). The NPs thus identified will be contacted by mail and asked to participate. All interested NPs responding within the first 30 days will be placed in a pool and 20 selected randomly for participation in either the experimental or control group. The NPs who offer to participate may not be a representative sample of all providers meeting the inclusion criteria, simply because of their willingness and ability to participate. This would probably introduce a selection bias that could reduce the generalizability of the findings.

Selected NPs will be asked to invite all African-American mother-daughter dyads on their client list to participate in the study. The inclusion criteria for mother-daughter dyads are (1) residing in the same home and (2) daughter age between 11 and 15 years. To attain a confidence interval of 10 with an ? Of 0.05, the sample size would have to be at least 96 mother-daughter dyads. Assuming a high dropout rate of 20%, at least 115 mother-daughter dyads will need to be enrolled in the study. The number of NPs enrolled in the study beyond the initial 20 will therefore depend on reaching the goal of 115 mother-daughter dyads.

The overall sampling strategy is probability sampling because providers, and thus their clients, will be randomized into an experimental or control group. The control NPs and their mother-daughter dyads will also be blinded to the intervention, because the pretest will not reveal that the intervention is cultural competency training for providers.

The ethical concerns are minimal because provider cultural competency training, as an intervention, has not been empirically proven to reduce risky behavior among African-American female teens. The possible negative consequences of study participation could be creating tension between mother-daughter dyads due to filling out the questionnaires, but the expectation is that any discord would be minimal and transient. No ethical issues concerning participating NPs have been identified.

All study subjects, including providers, will be required to sign an informed consent form before they will be included in the study. This form will describe the sexual nature of the survey questions, but will not reveal the intervention. The readability scores determined by Microsoft Word for the consent form is a Flesch-Kincaid Grade Level of 13.2 and Flesch Reading Ease score of 34.5.

Research Design -- Given the qualitative findings by Aronowitz and Eche (2013) the next logical step is to test the theory that a provider intervention that modifies parenting style will influence teen risky behavior patterns using a quantitative study design. The research design chosen is randomized-controlled trial (RCT) because providers will be randomly assigned to either the experimental or control group. The intervention will be provider cultural competency training and the outcome measure teen risky behavior.

The pretest-posttest design will allow a comparison between the experimental and control group baseline data, so that any difference between the posttest data can be attributed to the intervention. There is a chance that the pretest will sensitize the experimental group to the intervention, which represents the main threat to internal validity, but the intervention impacts the providers, not the mother-daughter dyads; therefore, all mother-daughter dyads should be theoretically blinded to the intervention. In addition, the Cronbach's alpha coefficient will be used to test for internal consistency.

Intervention -- The intervention will be cultural competency training for nurse practitioners providing primary care services in low-income communities with a significant African-American client base. The intervention will be the online continuing education course offered by the Office of Minority Health (n.d.). The course is free and a passing score of 70% is required to earn 9.0 contact hours.

Measures -- Demographic information will be collected from providers, mothers, and daughters using distinct forms. The demographic information collected from providers will be age, gender, racial/ethnic identity, education, nursing experience, primary care experience, years providing primary care services in low-income neighborhoods, years providing primary care services in multi-racial communities, and prior cultural competency training. The demographic information collected from mother-daughter dyads will be age, gender, racial/ethnic identity, education, college degrees, income, employment status, student status, family size, number of parents, and neighborhood violence rating.

The dependent variables are age of sexual debut, sexually transmitted infections (STIs), condom use, substance abuse, intimate partner violence, mental status, and comfort level during discussions about sex between teen and mother. Two distinct 20-item questionnaires based on a 3-item or 5-item Likert scale, multiple choice, and fill in the box will be given to the mother-daughter dyads to be completed at the time of enrollment into the study (pretest) and at the end of the study period (posttest). These questionnaires are distinct from the survey instruments that will collect demographic information. The mother's questionnaire will be structured so that the risky behavior questions will query the mother's opinion about her daughter's behavior, not the mother's. This should give some indication of how aware the mother is of her daughter's life.