Rooted in cultural humility, public health nurses tackle the social determinants

Public health has long known that we won’t achieve health equity without addressing the social determinants of health — the conditions in which you live, learn, work and play that affect your health. But doing so requires creativity, persistence and cultural humility.

At Tuesday’s session on “Diversity and Social Justice: Interventions to Address the Social Determinants of Health — Public Health Nursing Moves Upstream,” leaders in the field outlined what they had learned in working with high-risk populations to achieve better health outcomes in those communities.

One social determinant outlined in the session was health literacy. Many communities at higher risk for a variety of health issues are also home to low rates of health literacy, which is a technical way of saying many residents find it difficult to understand what a health care provider tells you — if you can get to one at all — or sort through health information offered online or at the pharmacy. Public health workers who want to improve health outcomes in these communities must work with the community to create programs that people want and that will work.

Session presenter Haeok Lee, a nursing professor at the University of Massachusetts in Boston, outlined how she and her collaborators created a storytelling narrative outreach program to share information about the human papillomavirus vaccine with Cambodian-American mothers and daughters. While cervical cancer rates caused by HPV are overall low among Asian Americans, when subgroups are explored, Southeast Asian women have higher rates than any other racial or ethnic groups.

The stories Lee told about interviews with the mothers, who mostly did not speak English or who spoke it as a second language, were heartbreaking. While moms are often the primary decision-makers regarding their kids’ vaccination schedules, they often weren’t included in conversations about their health. Many assumed their daughters, who went to English-language schools, were getting all the health information they needed there. One said that when she went to doctor appointments with her teen daughter, her child and the doctor only spoke in English, so she assumed she didn’t need to know what they were talking about. Lee called it a violation within practice.

Even in translations, there were issues. In Khmer language, there is no word for cervix — but moms easily understood when nurses speaking Khmer talked about “the mouth of the uterus.” Storytelling efforts were extremely effective, Lee said, because all moms could get behind one storyteller’s statement: “We can watch our daughters at home, but we cannot watch them all the time. By giving the vaccine, we can save our children from cancer.”

All of the speakers during the session touched on ideas of cultural humility. Amy Levi expounded on the topic in her 2009 research paper, in which she said:

“The approach of cultural humility goes beyond the concept of cultural competence to encourage individuals to identify their own biases and to acknowledge that those biases must be recognized. Cultural competency implies that one can function with a thorough knowledge of the mores and beliefs of another culture; cultural humility acknowledges that it is impossible to be adequately knowledgeable about cultures other than one’s own. Another term often used when discussing working with others outside of our own culture is cultural sensitivity. Cultural humility requires us to take responsibility for our interactions with others beyond acknowledging or being sensitive to our differences.”

Meeting people where they are has been the basis of nursing for a long time, said Laurie Abbott, an assistant nursing professor at Florida State University, who presented on influencing cardiovascular knowledge and habits in rural black populations. Abbott, who is white, said she gained access and trust by being known in the community and by taking care to be persistent, genuine and trustworthy. After all, she said, “Any population has to know you care about them and that you genuinely care about their health, not just your career.”