FAMILY NURSING

FAMILY NURSING

 

Sociocultural Influences on Family Health

 

How culture influences health beliefs

All cultures have systems of health beliefs to explain what causes illness, how it can be cured or treated, and who should be involved in the process. The extent to which patients perceive patient education as having cultural relevance for them can have a profound effect on their reception to information provided and their willingness to use it. Western industrialized societies such as the United States, which see disease as a result of natural scientific phenomena, advocate medical treatments that combat microorganisms or use sophisticated technology to diagnose and treat disease. Other societies believe that illness is the result of supernatural phenomena and promote prayer or other spiritual interventions that counter the presumed disfavor of powerful forces.Cultural issues play a major role in patient compliance. One study showed that a group of Cambodian adults with minimal formal education made considerable efforts to comply with therapy but did so in a manner consistent with their underlying understanding of how medicines and the body work.

Asians/Pacific Islanders are a large ethnic group in the United States. There are several important cultural beliefs among Asians and Pacific Islanders that nurses should be aware of. The extended family has significant influence, and the oldest male in the family is often the decision maker and spokesperson. The interests and honor of the family are more important than those of individual family members. Older family members are respected, and their authority is often unquestioned. Among Asian cultures, maintaining harmony is an important value; therefore, there is a strong emphasis on avoiding conflict and direct confrontation. Due to respect for authority, disagreement with the recommendations of health care professionals is avoided. However, lack of disagreement does not indicate that the patient and family agree with or will follow treatment recommendations. Among Chinese patients, because the behavior of the individual reflects on the family, mental illness or any behavior that indicates lack of self-control may produce shame and guilt. As a result, Chinese patients may be reluctant to discuss symptoms of mental illness or depression.

Some sub-populations of cultures, such as those from India and Pakistan, are reluctant to accept a diagnosis of severe emotional illness or mental retardation because it severely reduces the chances of other members of the family getting married. In Vietnamese culture, mystical beliefs explain physical and mental illness. Health is viewed as the result of a harmonious balance between the poles of hot and cold that govern bodily functions. Vietnamese don’t readily accept Western mental health counseling and interventions, particularly when self-disclosure is expected. However, it is possible to accept assistance if trust has been gained.

Russian immigrants frequently view U.S. medical care with a degree of mistrust. The Russian experience with medical practitioners has been an authoritarian relationship in which free exchange of information and open discussion was not usual. As a result, many Russian patients find it difficult to question a physician and to talk openly about medical concerns. Patients expect a paternalistic approach-the competent health care professional does not ask patients what they want to do, but tells them what to do. This reliance on physician expertise undermines a patient’s motivation to learn more about self-care and preventive health behaviors.

Although Hispanics share a strong heritage that includes family and religion, each subgroup of the Hispanic population has distinct cultural beliefs and customs. Older family members and other relatives are respected and are often consulted on important matters involving health and illness. Fatalistic views are shared by many Hispanic patients who view illness as God’s will or divine punishment brought about by previous or current sinful behavior. Hispanic patients may prefer to use home remedies and may consult a folk healer, known as a curandero.

Many African-Americans participate in a culture that centers on the importance of family and church. There are extended kinship bonds with grandparents, aunts, uncles, cousins, or individuals who are not biologically related but who play an important role in the family system. Usually, a key family member is consulted for important health-related decisions. The church is an important support system for many African-Americans.

Cultural aspects common to Native Americans usually include being oriented in the present and valuing cooperation. Native Americans also place great value on family and spiritual beliefs. They believe that a state of health exists when a person lives in total harmony with nature. Illness is viewed not as an alteration in a person’s physiological state, but as an imbalance between the ill person and natural or supernatural forces. Native Americans may use a medicine man or woman, known as a shaman.

As can be seen, each ethnic group brings its own perspectives and values to the health care system, and many health care beliefs and health practices differ from those of the traditional American health care culture. Unfortunately, the expectation of many health care professionals has been that patients will conform to mainstream values. Such expectations have frequently created barriers to care that have been compounded by differences in language and education between patients and providers from different backgrounds.

Cultural differences affect patients’ attitudes about medical care and their ability to understand, manage, and cope with the course of an illness, the meaning of a diagnosis, and the consequences of medical treatment. Patients and their families bring culture specific ideas and values related to concepts of health and illness, reporting of symptoms, expectations for how health care will be delivered, and beliefs concerning medication and treatments. In addition, culture specific values influence patient roles and expectations, how much information about illness and treatment is desired, how death and dying will be managed, bereavement patterns, gender and family roles, and processes for decision making.

Cross-cultural variations also exist within cultures. Strategies that you can use in working with patients from different cultures as displayed in Table 1.

Table 1.

Doing a cultural assessment

A growing realization that the United States is not a “melting pot” in which immigrants assimilate into the mainstream culture, but a country of many cultures has led to a growing appreciation of different ethnocultural groups. As a result, many health care professionals are concerned with providing culturally sensitive patient education. However, it is a daunting task for nurses and other health care providers to become familiar with the cultural dynamics of all the various ethnocultural groups in the United States. Rather than taking on the virtually impossible task of learning about multiple cultures, it is more practical and helpful for nurses to use a generic approach in doing a cultural assessment.

Data obtained from a cultural assessment will help the patient and nurse to formulate a mutually acceptable, culturally responsive treatment plan. The basic premise of the cultural assessment is that patients have a right to their cultural beliefs, values, and practices, and that these factors should be understood, respected, and considered when giving culturally competent care. The first step in cultural assessment is to learn about the meaning of the illness of the patient in terms of the patient’s unique culture. Table 2 shows questions to ask during a cultural assessment.

Table 2

By asking the patient and family these questions you can obtain valuable informatioeeded for a teaching plan. It is important to remember that the patient’s personal interpretation of the illness experience is more significant than your view of the disease. Health care providers should teach from a position of mutual understanding and collaboration rather than trying to impose traditional Western medical practices that are unlikely to be effective.

The next step in cultural assessment is to determine how embedded the patient is in his or her traditional culture. Cultural embeddedness refers to how aligned the patient is with the native culture. The extent of the patient’s cultural embeddedness has a major influence on health care teaching.

How recently the patient has immigrated to America, whether the immigration was voluntary or not, and whether the patient lived in intermediate countries are important to know. In general, the more recently the person has immigrated, the less acculturation will have occurred. If the person was forced to leave his or her native country and was detained in other countries, as has happened with many Southeast Asian immigrants, painful experiences may further delay acculturation. Many migrants from Haiti, El Salvador, and the Baltic States experienced physical and psychological terrorism in their own countries before migration. Such individuals often have had frequent moves or repeated changes before and after the migration-leading to physical and psychological rootlessness that can lead to physical manifestations of stress.

 

The nurse should also inquire about the process of immigration for the individual patient. For example, what country did the patient immigrate from and how different is the native culture from American culture? Does the patient associate with friends primarily or exclusively from his or her same ethnocultural group? Because moving to a new country and culture is stressful, it is common for newly arrived immigrants to associate only with people with whom they feel comfortable and secure-people who share their owative culture. It is important to remember than the greatest influences on reactions and responses to health care treatment and management may be very unfamiliar to nurses raised in the United States.

 

Frequently, when immigrants arrive in a new country, they live in an ethnically homogenous neighborhood with people from their same cultural group. Areas such as the Lower East Side of New York City are typical of immigrants to the United States. Within a generation, immigrants often move to other areas of a city. In the United States, it is possible for immigrants to remain in a community in which the native language is the primary language spoken and newspapers are in this language. A patient who is embedded in the original culture may not have much contact with the predominant cultural group and may present a greater challenge in patient teaching.

 

Does the patient have traditional dietary habits and wear traditional dress? Traditional dietary habits are often maintained for many generations, while traditional dress is usually given up sooner unless it is also closely associated with religious beliefs. For example, the dress of Muslim women represents their religious beliefs. Traditional dietary habits should be acknowledged, respected, and incorporated into patient teaching plans. Traditional dietary habits of native peoples are often healthier than U.S. eating habits because there is little use of processed foods or overuse of animal fats. In fact, modifying the patient’s native dietary pattern may make a disease like diabetes easier to manage than if the patient ate a typical U.S. diet.

 

Does the patient live exclusively within his own cultural neighborhood or does he venture out into the larger cultural American experience? Patients whose daily lives are spent within their own culturally defined neighborhoods are usually more culturally embedded than patients who leave the neighborhood are.

 

Does the patient use folk medicine or engage the services of a traditional healer? Is the patient from an urban or rural area in the country of origin? Immigration from a rural area is associated with less exposure to and knowledge about Western medical practices and the American health care system. This is especially true of rural immigrants from Asian, African, and South American countries.

Knowing the patient’s degree of cultural embeddedness helps the nurse to know where to start negotiating with the patient and his or her family to achieve health care goals. Patients who are highly embedded in the native culture are traditional individuals totally committed to their original cultures. People who are less embedded and more acculturated value open communication and ideas from both cultures. Bicultural individuals can move easily between both cultures.

The nurse may observe tension between acculturated children who want older members of the family to take advantage of Western medical practices and older members of the family who wish to follow traditional remedies. The challenge for the nurse in this situation is not to become involved in the transgenerational struggles, but to respect the two positions and allow opportunities for teaching that recognize the importance of both generations. The transgenerational impact of migration is illustrated in books such as The Joy Luck Club, The Kitchen God’s Wife, Rain of Gold, and Like Water for Chocolate.

Cultural negotiation

Once assessment is done, cultural negotiation can take place in terms of agreeing on a treatment regimen that is acceptable to both patient and provider. The goal of cultural negotiation is to join Western and non-Western beliefs in a way that helps the patient achieve a healthy outcome. For example, a dietitian can use Chinese beliefs about cold (yin) and hot (yang) foods to plan a diabetic diet that is both acceptable to the patient and that helps the patient maintain an appropriate blood sugar level.

In participating in cultural negotiation, nurses can use other health care providers who are from the patient’s own cultural group. However, it is important to remember that, if there is a large gap between the beliefs of providers and patients, and if providers are westernized, they may distance themselves or look down on those who hold traditional beliefs. When this happens, the care providers cease to be therapeutic, even though they share a common cultural heritage. It is important to remember that language alone does not ensure cultural understanding. Patients and care providers from the same country may come from different class and social structures and may not always communicate effectively.

 

The nurse must know when and how to present material so that it respects cultural values. At times, patients are encouraged to learew ways of approaching care, or when necessary, are helped to accept mandated changes, such as altering parenting skills to change more abusive child rearing practices to those legally acceptable in this culture. Native Americans may value nonverbal and more passive approaches to communication than Anglo-Americans. Responses to questions may be short and long periods of silence may mark the exchange. Knowing this aspect of culture, the nurse can become more comfortable with periods of silence without pressuring the patient to formulate an answer or assuming that he or she is uninterested. In Hispanic cultures, establishing a personal relationship with the patient that supports the norms of dignity, politeness, and respect is important in the counseling exchange. Latino patients often describe a successful interaction with a health care provider as “she was like a cousin or a good friend.

Using interpreters in health care

 

 

Language is the foundation for effective nurse-patient relationships and is important for interpersonal and cross-cultural communication. Being able to communicate with a patient is vital for obtaining an accurate and comprehensive patient and family assessment, formulating and implementing a treatment plan, determining the effectiveness of nursing care, and evaluating outcomes of care.As result of dramatic demographic changes in the United States, nurses are increasingly faced with the challenge of communicating with the patient who cannot speak English or speaks English with limited proficiency.

 

People who speak English with limited proficiency are a significant percentage of the U.S. population. According to the U.S. Census Bureau, 14 percent of the population speak a language other than English at home. This percentage is greater than 40 percent in major cities such as New York, Los Angeles, Miami, Honolulu, and El Paso, Texas. Of all non-English speakers in the United States, 17.3 million (54 percent) speak Spanish at home, and 8.3 million Hispanics report that they speak English less than “very well.” People who speak Chinese rank second among people who speak English less than “very well.”

 

The vast majority of health care and human service institutions receive federal financial assistance such as Medicare, Medicaid, or Hill-Burton funds and thus are subject to Title VI mandates, requiring policies that do not limit access of limited English proficiency persons (LEP) to health care services. The Department of Health and Human Services requires that reasonable steps be taken to provide services and information in languages other than English to ensure that LEP patients are informed and can effectively participate and benefit from health care. The JCAHO requires that health care institutions make translation services available. Demographic changes; federal, state, and local laws; accreditation standards for health care organizations, and the potential for legal liability are all important reasons for nurses to incorporate in their practice appropriate strategies for communicating with LEP patients.

There are important differences between a translator and an interpreter. A translator is a person who can speak English and the patient’s native language. However, the translator often does not have equal fluency in both languages and may lose important cultural nuances and meanings. In contrast, an interpreter is a professionally trained person who interprets the meaning of words and phrases from the health care provider’s language to the patient’s language and provides the same services on behalf of the patient to the health care provider.

Non-English speaking patients

It is helpful to learn a few words of the patent’s language, such as good morning and thank you. Taking the time to learn a few polite expressions shows an interest in the patient’s language. When you speak to the patient or an interpreter, use standard everyday English. Avoid slang expressions that may not be understood or may be misinterpreted by the patient or the person interpreting. Use simple words and phrases that are to the point and easily translated. However, using simple words does not mean the same thing as using simplistic words. Avoid talking to the patient or the interpreter as if they were children. Complete an entire sentence and then allow time for the interpreter to translate. When you stop in mid-sentence, the interpreter may not be able to understand the context of the entire sentence and may provide a confusing or inaccurate translation. Avoid giving long explanations. When the interpreter needs to interpret long speeches, he or she may try to make a synopsis of what you’re saying or forget part of the full thought you wish to communicate.

The cultural implications of topics as death, sexuality, childbirth, and women’s health are frequently poorly understood by health care professionals, and such topics should be probed with care and respect.

Be careful about making jokes or using humor to convey an English thought into another language. Remember that what is humorous in one language or culture may not be funny in another. What you may consider funny may, in fact, by considered offensive when it is translated. Know the language skills of the interpreter so that you have confidence that both you and the patient are having your ideas translated accurately. While the interpreter is translating what you have said to the patient, position yourself so that you are looking at the interpreter. Keep in mind that the patient is able to read your nonverbal messages. Look at the interpreter, smile occasionally or nod your head in agreement. If you look through the patient’s chart or gaze out the window while the interpretation is proceeding, you may send signals to the patient that you are not interested in the interaction. Table 3 shows methods of interpretation:

Table 3

Getting byrefers to using facial expressions and gestures, or using a few key words or phrases in the target language. For example, a nurse who “gets by” in Spanish may be able to communicate about a patient’s leg pain by understanding the words pierna for leg and dolor for pain. In addition to using a few words in the target language, the nurse may obtain information about the patient’s pain by pointing to an area of the body, making grimaces as if in pain. “Getting by” has both advantages and disadvantages. This method allows the nurse to communicate with the patient immediately without having to wait for an interpreter. “Getting by” is effective when only basic informatioeeds to be exchanged. It is often used in emergencies or wheo one can be found who speaks the patient’s native language. However, the amount and complexity of information that can be obtained is limited, and there is a danger of miscommunication. For example, if the patient is complaining of chest pain, knowing just a few words of the target language will not allow you to assess important aspects about the quality and timing of the pain that may be vital in making a correct diagnosis. Nurses also may use the “getting by” method because they feel that other methods are inconvenient. Sometimes we may also overestimate our basic skills in the target language.

An ad hoc interpreter is anyone available who speaks both languages, such as the patient’s friends or roommates. Using ad hoc interpreters has distinct advantages and disadvantages. In addition to being readily available, ad hoc interpreters often share the patient’s cultural background and can serve as sources of cultural information between the patient and the health care team. Disadvantages of using ad hoc interpreters include compromising the patient’s right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate.8 An example of this involves a young non-English speaking patient who comes to the emergency room with a long and detailed account of an acute episode of flank pain, nausea, and vomiting. The friend with her is used as an ad hoc interpreter. The interpreter tells the health care team that the patient has had back pain, but adds that she complains about back pain frequently. The interpreter also says that the patient has been vomiting, but states that in her opinion, it may be the flu because the patient’s husband was vomiting from what appeared to be the flu a few days ago. Thus, through omissions, additions, and opinions, an acute episode of kidney stones could be interpreted as a condition of less importance.

Volunteer interpreters can include the patient’s family and health agency employees who are bilingual. Health care professionals and administrators often think that using family and friends as interpreters is more cost-effective than using other methods of translation. However, strong anecdotal evidence suggests patient care and level of satisfaction are negatively affected by this method. Family and friends are not bound by any code of conduct. They may interpret, editorialize, or deliberately withhold information that they feel is embarrassing or that may upset the patient or health care provider. Family members are probably the least desirable source of translators because they may filter what the health care provider is trying to tell the patient. They may also “edit” what the patient is trying to tell the health care provider. Using family members as translators also puts undue stress on both the patient and family member.10 Because of the high possibility of misinterpretation, don’t use a minor child as an ad hoc interpreter except in an emergency.

Volunteer interpreters, usually drawn from a health care agency’s own workforce, can offer several advantages. The cost to use employee volunteers is low, and because the volunteer works in a health care setting, he or she is usually familiar with health-related terminology and procedures. Using volunteer interpreters instead of family or friends lets patients maintain their privacy and control the nature and amount of information shared with family members and friends. Using volunteer interpreters also has some disadvantages. Not all facilities provide training, and the educational, health care, and language backgrounds of bilingual staff who serve as volunteer interpreters vary widely. As a result, they may inadvertently commit errors or violate patient confidentiality. Another disadvantage is that the volunteer interpreter’s own work obligations may limit his or her availability.

Professional interpreters have excellent bilingual language skills and are bound by a code of conduct. Such individuals are usually contracted for directly or work with an interpreter agency. However, professional interpretation services are expensive, often costing between $50 and $100 an hour. They may also be unavailable on weekends or holidays or not be able to come in on short notice in an emergency. Some very large hospitals are able to employ professional interpreters or cultural mediators. A cultural mediator not only provides interpretive services, but also interprets cultural and social circumstances that may affect the patient’s care.

Using a telephone language line, an off-site interpreter communicates through a speakerphone or hand held phone. AT& T Language Line Services and Pacific Interpreters Inc. can provide access to interpreters in more than 140 languages, 24 hours a day, seven days a week. Language line interpreters receive training in medical interpreting and are tested for linguistic competency and knowledge of medical terminology. They also sign a code of ethics statement that protects the patient’s confidentiality. Agencies contracting with telephone language lines may pay a monthly fee plus a per-minute rate or just a per-minute rate. Such services are particularly useful in scarcely populated areas where there are few other options for interpretation other than the patient’s immediate family or close friends. A disadvantage of language line interpretation is that the interpreter must depend on oral language alone. The interpreters cannot see the patient’s body language or facial expressions and must depend solely on the content and tone of the conversation. In addition, this type of interpretation is difficult to do when teaching patients how to use equipment or perform a skill.

Written materials and educational programs

There are several issues to consider when translating written materials from English into other languages. Although the natural tendency is to translate materials directly from English into the target language, direct translation doesn’t always consider cultural influences and literacy limitations. The words used in an English version may not be appropriate for people of another culture. Keep in mind that many patients don’t read well in either English or their native language. It is helpful to ask an interpreter to talk with a sample of the intended population to determine if the instructioeeds to be in that language or whether a simplified version in English, which includes lots of illustrations, could meet their needs just as well. If you are designing written materials, have several members from the culture work with you in the overall design and approach. Often, graphics, diet lists, and procedures do not translate with the same meaning in other languages. If you don’t have access to other members of the cultural group, look for community resources. A number of community services are becoming available to meet specific translatioeeds. For example, some churches and community agencies offer translation services.

In addition to ensuring the accuracy of language translation, it’s also important to design education programs that have cultural appeal to the target population. For example, the Los Angeles Cancer Education Project conducted a learner verification of a number of national and local publications from potential users from the Hispanic community to evaluate several of its upcoming national and local publications. The group found the materials unsuitable because they dealt with facts rather than with people and their concerns. Group members felt keenly enough to create a new publication based on one extended family’s experiences with cancer – Hablaremos Sobre Cancer de la Familia (Let’s Talk About Cancer Among the Family). This became the centerpiece for a comprehensive community effort to detect early cancer-family participation for cancer detection is more culturally appropriate than individual participation.

Ways to communicate when you don’t speak the patient’s language:

◾Use pictures, synthetic body models, and demonstrations with actual equipment to get your message across.

◾Use simulations to show what you are trying to communicate.

◾Use audiotapes made in the language(s) of your patient population to present routine information such as admission procedures, room and unit orientation, or preoperative procedures.

It’s important that the patient has understood what you are communicating. After giving information verbally instead, test the patient’s comprehension by asking him or her to show, draw, or communicate with gestures what he or she is supposed to do. Ask the patient to repeat the feedback if there is hesitancy or body language shows uncertainty. Because some patients come from cultures that are very different from ours, it is important not to make assumptions that the patient knows what to do. Some of the most ordinary requests that we make in the health care system are not within the experiences of other cultures. For example, when a non-English patient who failed to fill a prescription was asked why he didn’t take it to be filled, he replied that the prescription was still in his car because he didn’t know what to do with it. He had never had a prescription before and had never been to a pharmacy.

Assess who should be included in patient teaching. The assumption in traditional American culture is that each person manages his or her own health care. However, in other cultures the critical decision making is influenced by others, e.g., the godmother, priest, or an outside group such as a council of elders; in those instances, the target audience broadens to include not only the patient but also the significant decision makers. Patients of other cultures also need to be taught to expect health professionals to ask questions about health history. Sometimes patients from other cultures may feel that if the nurse and physician have to ask so many questions, they aren’t very competent.

A model of care for cultural competence

 

 

The term culturally competent care refers to nursing care that is sensitive to issues regarding culture, race, gender, and sexual orientation. Cultural competence is a process in which the nurse strives to achieve the ability to effectively work within the cultural context of an individual, family, or community from a diverse cultural/ethnic background. Campinha-Bacote proposes a culturally competent model of care that includes cultural awareness, cultural knowledge, cultural skill, and cultural encounters. The components of this model are:

◾Cultural awareness

◾Cultural knowledge

◾Cultural skill

◾Cultural encounter

 

Cultural awareness is the process by which the nurse becomes aware of, appreciates, and becomes sensitive to the values, beliefs, life ways, practices, and problem-solving strategies of other cultures. During this process, you examine your own biases and prejudices toward other cultures as well as explore your own cultural background. Without becoming aware of the influence of one’s own cultural values, we have a tendency to impose our own beliefs, values, and patterns of behavior on other cultures. The goal of cultural awareness is to help you become aware of how your background and your patient’s background differ.

 

Cultural knowledge is the process by which you seek out and obtain education about various worldviews of different cultures. The goal of cultural knowledge is to become familiar with culturally/ethnically diverse groups, worldviews, beliefs, practices, lifestyles, and problem-solving strategies. Some of the ways you can acquire knowledge are by reading about different cultures, attending continuing education courses on cultural competence, and attending cultural diversity conferences. The next step, cultural skill, involves learning how to do a competent cultural assessment. Nurses who have achieved cultural skill can individually assess each patient’s unique cultural values, beliefs, and practices without depending solely on written facts about specific cultural groups. It is extremely important to remember that each patient you care for, whether born and raised in the United States or not, is a member of a specific cultural group that affects his or her health care beliefs. Therefore, cultural assessments should not be limited to specific ethnic groups, but conducted with each individual patient. Cultural encounter involves participating in cross-cultural interactions with people from culturally diverse backgrounds. Cultural encounter may include attending religious services or ceremonies and participating in important family events. However, it is important to remember that although we may have several friends of different cultural groups, we are not necessarily knowledgeable about the group as a whole. In fact, the values, beliefs, and practices of the few people we encounter on a social basis may not represent that specific cultural group which you provide nursing care for. Therefore, it’s important to have as many cultural encounters as possible to avoid cultural stereotyping. Below are some cultural professional resources for nurses.

◾Transcultural Nursing Society

◾Journal of Cultural Diversity

 

Madeleine Leininger, who has done pioneering work in the influence of culture on health care, suggests two guiding principles that nurses can use in caring for patients from many diverse cultures. The first is to maintain a broad, objective, and open attitude about each patient. The second is to avoid seeing all patients alike. By following these principles, we can open ourselves to learning about the way others view health and illness and form relationships that are therapeutic.

 

References

http://www.euromedinfo.eu/a-model-of-care-for-cultural-competence.html/

1.    Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.

 

2.    Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.

 

Recommended Optional Materials/References

 

3.    Hitchcock, J.E., Schubert, P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action /  Delmar.

 

4.    American Psychological Association. (1994) Publication Manual of the American Psychological Association (4th ed.). Washington, DC: Author.

 

See required Websites:

http://www.health.gov/healthypeople/.

www.health.state.mn.us/divs/chs/phn/definitions.pdf