Client and Family Education
Elaine T. Miller
INTRODUCTION
For the majority of clients and their families, a chronic illness constitutes a life-changing event uniquely affecting them as they deal with the added demands and long-term nature of the particular disease. Perhaps more importantly, chronic illnesses do not always have a similar trajectory of presentation and management (e.g., asthma, heart disease, depression, cancer, stroke, arthritis, diabetes, and hypertension), and they do not discriminate according to age, race, gender, socioeconomic status, culture or ethnicity, or learning capability. Furthermore, the client and family’s response and resources to cope with chronic illnesses may vary tremendously, requiring healthcare professionals (HCPs) to be attuned to each client and family’s particular needs, expectations, resources, and personal goals.
Data further indicate that treating clients with chronic diseases accounts for 75% of U.S. healthcare spending and two-thirds of our current increase in healthcare spending is related to the expanded prevalence of treating chronic disease (Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion, 2010). The vast majority of chronic diseases (e.g., pulmonary, hypertension, heart disease) could be prevented or better managed by adopting a more client-centered, multidisciplinary approach that fosters client and family involvement, client self-management, and continuous quality im-provement (Partnership to Fight Chronic Disease, 2010). For example, Woodhouse, Peterson, Campbell, and Gathercoal (2010) found a significant reduction in the costly use of emergency room visits by high user clients with chronic pain who received targeted educational/behavioral interventions to better manage their condition. Thus, maximizing the client and family’s coping with chronic illness and improving their knowledge, attitudes, and behaviors in conjunction with HCPs providing a more unified approach and subsequent monitoring, management, and evaluation of care outcomes are central aspects of the care-delivery process. Given that many clients and their families are likely to experience more than one chronic illness in a lifetime, it is critical for HCPs to be cognizant of the potential interplay of diverse chronic illnesses that may influence the client and family’s responses to further losses such as incontinence, fatigue, diminishing cognitive function, or mobility.
It is also well documented that educating clients and their families is critical to successful coping with chronic illnesses and overall longterm quality of life. Plus, the family frequently serves as the client’s primary support system affecting the client’s decision making about
health, seeking health care, and adherence to recommended healthcare recommendations (e.g., taking prescribed medication, following a diet, having a recommended procedure or test) (Falvo, 2011). Although there are often some commonalities, each client and family situation has its distinctive characteristics that require HCPs to approach every situation carefully and systematically without making assumptions as to the client and family’s resources, capability to learn, and ability to achieve educational outcomes. Moreover, HCPs must continually assess the factors influencing the client and family’s educational needs, the teaching and learning approach, and evaluation of short- and longterm outcomes. Another central element in this educational process is identifying what clients and their families want to learn, their priorities in terms of their educational needs, and having mutual goal setting, so that clients, families, and HCPs are working together to achieve common goals.
health, seeking health care, and adherence to recommended healthcare recommendations (e.g., taking prescribed medication, following a diet, having a recommended procedure or test) (Falvo, 2011). Although there are often some commonalities, each client and family situation has its distinctive characteristics that require HCPs to approach every situation carefully and systematically without making assumptions as to the client and family’s resources, capability to learn, and ability to achieve educational outcomes. Moreover, HCPs must continually assess the factors influencing the client and family’s educational needs, the teaching and learning approach, and evaluation of short- and longterm outcomes. Another central element in this educational process is identifying what clients and their families want to learn, their priorities in terms of their educational needs, and having mutual goal setting, so that clients, families, and HCPs are working together to achieve common goals.
Because numerous factors contribute to the success or failure of client and family education pertaining to chronic illness, this chapter presents an overview of the fundamental elements that should be considered and clarifies the state of evidence-based knowledge pertaining to client and family education related to chronic illnesses. Even though much is known regarding client and family education, the literature and research do not suggest simple solutions or approaches that will optimize this educational process in all situations. In addition, the nature of the chronic disease(s) as well as the specific attributes of the learner(s) such as age, gender, race/ethnicity, culture, socioeconomic status, motivation, self-efficacy, psychological conditions (depression, bipolar disorder), sensory deficits (low-level vision, hearing impairment, literacy, learning capability), and/or learning disabilities will significantly influence how the HCP approaches and evaluates the success of each client and family educational encounter. The primary focus of this chapter is the adult learner. However, a basic distinction is described regarding key learning differences between adults and children. Finally, because this chapter only purports to present a broad overview of key issues affecting client and family educational processes regarding chronic illnesses, it is highly recommended that additional evidence-based resources be obtained to more specifically target the chronic illness and client population of concern, recognizing that research and the associated findings continue to expand the science of what is known.
The Teaching-Learning Process
The teaching-learning process is characterized by multifaceted, dynamic, and interactive exchanges that are fundamental to client-family education and nursing practice. Teaching involves a deliberative, intentional act of communicating information to individuals in response to their identified educational needs and with the objective of achieving a desired outcome (Falvo, 2011; Bastable, 2006). Learning, on the other hand, assists the individual to acquire new knowledge, skills, and/or attitudes that can be measured (Bastable, 2006). A review of the literature reveals that there are more than 50 major teaching-learning theories that can shape an educational intervention (Learning Theories Knowledge Base, 2011).
Although many theories and frameworks are applicable to client and family education, behaviorist theory, social-cognitive learning theory, humanistic learning theory, and constructionist theory have been identified as particularly helpful in shaping educational interventions. Each offers a different orientation of what is most important and what should be the HCP’s focus of attention when educating individuals with chronic illness and their families. In addition, each has a particular perspective in terms of how teaching and learning are defined, measured, and structured, as well as the phases of learning.
For example, the behaviorist framework states that learning is the result of connections between the stimuli in the environment and the individual’s responses (Skinner, 1974). So if an educator wants a client and/or family to learn new information or alter their attitudes and responses, such as the new need for a client to receive a subcutaneous insulin injection twice daily, the educator would alter the conditions in the environment (e.g., information available on the hospital educational cable system) and reinforce positive new behaviors when they occur (e.g., praise when the injection is given correctly).
On the other hand, social-cognitive theory includes role modeling as a central concept and offers a different approach to teaching clients and their families to perform the same task (Bandura, 1986). In this identical situation, using the social-cognitive theory, the nurse educator would demonstrate how to perform the insulin injection and then have the client, if capable, perform the insulin injection when next scheduled.
Meanwhile, if Maslow’s Hierarchy of Needs, one of the best known humanistic frameworks, was applied to this identical scenario, the educator would first need to fulfill lower level needs such as physiologic needs and safety before being concerned about teaching the client how to perform the insulin injection.
Finally, the constructionistic learning theory offers an additional alternative theoretical perspective to guide the HCP’s educational encounter, asserting that learners are actively creating meaning as they learn. When viewed from this constructionist orientation, learning is perceived as contextual, requiring not only time, social contact, and motivation, but also creating meanings that foster learning over time and its application (Hein, 1991). In the case of learning how to properly give an insulin injection, the constructionist theory provides a framework to connect the client’s understanding/meaning of how the insulin injection should be correctly given, the client’s motivation to learn this activity, the time required to correctly perform this task, and the contribution of the HCP who is teaching this skill.
In summary, theoretical frameworks offer alternative ways to approach a teaching-learning situation involving clients and their families. Because there are a myriad theoretical frameworks, it is important that HCPs determine what is most relevant to their situations, examine available evidence-based research pertaining to that framework (preferably evidence published in the last 5 years), and then translate that framework to their particular client-family interactions, and systematically evaluate the efficacy of using that perspective to direct their educational interventions.
In conjunction with the numerous teaching -learning theories that guide the HCP’s
client-family educational encounters, it is valuable to contemplate several basic assumptions underpinning these interactions. According to Petty (2006), learning involves “an active process of making sense and creating a personal interpretation of what has been learned” (p. 8), rather than simply an exact interpretation of what has been taught. What occurs is more than just a storing of personal interpretations of facts and ideas, it is “also linking them in a way that relates ideas to other ideas, and to prior learning, and so creates meaning and understanding” (p. 8). When viewed from this perspective, learners construct meaning that is more easily applied to solve problems, make judgments, and assist clients and their families to perform the numerous tasks associated with living with one or more chronic illnesses. Evidence is steadily expanding to support the constructivism perspective and its positive outcomes (Muijs & Reynolds, 2005). In addition, results from multiple metaanalyses of educational research reinforce the pivotal influence that feedback and reinforcement exert on individual as well as group learning (Petty, 2006).
client-family educational encounters, it is valuable to contemplate several basic assumptions underpinning these interactions. According to Petty (2006), learning involves “an active process of making sense and creating a personal interpretation of what has been learned” (p. 8), rather than simply an exact interpretation of what has been taught. What occurs is more than just a storing of personal interpretations of facts and ideas, it is “also linking them in a way that relates ideas to other ideas, and to prior learning, and so creates meaning and understanding” (p. 8). When viewed from this perspective, learners construct meaning that is more easily applied to solve problems, make judgments, and assist clients and their families to perform the numerous tasks associated with living with one or more chronic illnesses. Evidence is steadily expanding to support the constructivism perspective and its positive outcomes (Muijs & Reynolds, 2005). In addition, results from multiple metaanalyses of educational research reinforce the pivotal influence that feedback and reinforcement exert on individual as well as group learning (Petty, 2006).
CASE STUDY
Mrs. McGill is a 63-year-old African American grandmother with a history of chronic obstructive pulmonary disease and obesity (BMI > 30) as well as 2 falls in the last 4 months resulting in bruises, but no fractures. About 6 months ago, she was also diagnosed as a type 2 diabetic and is receiving medication, but getting her blood sugars under control and adhering to her diet restrictions has been somewhat of a challenge.
Mrs. McGill lives with her husband of 34 years and is currently raising 2 grandsons ages 6 and 10. Although she loved being a substitute English teacher in the high school where she taught, Mrs. McGill has been unable to do so since obtaining custody of her 2 grandsons 9 months ago. Her husband, who is a pharmacist, still works part-time and is very supportive of his wife. The couple live with their grandsons in a comfortable duplex.
Discussion Questions
1. What appear to be the primary educational objectives for Mrs. McGill?
2. What additional assessment data would be helpful in identifying your educational objectives and structuring your related interventions?
3. What teaching method(s) would be most appropriate and what is your rationale for this decision?
4, What websites or national practice standards may be of assistance in helping to develop your teaching plan?
5. Briefly describe what your teaching plan would consist of in terms of objective(s), content, timeline, and teaching strategies?
Significance of Client and Family Teaching to Practice and Healthcare Costs
Practice standards from the American Nurses Association (ANA), the American Association of Colleges of Nursing (AACN), the National League for Nursing (NLN), specialty nursing practice standards, and other national documents consistently identify health teaching as a fundamental component of nursing practice (ANA, 2004; Lindell et al., 2005). Even in the early writings of Florence Nightingale, teaching was recognized as a prominent nursing activity (Nightingale, 1992). In addition, all state nurse practice acts include teaching within the scope of nursing practice responsibilities and essential to promoting optimal health and disease management of clients and their families.
The underlying premise of Healthy People 2010 and Healthy People 2020 (U.S. Department of Health and Human Services, 2010) is that an individual’s health is almost inseparable from the health of the larger community and is profoundly influenced by the collective beliefs, attitudes, and behaviors of this community. Throughout this comprehensive national health promotion and disease prevention roadmap, there is a recurrent theme emphasizing the improvement of “the availability and dissemination of health related information” (Healthy People 2010, p. 17) pertaining to the leading health indicators of our society. Central to accomplishing these health objectives is education of all stakeholders (i.e., clients, families, HCPs, the overall community). Healthy People 2020 further emphasizes how disparities in income and education are associated with higher levels of occurrence of illness and death and place greater importance on targeting community-based health educational programming. For instance, Healthy People 2020 focuses on the systematic and targeted health promotion education and preventative actions for adults who are most at risk for long-term health problems/diseases. Plus, the 2020 edition emphasizes the coordination and targeting of health promotion education and other activities beginning in preschool and continuing through high school. Healthy People 2020 concentrates on health problems such as unintentional injury, violence, dental caries, unhealthy dietary patterns, tobacco use and addiction, and alcohol and drug use—all having ramifications for long-term chronic health issues.
In addition to Healthy People 2020 emphasizing the importance of evidence-based, coordinated, targeted, and individualized client and family education, the Joint Commission (JC, 2010) 2011 Hospital Accreditation Standards identify specific critical educational standards that must be achieved by organizations seeking accreditation. The JC (2010) standards include:
PC.02.03.01 The hospital provides client education and training on each client’s needs and abilities.
1. The hospital performs a learning needs assessment for each client, which includes the client’s culture and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations and barriers to communication.
4. The hospital provides education and training to the client based on his or her assessed needs.
5. The hospital coordinates the client education and training provided by all disciplines involved in the patient’s care, treatment, and services.
10. Based on the client’s condition and assessed needs, the education and training provided to the client by the hospital include any of the following: An explanation of the plan of care, treatment, and services. Plus, basic health and safety information need to be included with a special emphasis on the safe and effective use of medication…. Discussion of pain, risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management, information on oral health, safe and effective use of medical equipment, supplies provided by the hospital, also what rehabilitation techniques need to be in place to help the client reach maximum independence, strategies to reduce falls.
25. The hospital evaluates the client’s understanding of the education and training it provided.
27. The hospital provides the client education and how to communicate concerns about the client’s safety issues that occur before, during, and after care is provided.
The Joint Commission patient education standards further specify that clients and families assume an active role in this process and have responsibilities just as the educator does. In instances where they do not understand the information, they are to indicate this and must take responsibility for self-management of their needs when capable (e.g., medication, safety, nutrition, pain). Moreover, the educator is expected to consistently and comprehensively assess the client and family’s learning needs and barriers affecting the educational outcomes. In addition, the Joint Commission expects that educational activities be coordinated, tailored according to the clients and families needs/abilities, and evaluated to determine if learning has occurred.
During the 2002 Summit on the Education of Health Care Professionals (Institute of Medicine [IOM], 2003), it was emphasized that the education of all HCPs is in serious need of a “major overall” (p. 1) to be better prepared to fulfill the needs of clients and the changing healthcare system. Current nursing graduates must engage in evidence-based practice and integrate research findings pertaining to client and family teaching (IOM, 2003). Building upon this trend of expanding nursing roles, the National League for Nursing Task Group on Nurse Educator Competencies identified core competencies of nurse educators, underscoring their need to engage in scholarly activity pertaining to teaching and learning.
Data from the Centers for Disease Control and Prevention (CDC) highlight the pivotal role that education has in clients’ self-management of chronic illness. For instance, the CDC reports that for each dollar invested in diabetic education to assist clients to self-manage their diabetes and prevent hospitalizations, healthcare costs are reduced by $8.76 (CDC, 2005). With regard to heart disease and stroke, they further emphasize that much of the burden associated with these two diseases can be eliminated by reduction of major risk factors such as high blood pressure, high cholesterol, tobacco use, limited physical activity, and poor nutrition. By targeting client and family education on those modifiable risk factors, the likelihood of heart disease and stroke can be significantly diminished and personal and financial costs reduced. The 2010 passage of the
Patient Protection and Affordable Care Act into law is estimated to reduce the number of uninsured by 31 million in 2019 at a net cost of $938 billion over 10 years while reducing the deficit emerging from escalating healthcare costs by $124 billion during that same time period (Kaiser Foundation, 2010). Several of the benefits of this law are as follows:
Patient Protection and Affordable Care Act into law is estimated to reduce the number of uninsured by 31 million in 2019 at a net cost of $938 billion over 10 years while reducing the deficit emerging from escalating healthcare costs by $124 billion during that same time period (Kaiser Foundation, 2010). Several of the benefits of this law are as follows:
Insurance for people with pre-existing conditions
Coverage for preventive care and screenings such as immunizations and screening for conditions such as cancer and diabetes
More spending on care—at least 80% of a customer’s premium dollars need to be for direct medical care and efforts to improve quality care
All insurance plans must include mental health and substance abuse services by 2014
Starting in 2011 persons with Medicare will have an annual wellness visit that includes a personalized prevention plan that identifies health risk factors and treatment options
A main feature of these changes and others included within this legislation is the focus on prevention and management of chronic healthcare conditions. As a result, identifying evidencebased effective, timely, and targeted educational interventions will be pivotal to achievement of short- and long-term health outcomes in settings spanning from acute to long-term care. In addition, with the passage of this legislation, there is a growing demand to perform research focusing on the expansion of the evidence that underpins our educational interventions and attainment of the preferred client and family outcomes. When contemplating how to choose and develop written educational materials, Pierce (2010) provides valuable recommendations that should be considered.
Basic Differences Between Child and Adult Learners
The term pedagogy is defined as the art and science of teaching children, while andragogy refers to adult learning (Bastable, 2006, p. 451, 466). When teaching children versus adults, the key principles operating during the teachable moment are distinctly different, as indicated in Table 15-1.
Quality of Research and Evidence
When developing educational interventions for clients and their families, it is important to first determine the quality of the evidence forming the basis for the planned actions. Evidence-based practice (EBP) refers to a problem-solving approach used in practice that combines the following three components: the best available evidence; the HCP’s clinical expertise; and the client’s values and preferences (Melnyk & Fineout-Overhold, 2010). The highest level of evidence is a well conducted meta-analysis and systematic review of randomized control trials (RCTs) (Craig & Smyth, 2002; Melynk & Fineout-Overhold, 2010). However, a review of the literature reveals that a sizable portion of present knowledge directing our educational interventions is of a lower level of evidence quality than preferred such as single randomized trials, nonrandomized studies, consensus opinion of experts, and case studies. Results of a systematic review of 139 educational RCTs involving more than 22,000 clients with diabetes, asthma, or congestive heart failure (CHF) reveal that many of these RCTs draw inappropriate conclusions, with researchers frequently tending to overgeneralize their findings and include their opinions that are
not based on research evidence (Boren, Balas, & Mustafa, 2003). Therefore, educators need to carefully scrutinize the level of available evidence that underpins their practice, determine whether stated implications in research studies extend beyond the documented evidence, and recognize the tentative nature of our knowledge.
not based on research evidence (Boren, Balas, & Mustafa, 2003). Therefore, educators need to carefully scrutinize the level of available evidence that underpins their practice, determine whether stated implications in research studies extend beyond the documented evidence, and recognize the tentative nature of our knowledge.
Table 15-1 Comparison of Assumptions Pertaining to Teaching and Learning for Children and Adults | ||||||||||||||||||
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An excellent illustration of how knowledge evolves is demonstrated by the Internet and the increasing prevalence of online learning that has reshaped, in many instances, the education of clients, families, and HCPs worldwide. In a study investigating clients’ seeking trends for additional health information regarding their disease/health problem, Rahmqvist and Bara (2007) identified from a sample of 24,800 respondents that young and middle-aged clients primarily use the Internet to expand their knowledge. Despite this Internet access facilitating clients becoming more informed, they stress the inherent quality issues associated with public access to a blend of poor as well as high-quality, evidence-based online health information. Their findings were reaffirmed by Gremeaux and Coudeyre (2010), who performed a systematic review of the Internet and therapeutic education of patients and found that HCPs must work to create quality sites that provide accurate evidence-based data and best practices pertaining to chronic disease management for clients and their families.
Assessment of the Learner
A critical aspect of the client and family educational process is the assessment phase that shapes the other steps in the process, such as planning the
educational event/program, its implementation, and evaluating outcomes. However, just as vital signs are obtained to determine the client’s physiologic state, so too must certain essential information be obtained in this initial assessment that will affect how the education is structured, delivered, and evaluated. Because it is assumed that the client and family dealing with the chronic illness are equal partners with the HCP, the following are critical questions to ask the client and family:
educational event/program, its implementation, and evaluating outcomes. However, just as vital signs are obtained to determine the client’s physiologic state, so too must certain essential information be obtained in this initial assessment that will affect how the education is structured, delivered, and evaluated. Because it is assumed that the client and family dealing with the chronic illness are equal partners with the HCP, the following are critical questions to ask the client and family:
What information do you want provided? Recognize that the client and family may identify different needs. If so, make sure each of their needs is addressed.
Are there any new skills that you want to learn or ones you want to review?
What are your specific educational goals for the client and family? You may need to give an example (e.g., correctly identify signs/symptoms of hypoglycemic reactions; know what to do when an insulin reaction occurs and how to correctly give an insulin injection). The HCP must recognize that client and family goals can focus on knowledge, attitude (i.e., self-efficacy), and/or skill acquisition.
Of the goals identified, what is most important? Once again, the client and family may differ markedly in specific goals and priorities. Listen carefully to both of them.
What do you perceive as factors that affect your ability to achieve these educational goals? How will barriers be overcome?
Do you feel confident using the information provided to you? If not, how may I assist you in increasing your confidence and ability to use this information?
When clients and family members are providing answers, the HCP must always be an astute listener, nonjudgmental, capable of developing individualized and attainable client and/or family goals, and reflect back to the client and family their understanding of what has been heard (Miller, 2003). While collecting the relevant client and family data, the HCP needs to be organized, perform the assessment in a timely manner, and be aware of readability of assessment materials. In addition, the client with chronic illness often has associated limitations that affect the assessment (e.g., easily fatigued and diminished hearing and/or vision and/or comprehension).
INFLUENCES ON TEACHING AND LEARNING
This section identifies a variety of factors that may influence the teaching-learning process; however, the list is not all inclusive as each individual with chronic illness is unique and their teaching-learning may be influenced by other factors.
Family Structure and Function
Families can vary significantly in structure and function. The chronic illness of a family member can precipitate changes in the family structure and function, as do changes associated with marriage, raising children, or death of a family member. When a family has a member with a chronic illness, the family’s response to this change and its capability to adapt and make decisions can influence their receptiveness to education. When the client and family experience high anxiety, it can markedly interfere with their ability to receive and comprehend information, maintain normal patterns of family functioning, and use appropriate coping skills. Because culture and lifestyle affect the development of family norms and beliefs, differences in these client/family and
HCP factors can affect the dynamics of the educational process (Rankin, Stallings, & London, 2005). Once these beliefs and values are identified, they can be addressed through individualized teaching. It is imperative, therefore, that the family structure, function (i.e., roles, resources, strengths, and weaknesses), and norms be considered in the assessment and educational planning process.
HCP factors can affect the dynamics of the educational process (Rankin, Stallings, & London, 2005). Once these beliefs and values are identified, they can be addressed through individualized teaching. It is imperative, therefore, that the family structure, function (i.e., roles, resources, strengths, and weaknesses), and norms be considered in the assessment and educational planning process.
According to the 2010 Joint Commission standards, the family is to be included in client teaching (e.g., fall-reduction strategies, reporting concerns related to care and safety). Because the client’s family may be large with varying functions, the HCP must determine the primary family member who should receive the relevant education. Just as in the case of the client, the HCP needs to assess the primary family caregiver’s role, expectations, learning needs/goals, learning style, fears, concerns, cognitive and physical abilities, and present knowledge pertaining to the client’s healthcare needs (Bastable, 2006). Moreover, the client and the family member may need to receive similar information, reinforcement, and feedback related to their knowledge and/or skill performance. In many instances, the family member is the single most important factor in determining the success or failure of the teaching plan (Haggard, 1989).
Culture
When working with clients and their families, culture can dramatically affect how educational activities are structured, delivered, and evaluated. The client and family’s culture comprise “an integral part of each person’s life and includes knowledge, beliefs, values, morals, customs, traditions, communication patterns, and habits acquired by members of a society” (Bastable, 2006, p. 455). When educating clients and families, an important initial step is becoming culturally sensitive. This refers to the process of becoming aware of one’s own biases and prejudices about another culture or ethnic group. Cultural competence, a higher level, denotes educational interventions reflecting knowledge, understanding, respect, and acceptance of the clients and/or family’s culture (Bastable, 2006).
For a successful educational encounter to occur, HCPs and clients and their families must bridge these cultural differences through the use of effective interpersonal communication. This establishment of common understanding between HCPs and clients and their families is facilitated by the HCP performing the following:
Explore and respect the client’s/family’s beliefs, values, meaning of the chronic illness, preferences, and needs.
Identify what will build rapport and trust. Potential sources of information to assist in this process are other colleagues, family members of the client, community groups, and reputable websites.
Determine if there are any common views or interests.
Identify own biases and assumptions.
Maintain and convey an unconditional positive regard. Be an excellent listener, be open and nonjudgmental, and use consistent perception checks to assess comprehension of what has been communicated.
Become knowledgeable of the culture and health disparities/discrimination of the particular client/family’s culture. Review some of the websites listed at the end of this chapter that provide a starting point for resources from reputable sources.
Use interpreter services when needed.
Cultural differences make each client and family situation unique, but there are also essential considerations in communication, interactions, and the ultimate delivery of any educational activity. Because culture has been linked to cancer-related beliefs and practices, Kreuter and associates (2003) examined the effects of culture on responses to cancer education materials. With a convenience sample of 1227 African American women, it was determined that responses to culturally tailored materials were no different than to other materials, regardless of the women’s cultural characteristics. However, for all types of educational materials, women with higher religiosity and racial pride paid more attention to the educational materials. In this study, it appeared that select cultural attributes (e.g., religiosity and racial pride) moderated responses to tailored health education materials.
A number of other contextual factors have been demonstrated to influence health-related attitudes and beliefs of the cancer information-seeking behavior of African American men. For example, living in the South where the Tuskegee Syphilis Study took place has resulted in distrust of the healthcare delivery system among many African Americans (Freimuth et al., 2001; Green et al., 2000). In a study investigating factors predicting prostate cancer information seeking by 52 African American men, it was discovered that the men increased their awareness by obtaining accurate information regarding the disease, early detection and screening, and treatment. However, negative beliefs such as fear, distrust, and inconvenience of the symptoms and treatment were identified. It was further revealed that peers, siblings, and religious leaders had a significant influence on the study subjects’ behaviors.
Viswanathan and Lambert (2005), in a study with 20 adult African Americans with cardiovascular disease, ranging in age from 45 to 64 years, discovered that the subjects expressed fear. Subjects’ fears were related to side effects from their medication, fear of dependence, and worry about forgetting to take their medication correctly. Despite the fears identified, these subjects perceived their medications to be lifesaving, an important part of life, and recognized the necessity to take medication properly to prevent the complications associated with hypertension. In Hatcher and Wittemore’s study (2007), the subjects also experienced fear, but the stated reasons were distinctly different. This finding emphasizes that not all African Americans experience situations in the same manner, and that individualized assessment and planning needs to occur without making assumptions and applying them to all members of that cultural group.
In an integrative review that focused on Hispanic adults and their beliefs about type II diabetes, Hatcher and Wittemore (2007) identified several valuable findings that should be considered when developing educational interventions for this population. After reviewing 15 research studies, they identified that generally Hispanic adults’ understanding of the etiology of diabetes was an integration of biomedical causes (e.g., heredity) and traditional folk beliefs. With knowledge of the importance of heredity and folk beliefs in how Hispanics view diabetes, Hatcher and Wittemore (2007) recommend this as a starting point to clarify misconceptions and develop individualized plans of teaching and care. Results from this synthesis of the research literature highlight the necessity of obtaining specific knowledge of how race and culture can affect the structure, implementation, and evaluation of educational outcomes.
Determination of the family’s sense of burden, ability to cope, and the role of culture is another aspect of the client and family assessment
that needs to be taken into consideration when planning individualized educational activities. Cain and Wicke (2000), in a study involving 138 family caregivers of clients with chronic obstructive pulmonary disease (COPD), discovered that African American caregivers experienced less burden than their Caucasian counterparts. Similar levels of burden occurred in men compared with women and spouse caregivers compared with nonspouse caregivers. In addition, younger caregivers indicated more burden than those age 55 and older. Although these findings are not generalizable beyond this study, the researchers acknowledge the importance of educators being cognizant of contextual factors such as caregiver burden and age, and how these factors may affect other activities such as client and family teaching. Table 15-2 provides additional resources to facilitate cultural competence with diverse client and family populations.
that needs to be taken into consideration when planning individualized educational activities. Cain and Wicke (2000), in a study involving 138 family caregivers of clients with chronic obstructive pulmonary disease (COPD), discovered that African American caregivers experienced less burden than their Caucasian counterparts. Similar levels of burden occurred in men compared with women and spouse caregivers compared with nonspouse caregivers. In addition, younger caregivers indicated more burden than those age 55 and older. Although these findings are not generalizable beyond this study, the researchers acknowledge the importance of educators being cognizant of contextual factors such as caregiver burden and age, and how these factors may affect other activities such as client and family teaching. Table 15-2 provides additional resources to facilitate cultural competence with diverse client and family populations.
Table 15-2 Cultural Competence Resources for Client-Family Education | ||||||||||
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