The constitution of the World Health Organization (WHO) states that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic or social condition (WHO, 1948). More than 60 years after this constitution was adopted, wide variations in health still exist. In 2009, the WHO stated that

Psychiatric-mental health nurses (PMHNs) must be cognizant of the impact of globalization on health care and be prepared to intervene appropriately with patients who are culturally, ethnically, and spiritually different. Yet, we must also understand that the process of globalization is blurring the differences between cultures and groups. It is most important to heed the words of psychiatrist Harry Stack Sullivan (1947, p. 7) who noted, “we are all more basically human than otherwise.” There is a common nature among all human beings and the belief that we are all more alike than different should pervade our mental health understandings and work (Sullivan, 1947).

Within the context of understanding that the similarities are more important than the differences among individuals and cultural groups, we must not lose sight of individuals as distinct beings, each with unique values, cultural practices, and spiritual beliefs. To provide optimal person-centered care that respects cultural, spiritual, and ethnic differences, nurses must empower patients to act as full partners in the health care process to improve their health outcomes (Cronenwett et al., 2007). The Institute of Medicine (IOM) report, Unequal Treatment, stressed the importance of cultural competence in eliminating racial and ethnic health care disparities (Smedley, Stith, & Nelson, 2002).

This chapter discusses the relationship among culture, ethnicity, spirituality, and health, and identifies the influence these factors have on mental health and illness. It also describes the essential need for nurses to continuously strive toward cultural competence when providing mental health care.

CORE CONCEPTS

It is important to have an understanding of the key concepts related to CULTURE and diversity. Box 27-1 presents the definitions for the major concepts. These definitions have been formulated from the current literature and are widely accepted in nursing and health care. The constructs of diversity and patient-centered care are essential perspectives that will frame the discussion within this chapter and frame the core concepts, which provide the context for culturally, spiritually, and socially appropriate care in mental health (as well as other nursing specialties). The approach to delivery of mental health care has consistently involved an interprofessional style and has been typified by collaboration of professional teams (nursing, medicine, psychology, psychiatry, social work, and others) to meet patient needs. Therefore, this chapter stresses the need for interprofessional team collaboration to address the needs of diverse populations.

DIVERSITY is defined narrowly to include age, race, gender, ethnicity, religion, and sexual orientation. Most comprehensively, diversity also includes variations in identity, community/geography, privilege, power, social context, and economic circumstance. Diversity may be reflected in a broad spectrum of demographic and philosophical differences.

Patient-Centered Care

The IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasized the necessity for patient-centered care as one of the six goals for high-quality care (IOM, 2001). Patient-centered care recognizes “the (person) or their designee as the source of control and (a) full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs” (Cronenwett et al., 2007, p. 123). Furthermore, nurses must value seeing the health care encounter through the eyes of their patient. The nurse supports the patient’s preferences even when the nurse has conflicting points of view. The nurse advocates for the patient when the patient’s cultural and/or spiritual practices and values conflict with the prescribed medical regimen (Campinha-Bacote, 2011). Patients and families must be empowered throughout the health care encounter in order for shared decision making to occur. With this multidimensional approach, patient-centered care is realized (Cronenwett et al., 2007).

Interprofessional Teamwork and Collaboration

The essentials for baccalaureate nursing education recognize that interprofessional communication and collaboration are critical to safe high-quality care and for improving patient health outcomes (American Association of Colleges of Nursing [AACN], 2008).

Cronenwett et al. (2007) defined teamwork and collaboration as the ability to “function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (p. 125). In order to achieve effective teamwork, nurses must first recognize their personal contributions to the team and the significance of their collaboration in support of culturally and spiritually appropriate mental health care. Collaboration can only be realized through respect for the varying points of view of each team member. Each member of the team brings a unique perspective of, and expertise regarding, his or her clinical practice area. Nurses must value the communication style of patients and families as well as other members of the team. Nurses function as valuable team members but also can effectively assume the critical role of team leader (Cronenwett et al., 2007).

Interprofessional collaboration is not without challenges. Chong, Aslani, and Chen (2013) described perceived barriers of shared decision making and interprofessional collaboration among members of health care teams that included both mental health and non–mental health professionals. The stigma of mental illness was a perceived barrier to collaboration with non–mental health care colleagues. Chong et al. (2013) found that team members who experienced low levels of satisfaction with interprofessional collaboration believed that the interprofessional views of all members were not valued equally and that there appeared to be a predominance of influence from non-mental health providers. Chong et al. (2013) also identified that a key facilitator of shared decision making was a willing attitude on the part of the health care providers (HCPs) to involve the patient in the decision-making process. The investigators found that HCPs’ personal attitudes and beliefs, professional role, knowledge, and skills were associated with interprofessional collaboration. Good interprofessional collaboration was supported through mutual respect, knowledge, and shared goals. Successful interprofessional collaboration is even more important when health care professionals are working with individuals who may require mental health strategies different from those to which they are accustomed.

GLOBALIZATION AND HEALTH CARE DISPARITIES

The world is viewed as a global community, and as part of that global community, the U.S. population has become increasingly diverse. Although some literature indicates significant progress in the U.S. health care system for racial, ethnic, and cultural minority groups (Collins et al., 2002; Martinez, Arriola, & Corvin, 2015), evidence exists identifying that the need for equitable health services among racial, ethnic, and cultural groups is still high (Collins et al., 2002; Kaiser Family Foundation, 2011; Smedley et al., 2002).

In addition, the United States is experiencing an increase in people coming from economically developing countries and/or countries experiencing military or political strife. These groups are particularly at risk of poor health care services due to unfamiliarity with the U.S. health care system, lack of health care coverage and/or limited access, and language barriers. Research with a variety of populations, such as African, Arabic, Asian, Australian, British, and Caribbean, have identified that understanding culture, religion, and social and political forces are critical to adequately meet the health care needs of individuals and groups (Kim, Atkinson, & Umemoto, 2001; Kohrt et al., 2015; Morgan et al., 2005; Owen & Khalil, 2007; Scheffler et al., 2011; Steel et al., 2006).

The Health Care Quality Survey study, completed by the Commonwealth Fund in 2001, was performed to evaluate health care quality from the perspective of patients who received care. The study found that minority Americans reported a lower level of health care quality when compared to American European counterparts (Collins et al., 2002).

As with other areas of health care, disparities in the provision of mental health care have also been clearly identified (U.S. Department of Health and Human Services [DHHS], 2001). Research in the United States has shown lower rates of mental health service usage by ethnic, racial, cultural, and social (including religious) minorities. Additionally, when these minority individuals use care, it is more likely to be poor in quality (DHHS, 2001). As a result, ethnic, racial, cultural, and social minority groups carry a greater burden from unmet mental health needs. Therefore, it is important to understand how mental health services are provided to meet special sociocultural needs of these identified groups (Kim et al., 2001; Kirmayer, Groleau, Guzder, Blake, & Jarvis, 2003; Rostain, Ramsey, & Waite, 2015; Shin, 2002; Sorsdahl et al., 2009; Wang, Berglund, & Kessler, 2001; Woodward et al., 2008).

RACE, ETHNICITY, AND CULTURE AND MENTAL HEALTH

Race, ethnicity, and culture are a significant part of the context in which each individual exists. Therefore, they have influence on perceptions of well-being and illness, health care decision making and help seeking, and health service usage.

Racial, Ethnic, and Cultural Diversity

Diversity in race, ethnicity, and culture affects three areas of functioning that influence mental health and mental health care delivery. These three areas are cognitive styles, negotiation strategies, and value systems. Table 27-1 explains these three areas.

Consider the area of value systems and decision making. Some cultural groups view decision making as a role to be assumed by the designated family head or leader rather than the affected individual. When health decisions must be made, the providers and the patient must include the family leader before any decision is made. Although very different from most experiences in the United States, this process is one that is common in other cultural groups. Awareness of this family dynamic on the part of the nurse is essential in helping individuals to think through a problem, determine what is and is not appropriate or acceptable based on their value system, and decide on a course of action. Nurses and other HCPs must assess the impact of these influences with each patient, and assist the patient by providing information and support for the decision-making process.

Studies have shown that ethnic and racial groups with histories of inequality and who are experiencing current disadvantaged socioeconomic circumstances are at a higher risk for mental health conditions (Giurgescu et al., 2015; Pearson et al., 2014). However, despite these risks for emotional distress and mental illness, diverse ethnic, racial, and cultural groups also demonstrate protective factors that mediate risks for mental illness. The literature has identified the role of family, closely held beliefs, group identity, and community and mutual support as external mediators against stress and mental illness.

Language Variations

Variations in language may also influence how mental health and illness are discussed. For example, research has shown that in some racial or ethnic groups such as Iranian, Rwandan, and Eastern Indian, mental and physical health are encompassed into one word or emotional distress is reflected through descriptions of the “body” being sick (Khandelwal, Jhingan, Ramesh, Gupta, & Srivastava, 2004; Martin, 2009; Summerfield, 2005). In addition, studies have identified that cultural and ethnic or racial groups may avoid using the word mental illness and use other terms such as nerves, feeling down or blue, and emotional problems. PMHNs who become aware of the language that is and is not used by diverse patient groups are better able to respond appropriately when counseling, educating, or referring individuals for treatment. Because there is stigma associated with the term mental illness, using more culturally or socially acceptable terms may avoid an unintended barrier to mental health care.

Gender Roles, Gender Identity, and Family Expectations

Cultural precepts related to gender roles and expectations differ from culture to culture. Some cultural groups assign specific daily tasks and responsibilities according to whether the person is female or male. Many identify who makes important family decisions based on gender. Although in most Western philosophy societies these gender roles and expectations vary and are not as clearly defined, these beliefs can significantly affect mental health within societies that have long-held traditions as part of daily living (Shafer & Wendt, 2015). The focus on gender and mental health has also been expanded to focus on important considerations related to gender identity and sexual orientation. The National Alliance on Mental Illness (www.nami.org) identifies that although there has been increasing recognition and understanding of the social factors that impact the mental health of these populations, and the removal of these populations from the list of mental health pathology, there continues to be disparities in access to mental health care and adequate numbers of culturally and socially competent mental HCPs (Bostwick, 2007; Willging, Salvador, & Kano, 2006).

Within the United States, Native American populations hold views and expectations that may vary, and have great impact on customs, values, and beliefs that influence spiritual healing and holistic health. Traditional mental health care within this country identifies that there is significant incongruence between the importance of family and community, and spiritual harmony as perceived by these populations. The path to wellness (a combination of physical, mental, and spiritual health) is seen as one that is a partnership and is a complex interaction of significant others (Moghaddam, Momper, & Fong, 2015). The historical trauma experienced by people within these populations and the socioeconomic disparities that still exist for members of these tribal groups serve as risk factors for negative mental health outcomes.

Consider the traditional perspectives of many within the Asian culture. Traditional Asian group values include collectivism, conformity to norms, deference to authority, emotional self-control, family recognition through achievement, filial piety, humility, compliance, and avoidance of shame based on hierarchical relationships (Cheung, 2009; Kim et al., 2001). “Saving face” (chemyun in Korean culture) or honor is critically important. Thus, being exposed to circumstances that threaten one’s ability to “save face” can affect emotional health.

Increasing evidence reveals that many cultures focus on the family and identified significant others as a collective unit whereby important decisions are made, with all relevant individuals engaging in or influencing the decision-making process. The emphasis in Western culture is on individual decision making, which may be in stark contrast to other cultural groups; as a result, it may act as a barrier to care (Goodkind, Gorman, Hess, Parker, & Hough, 2015; Mir et al., 2015; Morgan et al., 2005; Steel et al., 2006).

Immigration

Experiences related to refugee and immigrant status add stressors to an individual or group. These stresses may be related to clashes of culture and the process of acculturation into a different society and its accompanying norms; that is, adapting to a culture other than one’s own. Research conducted with African, Korean, Mexican, and Yugoslavian immigrant populations have identified a cluster of factors affecting the mental health of those who flee from or leave their country of origin, and now find themselves part of a minority population elsewhere (Borges et al., 2009; Fozdar, 2009; Shin, 2002). Box 27-2 lists these risk factors.

Mental Health, Mental Illness, and Mental Health Service Use Among Ethnic, Racial, and Cultural Groups

Although the overall incidence of mental health conditions is similar among and between racial and ethnic groups, some variability does exist for different types of disorders. For example, some studies have found higher rates of depressive disorders among Latinos than non-Latino Whites in U.S. population-based studies (Mental Health America, 2014; Dunlop, Song, Lyons, Manheim, & Chang, 2003; Minsky, Vega, Miskimen, Gara, & Escobar, 2003). Mexican nationals who have family members working within the United States have higher rates of suicidal ideation and are at increased risk for alcohol and substance abuse (Borges et al., 2009). Immigrant Mexican American youth reported significantly higher social anxiety and loneliness than U.S.-born Mexican American youth (Polo & López, 2009). However, the literature also identifies that risks for mental health conditions and negative mental health outcomes that are described are significantly influenced by social, contextual, and economic factors (or social determinants of health) as culturally diverse populations navigate within new environments (American Psychological Association Presidential Taskforce on Immigration, 2011).

Approximately 7.5 million African Americans have a diagnosed mental illness. Their risk for depression is higher, in part due to socioeconomic factors such as urban living and risk for exposure to traumatic events. African Americans also are less likely than Whites to use outpatient mental health services and to find antidepressant medication acceptable. In fact, only 32% of African Americans with mental health disorders have been found to use professional services, with 48% of those with severe major depressive symptoms receiving treatment (Williams et al., 2007). Moreover, African American men are less likely to use mental health services than their female counterparts.

Use of mental health services by minority children and adolescents also varies. The use of crisis care by African American and Native American children and youth is greater than that by Whites. In addition, studies reveal that Latino and Asian youth used intensive crisis services to a higher degree. However, access to non-crisis services by minority youth is less than that of White youth. Moreover, African American adolescents received less mental health treatment, including outpatient care, than White adolescents, and Latino children received fewer counseling sessions and specialty mental health services than White children (Pumariega & Rothe, 2003; Snowden, Masland, Libby, Wallace, & Fawley, 2008; Snowden & Yamada, 2005).

Much of the current literature has identified stigma as a critical barrier to seeking mental health services among individuals from minority groups (Roh et al., 2015). Research on the Asian culture reveals influences on mental health and illness and accessing mental health care. For example, those who hold traditional Asian values believe that each individual should be able to resolve his or her own mental health problems by using inner resources and willpower (Kim et al., 2001, Shin, 2002). Thus, mental health problems are best addressed through moderating one’s emotions and behavior, controlling troublesome thoughts, and seeking inner peace. For some Asians, the need for mental health assistance is a sign of weakness. Asian Americans and Asian immigrants have been shown to underuse mental health services. In addition, they typically wait longer before accessing treatment than African Americans and White Americans (Park, Chesla, Rehm, & Chun, 2011; Shin, 2002).

Research among Pakistani Muslim populations indicate that facilitators and barriers to mental health service use include language, acculturation, family dynamics, community networks, and religious identity (Gater et al., 2010; Mir et al., 2015; Naeem et al., 2015; Rahman, Malik, Sikander, Roberts, & Creed, 2008). Variations in perspectives among diverse populations are complex and discussion is beyond the scope of this chapter. However, in-depth understanding of the culturally, religiously, and socially diverse populations with whom one works is essential for nurses who address mental health needs regardless of the setting (Broman, 2012; Cheon & Chiao, 2012).

In Latin American countries, information about mental health is limited (Razzouk et al., 2008). However, in one study examining the Brazilian population, 9% of the population older than 16 years sought mental health treatment in the previous year. Most of these individuals used public mental health services (de Toledo Piza Peluso, de Araujo Peres, & Blay, 2008). Unfortunately, understanding of mental illness is still poor and most individuals who express having mental health concerns do not seek treatment.

Information about mental health in developing and low- and middle-income countries lags behind what has been written about high-income countries but is becoming more available (Padmavati, 2005; Patel & Bloch, 2009; Stein & Sedat, 2007). Although conditions such as depression, anxiety, and posttraumatic stress disorder are widespread and have been identified by WHO, research articulating the extent of these conditions and perceptions of mental health is limited. For example, studies from India identify that the prevalence of mental illness ranges from 9.5 per 1,000 to 370 per 1,000 people within the general population. Among the homeless (beggars) in India, mental illness ranges from 22.6 to 131 per 1,000. Most recent estimates of mental health conditions in India indicate that approximately 12.5% to 18.9% of primary care patients have a mental health condition. Of these conditions, affective disorders, neuroses, and alcohol and drug disorders rank the highest (Khandelwal et al., 2004).

New studies from South Africa indicate that approximately 30% of adults have experienced a mental health disorder in their lifetimes. Anxiety disorders account for 16% of the disorders, mood disorders account for 10%, while substance abuse disorders account for 13% (Jack et al., 2014; Stein et al., 2008). In areas where traditional African belief systems predominate, many individuals believe that mental health problems result from bewitchment or current influences exerted on them by their dead ancestors, such as feelings of being cursed, punished, or controlled by them (Abdool & Ziqubu-Page, 2004).

 

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