As a young nursing doctoral student I spent time on a Caribbean island learning how to conduct ethnographic research on elder care.1 During the second week of my fieldwork, an older woman approached me and asked, "What [are] you here to do?" Feeling a bit intimidated by this older, stronger, taller, somewhat imposing Caribbean woman, I modestly answered that I was hoping to learn about elder care. She laughed and asked me "What program [are] you doing for us? [Are] you Peace Corps?" "No," I explained. "I'm a nurse, working with the Ministry of Health Nurses, doing research, to learn from you about how you take care of older people. We hope it will help all of us learn how to better care for our senior citizens."
She stood up straight, looked me in the eyes, smiled, and said, "Eh, you going to learn from us." She was right, I learned a lot!
Informed Providers are Necessary
To build sustainable community health programs, the critical importance of providers and community members being informed about one another was one of the most important and foundational lessons my partners and I were to learn from islanders in the West Indies, then community members in the United States, and more recently from villagers in south India. This certainly was not where I started my journey. Rather, incorporating the community study method,2 my experience as a public health nurse, recommendations from my mentors in anthropology and gerontology, a review of the literature, expert opinion, and epidemiological databases, I went to the island fieldwork experience armed with many ideas about islanders and elders. And the "problem statement" of what needed to be fixed.
Working with community members, the research demonstrated that islanders were not all alike, but rather they were situated in a cultural context that must be understood before one could understand health, healthcare or how people relate to health and healthcare. Community members do not like to have their community "problematized." Recognizing that they have strength and rather, identifying healthcare "issues" was preferred by some participants.
Furthermore, the language of culturally competent care implied an expert provider who had the requisite healthcare knowledge and skills to deliver a service or program to the community members of a particular ethnicity, who had a specific set of healthcare needs.3There were a couple of issues with that line of thinking.
Interconnectedness of Community Care
First, culture is a group or community concept, not limited to an ethnicity. Second, both the community and the healthcare providers have essential knowledge, skills and resources that inform an understanding of a community's health. Communities and providers are in an interdependent and equitable partnership of information exchange for building community capacity for health. Culturally informed nursing practice was an approach developed to address these issues. To be culturally informed providers partner with community members to conduct a systematic ongoing cultural inquiry to understand the people, the environment in which the people live, and how the people organize themselves to acquire the things they need to live.
Building upon this cultural inquiry, a systematic ongoing community health assessment determines the health of the people, the health of the environment in which they live, and how they organize to get their healthcare needs met. Strategies from nursing, anthropology and epidemiology are used to describe and analyze the cultural matrix of a community in which all health is situated. Following are cross-national examples of situations that informed the development of this approach.
Best Interest of Patients
The island villagers shared a story of a situation that occurred in the 1970s. A service group from the United States had worked with local officials and community members to decide on a service project. It was determined that they should build a wheelchair ramp for a group of older adults who lived on the second floor of an old persons' home and did not have access to the outdoors. While key partnership strategies were used, an unintended consequence was that people were harmed because the ramp allowed elders who
were confused to wander off into the rain forest. An assessment of the environment (rain forest surrounding the old persons' home), people (older persons with cognitive impairment) and social organization (two village caregivers for more than 50 older persons) might have helped inform the design of the intervention and prevent the untoward outcomes.4
In the rural United States it was found that some elders were being confined in their homes while their adult children worked. One elder dearly missed her past lifestyle that included walking about the village she once lived in, spending time visiting with other older persons, and engaging in community activities. Upon first analysis, it could be questioned if the adult children were abusing their older parent; denying the elder the right to free movement and choice. For the adult children and elder, this was the agreed upon best strategy to prevent the non-English speaking elder from being picked up by immigration officials at a time of great uncertainty about the political climate for documented and undocumented immigrants. Understanding the cultural patterns of the immigrant as well as the local community was helpful in designing interventions to address immigration policy.
Community as a Resource
Finally, culturally informed programming includes using supplies that can be purchased locally, thus improving sustainability of the program, community awareness of the work, community buy-in, and economic opportunities for local businesses. A culturally informed assessment of a rural village in India led to the development of diabetes prevention and management program. The program included a foot care intervention that incorporated foot care supplies and diabetic footwear. Initially the use of footwear was stigmatizing for the older adult, in particular older women. Awareness of the local culture where the shops competed for customers led to two of the shops advertising that they had the best footwear. The selection of footwear improved, as did sales and, to the local healthcare providers' surprise, the number of adults, including older women, who were requesting notes (prescriptions) from the doctors for the footwear increased.
Working with communities to build capacity for health and healthy aging is exciting, rewarding and dynamic. It can also feel overwhelming. Just like a nurse assesses an individual patient prior to intervening in their care, so must also the nurse assess the community to prevent unintentional harm. Unintentional harm may be caused by creating community programs that erode local community processes that already work and by blaming peoples' or communities poor health outcomes on individual or cultural haracteristics, rather than by understanding the unique cultural context that not only helps one understand the health issue, but engages community members in managing the issue and building community capacity for health from within the community.
The author wishes to acknowledge the community partners and participants, students, and colleagues who have participated in the ongoing cross-national program of research. Human Subjects Internal Review Board approval was obtained from the St. Lucian Ministry of Health, Swami Vivekananda Youth Movement, and the University of Iowa.
Lisa Elaine Skemp, PhD, RN, FGSA, FAAN, is professor and chair for the Department of Health Systems, Leadership, and Policy at Loyola University Chicago. Skemp received the American Public Health Association New Investigator's Award for her cross-cultural research in the Caribbean and is a Claire M. Fagin Fellow for her work in rural community healthy aging. She is the author, along with Melanie Creagan Dreher, PhD, RN, FAAN and Susan Primm Lehmann, MSN, RN, of Healthy Places, Healthy People, 3rd ed.
1. Skemp Kelley, L. (2002). Expectations and Elder Care Networks in a St. Lucian Village. (Doctoral dissertation, The University of Iowa, 2002). Dissertation Abstracts International, 63(07), DAI-B. (UMI No. 3058415).
2. Arensberg, C. & Kimball, S. (1965). Culture and community. New York: Harcourt, Brace & World, Inc.
4. Skemp, L, Dreher, M., & Lehmann, S. (2016). Healthy Places Healthy People. A handbook for culturally informed community nursing practice. (3rd Ed.). Sigma Theta Tau International: Indianapolis, IN.