UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1 49

African Americans are one of the largest ethnic groups in the UnitedS t a t e s . Data from the U. S . D e p a rtment of Commerc e, Bureau of theCensus (2001) reveal that there are approx i m a t e ly 34,333,000 AfricanAmericans residing in the United States, representing 12.1% of thetotal population. The African-American population is expected toincrease to 40.2 million by 2010 (American Demographics, I n c . , 1 9 9 1 ) .Health disparities among the African-American population incl u d el i fe ex p e c t a n cy, h e a rt disease, hy p e rt e n s i o n , infant morality and mor -bidity rates, c a n c e r, H I V / A I D S , v i o l e n c e, type 2 diabetes mellitus, a n da s t h m a . The purpose of this art i cle is to address the issue of healthdisparities among African Americans by providing nu rses with apractice model of cultural competence.

© 2009 Society of Urologic Nurses and AssociatesU rologIc Nurs i n g , p p . 4 9 - 5 4 .

African Americans arel a rgely the descendantsof Africans who wereb rought forcibly to the

United States as slaves between1619 and 1860. The literature con-tains conflicting re p o rts of theexact number of slaves that arr i v e din the U.S., with varying estimatesrevealing that anywhere from 3.5to 24 million slaves landed in theAmericas during the slave tradeera. African-American slaves gen-erally settled in Southern states,and curre n t l y, over 50% of AfricanAmericans still live in the South;19% live in the North andN o rtheast, 9% live in the We s t ,and 19% live in the Midwest(Campinha-Bacote, 2008). Thehighest concentration of AfricanAmericans can be found in metro-politan areas, with over 2 millionresiding in New York City andover 1 million living in Chicago(U.S. Department of Commerc e ,B u reau of the Census, 2001). Wa t t s(2003) asserts that race is an issuefor African Americans, and “theBlack experience” in America ismarkedly diff e rent from that ofother immigrants, specifically int e rms of the extended period ofthe institution of slavery and theissue of skin color as a means fordehumanization of Black persons.

A Model of Cultural Competence

The Process of CulturalCompetence in the Delivery ofH e a l t h c a re Services is a practicemodel of cultural competencethat defines cultural competenceas the ongoing process in whichthe nurse continuously strives toachieve the ability and availabili-ty to work effectively within thecultural context of the patient(individual, family, community)(Campinha-Bacote, 2007). Thispractice model re q u i res nurses tosee themselves as becoming cul-turally competent rather thanbeing culturally competent, andit involves the integration of cul-tural desire, cultural aware n e s s ,cultural knowledge, culturalskill, and cultural encounters(see Figure 1). Each of these con-s t ructs will be applied to caringfor the African-American patient.

Cultural Desire

Cultural desire is defined as themotivation of the nurse to “wantto” engage in the process ofbecoming culturally competentwith African-American patients;not the “have to” (Campinha-Bacote, 1998). Cultural desire isthe pivotal construct of culturalcompetence that provides thee n e rgy source and foundation forone’s journey toward culturalcompetence. Humility is a keyfactor in addressing one’s culturald e s i re. Nurses who are humblehave a genuine desire to discoverhow their patients think and feeld i ff e rently from them. Culturalhumility is a quality of seeing theg reatness in others and cominginto the realization of the dignityand worth of others. As healthc a re professionals, nurses do nothave to accept the patient’s belief

A Culturally Competent Model Of Care for African Americans Josepha Campinha-Bacote

Josepha Campinha-Bacote, P h D, M A R ,P M H C N S - B C , C T N , FA A N , is President,Tra n s c u l t u ral C. A . R . E . A s s o c i a t e s, Cincinnati,O H .

Au t h o r ’s Note: Tra n s c u l t u ral C. A . R . E . A s s -ociates is an organization that prov i d e sclinical, administra t i ve, research, and ed -ucational services related to tra n s c u l t u ra lhealth care and mental health issues.

Key Wo rd s : African Americans, health disparities, cultural assessment, cultural competence, culture, diversity,inequality, cultural awareness, racism.

50 UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1

system; however, nurses mustt reat each person as a uniquehuman being worthy and deserv-ing of love and care. In this sense,cultural desire is expressed int e rms of human dignity, humanrights, social justice, and equity(Campinha-Bacote, 2005). Researc hcontinues to demonstrate a dire c tcorrelation between inequalityand negative health outcomes,and it is because of this link thatnurses must consciously connectcultural competence with socialjustice. Stacks, Salgado, andHolmes (2004) contend that whencultural competence partnerswith social justice, equality inhealth outcomes can finally beachieved for all, re g a rdless ofr a c e / e t h n i c i t y, language, gender,religion, or sexual orientation.

Cultural Aw a r e n e s s

Cultural awareness is the con-scious self-examination and in-

depth exploration of our person-al biases, stereotypes, pre j u d i c e s ,and assumptions that we holdabout individuals who are diff e r-ent from us. In addressing cultur-al awareness, nurses must ask thequestion, “Am I aware of anybiases or prejudices that I mayhave toward African-Americanpatients?” An example of oneunconscious area of bias may bethe African-American dialect.

Although the dominant lan-guage spoken among AfricanAmericans is English, there is away of speaking among someAfrican Americans that sociolin-guists refer to as African AmericanEnglish (AAE). These term sinclude Black English, Ebonics,Black Ve rnacular English (BEV),and African American Ve rn a c u l a rEnglish (AAVE) ( B l a n d - S t e w a rt ,2005). The major problem thatAAE speakers face is pre j u d i c e .Most people believe that AAE isinferior to Standard American

English. At times, AfricanAmericans who use AAE arem i s i n t e r p reted as being unedu-c a t e d .

A nurse’s personal beliefs andbiases about African Americansmay lead to unequal tre a t m e n t ,misdiagnosis, and over- m e d i c a-tion (Levy, 1993; Smedley, Stith,& Nelson, 2002). For example,African Americans are at a high-er risk of misdiagnosis for psy-chiatric disorders, and there f o re ,may be treated inappro p r i a t e l ywith drugs. Studies have foundthat African Americas are morelikely to be over-diagnosed withhaving a psychotic disorder andm o re liable to be treated withantipsychotic drugs, re g a rdless ofdiagnosis (DelBello, Soutullo, &Strakowski, 2000; Lawson, 1999;Strakowski, McElro y, Keck, &West, 1996; Strickland, Lin, Fu,Anderson, & Zheng,1995). Whilet h e re are several possible expla-nations, DelBello et al. (2000)contend that one plausible expla-nation is that clinicians per-ceived African Americans to bem o re aggressive and more psy-chotic, and as a result, were pre-scribed the antipsychotics.

In examining the construct ofcultural awareness, nurses mustalso examine the possibility ofracism and ask the question, “Ist h e re racism in health care?” Whilep revious re s e a rch attributed thep roblem of health disparitiesamong African Americans andother minority groups to access-related factors, income, age, comor-bid conditions, insurance coverage,socioeconomic status, and expre s-sions of symptoms; the Institute ofMedicine (IOM) cites racial pre j u-dice and diff e rences in the qualityof health as possible reasons fori n c reased disparities (Burro u g h s ,M a x e y, & Levy, 2002; Smedley etal., 2002; Stolberg, 2001).

Cultural Knowledge

Cultural knowledge is thep rocess of seeking and obtaininga sound educational base aboutAfrican Americans (Campinha-Bacote, 2007). In acquiring thisknowledge, nurses must focus onthe integration of three specific

Figure 1.The Process of Cultural Competence in the Delivery of

Health Care Serv i c e s

CULTURAL

AWARENESS

CULTURAL

ENCOUNTERS

The Process

of Cultural

Competence

C o py right © Campinha-Bacote, 1998. P rinted with permission from Tra n s c u l t u r eC. A . R . E . A s s o c i a t e s.

UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1 51

issues: health-related beliefsabout practices and cultural val-ues, disease incidence and pre v a-lence, and treatment eff i c a c y( L a v i z z o - M o u re y, 1996). B e c a u s emost African Americans tend tobe suspicious of health care pro-fessionals, they tend to see aphysician or nurse only whenabsolutely necessary and may usehome remedies to maintain theirhealth and treat specific healthconditions. Some African A m e r i-cans, particularly of Haitian back-g round, may believe in sympathet-ic magic. Sympathetic magicassumes everything is interc o n-nected and includes the practiceof imitative and contagious magic.Contagious magic entails thebelief that once an entity is phys-ically connected to another, it cannever be separated; what is doneto a specific part is also done tothe whole. This type of belief isseen in the practice of voodoo,when an individual will take apiece of the victim’s hair or fin-g e rnail and place a hex, whichthey believe will cause the personto become ill (voodoo illness)(Campinha-Bacote, 1992).

Imitative magic assumes thebelief that “like follows like.” Forexample, a pregnant woman maysleep with a knife under her pil-low to “cut” the pains of labor.African Americans considerthemselves spiritual beings, andGod is thought to be the supre m eh e a l e r. Spiritual beliefs stro n g l yd i rect many African Americans asthey cope with illness and the endof life. In a review of the literatureon spiritual beliefs and practicesof African Americans, Johnson,E l b e rt -Avila, and Tulsky (2005)noted that “spiritual beliefs andpractices are a source of comfort ,coping, and support, and are themost effective way to influencehealing; God is responsible forphysical and spiritual health,and the doctor is God’s instru-ment” (p. 711).

In re g a rd to disease incidenceand prevalence, Underwood andcolleagues (2005) assert thatAfrican Americans experience an“excessive burden of disease.”When examining the re l a t i o n s h i pof social characteristics, such as

education, income, and occupa-tion to health indicators, AfricanAmericans have worse indicatorswhen compared to Caucasians( N a v a rro, 1997). African Ameri-cans are at greater risk for manydiseases, especially those associ-ated with low income, stre s s f u llife conditions, lack of access top r i m a ry health care, and negatinghealth behaviors.

H y p e rtension is the single gre a t-est risk factor for card i o v a s c u l a rdisease and heart attacks amongAfrican Americans. Compare dwith hypertension in other ethnicg roups, hypertension amongAfrican Americans is more severe ,m o re resistant to treatment, andbegins at a younger age, and theconsequence is significantly worse,including organ damage (Bre w s t e r,van Montfrans, & Kleijnen, 2004;M o o re, 2005). African Americansalso experience higher overall can-cer incidence and mortality rates,and less than 5-year survival rateswhen compared to non-HispanicCaucasian, Native American,Hispanic, Alaskan Native, AsianAmerican, and Pacific Islanderpopulation groups (Underwood &Powell, 2006). Because AfricanAmericans are concentrated inl a rge inner cities, they are at risk forbeing victims of violence. Deathdue to violence is the sixth leadingcause of death among AfricanAmericans (National Center forHealth Statistics, 2002). It is alsonoted that African Americans havea dispro p o rtionally higher rate ofpoor asthma outcomes, includinghospitalizations and deaths.Deaths due to asthma are thre etimes more common amongAfrican Americans than amongCaucasians (Asthma and Allerg yFoundation of America and theNational Pharmaceutical Council,2 0 0 6 ) .

African Americans suffer fro mc e rtain genetic conditions. Sicklecell disease is the most commongenetic disorder among theAfrican-American population,a ffecting one in every 500African Americans. In additionto sickle cell disease, glucose-6-phosphate dehydrogenase defi-c i e n c y, which interf e res with glu-cose metabolism, is another

genetic disease found amongAfrican Americans. Finally, AIDScontributes to the lower lifeexpectancy of African Americansc o m p a red to European Americans.In 2003, African Americans, whomake up approximately 12% ofthe U.S. population, accounted forhalf of the HIV/AIDS cases diag-nosed. Treatment eff i c a c y, espe-cially the field of ethnic pharm a-c o l o g y, is important to addre s swhen obtaining cultural knowl-edge. Examples of drugs thatAfrican Americans respond to ormetabolize diff e rently are psy-c h o t ropic drugs, immunosuppre s-sants, antihypertensives, card i o-vascular drugs, and antire t ro v i r a lmedications (Burroughs et al.,2002; Campinha-Bacote, 20 0 7 ;Dirks, Huth, Yates, & Melbohm,2004; Glazer, Morg a n s t e rn, &Doucette, 1993). For example,Dirks et al. (2004) found that theoral bioavailability of specifici m m u n o s u p p ressants in AfricanAmericans was 20 and 50%lower than in non-AfricanA m e r i c a n s .

In obtaining cultural knowl-edge of health-related beliefspractices and cultural values,disease incidence and pre v a-lence, and treatment eff i c a c yamong African Americans, it iscritical for nurses to re m e m b e rthe concept of intra-cultural vari-ation. There are marked diff e r-ences within as well as acro s scultural groups (Campinha-Bacote, 2007). African Ameri-cans are not a homogenousg roup, but rather, reflect a veryh e t e rogeneous group composedof a gene pool of over 100 racialstrains. There f o re, nurses mustdevelop the skill to conduct acultural assessment with eachAfrican-American patient.

Cultural Skill

Cultural skill is the ability tocollect relevant cultural datare g a rding the patient’s pre s e n t i n gp roblem, as well as accuratelyp e rf o rm a culturally based, physi-cal assessment in a culturally sen-sitive manner (Campinha-Bacote,2007). The goal of a culturalassessment is to explore the

52 UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1

p a t i e n t ’s explanation of his or herillness. Kleinman (1980, p. 106)finds it useful to ask the followingopen-ended questions in elicitingthe details of the patient’se x p l a n a t o ry model: • What do you call your pro b-

lem? What name does ith a v e ?

• What do you think hascaused your pro b l e m ?

• Why do you think it start e dwhen it did?

• What do you think your sick-ness does to you? How doesit work?

• How severe is it? Will it havea short or long course?

• What do you fear the mostabout your sickness?

• What are the chief pro b l e m syour sickness has caused fory o u ?

• What kind of treatment doyou think you should re c e i v e ?What are the most import a n tresults you hope to re c e i v ef rom this tre a t m e n t ?

Nurses also need to develop cul-tural skill when perf o rming a phys-ical assessment with African-American patients. In perf o rming aculturally based physical assess-ment, Bloch (1983) encouragesnurses to internally ask questionssuch as, “How does skin color vari-ation influence assessment of skincolor changes and its re l a t i o n s h i pto the disease process?” This ques-tion raises important concerns forthe African-American patient.Nurses are trained in the art ofusing alterations in skin color anddeviations from an individual’sn o rmal skin tone to aid with diag-noses. For example, yellow jaun-dice is a sign of a liver disord e r ;pink and blue skin changes areassociated with pulmonary dis-ease; and ashen or gray color sig-nals cardiac disease (Salcido,2002). However, these acquire dassessment skills are based on aE u rocentric rather than a melano-centric approach to skin assess-ment. Assessing the skin of mostAfrican-American clients re q u i re sd i ff e rent clinical skills from thosefor assessing people with whiteskin (Campinha-Bacote, 2008). Forexample, pallor in dark-skinnedAfrican Americans can be observ e d

by the absence of the underlyingred tones that give the brown andblack skin its “glow” or “livingc o l o r.” Lighter-skinned AfricanAmericans appear more yellowishb rown, whereas darker- s k i n n e dAfrican Americans appear ashen.Cyanosis and blood oxygenationlevels may present diff e rently indark-skinned clients than in light-skinned clients. For example, somedark-skinned African-Americ a npatients may have very blue lips,which may give a false impre s s i o nof cyanosis. In striving toward amelanocentric approach to assess-ing the skin of culturally diversepatients, Purnell and Paulanka(2003) offer the following guide-lines for assessing skin variations:1) establish a baseline color (ask afamily member), 2) use dire c tsunlight, if possible, 3) observ ea reas with the least amount ofpigment, 4) palpate for rashes,and 5) compare skin in corre-sponding are a s .

Cultural Encounters

Cultural encounter is the delib-erate seeking of face-to-face inter-actions with African-Americanpatients. Ti n g - Toomey (1999) con-tends that effective cultural en-counters should consist of “mind-ful intercultural communications”and argues that the opposite ofmindful cross-cultural communi-cation is “mindless stere o t y p i n g ”(p. 16), which is a closed-ended,exaggerated over-generalization ofa group of people based on little orno external validity. Negativeencounters from health care pro-fessionals can greatly aff e c tAfrican Americans’ decision toseek medical attention (McNeil,Campinha-Bacote, Tapscott, &Vample, 2002). One study re p o rt e dthat 12% of African Americans,c o m p a red to 1% of Caucasians, feltthat health care practitioners tre a t-ed them unfairly or with disre s p e c tbecause of their race (Kaiser FamilyFoundation, 2001). Because mostAfrican Americans tend to be sus-picious of health care pro f e s s i o n-als, effective cultural encountersa re key in establishing a tru s t i n grelationship. The case study inF i g u re 2 presents a communica-

tion gap between the nurse and anAfrican-American patient.

When interacting with AfricanAfricans, it is important to knowthat most prefer to be greeted for-m a l l y, such as Doctor, Revere n d ,P a s t o r, Mr., Mrs., Ms., or Miss.They prefer their surn a m ebecause the “family name” ishighly respected and connotespride in their family heritage.African-American communica-tion has been described as high-context (Cokley, Cooke, &Nobles, 2005). They tend to re l yon fewer words and use morenon-verbal messages than what isactually spoken. The volume ofAfrican Americans’ voices isoften louder than those in someother cultures; there f o re, nursesmust not misunderstand thisattribute and automatically as-sume this increase in tonereflects anger. African-Americanspeech is dynamic and expre s-sive. They are also re p o rted to bec o m f o rtable with a closer person-al space than other culturalg ro u p s .

Health literacy must also bea d d ressed during the culturalencounter with African Ameri-cans; re s e a rch shows that healthliteracy is the single best pre d i c-tor of health status. H e a l t h yPeople 2010 defines health litera-cy as “the degree to which indi-viduals have the capacity toobtain, process, and understandbasic health information ands e rvices needed to make appro-priate health decisions” (U.S.D e p a rtment of Health andHuman Resources, 2002). Lowhealth literacy affects 40% ofAfrican Americans and is consid-e red a barrier to receiving opti-mal health care.

Conclusion

The Process of CulturalCompetence in the Delivery ofH e a l t h c a re Services model(Campinha-Bacote, 2007) pro-vides nurses with a model ofpractice to render culturallycompetent and culturally re s p o n-sive health care to AfricanAmericans. In applying this prac-tice model of cultural compe-

UROLOGIC NURSING / January-February 2009 / Volume 29 Number 1 53

tence, nurses should consider thefollowing question: “In caring forAfrican-American patients, haveI A S K E D myself the right ques-tions?” The mnemonic “ASKED”(Campinha-Bacote, 2002, p. 187)re p resents the following ques-t i o n s :• Aw a reness: Am I aware of

my biases and pre j u d i c e st o w a rd African Americans,as well as the existence ofracism in health care ?

• S k i l l : Do I have the skill ofconducting a cultural assess-ment with African-Americanp a t i e n t s ?

• Knowledge: Am I knowledge-able about health-re l a t e dbeliefs, practices, and cultur-al values; disease incidence

and prevalence; and tre a t-ment efficacy among AfricanA m e r i c a n s ? ”

• E n c o u n t e r s : Do I seek outface-to-face encounters withAfrican Americans?

• D e s i re : Do I really “want to”become culturally competentwith African-American pa-tients?

R e f e re n c e sAmerican Demographics, Inc. (1991).

American diversity. What the 1990Census reveals about populationg rowth of Blacks, Hispanics, Asians,ethnic diversity, and children – andwhat I means to you. A m e r i c a nDemographics Desk Refere n c eS e r i e s, 1 , 1 2 - 1 3 .

Asthma and Allergy Foundation ofAmerica and the National Pharm a-ceutical Council. (2006). Ethnic dis -

parities in the burden and tre a t m e n tof asthma. Washington, DC: Author.

B l a n d - S t e w a rd, L. (2005). Diff e rence ordeficit in speakers of African-American English. What every clini-cian should know. ASHA Leader,1 0(6), 6-7, 30-31.

Bloch, B. (1983). Bloch’s assessmentguide for ethnic/cultural variations.In M. Orque, B. Bloch, & L. Monro y(Eds.), Ethnic nursing care. St.Louis, MO: C.V. Mosby Co.

B re w s t e r, L., van Montfrans, G., &Kleijnen, J. (2004). Systematicreview: Antihypertensive drug ther-apy in Black patients. Annals ofI n t e rnal Medicine, 14(18), 614-627.

B u rroughs, V., Maxey, M., & Levy, R.(2002). Racial and ethnic diff e re n c e sin response to medicines: To w a rd sindividualized pharmaceutical tre a t-m e n t . J o u rnal of the NationalMedical Association, 94(10), 1-20.

Campinha-Bacote, J. (1992). Voodoo ill-ness. Perspectives in PsychiatricNursing, 28(1), 11-19.

Campinha-Bacote, J. (1998). The process ofcultural competence in the delivery ofh e a l t h c a re services: A culturally com -petent model of care ( 3 rd ed.).Cincinnati, OH: Tr a n s c u l t u r a lC.A.R.E. Associates.

Campinha-Bacote, J. (2002). Culturalcompetence in psychiatric nursing:Have you “ASKED” the right ques-tions? J o u rnal of the AmericanPsychiatric Nurses Association, 8( 6 ) ,1 8 3 - 1 8 7 .

Campinha-Bacote, J. (2005). A Biblicallybased model of cultural competencein the delivery of healthcare serv i c -e s. Cincinnati, OH: Tr a n s c u l t u r a lC.A.R.E. Associates.

Campinha-Bacote, J. (2007). The pro c e s sof cultural competence in the deliv -e ry of healthcare services: The jour -ney continues (4th ed.). Cincinnati,OH: Transcultural C.A.R.E. Asso-c i a t e s .

Campinha-Bacote, J. (2008). People ofAfrican-American heritage. In L.P u rnell & B. Paulanka (Eds.), t r a n -scultural health care: A culturallycompetent approach ( 3 rd ed.).Philadelphia: F.A. Davis.

C o k l e y, K., Cooke, B., & Nobles, W. (2005).Guidelines for providing culturallya p p ropriate services for people ofAfrican ancestry exposed to the trau -ma of Hurricane Katrina. Wa s h i n g t o n ,DC: The Association of Black Psy-chologists. Retrieved January 15, 2009,f rom http://www. a b p s i . o rg / s p e c i a l /h u rricane-info1.htm

DelBello, M., Soutuillo, C., & Strakowski,S. (2000). Racial diff e rences in thet reatment of adolescents with bipolard i s o rder (letter). American Journal ofP s y c h i a t ry, 157(5), 837-838.

Dirks, N., Huth, B., Yates C., & Melbohm,B. (2004). Pharmacokinetics ofi m m u n o s u p p ressants: A perspectiveon ethnic diff e rence. I n t e rn a t i o n a lJ o u rnal of Clinical Pharm a c o l o g yand Therapeutics, 42(12), 719-723.

The patient presents at a local urologic group as a refe r ral from a commu n i-ty clinic. The nurse rev i ews the chart prior to entering the examination room.T h enurse notes that the next patient is LaShawn, a 24-year-old Afri c a n - A m e ri c a nfemale with a chief complaint of low pelvic pain and bu rning during voiding for 2to 3 we e k s. The nurse sees that the chart has been flagged, noting thatL a S h awn is not employed, has no insura n c e, and lives in subsidized incomeh o u s i n g . The nurse sighs and rolls her eye s, and enters the room to collect theinitial assessment info rm a t i o n .

N u rs e : (enters the room, looking through the chart) “ W hy are you here”?

L a S h aw n : (sitting on the end of the examination table) “I told the other nu r s e,

w hy she didn’t tell yo u ? ”

N u rs e : (rolls eyes) “ Well, just tell me again.”

L a S h aw n : “It hurts to go to the bathroom.”

N u rs e : (sighs) “ H ow long have you had this probl e m ? ”

L a S h aw n : “About 2 we e k s. It got better because I drank baking soda like my

G randma told me. Then I took a bath in Epsom salts, and that helped too.”

N u rs e : “ Well, those things might have made things wo r s e, and you should have

come right away.”

L a S h aw n : “I don’t have insura n c e, and I was trying to fix my s e l f. I don’t know

h ow I will be able to pay the bill, lettin’ on getting the medicine for this.”

N u rs e : “ O K .” ( Tu rns and walks out of the room.)

The nurse gives a report to the physician as fo l l ow s : “This patient will not bec o m p l i a n t . She is using home remedies of drinking baking soda water and usingEpsom salts. She said she won’t get the prescription filled. She also is challeng-ing authori t y, so I am not sure how well she will listen to yo u .”

As you consider The Process of Cultural Competence in the Delive ry ofHealthcare Services model of culturally competent care and above case study,i d e n t i f y :

• Potential and actual barriers to commu n i c a t i o n .• Issues relative to cultural desire.• Issues relative to cultural awa r e n e s s.• Implications of cultural knowledge as it relates to self care.• The impact of cultural skill on the outcome of care.• The impact of cultural encounters on the outcome of care.

Figure 2.Case Study

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G l a z e r, W.M., Morg a n s t e rn, H., &Doucette, J.T. (1993). Predicting thel o n g - t e rm risk of tardive dyskinesiain outpatients maintained on neu-roleptic medications. J o u rnal ofClinical Psychiatry, 54(4), 133-139.

Johnson, K., Elbert - Avila, K., & Tu l s k y, J.(2005). The influence of spiritualbeliefs and practices on the tre a t-ment pre f e rences of AfricanAmericans: A review of the litera-t u re. J o u rnal of the AmericanGeriatrics Society, 53(4), 711-719.

Kaiser Family Foundation. (2001).African Americans view of theHIV/AIDS epidemic at 20 years.Menlo Park, CA: Author.

Kleinman, A. (1980). Patients and healersin the context of culture. Berkeley,CA: University of California Pre s s .

L a v i z z o - M o u re y, R. (1996). Cultural com-petence: Essential measurements ofquality for managed care org a n i z a-tions. Annals of Internal Medicine,1 2 4(10), 919-921.

Lawson, W. (1999). Ethnicity and tre a t -ment of bipolar disord e r. Pre s e n t e dat the 152nd Annual Meeting of theAmerican Psychiatric Association,May 19, 1999. Washington, D.C.

L e v y, R. (1993). Ethnic and racial diff e r-ences in response to medicines:P re s e rving individualized therapy inmanaged pharmaceutical pro-grammes. P h a rmaceutical Medicine,7, 139-165.

McNeil, J., Campinha-Bacote, J., Ta p s c o t t ,E., & Vample, G. (2002). B E S A F E :National minority AIDS educationand training center cultural compe -tency model. Washington, DC:H o w a rd University Medical School.

M o o re, J. (2005). Hypertension: Catchingthe silent killer. Nurse Practitioner,3 0(10), 16-18, 23-24, 26-27.

National Center for Health Statistics.(2002). Hyattsville, MD: United StatesD e p a rtment of Human Serv i c e sCenters for Disease Control andP revention National Center for HealthS t a t i s t i c s .

N a v a rro, V. (1997). Race or class versusrace and class: Mortality diff e re n-tials in the U.S. In P.R. Lee & C.L.Estes (Eds.), The nation’s health ( p p .32-36). Sudbury, MA: Jones &B a r l e t t .

P u rnell, L., & Paulanka, B. (2003).Transcultural health care: A cultur -ally competent approach (2nd ed.).Philadelphia: F.A. Davis.

Salcido, S. (2002). Finding a window intothe skin. Advances in Skin & Wo u n dC a re, 15(3), 100.

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involvement and health statusamong African-American males.J o u rnal of the National MedicalAssociation, 86(11), 825-831.