MEXICAN AMERICAN PARENTS’ PERCEPTIONS 33 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 MEXICAN AMERICAN PARENT’S PERCEPTIONS OF CULTURALLY CONGRUENT INTERPERSONAL PROCESSES OF CARE DURING CHILDHOOD IMMUNIZATION EPISODES- A PILOT STUDY Teresa Keller RN, PhD 1 1 Assistant Professor, School of Nursing, New Mexico State University, tkeller@nmsu.edu Key words: Mexican-Americans, Nurse-Patient Relationships, Qualitative Research, Health Disparities ABSTRACT One of the goals of Health People 2010 is to eliminate health disparities among minority populations by 2010, including improved childhood immunization rates among Mexican-American children. Prior research has identified the importance of interpersonal process-related factors as significant components of care sought by Mexican-Americans, but more knowledge is needed about what Mexican-American parents view as a beneficial relationship with the nurse during the immunization encounter. The purpose of this qualitative, descriptive pilot study was to explore and describe the perceptions of Mexican- American parents‟ regarding their relationships with clinic nurses in a rural, primarily agricultural community. Thematic analysis of data describes a beneficial relationship between Mexican American women, their children, and nurses during immunization encounters as consisting of 1) trust in the nurse, 2) building confidence in the mother and child, and 3) language concordance. INTRODUCTION One of the goals of Health People 2010 is to eliminate health disparities among minority populations by 2010, including achieving a national immunization rate for children of 90% (Centers for Disease Control [CDC], 2006a). For Hispanic minority populations, including Mexican Americans, one of the barriers that leads to health disparities is a lack of access to preventive care (CDC, 2006b) This challenges all nurses working with minority populations to examine their practice for ways to improve the use of this important preventive service by Mexican Americans. Prior research has identified the importance of interpersonal process- related factors as significant components of care sought by Mexican Americans (Fongwa, Stewart, & Pérez-Stable, 2002; Warda, 2000; Zoucha, 1998). Furthermore, interpersonal factors, including interactions with health care providers, are identified as explaining and predicting health behaviors in Pender et al‟s (2002) health promotion model for nursing practice. Since nurses are often involved in the delivery of immunization services to Mexican Americans, more knowledge is needed about the nurse-client relationship as a part of the interpersonal process of care experienced by Mexican American families seeking childhood immunizations. The purpose of this qualitative, descriptive pilot study was to explore the nature of a meaningful and beneficial relationship between the clinic nurse and Mexican-American parents and their children. Specifically, this research examines the nurse‟s role in the interpersonal process of care while providing immunization services to Mexican Americans at a community health services center in a low-income, rural section of southern New Mexico. The research aims were to: http://www.nmsu.edu/~nursing/ tkeller@nmsu.edu 34 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 1. Describe how Mexican American parents perceive their relationship with nurses as they seek immunization services for their children. 2. Understand what these Mexican American parents perceive as a helpful relationship with nurses. 3. Contribute to the theoretical understanding of culturally congruent nursing care for Mexican Americans. RELEVANT LITERATURE The U.S Hispanic population grew by 57.9% between 1990 and 2000. The Mexican American subset accounts 58% of the estimated 35.5 million Hispanics currently residing in the United States (U.S. Census Bureau, 2001). The group‟s historical, cultural, and demographic characteristics present unique challenges for health care professionals working with this population in rural and urban settings. Significant health disparities exist for Hispanics, including Mexican Americans, in categories such as cancer, cardiovascular disease, Type II diabetes, when compared to non-Hispanic Whites (CDC, 2006b). Health care disparities for Hispanics are also a reflection of their use of primary preventive services, especially childhood immunizations. The rate of childhood immunizations in Mexico is 95% compared to the U.S childhood immunization rate of 82% (Paso Del Norte Health Foundation [PDNHF], 2004). The childhood immunization rate for Hispanic children living in the United States is 79% (Federal Interagency Forum on Child and Family Statistics, 2005) For Hispanic children living in the U.S. border region of El Paso and Dona Ana County, New Mexico, the rate of childhood immunizations is 77% and 79% respectively (PDNHF, 2004). While the gap in immunization rates between Hispanic children and white, non-Hispanic children living in the United States is closing, it is still a significant drop from the much higher childhood immunization rates in Mexico. Research has identified multiple barriers imposed by the health care system to utilization of services by Mexican-Americans and other Hispanics, including financial constraints (Zambrana, All, Dorrington, Wachsman, & Hodge, 1994), discrimination (Cornelius & Altman, 1995; Zambrana et al., 1994), lack of availability of non-emergency room and primary care services (Shaffer, 2002), long waiting periods and lack of transportation (Byrd, Mullen, Selwyn, & Lorimor, 1996). Timmins‟ (2002) analysis of research literature concluded that while language is probably a significant barrier to access for Latino populations, it is not the most significant barrier for this population group. Cultural congruence between health care professionals (including nurses) and Hispanics is assumed to be a significant factor in the population‟s utilization of health care services. Although some variation exists in the terms and definitions used to describe culturally congruent care (e.g., culturally competent or culturally sensitive care), all share the attributes and spirit of Leininger‟s definition (1991). According to this cultural theorist, culturally congruent care: Refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor made to fit with the individual and group cultural values, beliefs, and lifeways in order to provide or support meaningful, beneficial, and satisfying health care, or well being services (p. 49) 35 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 The relationship between patient and nurse has been articulated as nursing‟s essence (Benner & Wrubel, 1989; Gadow, 1980; Newman 1999; Paterson & Zderad, 1976/1988; Travelbee, 1966). Although the importance of culturally congruent care is not an issue of debate for the nursing profession, the most fundamental component of this care- the nurse/ client relationship- has not been empirically explored as it applies to Mexican American parents and their children. The assumption that underlies the purpose is that culturally congruent care cannot occur without some knowledge of what Mexican American clients are seeking in their relationships with nurses. Shaffer (2002) explored factors influencing access to prenatal care among pregnant Hispanic women and found health care providers‟ cultural knowledge of customs, expectations, and norms was an important influence on the women‟s decisions to access care. However, another study revealed an equivocal response by Mexican-American, high-functioning, chronically mentally ill clients to having a health professional from their own culture care for them in a clinic setting: 39% thought it was better, 38% thought it was not better, and 23% stated, “It really doesn‟t matter” (Lantican, 1998, p. 132). Flaskerud‟s (1986) study of culturally congruent components such as language match and ethnic or racial match between provider and client in a mental health setting did not demonstrate a significant relationship between these barriers; some other factor or factors must exist for such care to occur. Several studies point to the patient/client-health care professional relationship or something within the relationship as a potentially essential component to culturally congruent care. Warda‟s (2000) qualitative inquiry into Mexican-American perspectives identified their preferences for culturally congruent nursing care. Warda describes culturally congruent care as including 1) Valuing- seeking to incorporate the client‟s knowledge, beliefs and values into the plan of care, 2) Cultural Comprehension- acknowledging and integrating the individual‟s cultural context into the plan of care, 3) System Supports such as harmonious verbal and nonverbal communication, including language concordance, and 4) personalismo, an identified subset of provider behaviors that include showing respect, building confidence, taking time, and displaying generosity, caring and kindness to clients. An ethnographic nursing study of the experience and cultural values of Mexican Americans receiving nursing care identified the importance of nurse behaviors that build the client‟s confidence in the relationship (Zoucha, 1998). According to Zoucha, this confidence is essential for the client to experience a satisfactory episode of care. The nurse earns the client‟s confidence through the display of behaviors such as showing respect, paying attention, taking time and attempting to communicate in Spanish during the care encounter. Another study of the health seeking process of Mexican American migrant farm workers found efficacy of treatment directly related to the rapport established with the nurses. (Stasiak, 1991). Although Smith‟s (1994) study focused on white nurse practitioners working with African American families on health promotion, it is notable that nurses‟ knowledge or lack of knowledge about differences in cultural health beliefs and practices was in the background, whereas the nurse-client relationship was central to their care. No research was identified that specifically addresses the interpersonal processes of care that might affect the use of immunization services among Mexican Americans. However, one study identified that relationships developed between nurse practitioners and families exerted a strong positive influence for the use of immunization services in a rural primary care setting serving a predominantly white population (Wilson, 2000). 36 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 METHODS A qualitative research design was selected because of the lack of research specifically addressing Mexican American viewpoints about the interpersonal process of care that occurs during immunization episodes. A semi-structured interview format was selected and open-ended interview questions developed based on the research purpose. These questions asked the participants to describe their encounters with nurses while seeking immunizations for their children and what they thought were positive or helpful behaviors by the nurse during these encounters. The participants were also asked to describe negative or unhelpful behaviors displayed by nurses. The interviews took place in a community health center in a rural, agricultural town in southern New Mexico. All participants were regular clientele of this health center and were identified for participation by the center‟s social worker. Participants were eligible if they were Mexican Americans with children of immunization age. Twelve participants were interviewed for this pilot study. All participants were women between the ages of 17 and 35 with children between the ages of six months and 11 years. Socioeconomic status and education of the participants was varied. Six of the women were immigrants from Mexico with less than five years of residency in the United States, five were first generation Mexican Americans who had graduated from a U.S. high school in the region, and one participant was a 4 th generation Mexican-American with a college education obtained in the United States. All participants were informed of their rights as research subjects and were provided with consent documents in their preferred language. After obtaining informed consent, the interviews were conducted in Spanish or English, according to the research participant‟s preference. A certified Spanish language interpreter was used to simultaneously interpret for interviews conducted in Spanish. Interviews were recorded and then transcribed by a bilingual transcriptionist prior to analysis. All participants received a monetary incentive for the time they spent participating in this study. Interview transcripts were analyzed for emergent themes, using a grounded theory approach. Three common themes that emerged were trust, confidence, and language concordance. Data was then organized according to these themes and cross-checked with the supporting literature. FINDINGS Data saturation was achieved very quickly in these interviews and the themes identified support the findings of Warda (2000) and Zoucha (1998). These themes describe a beneficial interpersonal process of care between Mexican American women, their children and nurses during immunization encounters as consisting of 1) trust in the nurse, 2) building confidence in the mother and child, and 3) language concordance. Trust Every participant described the need for the nurse to be trustworthy. Further, the nurse must not only be trusted by the mother but also by the child. Nurses gained the trust of mothers and children best by adopting behaviors that helped put the mother and child at ease during the immunization encounter. Displaying a friendly, sociable attitude was identified as essential to 37 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 decrease the anxieties surrounding immunizations for both parent and child. As one participant explained: To earn a child‟s trust, they need to be friendly with them, talk to them-so they can have trust. That‟s one thing about my children, if they don‟t know someone, they won‟t go near them and they won‟t talk to them. From all the interviews it is evident that these mothers placed great value on nurses who were able to engage their children and establish a trusting relationship. Participants deplored the practice of entering a room and beginning the immunization procedure without an attempt to establish rapport with both the mother and child through friendly, social interaction. Closely related to this was the need to appear unhurried and attentive to the mother and child during the visit. The nurse should not appear “rushed”, “mad‟, or “frustrated”. Participants described positive experiences as those in which the nurse took the time to explain the procedure to the mother, inquire about questions she might have and engage the child in a way that lessens their fear and /or anxiety. For older children, the nurse should explain the reason for the vaccination, acknowledge their fear, and describe the benefits: …if they aren‟t patient he sees them, he can tell and he‟s afraid. And others talk to him and tell him „look this medicine is going to help you so that your bones will be strong so you can run and you can help your mom and it will hurt for just a little bit but then the pain will go away. For infants and younger children, trust and rapport is best established by gentle handling and friendly, soothing verbal communication by the nurse. Asking the mother to help restrain a young child during the procedure provoked some anxiety in the sense that the mothers felt they would be perceived by their children as contributing to the pain of the procedure. Being asked to hold young children in their laps for examinations and vaccinations were more acceptable practices for these participants. The participants all described being able to hold and hug their young children after the procedure as a routine expectation. Friendliness and an unhurried attitude were not the only methods for establishing trust among children. Several participants mentioned that the common pediatric strategy of rewarding children with candy, stickers or verbal praise was a helpful comfort measure that served to increase the child‟s willingness to receive immunizations. These small rewards were appreciated as comfort measures that reflected kindness and caring by nurses. When questioned about their responses to situations in which the nurse appeared unfriendly, hurried or inattentive, the participants all described reluctance on their own part to ask questions. In addition, a nurse who projects this kind of attitude also increases a child‟s anxiety about receiving the vaccination. Participants felt that nurses who took the time to talk and attend to the concerns of both mother and child were more trustworthy: Building Confidence Trust is the foundation for building the client‟s confidence in the care provided by the nurse. For these mothers, confidence in the care provided increased their comfort with the services they received and contributed to a satisfactory episode of care. The participants 38 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 described the role of confidence in the interpersonal process of care along two dimensions. First, the mother needs to have confidence in the nurse‟s professional competence. These participants described actions taken by the nurse that communicate professional competence such as wearing gloves, cleaning the injection site with alcohol, and the skillful administration of vaccines. They specifically mentioned practice inefficiencies, such as not having all required supplies assembled before beginning the procedure, as a sign to them that the nurse was inexperienced or inattentive. Practice inefficiencies result in a loss of confidence in the nurse and less satisfaction with the care received. Related to the issue of professional competence is the nurse‟s communication competence. Conducting the encounter in the mother‟s preferred language will be discussed later, but other aspects of communication were also identified by these participants as important to promoting confidence in nurses and other staff as well. During the encounter, nurses should again adopt an unhurried attitude and provide accurate information conveyed in a friendly manner. Participants also reported greater confidence with nurses and other clinic staff if they could easily call and get answers for their questions about appointments, medicines or after-care. The participants reported discomfort with having their personal health information discussed in places where other people might overhear, such as the waiting room or in hallways. The same holds true when the client hears nurses and staff discussing other clients in public places. These breaches of confidentiality are interpreted as a lack of respect and result in a loss of confidence in the nurse. The second dimension of confidence is related to how the nurse contributes to the mother‟s confidence in her own ability to adequately care for her child after the procedure. Participants valued nurses who took the time to carefully explain the vaccines, their benefits and potential side effects. Ensuring that the mother received adequate information, either through verbal instructions or printed education materials and in an unhurried manner is an essential aspect of satisfactory care, as one participant explained: …if I don‟t feel confident or I am nervous of the vaccine (sic) the children are going to be nervous as well. If I am comfortable, the children are going to be more relaxed. Language Concordance For these mothers, the importance of being able to make informed choices for their children and to adequately care for them after immunization was of paramount importance. Every participant expressed the view that the immunization encounter should be conducted in the language with which the mother was most comfortable. The reason for this view is that the mothers wanted and needed to know why the vaccinations were important, what is appropriate after-care, and what adverse outcomes were possible. It was also important that printed educational materials or consent forms are in the preferred language of the mother. The six participants who were recent immigrants from Mexico wanted their nurses and providers to speak Spanish during encounters, while the participants who attended school in the United States were comfortable with either English or Spanish. The participants also described the race and ethnicity of the provider or nurse as unimportant as long as there was language concordance. These participants felt that it was more important to speak in the mother‟s 39 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 preferred language rather than the child, perhaps as a reflection of the mother‟s primary care- giving responsibilities. DISCUSSION The findings in this pilot study support the prior work of Warda (2002) and Zoucha (1998). The components of a culturally congruent interpersonal care process as perceived by the Mexican-American participants in this study are consistent with Warda‟s descriptions of care delivered with respect for the client‟s cultural background (including their language preferences), the behaviors associated with personalismo, and system supports such as harmonious verbal and non-verbal communication. These participants described a beneficial relationship as one in which the nurse was “formally friendly” (Warda, 2002), is attentive to the needs of both mother and child, is able to take time to answer questions and comfort the child, and demonstrates competence in professional skill and communication. Nurses who demonstrate these behaviors within the interpersonal process of care are more likely to be viewed as trustworthy and obtain the confidence of their Mexican-American clients. According to Zoucha (1998) confidence in their health care providers is essential before Mexican-Americans will adopt the health promotion behaviors that will enhance their use of primary preventive services such as routine childhood immunizations. This pilot study sought to examine the perceptions of Mexican-American parents regarding culturally acceptable interactions with nurses during clinic visits for childhood immunizations. As with any research, there are limitations in this study. First, all the participants were regular clientele of the community health center and their childrens‟ vaccination status was current. From the interviews, it was evident that participants were mostly satisfied with the care provided by the nurses at this particular center. However, this rural health center was also the only provider of preventive services in this community, so participants had little choice in where they obtained preventive care- especially the recent immigrants with questionable legal status within the United States. Future research should be conducted among parents who have no regular source of preventive services. A confounding factor for this study is a state requirement for immunization of children prior to beginning public school. This provides an added inducement for parents to access the health care system regardless of their view of the personal and professional attributes of the clinic nurse. Future research could be developed that involved participants requiring preventive services with no exclusionary government mandate, such as immunizations for influenza among adults. This research has benefited from the prior work of others and, in turn, confirms their findings. The need for a personal, relaxed and unhurried approach by the nurse during the immunization encounter is confirmed by the Mexican-American participants in this study. The qualitative data obtained in this study furthers the current theoretical understanding of culturally congruent care practices that help to establish trust, build confidence and enhance the use of preventive services for Mexican-Americans in the U.S. health care system. REFERENCES Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Menlo Park, CA: Addison-Wesley. 40 Online Journal of Rural Nursing and Health Care, vol. 8, no. 2, Fall 2008 Bureau of the Census. (2001). Census 2000: Hispanic or Latino by race-universe: Total population. Retrieved March 3, 2003 from http://factfinder.census.gov/servlet/DTTable?_ts=25902237020 Byrd, T., Mullen, P., Selwyn, B., & Lorimer, R. (1996). Initiation of prenatal care by low- income Hispanic women in Houston. 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