Culturally Appropriate Heart Strategies to Target Cardiovascular Risk Ethno-Cultural Communities
The most recent Heart and Stroke Foundation report warns that “a perfect storm of risk factors and demographic changes are converging to create an unprecedented burden on Canada's fragmented system of cardiovascular care.”1 Indeed, statistics show a significant and troubling rise in the number of Canadians affected by cardiovascular complications such as high blood pressure and diabetes. In an effort to combat these higher incidences of cardiovascular crisis, the Heart and Stroke Foundation is urging both the Canadian and provincial governments to begin funding and implementing coordinated national heart health strategies, which have been developed by cardiovascular researchers.
A key part of this proposal is the recommendation that specific attention be paid to improving the health status of Aboriginal peoples and at risk and ‘disadvantaged’ groups, which include various ethno-cultural communities.1 Accordingly, the Heart and Stroke Foundation is calling upon provincial and federal governments to develop plans with specific strategies to help at risk populations better understand and manage their cardiovascular conditions. Given the diversity of at risk populations, any initiated government schemes should be congruent with the values of the targeted groups and anchored by culturally sensitive understandings of health.
One effective strategy for meeting this goal would be to develop innovative and culturally appropriate heart health educational programmes. In this context, cultural appropriateness refers to taking a target group’s cultural values, beliefs and behaviours into account when designing and delivering health promotion interventions, services and/or information.2 Programmes which are culturally appropriate could help to significantly reduce the high morbidity rates of cardiovascular complications currently affecting at risk groups.
A culturally inclusive approach to heart health should also bear in mind that cultural, ethnic, linguistic, and socio-economic differences significantly impact how individuals, especially those from minority groups, access and use health, education, and social services. When these cultural complexities are not taken into account, they can result in barriers to effective health care provision. For instance, this may happen when clinicians, knowingly or unknowingly, stereotype, misinterpret, make faulty assumptions or otherwise mishandle their encounters with minority individuals or groups who they view as different. On a more systemic level, mainstream health programmes and services are often structured on traditionally Eurocentric norms, attitudes, values and beliefs despite the fact they are being offered to diverse and ethnic populations.
An influx of immigrants and growing diversity in the population of the United States (US) has led to serious attention being paid to issues of culture and health in that country. In particular, efforts have been made to introduce culturally appropriate approaches to health as a means of reducing ethnic and social class health care disparities. As part of these efforts, US government health agencies, in partnership with other public health organisations, have begun funding culturally specific cardiovascular educational programmes that targets minority populations, especially African Americans with cardiovascular diseases. Initial research into these programmes suggests that the culturally specific nature of them does, indeed, seem to make them more effective.3 A number of American studies that looked at culturally sensitive cardiovascular educational programmes (designed specifically for African Americans) reported positive outcomes like increased knowledge about hypertension and how to manage it and a reduction in blood pressure among the participants.3,4 Clearly American health policy makers, educators, and clinicians recognise the importance and efficacy of establishing culturally sensitive health care programmes to promote positive lifestyle changes among African American and other minority groups.
A more in-depth assessment of culturally appropriate health care delivery is offered by Resnicow, Jackson, Braithwaite, Dilorio, Blisset, Rahotep and Periasamy.5 They note that two levels of culturally structured health programmes exist. The first level, which they call surface structure, focuses on incorporating cultural images, language, music and food from the target group into the resources and materials that are made available.2,5 In this way, surface structure is limited to matching health promotion resources and messages to the social and cultural cues of the population in question. The second possible level of multidimensional models of cultural sensitivity is deep structure, which concerns itself with reflecting “how cultural, social, psychological, environmental and historical factors influence health behaviours differently across racial/ethnic populations”.5 Thus, a deep structure approach takes a more complex look at culture and health, aiming to understand how members of a target population perceive the causes, course and treatment of their illnesses.2 A culturally sensitive health promotion scheme with deep structure would take the values and beliefs of the target population and integrate these into the curriculum design of the programme. Inclusion of deep structure dimensions into culturally sensitive health programmes/services (as opposed to using only surface structure) increases interest, making these programmes more attractive and meaningful for the target group to take part in.5
Another positive strategy when creating culturally sensitive health programming is to actively include members from the target community in the planning, development, implementation and evaluation of the programme. In health programmes intended for African Americans, for instance, volunteer workers, or peer health educators from the Black community can be trained to deliver health education modules, or to lead exercise classes.5 This kind of active and meaningful participation of members from the target population improves the cultural relevancy and general efficacy of the resulting programme. Health promotion researchers Kreuter, Lukwago, Bucholtz, Clark and Sanders-Thompson echo this point, using their work to emphasise the importance of including community members who are indigenous to the culture, in the overall programme curriculum. They go on to note that by working collaboratively with a community member, a health practitioner is likely to gain insight into the given groups’ values, norms and beliefs, information which would not otherwise have been visible to them as an outsider.2 Without a doubt, inviting and integrating community participation and knowledge when planning culturally targeted heart health programmes is likely to yield encouraging results such as higher participation rates, adherence to instruction, satisfaction and positive health results.
The pervasive rates of cardiovascular crisis among Aboriginal peoples and at risk groups, such as African Canadians, are a serious problem that requires immediate attention. While improvements in the economic and social conditions and physical environments of these groups would improve their health outcomes in the long-term, in the short term, culturally specific health programming could go a long way to reducing their risk of cardiovascular crisis. Taking a different, unique and culturally relevant approach to reaching African Canadians and Aboriginal peoples may provide the key to decreasing their prevalence for cardiovascular conditions. If the soon to be introduced government schemes to deal with heart health want to have maximum impact with these groups, they must to be designed with cultural relevancy in mind. As the changing face of Canada emerges, more careful, appropriate and sound approaches to health are needed. A failure to acknowledge the importance of cultural relevancy in health programmes aimed at diverse populations with cardiovascular conditions may have significant consequences as the health status of these groups are at risk of further decline.
References
A Perfect Storm of Heart Disease Looming on our Horizon: The Heart and Stroke Foundation’s 2010 Annual Report on Canadians’ Health. Available at http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5761931/k.8118/2010_R....
Kreuter, M.W., Lukwago, S.N., Bucholtz, D.C., Clark, E.M., & Sanders-Thompson, V. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ & Behav. 2003 Apr; 30(2):147-50.
Levine, D.M., Bone, L.R., Hill, M.N., Stallings, R., Gelber, A.C., Barker, A., Harris, E.C., Zeger, S.L., Felix-Aaron, K.L., & Clark, J.M. (2003, Summer). The effectiveness of a community/academic health center partnership in decreasing the level of blood pressure in an urban African-American population. Ethn Dis. 2003 Summer; 13(3): 354-61.
Williams, J.H., Auslander, W.F., De Groot, M., Robinson, A.D., Houston, C., & Haire-Joshu, D. Cultural relevancy of a diabetes prevention nutrition program for African American women. Health Promot Pract. 2006 Jan; 7(1):56-67.
Resnicow, K., Jackson, A., Braithwaite, R., Dilorio, C., Blisset, D., Rahotep, S., & Periasamy, S. Healthy Body/Healthy Spirit: a church-based nutrition and physical activity intervention. Health Educ Res. 2002 Oct; 17(5):562-73.