This summary of considerations from stakeholder interviews, and the case studies developed as a result, create some guidance for healthcare providers on factors to consider when approaching conversations and counseling for pregnancy loss among refugee and immigrant patients and families. The need for provider training to support culturally responsive care for immigrant and refugee patients experiencing pregnancy loss arose from conversations with providers in the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region who expressed a need for training and shared knowledge on this topic. We conducted a literature review and a qualitative exploration of provider experiences with refugee and immigrant patients who have experienced pregnancy loss. We shared the findings from the qualitative exploration with leaders and members of community based organizations serving various refugee and immigrant clients in the Seattle area and sought feedback and input. In this document, we provide a summary of our findings.
Introduction
Although overall rates of neonatal deaths and stillbirths have decreased in the United States (Chichester, 2005), medical care can still have a large impact on grieving families. There is growing recognition of the importance of educating health providers on how to appropriately approach families in sensitive times. While some guidelines on addressing pregnancy loss in the healthcare setting currently exist, they are often narrowly-defined, and there are currently no widely-utilized frameworks or best practices to guide pregnancy loss discussions with diverse patients. Furthermore, while it is helpful to recognize specific communities or groups that may share culture, language, and practices, it is important to note that not all people within a community have the same needs in the event of pregnancy loss.
Expectations of healthcare, pregnancy, and childbirth are strongly influenced by the patient’s country of origin (Benza & Liamputtong, 2014), yet these expectations intersect with the patient’s experience in the U.S. medical system with its own set of cultural values, procedures, and norms. Immigrant and refugee patients’ level of comfort in the U.S. medical system has its own implications for access to care, self-advocating, and feeling cared for. Health literacy, language barriers, and lack of available interpreters may further influence the cultural perception about what constitutes appropriate care (Kang, 2014).
These perceptions begin to emerge with prenatal care and extend throughout pregnancy, in addition to contributing to varying perceptions of pregnancy loss and grieving. Healthcare providers have the opportunity to play an important role in shaping the experiences of patients with pregnancy loss, especially in immigrant and refugee patients. However, many patients report feeling a lack of acknowledgement, compassion, and support from providers (Bellhouse, Temple-Smith, Watson & Bilardi, 2018). These feelings may be exacerbated by the provider’s inability to communicate well in the same language of the patient, or the intent may be lost in the interpretation, in addition to a mismatch or misunderstanding of the cultural aspects of pregnancy loss.
While some clinical guidelines for approaching patient care in the setting of pregnancy loss currently exist, these published guidelines do not provide specific guidance for considerations healthcare providers should make in their care of immigrant and refugee populations (American College of Obstetricians and Gynecologists, 2020; Catlin, 2018; Kingdon, Givens, O’Donnell, & Turner, 2015).
Frameworks such as the Interdisciplinary Guidelines for Women Presenting to the Emergency Department with Pregnancy Loss give general guidance for healthcare providers on exploring the meaning of pregnancy loss to individual patients and families, providing patient education on expected post-pregnancy course, and offering choices for dignified disposition of fetal remains and bereavement support (Catlin, 2018). However, this document does not include detailed information on considerations for how to apply cultural sensitivity and responsiveness to discussions and counseling for pregnancy loss in specific patient populations.
Cultural responsiveness relies on providers offering tailored, dialogue-based commitment to a contextual understanding of cultural, socioeconomic, political, and linguistic disparities in medicine; furthermore, it necessitates a dynamic and individualized approach to patient care (National Alliance of State and Territorial AIDS Directors, 2015). Utilizing only mainstream or Westernized best practices assumes that all families mourn in the same way and imposes a prescribed grief process rather than allowing families to guide health providers in meeting their individual needs (Chichester, 2005).
Summary of Findings: Interviews
Project Description & Methods
We conducted seventeen semi-structured interviews, including sixteen interviews with members from perinatal healthcare teams (i.e. physicians, registered nurses, certified nurse midwives, perinatal coordinators, and clinical social workers) and one interview with a community leader of a Seattle based organization serving refugee and immigrant women. All interviews were conducted either in-person or over the telephone by two project team members between November 2019 and August 2020. The interviews lasted between 30-45 minutes and were recorded with participant consent, de-identified and transcribed by one interviewer.
Participants were recruited by convenience sampling through the project team’s professional networks. Participants included adult healthcare providers and clinicians who work with pregnant refugee/immigrant clients in Washington, Idaho, and Alaska. Open-ended semi-structured interview questions focused on attitudes, beliefs, and experiences of participants in caring, or observing care, for refugee and immigrant mothers experiencing pregnancy loss.
Interview transcripts were reviewed by project team members in order to identify major themes. The project findings were reviewed with local community members as well. The study was deemed exempt by the Seattle University IRB.
Interview Themes
We identified five major themes from participant interviews. These themes included a desire for more training in how to respond to pregnancy loss with cultural sensitivity, limitations of the structure, policies, and practices of hospitals and clinics, language barriers and interpretation challenges, the impact of culture and religion on the perinatal loss experience, and appreciation for variation in the grieving process. Participants shared patient stories to highlight instances in which they, or the healthcare system, had been underprepared to offer culturally responsive care during pregnancy loss.
Desire for Further Training
Healthcare team members often said they learned what they know on the job rather than during formal healthcare or medical education. Participants stated they desired formal training on how to care for refugee and immigrant families during pregnancy loss, including sessions on trauma-informed care, cultural sensitivity, and the history of the refugee experience in their regions.
One physician shared that in a group prenatal class she learned her pregnant patients write a section of the Quran on a piece of paper and affix it to their bodies to recite during labor to help cope. The physician shared, “I have never made this recommendation and would never have known. There’s all these cultural practices that are so foreign to me, I would be a better provider if I knew about any of them.”
One physician shared that they have learned to manage cases of pregnancy loss in a style that includes factors beyond evidence-based algorithms specific to their clinical training: “you realize that you can’t be the normal type of robot doctor that you were trained to be, because the medical explanation is not particularly valuable…because their desire to have a family is not a quantifiable risk-based algorithm.”
Another physician shared they had not been trained in pregnancy loss counseling, but their ideal training scenario would include “…involvement from the folks from the community sharing experiences and having a big hand in how to do the talking, or how to do the counseling, and maybe even opportunities to practice feedback with different members of the community.”
One registered nurse suggested “I think a training itself needs to be more about giving patients choice and understanding how to respect those decisions as opposed to what you do in this situation because that’s where we get stuck is when we’re trying to come up with a protocol.” Another registered nurse suggested their practice setting could “add more of the cultural consideration and linguistic considerations into the routine prenatal bereavement training that all the labor and delivery nurses go through.”
Multiple participants expressed worry that they unintentionally cause more trauma due to a lack of comprehensive training in addressing and navigating individual patient and family needs.
Limitations of Hospital & Clinic Structure, Policies and Practices
Hospital and clinic structures, practices and policies created challenges for providers when caring for patients who were experiencing pregnancy loss. Participants discussed how typical provider schedules are not set up for providing comprehensive patient-centered care. As one physician described, “No practice is necessarily set up to have [intrauterine fetal demise] happen in the middle of their day but that’s why doctors run late is because you end up spending 45 minutes with that patient, what was booked as a 10 minute visit.”
When delivering a diagnosis is out of scope for certain members of the healthcare team, such as nurses and ultrasound technicians, patients may be left waiting a long time for a clinician to be available to deliver news. A nurse described “I feel like the worst experiences that I’ve been a part of are the ones where the patient has to sit there for an hour and a half waiting, and they know something’s not right. But yet, we can’t tell them anything. They’re just sitting there in a room by themselves while we’re trying to get a provider in there. And then some of the providers have five minutes, and so it’s very difficult in that sense.”
Short visit times during busy clinic schedules were cited as problematic, especially when interpretation is necessary. One physician shared how essential other support services such as social work and behavioral health are, “…because you get 15 minutes, so you need someone to give her the proper time because we are evaluating their bleeding, evaluating their pain, evaluating do they want to start a birth control method, all those things that you need to do medically. And to also expect to be able to listen to her whole story, you know, it’s really hard to do in 15 minutes.” While in-house comprehensive care is ideal, most participants had concerns about barriers to mental health services for their patients. Interpretation adds time to a visit, which further taxes tightly scheduled systems.
Language Barriers and Interpretation Challenges
Interpretation challenges were mentioned in every interview, including patient hesitancy to accept interpretation in small communities due to privacy concerns, not having access to an interpreter who spoke a less common dialect, and asking family members to interpret. A community leader shared, “…they brought an interpreter who doesn’t speak the same dialect as the Sudanese [patient] so the interpreter is there, the patient was there, not understanding, and even the interpreter [was] ‘like, really, I can’t understand what she’s saying.’”
Participants also mentioned the impact of transportation barriers and interpreter scheduling, “…if they take public transportation they are behind because of the bus schedule. They lose their appointment and because they showed up late, the interpreter is not there. Nobody informed them not to come because there’s no interpreter, and they wasted the day.” A perinatal coordinator described patient concerns about confidentiality that led to some patients declining the use of interpreters: “We have had quite a lot who declined an in-person interpreter, they don’t mind if it’s over the phone. But if it’s videoed or in-person then they do decline just because a lot of these families that we serve are small populations, and so they don’t want that information to go out there into the community.”
Impact of Culture and Religion on Perinatal Loss
The majority of participants shared experiences noting healthcare staff members showing a lack of understanding or misinterpretation of the impact of culture, religion, and individual attitudes and beliefs impacting health behaviors and experiences. The role of family members in healthcare decision-making was observed by several participants. Participants described scenarios on labor and delivery when a father of a baby or another community member was perceived to be “taking over” healthcare decisions for mothers during labor, delivery, and in the postpartum setting.
Some healthcare providers perceived that by assuming the decision-making authority in these situations, family members or community members were taking away the autonomy of the mother. One physician said, “Often the husband or somebody else is the one that’s receiving the medical information, they are the ones that are generally speaking and making the decisions. And we’ve had a lot of pushback, like ‘oh, they’re taking away the woman’s rights to make her own decisions.’ And the family is trying so hard to show their love by caring for her.”
The influence of religion on the perinatal loss experience and healthcare decision-making was another common interview theme. The participant who is a community leader shared a perspective on why autopsy may not be necessary for some families: “…determining the cause of death might not be a top priority. And this is part of their submission to the will of God.” Several healthcare team members shared that religion was a source of strength when discussing a pregnancy loss diagnosis, that many patients say, “it’s part of God’s plan, it was meant to be for me.”
In a situation shared by a physician where a patient’s pregnancy was diagnosed as incompatible with life, faith impacted the patient’s decision-making. The patient declined genetic testing and said, “God will provide, I’m just going to come back every week. I don’t know what’s going to happen, but I want this baby and this is my baby.” The patient returned every week until at 25 weeks gestation the baby no longer had a heartbeat. The physician gave the patient the infant’s medical information in a sealed envelope so that the patient could have it if needed for future care, but would not be forced to look at it.
A strong religious faith was overall described as protective to the patient in the case of pregnancy loss, yet participants recognized that individual experiences may vary regardless of religious beliefs or affiliations. One physician mentioned, “I think it’s incredibly important that we don’t pigeonhole people by religion, or by background, or where they immigrated from or how long they’ve been in the country, or whether or not they speak English.”
Appreciation for Variation in Grieving Process
Participants described the grief process being influenced by many factors, including cultural, religious, family-specific, and individual factors. Many participants reflected on times when they or their coworkers made assumptions or criticized a patient’s or family’s response or experience of pregnancy loss.
A clinical social worker described her response to her co-workers’ reactions, “I feel very protective then of trying to help people understand that grief can look different and that especially depending on religious background, and the trauma pieces that most refugees bring with them, there’s just so much that’s happening for people that they need care and support. They don’t need more judgment and finger wagging.”
One nurse reflected, “You know, when we’re used to a certain way of people reacting with loss and with death, for someone who seems to act so matter of fact about it, I think for a lot of people [that] can bring up a lot of judgment.” Regarding differences in outward emotion, one physician said, “I don’t see as many tears as I would expect and it’s hard. I always wonder is that really the way it is? Or is it just inappropriate to express themselves in that way in front of other people? Are they saving that for home?”
Several participants mentioned the assumption among health care providers that parents experiencing pregnancy loss or fetal death may want to take photos with and/or hold the body of the infant after birth. The participant who is a local community leader shared a case where, “After birth, they wrapped the baby and brought it back, and they asked the mother if she would like to have pictures with the child. [She said] ‘we don’t take pictures with dead bodies in our culture.’
Having the corpse of the baby in the room for hours. The feeling in the room is like, ‘this is a dead body, what is it doing here?’ The family didn’t know what to do or how to say no.” The same participant also mentioned that while pregnancy loss is often unexpected, when it is not an emergency, the healthcare team should have sufficient time to plan better support for the patient, no matter their country of origin.
Discussion
Though pregnancy loss happens all around the world, training for healthcare providers on how to provide culturally responsive support to patients and their families during loss is not widely integrated into medical training. The loss experience is influenced by many factors, including culture, religion, setting, and individual experiences. There is limited research available on the patient-centered outcomes, experiences, and preferences of how the healthcare system and providers approach caring for refugee and immigrant patients and families through pregnancy loss.
Substantial differences in healthcare systems between the U.S. and the countries of origin of immigrants and refugees make it even more essential to investigate pregnancy loss among diverse populations, all of whom experience this within the context of the U.S. system. None of the clinicians who we interviewed felt that their medical education prepared them to provide culturally responsive care to the immigrant and refugee patient populations they serve. Though research shows increased cultural humility improves provider-patient communication and satisfaction, Western medical training does not routinely focus on multicultural care provision (Kripalani, Bussey-Jones, Katz, & Genao, 2006).
The majority of project participants were interested in more professional training on the subject of pregnancy loss in immigrant and refugee populations. Under the model of cultural humility, the topic of care during pregnancy loss is not mastery-based, and accomplished by a single training or protocol, but rather an ongoing dynamic process of listening, learning, and responding (Chang, Simon, & Dong, 2012).
Certainly, trainings in culturally responsive care would be difficult as it would be challenging for providers to know everything about how culture, environment, family, religious, and even personal factors may influence the experience of pregnancy loss for a patient, regardless of their country of origin. Instead, starting from an approach of asking for preferences, checking one’s own assumptions or expectations, examining one’s own biases, and centering the patient and family’s needs may be the best place to begin.
Asking “How can I help you honor your family traditions at this time?” can be an effective starting place for communicating with families about their needs and beliefs (Chichester, 2005). Providers can tailor their interactions, counseling, interventions, and referrals based on their patient’s response (Bellhouse et al., 2018). Providers should remind themselves that there is no appropriate or standard way to grieve, and it is important to respect that patients may grieve in a way that is different from expectations (Koenig & Gates-Williams, 1995).
Beyond individual and interpersonal interactions, pregnancy loss is often experienced in the setting of institutions. Institutional practices should be examined with cultural responsiveness in mind, and although systems changes can be slow, individual practices can still be adjusted to maximize impact on patients. Practitioners should reflect on how hospital or clinic structures, policies, and procedures can be reconstructed to enhance a culturally responsive environment for pregnancy loss. Advocating for longer scheduled visits for may allow for flexibility and extra time to deliver pregnancy loss news to patients, and allow patients more time to have their questions answered.
Furthermore, advocating for expanded access to high-quality interpreter services within the institution, with both phone/video as well as in-person services available if possible, may improve the patient experience and ensure their understanding. Beyond these services that directly impact patients, providers can also advocate for pipeline programs that ensure future providers are representative of the patient and community population (Filler, Jameel, & Gagliardi, 2020).
Though there are many overlaps with how immigrants in general, and more specifically refugees, experience pregnancy loss in the setting of U.S. healthcare there may be some differences dependent on immigration history. In particular, refugees have unique experiences of persecution, both physical and emotional trauma, and forced relocation that may predispose them to psychological disturbances throughout the resettlement process (Murray, Davidson, & Schweitzer, 2010).
These experiences may be different than the general immigrant experience and certainly could manifest differently when experiencing a psychologically challenging event like pregnancy loss. Therefore, it is especially important to integrate a trauma-informed approach to providing culturally responsive care among refugees and other immigrants as well.
One participant explained the “Healing Encounters” framework their setting developed in order to promote better care, especially for the refugee population they serve. The assumption is that no encounter with healthcare can be neutral, and thus steps must be taken to ensure encounters are healing rather than triggering or traumatizing (Harrod & Lipscomb, 2010). In the Healing Encounters structure, in order for an encounter to be healing, it must be trauma-informed, linguistically appropriate, and culturally responsive. These elements make up the Healing Encounters Equitable Triad (Harrod & Lipscomb, 2010) that may be a good resource when caring for all patients, but especially refugee and immigrant patients who carry a trauma history into the experience of pregnancy loss.
The availability of culturally responsive maternal health services, such as supportive structures that address language barriers and cultural recognition and appreciation, contributes to positive health outcomes (Benza & Liamputtong, 2014). Interview participants shared stories of patients who returned to the same practice setting to have a subsequent pregnancy after a loss because they felt supported and listened to during the loss experience. As a starting point, providers may want to begin by determining the significance of pregnancy loss for family and patient, recognizing that the event could be experienced as a minor or major event (Catlin, 2018). Patients and their families have increased satisfaction in communication when the providers showed acknowledgement, compassion, and empathy (Chichester, 2005).
Language barriers, scheduling issues, concerns about confidentiality in small communities, and lack of available interpreters continue to be major factors that hinder immigrant and refugee women from getting appropriate care in obstetrical settings (Brooks et al., 2016). Despite patients’ legal right to language services regardless of citizenship status, our interview findings suggested that barriers to and challenges with interpretation continue to be commonplace. However, even with a medical interpreter, other cultural or individual considerations may influence how communication occurs around delivering the news of a loss to a patient and family.
Providers can have a pre-conference with the interpreter when sensitive topics are anticipated, thus allowing for pre-planning in the communication of information with a patient/family (EthnoMed, 2016). Furthermore, teams can consider offering religious or spiritual support to patients, however that may be received by patients themselves.
When speaking about remains practices, participants frequently brought up healthcare providers’ frustration and discomfort with patients’ preferences, cultural practices, and decisions. Participants described staff putting pressure on patients to make certain choices during an experience of fetal death and pressure to make certain choices during pregnancy loss. While patients may wish to have bereavement care in the form of religious blessing, taking photos, skin-to-skin holding for babies of larger sizes, dressing or washing the baby, or memory boxes, these types of mementos are more often desired by American Christians and may not be desired by those of other religious or cultural backgrounds (Chichester, 2005; Catlin, 2018).
In Muslim communities, mementos can be considered desecration in Islam and cause distress to the family (Arshad, Horsfall, & Yasin, 2004). In Islam and Orthodox Judaism, both autopsy and cremation are forbidden. According to Muslim traditions, burials should take place within 24 hours of death (Chichester, 2005). In order to ensure optimal care, providers should always ask what the family prefers before obtaining mementos (Arshad et al., 2004). While it is helpful to recognize specific communities or groups that may share culture, language, and religious beliefs, it is important to be aware that not all people within a community have the same needs or beliefs and that individual needs may vary within groups and communities.
Health care providers should focus on working with women and families to determine their preferred coping methods (Van, 2012). Emphasis should be placed on ensuring family and community support, assessing for PTSD, and follow up care. Where appropriate and desired by the patient, partners and families should be encouraged to be present to provide support to cope with the loss (Van, 2012). Healthcare providers should offer additional follow-up and support following a miscarriage: there are improved outcomes with referrals to mental health services and support groups (Bellhouse et al., 2018).
Furthermore, for those who have experienced pregnancy loss, PTSD assessments are recommended to ensure at-risk patients receive proper support and counseling (Van, 2012). When applicable, follow up with the patient’s primary care provider and/or pregnancy provider can helpful to check in on emotional wellbeing, not just physical wellbeing (Bellhouse et al., 2018).
The participants in this study, who were mostly comprised of healthcare team members, shared their lack of lived experience as a barrier to understanding all of the internal and external factors influencing refugee and immigrant patients’ and families’ experiences with pregnancy loss. However, they all expressed a desire for more training on how to approach counseling and care for refugee and immigrant families experiencing pregnancy loss in order to better serve their patients and communities. Though the community leader we interviewed shared immigrant and refugee stories, a limitation of our findings is the fact that it does not reflect the individual voices and experiences of refugee and immigrant individuals and families who have experienced pregnancy loss.
In addition, we understand that the themes from our interviews and quotes from participants do not apply to all immigrant and refugee communities. Future directions for this work should include interviews with individuals from immigrant and refugee backgrounds who have experienced pregnancy loss, or been affected by pregnancy loss, after arriving in the United States.
There is a gap in knowledge and need for further research on best practices for healthcare teams providing care during pregnancy loss experienced by refugee and immigrant families in the U.S. The deficit in knowledge has the potential to cause additional trauma to patients in an already vulnerable situation. Individual healthcare providers should reflect on their own personal assumptions and expectations about how bereavement be experienced by individuals.
Healthcare providers also need to recognize that institutional and organizational policies and structures, including interpretation barriers, clinic scheduling, lack of culturally responsive educational materials, and traditional/Westernized information on delivery practices may cause distress, or trauma, to patients during the time of pregnancy loss. The experience of pregnancy loss is influenced by religious, cultural and individual factors, and the needs of each person and family will be unique. All families, no matter their country of origin, deserve culturally responsive care. In order to achieve cultural safety and provide more culturally responsive and equitable care, healthcare providers, organizations, and institutions need to critically reflect on the impact of power imbalance on patients and their families as they move through the healthcare system (Curtis et al., 2019).
Further Reading and Other Resources
Guidelines for Interpreted Visits Basic steps and practices for interpreted visits including how to conduct a pre-visit conference with the interpreter.
Culturally and Linguistically Appropriate Services (CLAS) in Maternal Health Care This free, 2-hour e-learning program from the U.S. Department of Health and Human Services (HHS) is designed for providers and students seeking knowledge and skills related to cultural competency, cultural humility, person-centered care, and combating implicit bias across the continuum of maternal health care. This program is approved for continuing education credits for Nurse-Midwives (ACNM), Nurses, Physicians and Physician Assistants.
Practicing Cultural Humility when Serving Immigrant and Refugee Communities Article by nurse Lea Ann Miyagawa highlighting the concept of cultural humility developed by Drs. Melanie Tervalon and Jann Murray-Garcia to more deeply look at the care and service provided to diverse populations, honoring the patient’s lived experience. The concept has three tenets: Lifelong learning and self-reflection, Mitigating power imbalances, Institutional accountability.
Concept of Trauma and Guidance for a Trauma-Informed Approach Prepared by U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration’s (SAMHSA) Trauma and Justice Strategic Initiative.
Best Practices for Promoting Wellness and Supporting Refugee Populations Toolkit prepared by the International Rescue Committee (IRC) U.S. Programs was designed to support efforts to help refugees orient, adjust, and thrive in their new communities, with a mixture of best practice descriptions, guidelines, samples, presentations, training activities, worksheets, etc. Included is discussion of the Triple Trauma Paradigm, developed in the early 1990s and widely used to describe the unique stressors refugees and immigrants fleeing violence or persecution face during their three phased journey to safety.
Cultural Assessment Models with Sample Scripts Phyllis R. Coolen, DNP, MN, RN, provides examples of a number of cultural assessment models, with questions, sample scripts and strategies for the health care provider that may be useful in eliciting information related to culture, including Kleinman and Campbell’s Patient Explanatory Assessment Model, Geiger-Davidhizar’s Cultural Assessment Model and Kagawa-Singer & Blackhall’s ABCD Cultural Assessment Model.
Project Implicit is a non-profit organization and international collaboration between researchers who are interested in implicit social cognition – thoughts and feelings outside of conscious awareness and control. The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report.
Acknowledgements
Funding for this project was provided by the King County Academy of Family Physicians (KCAFP) Mission Grant. Beth Farmer, LICSW (International Rescue Committee) identified the need for training and information on this subject.
Risho Sapano, MA (Mother Africa), Elizabeth Rutten-Turner, LCSW (St. Alphonsus Medical Center, Boisie, Idaho) and Traci Harrod (St. Alphonsus Medical Center, Boisie, Idaho) provided advising in further understanding patient, client and provider needs around this topic to scope the project, participated in interviews and reviewed materials.
Jasmine Matheson, MPH and Laura Newman, PhD of the Washington State Department of Health provided support in grant writing and project scoping.
Fardous Guled, RN, BSN, PHN (Somali Health Board Nurse Consultant); Hani Mohamed, MHI and Ladan Hassan, of the Somali Health Board’s Centering Motherhood Program advised on project scoping and reviewed drafts of project materials. Zainab Al-Tameeni, MD, MPH (Iraqi/Arab Health Board) reviewed project materials.
Lea Ann Miyagawa, MN, RN (Harborview Medical Center Community House Calls Program) provided clinical input and reviewed drafts of project materials. Robin Narruhn, PhD, MN, RN (Seattle University), Elizabeth Gabzdyl, CNM, DNP, ARNP (Seattle University) and Kelly McBroom, CNM, ARNP, PhD (Seattle University) provided academic and cultural advising.
Many thanks to the health care providers who contributed their time to participate in interviews.
This project is a collaboration between the EthnoMed Program, based in the Interpreter Services Department of Harborview Medical Center, University of Washington Department of Family Medicine, and Seattle University’s Doctor of Nursing Practice Program.
General Caveat
It is important to remember that simply because a person is identified as a member of a particular ethnic group or religion does not necessarily mean that the person or the person’s family has the set of beliefs that may be associated with the ethnicity or religion. An assessment should be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed. Be aware of some of the overall cultural values of the community and then explore the pertinent themes as they relate to providing health care for individual patients. Remember there is great diversity within community. Experiences will vary greatly depending, for example, on whether people lived in rural or urban communities in their countries of origin, how long they have been in the United States, immigration process, former occupations and levels of education. Remember that patients are individuals and are not defined by their cultural group.
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