Intercultural Competence and Patient-Centered Care _ _____________________________________________
describes disability in terms of functional limitations, 12.6% of the civilian U.S. noninstitutionalized population has a disability, defined as difficulty in hearing or vision, cognitive function, ambulation, self-care, or independent living [104]. The U.S. Department of Education, which uses categorical disability labels, estimates that 13% of children and youth 3 to 21 years of age have a disability (defined as specific learning dis- abilities, speech or language impairments, intellectual disabil- ity, emotional disturbance, hearing impairments, orthopedic impairments, other health impairments, visual impairments, multiple disabilities, deaf-blindness, autism, traumatic brain injury, or developmental delay) [104]. People with disabilities experience many health disparities. Some documented disparities include poorer self-rated health; higher rates of obesity, smoking, and inactivity; fewer cancer screenings (particularly mammography and Pap tests); fewer breast-conserving surgeries when breast cancer is diagnosed; and higher rates of death from breast or lung cancer [104]. Disability cultural competence requires appreciation of social model precepts, which recognize patients’ rights to seek care that meets their expectations and values. The social model of disability has been characterized as centering disability as a social creation rather than an attribute of the patient [105]. As such, disability requires a social/political response in order to improve environmental factors affecting access and acceptance [105]. This involves adoption of person-first language, acknowl- edgement of social and environmental factors impacting persons abilities, and confronting disability-associated stigma. VETERANS The effects of military service and deployment to military com- bat on the individual and the family system are wide-reaching. According to the U.S. Department of Defense, there were 3.5 million current military personnel in 2020 and 18.3 million veterans in 2017 [132; 133]. The Army has the largest number of active duty members, followed by the Navy, the Air Force, and the Marine Corps [132]. Military service presents its own set of risk and protective factors for a variety of mental health issues, including post-traumatic stress disorder (PTSD), trau- matic brain injury (TBI), depression and suicide, substance abuse, and interpersonal violence. In particular, transitioning from combat back to home life can be particularly trying for veterans and their families. As the number of military conflicts and deployments has increased since 2001, the need to identify and provide bet- ter treatment to veterans and their families has become a greater priority. The first step in providing optimal care is the identification of veterans and veteran families during initial assessments, with an acknowledgement that veterans may be any sex/gender and are present in all adult age groups [133]. Unfortunately, veterans and military families often do not voluntarily report their military service in healthcare appoint- ments. In 2015, the American Medical Association updated its recommendations for social history taking to include
military history and veteran status [134]. In addition, the American Academy of Nursing has designed the Have You Ever Served? Initiative to encourage health and mental health professionals to ask their patients about military service and related areas of concern [135]. This program provides pocket cards, posters, and resource links for professionals working with veterans and their families. Recommended questions for intake include [135]: • Have you or has someone close to you ever served in the military? • When did you serve? • Which branch? • What did you do while you were in the military? • Were you assigned to a hostile or combative area? • Did you experience enemy fire, see combat, or witness casualties? • Were you wounded, injured, or hospitalized? • Did you participate in any experimental projects or tests? • Were you exposed to noise, chemicals, gases, demoli- tion of munitions, pesticides, or other hazardous substances? DIETARY CONSIDERATIONS Cultural or personal beliefs can also impact the dietary needs of patients, which, in turn, can affect their health and adherence to prescribed treatments. For example, health issues related to fasting may arise among Buddhists, Hindus, Muslims, and some Christian patients, as well as persons of other faiths. This may particularly become an issue during extended fasts, such as the Muslim observance of Ramadan, which continues for one month [148]. Fasting is done during Ramadan as a spiritual exercise and is mandatory for all healthy adults. Those exempt from Ramadan fasting include children (prior to the onset of puberty); developmentally disabled individuals; the elderly; those who are acutely or chronically ill, for whom fasting would be detrimental to health; travelers who have journeyed more than approximately 50 miles; and pregnant, menstruating, or breastfeeding women [148]. Practitioners should advise all patients for whom fasting would prevent healing or adequate care (e.g., inability to take medication) to postpone or abstain from the ritual, if possible [148]. Another dietary consideration for some patients is whether medications contain animal-sourced ingredients. Vegetarians, vegans, Jewish people, Muslims, and others may need to know which products are from animal sources. Common examples of meds that contain ingredients from animals include: • Desiccated thyroid from pig thyroid glands • Heparin from pig intestines • Pancreatic enzymes from pig pancreases • Certain vaccines grown in eggs • Conjugated estrogens from pregnant mares’ urine
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