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Identifying Health Promotion Needs Among Dominican-American Adolescents
Journal of Pediatric Nursing (2016) xx, xxx–xxx
Identifying Health Promotion Needs Among Dominican-American Adolescents Jane Dimmitt Champion DNP, PhD, FNP, AH-PMH-CNS, FAANP, FAAN a,⁎, Carol F Roye EdD, RN, CPNP, FAAN b a
Lee and Joseph D. Jamail Endowed Professorship in Nursing, School of Nursing, The University of Texas at Austin, Austin, TX Pace University, College of Health Professions, Pleasantville, NY
b
Received 6 November 2015; revised 25 August 2016; accepted 17 September 2016
Key words: Adolescents; Dominican-American; Health promotion; Sexual health; Substance use; Obesity
Purpose: Immigration from the Dominican Republic to the United States has grown rapidly. Yet, although adolescent pregnancy and obesity are common concerns among Hispanics, little is known specifically about Dominican adolescent health. This study was undertaken to assess DominicanAmerican adolescents' health concerns and their perceptions about their health promotion needs. Design and methods: Dominican-American adolescents (N = 25) were recruited in a pediatric clinic in New York City which primarily serves a Dominican population. Eligibility criteria included age 13– 21 years, self-identifying as Dominican ethnicity, and able to speak and read English. They completed a questionnaire, with demographic questions and questions about their risk behaviors including sexual and substance use. After completing the questionnaire, they participated in a semi-structured interview addressing their health education experiences and suggestions for such programs. Quantitative data were analyzed using frequencies to provide a demographic and behavioral profile. Qualitative data were analyzed using thematic analysis. Results: Twenty-five adolescents, ages 13—21 years, (female N = 19, male N = 6) participated in the study. Most were in school (92%) and were sexually experienced (68%). Programmatic preferences included inperson programs rather than online. They spontaneously addressed the importance of cultural issues, and the need to address several issues in addition to sexuality, including obesity and substance use. Conclusions: Programming for this population should address a broad conceptualization of health, and incorporate Dominican cultural issues. Practice implications: Nurses working with adolescents of Dominican origin, should provide health education that incorporates the specific needs of this population, including culturally congruent face-to-face interventions. © 2016 Elsevier Inc. All rights reserved.
Purpose There is a gap in research concerning Hispanic health issues. Research assessing health behaviors of Spanish speaking populations, and health promotion programs designed for them, typically refer to “Hispanics” as a homogenous group. This is important because “Hispanics” experience multiple
⁎ Corresponding author: Jane Dimmitt Champion, DNP, PhD, FNP, AH-PMH-CNS, FAANP, FAAN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2016.09.004 0882-5963/© 2016 Elsevier Inc. All rights reserved.
health disparities. Notably, Hispanic adolescents have the highest birth rate among adolescents (Hamilton, Martin, Osterman, & Curtin, 2015). Obesity and diabetes also represent prevalent problems in this population (Daviglus et al., 2012; Ferdinand, 2005; Gordon-Larsen, The, & Adair, 2010; Heiss et al., 2014; Krauss, Powell, & Wada, 2012; Ogden, Lamb, Carroll, & Flegal, 2010). Recent research however has demonstrated that the term “Hispanic” is inadequate as there are meaningful health-related differences between Hispanic subgroups (Aponte, 2009; Daviglus et al., 2012; Heiss et al., 2014; Vangeepuram, Mervish, Galvez, Brenner, & Wolff,
2 2012). Health providers must understand these differences in order to implement tailored health promotion programs. Among Hispanic adolescents, those from the Dominican Republic have received relatively little attention however experience these health disparities. Although expansive evidence indicates that Hispanics adolescents have a high rate of obesity (Ferdinand, 2005; Gordon-Larsen et al., 2010; Krauss et al., 2012; Ogden et al., 2010), Dominican-American children and adolescents have been found to have the highest rate of obesity among Hispanics (Vangeepuram et al., 2012). Hispanics in general have a high rate of adolescent pregnancy (Fennelly, Cornwell, & Casper, 1992; Orshan, 1999; Wasserman, Rauh, Brunelli, Garcia-Castro, & Necos, 1990). Current data however concerning Dominican-American adolescent pregnancy rates is unavailable (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013) though the highest adolescent pregnancy rates have been identified in neighborhoods with higher proportions of Dominican-American populations (Kaplan, 2013). These data are of particular importance as the Dominican population in the U.S. is growing rapidly with a recent increase of 85% according to the 2010 census (Martin et al., 2013). Limited study has addressed programming of interventions to ameliorate these health disparities among DominicanAmerican adolescents. Attention should be directed at understanding health behaviors of this population so that effective health promotion interventions can be tailored to their needs. The purpose of our study was to assess Dominican-American adolescents' health concerns and perceived health education needs. This assessment will inform design of health promotion programs thus facilitating the efforts of pediatric nurses who provide care to this population.
Design and Methods The study used a mixed methods design. It was approved by the relevant institutional review board before data collection began. Study participants were recruited in a pediatric primary care clinic in the New York City Metropolitan area, where the population is primarily Dominican. The clinic has a large adolescent clientele. A research assistant approached adolescent patients in the clinic waiting room to introduce them to the study. Adolescents who indicated interest were asked to accompany the research assistant to a private area where the study was described. Study eligibility was assessed by asking the adolescents to complete an intake form to ensure that they met eligibility criteria, including age 13–21 years and self-identifying as being of Dominican ethnicity, and able to speak and read English. The study was conducted in English because funding did not allow for translation. Furthermore, the vast majority of adolescents in the clinic speak both English and Spanish. Adolescents eligible for this study were seeking sexual health and reproductive health services at the clinic. This is the reason that parental consent was not indicated for this study. Consistent with New York State law and the recommendations of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research consent was obtained
J.D. Champion and C.F. Roye from the study participants and not from parents. According to New York State Law, adolescents can receive reproductive health care without the knowledge or consent of their parents. After informed consent was obtained, participants completed a self-report questionnaire using paper and pencil. They subsequently engaged in a face-to-face interview with the RA.
Questionnaire The questionnaire is a 15-item survey, which is based on instruments developed by the investigators in previous studies. It asks about demographic factors including educational level and ethnicity; and addresses participants' risk-behaviors, including substance use, sexual behaviors and sexual health history including pregnancy and sexually transmitted infections (STIs). (Champion & Collins, 2012; Champion & Roye, 2014; Roye, Krauss, & Silverman, 2010; Roye, Silverman, & Krauss, 2007). It was amended to include behaviors which have recently come to light among Dominican adolescents, such as hookah use, but was otherwise similar to that used in earlier studies. It took participants approximately 15 minutes to complete, on average. Because the instrument had been used with a similar population, the authors did not do a pilot test for readability or reliability. There is no total score as the instrument is used to provide a behavioral profile.
Interview After completing the self-report questionnaire, participants were interviewed face-to-face by the research assistant. A semi-structured interview guide was used. The focus of the qualitative interview was for assessment of the type of health-promoting programs the adolescents had participated in; their assessment of the program, the issues they would like to address in a health program and suggestions that they had for design of a program to promote health among their peers. The interviews lasted 20–25 minutes. They were audio-recorded and transcribed by the research assistant.
Data Analysis Quantitative Descriptive statistical methods using SSPS were utilized to obtain a behavioral profile for the adolescents. These methods included frequencies, percentages, means, and standard deviations. Qualitative Content analysis of the semi-structured face-to-face interviews was conducted to assess 1) the type of health-promoting programs the adolescents had participated in, 2) their assessment of the program and 3) how they would design a program to promote health among their peers. For almost all participants, the only formal health education they had had was the mandatory school health course. In addition, the interview explored the health-related issues of concern to the participants; and revealed which professionals, friends, family and services they turn to for help. While the questioning was limited to these issues, participants brought up their own issues during the
Health Promotion Needs
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interviews, such as embarrassment about their obesity, which provided additional data that will be helpful in designing health education programming for this population. Data were analyzed using inductive content analysis as described by Elo and Kyngäs (2008) to understand critical processes and to address meanings, intentions, consequences and context (Elo & Kyngäs, 2008). Both authors read through the data multiple times, independently, to make sense of it and broad categories were created. These categories were examined for more specific content, seeking similarities and dissimilarities in content. Content was grouped by similarities into themes in the process of abstraction. Themes were used to explain the meaning of categories. The authors had ongoing discussions of categories and themes to maintain rigor in the study design. Text descriptive of the categories was selected and new themes were created. Each interview was re-read in detail and the authors returned to the data once again to check the reliability of the themes against the data. One author is a pediatric nurse practitioner who practices with Dominican-American adolescents in New York and so brought an insider perspective to the analysis of the interviews; the other author is a family nurse practitioner who has developed sexual health promotion interventions for Mexican-American adolescents and so provided an outsider perspective. The two perspectives allowed for analytic negotiation, which brought a richer understanding to the data (Thomas, Blacksmith, & Reno, 2000). This process also revealed individual biases, allowing the authors to recognize and reduce bias in the final analysis. The identified themes provide important structural information for the development of health promotion programs for Dominican-American adolescents. We provide an extensive listing of quotations to substantiate themes as there was consistency, but also diversity in their suggestions. Additionally, we elected to preserve the linguistic context of the participants' viewpoints via use of extensive quotations rather than risking its potential loss via paraphrasing of participants' words.
hookah (63%), alcohol (41%) and marijuana use (30%). While hookah use was high, only 4% reported smoking cigarettes.
Results
This theme concerns preferences about who would be the most appropriate professional or nonprofessional person to facilitate the health promotion program. They had many suggestions concerning the type of facilitator for the health program. Overall, the participants suggested health professionals, specifically a nurse most often followed by a doctor or social worker. Those who preferred a nonprofessional displayed some ambivalence, still wanted some aspects that a professional would bring, because they wanted a very knowledgeable nonprofessional. This can be seen in the following excerpts;
Sample Twenty-five adolescents participated in the study, including 19 females and 6 males. Participants all self-reported Dominican ethnicity and ranged in age from 13–21 years (mean, 17.28; standard deviation = 2.372).
Behavioral Profile Almost all participants (N = 23, 92%) reported that they were currently in school. Sixty-eight percent (N = 17) reported having had vaginal intercourse with the opposite sex. All sexually active participants reported having ever used a method to prevent pregnancy or infections; including ever use of condoms. Four (23.5%) of those who were sexually active reported having been diagnosed with a sexually transmitted infection. One female participant reported a history of pregnancy. All the males denied having caused a girl to become pregnant. The participants disclosed high rates of
Qualitative Results Several themes pertain to the respondents' preferences for health education. The first set of responses below reflect logistical issues about a health education program, which may not be specific to the Dominican culture. It may be a reflection that Dominican adolescents share many attitudes with a large portion of American adolescents. After these themes, we present themes that are specific to the Dominican culture.
Gender Doesn't Matter…Mostly The theme “Gender doesn't matter … mostly” provides the participants' perspectives about whether or not the gender of the facilitator would make a difference for the program. All participants stated that the gender of the facilitator for the program would not make any difference to them. Yet, as can be seen from the following excerpts, there was some ambivalence. In addition, a separate suggestion was to have a man and woman co-facilitate the program for others who may not be comfortable with receiving this information from the opposite gender. I think sometimes gender does matter. Um (pause) …I know I don't care, I could talk to a boy or girl, I don't care. But other people wouldn't necessarily wanna say some things to a man that they would say to a woman. Both, because maybe a boy won't feel comfortable talking to girl, and maybe a girl won't feel comfortable talking to a boy.Well my doctor is a male so I can't really tell him when I have my period and stuff like that it's awkward.
One young man expressed a preference for a man.
Anyone Who Has Seen a Lot of Whatever It Is You're Gonna Speak of ….
A nurse, yeah....definitely. I think a nurse, or anyone who has seen a lot of whatever it is you're gonna speak of, so maybe a social worker. I dunno. I guess someone who is well-informed I'm whatever the topic is. I think most people feel comfortable with a professional compared to a college student.
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J.D. Champion and C.F. Roye Someone who is very informed on whatever subject. Someone who has experience with the topic. Sometimes you put a random person and they say textbook things...and I can tell if you're telling me what I can read.
Two participants, however, did not think that it needed to be either a doctor or a nurse and would rather have someone who they perceived as more “relatable”. The suggestion here is for a college student. I think that it shouldn't be a doctor. It shouldn't be a nurse. I think it should be someone who can be more relatable to the individuals who are coming and then people will be like, “Oh, she is just like me”.
Several participants suggested that it would be beneficial to have more than one person who was facilitating the program. This was primarily to meet the needs of those who just want somebody to talk to.
Where Would You Go for a Health Program? The theme “Where would you go?” contains descriptions of participant preferences for location of a sexual health program. Almost all of the participants indicated that they would attend a health promotion program at their clinic. This was in part a result of their familiarity with the clinic setting as well as program content. I would recommend a clinic or health center of some kind... basically anywhere that most people would feel comfortable going to. People would come to the clinic, I think what's going on here is really cool … And it's nice to see everyone in this community and everything.
This finding has implications for implementation of adolescent health programs within primary care-based settings. Issues providers may encounter within this setting include the availability of physical space.
Face to Face The theme “Face to face” contains descriptions of the reasons that participants gave for a preference for face to face provision of health programming. The respondents overwhelmingly preferred having a face to face group intervention for delivery of health information, as opposed to an online intervention, though some suggested augmentation via a “credible” website. Well, for a group I would say, um....just health in general. Teaching people dietary, foods you should eat, things like...hygiene, things like that, that could be group and universal, and people could be like ‘Oh, well I do this when I shower,’ or ‘I do this when I eat, just to like help me’, and ‘this is what I do in the morning,’ so that people can learn from each other–things like that. But individual....”I might have an STD,’ that should be left for people by themselves.
As can be seen from this quote, the group option was desirable in part because the adolescents' felt that they could learn from each other. However they indicated consistently that they believed it would be best to also offer an option for individual interventions during which they could discuss personal sexual health questions and concerns. It was interesting that the adolescents perceived this need by others however perhaps this was indicative of their need as projected upon others.
I Did it Myself The theme “I did it myself” describes how participants learned about sexual health. Participants related learning about sexual health on their own. They did not relate receiving any health promotion programs outside of the school system. The health programs that the participants did receive through the school system were not perceived as beneficial by many participants. I mean, I think that whenever I wanted to look something up I did it myself. I don't remember learning anything that I would remember that stood out to me cuz I went somewhere. Usually I do a lot of research on everything.
This quote summarizes the experiences related by the participants. They basically sought information using their own initiative and based upon their self-identified needs.
Do Not Trust Online Information The theme “Do not trust online information” contains the participants' description of their use of the Internet to access sexual health information and also their perceptions of the utility of this information. The participants indicated that they use blogs/WebMD/Google to obtain sexual health information. However they stated that they do not trust the online information. Most said they may go online, but then verify the information with a health professional or counselor. Some indicated that they use multiple sources to validate information. But naw, to find information I'll Google, but I don't like the pictures they show. I need someone who has knowledge on the topic, because Google exaggerates and is not really reliable. Google is a go-to for me. When I have any questions that I can't see a doctor, I go to Google to get an idea, and I usually go to certified websites such as Mayo Clinic. Yeah, there are times I research stuff on the computer or on my phone, but I don't really like, I don't know, I'm not 100%...there is always a detail missing. So what I do is, I go to my counselor, I have one in my high school and I talk to her. Like sometimes I call my school and that's the only way I can talk to her now …Cuz it's better like, someone that has a lot of experience … like … she is really old, and she knows a lot, and she has been in the medical field for years. So I would rather ask her than a computer or a friend.
Health Promotion Needs Other participants indicated that they do not use the Internet to access information. Reasons they gave for this included a preference for in-person discussions about their health. One participant suggested that program leaders could use technology to send information, as described below: Nope. I know that every teen is on there for like 24/7, but I feel like it's better in person … you learn more in person … but you guys could do like an Instagram, like everyone could follow it, send motivation, send tips and be aware of things. That would be good. Yeah, if I'm like searching yeah, but I don't consider it credible until I hear it from a doctor. Like if I came today, I would ask the doctor about those things.
Several participants indicated that they used the Internet to access information because they felt it provided anonymity. One participant stated this was particularly important when embarrassed about some of the questions being asked. Sort of...I just ask like silly questions that I don't want to ask other people cuz I'm embarrassed. I think it better to be electronic because there is no proof....it's not face to face, so people can keep themselves confidentially.
The theme “Do not trust online information” exemplifies the overall preference adolescents have for face-to-face, interpersonal, individual interactions for obtaining sexual health information. A facilitator for interventions may be conceptualized as a mentor, as in many situations adolescents may not sense comfort in discussion of sexual health with their parent or guardian. The following themes reflect issues which are prevalent in Dominican-American communities and the DominicanAmerican culture. These adolescents initiated discussion of cultural issues, even though there were no specific questions about their culture or how it impacts their health behaviors or education.
I Want to Learn More About… Participants reflected on a variety of health-related topics about which they would like to learn more, including sexual health, substance use, eating issues, poverty, obesity, self-harm and abuse. Many of these issues, while perhaps of general interest to adolescents, reflect issues that are particularly cogent in Dominican communities. One participant summed it up as: “So I think having a program that has all of it combined, and focuses on the individual and what their needs are would help....” Quotations from other participants substantiate this perception with descriptions of specific topic foci. We provide an extensive listing of quotations as there was some consistency and some diversity in their suggestions.
5 I think sexual health is really important. Like even when you're having sex and after, you still don't know everything … it's very important for people to understand...like a lot of people are very naive to the way you can get diseases, and … like going deeper into how it's just not...sex...it's oral, it's like different types of sex and stuff like that. I think it should be...in a community where you see a lot of people having kids at an early age I think sex that's really up there in the education, and even dieting too, because I′m getting so big. … Obesity … It hasn't been hard to speak about....but it's been difficult, a difficult journey...to try and want to lose the weight and know the direction to take. So, yeah....I like … touch upon topics that people do know about, but they go into more depth and really like...get into your mind, like this is what is going, here are the things, the measure that you can take to prevent this, or this is what you can do if you wanna lose weight, and they give you options that are very realistic and accessible to people of the Dominican community. …life motivation … poverty is usually a reason for these alternatives [risk behaviors such as drug use]. Because, if you can't find a job, or if you're bored, you just know, go to drugs. Especially if there are no recreational activities going on. So, I think life motivation is so helpful. Especially for those who feel like they can't get a job, or those who are like me who feel like they aren't getting anywhere with their weight, or someone who is fighting an addiction. I would like to learn more about abuse–like what takes people to do that. Because I have friends, I don't know why, but it's like every time I meet someone they come from an abusive house or something and I always help them. Like, during my high school year, I had a...my best friend, she used to cut herself.... Maybe more on hookah … cuz it's something that I do once in a blue ... and they're like “it's bad for you, but it's not so bad for you because blah blah”–I dunno, the whole point is it's not clear to me.
These quotations reflect considerable insight by the participants concerning dilemmas facing adolescents maturing within this society. These dilemmas concern key decisions adolescent face regarding their personal health within their unique environment.
I Ask My…Not My Mom Participants were asked who they typically go to for health information. In the theme, “I ask my … not my mom,” participants described seeking information from their health care providers, as it provided more confidentiality and fewer questions. Importantly, they do not feel judged by their providers. It is important to note that participants used the terms “doctor” or “nurse” interchangeably to describe health care providers; going to the “doctor” meant going to the clinic for health care. Nurse practitioners provided the majority of health care to adolescents at the clinic.
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J.D. Champion and C.F. Roye It's like anytime I have questions, I just call my doctors. I tell them what's happening, what do you recommend? And she'll say “Oh, come see me, we can talk more about that”, and I just make an appointment and come. Cuz like, about my sexual life–I cannot talk about that to my mom. I just do that behind her back … … But with doctors, I'm very open to. These are the people who know, these are the people who go to school for this. I am very open to tell them how it is, but my parents ……I can't tell her anything.
Other reasons cited by participants as contributing to their reluctance to seek sexual and other health information from parents had to do with perceived lack of time or interest on the part of parents. One participant related trust as a motivator to withhold information from a parent as described in the following excerpt. Yes … sometimes I do things that I'm not gonna go to my father or my mother...my mother is like my therapist like my diary … but then again, there are things you don't even tell your own diary. Can talk to my doctors about sex stuff or birth control … I can't tell my Mom.
However, it is not only sexual health that adolescents are uncomfortable discussing with their parents. As one participant expressed “Can't talk to mom or teachers (about my obesity), but tell doctor everything because they're there to help me.” In response to a query about whether there is any health concern that is difficult to speak about with your parents, your health care providers, or maybe a teacher, one young man contextualized a problem with confiding in his parents: Maybe my mother... cuz the fact of the matter with my father … our relationship is kind of, you know...I didn't learn that Plan B, I had to learn that myself in the moment, I didn't have no Plan B. Cuz I was selling drugs in school and I got suspended, could have been a court case, could have been in jail, the world of “what ifs”. So he looks down upon me, so that relationship is no longer the same, and it feels fake. Cuz in front of the doctor he is calling me “his baby”, “his son”, and I'm just like … but you don't say that in the house. So for the world, it's like yeah, everybody has smiles. But behind doors, everybody has closed cases.
Other participants related becoming more comfortable and seeking information and guidance from parents later during adolescence. One participant anticipated being able to talk with her mother when she became older. These experiences are described in the following excerpts. Yeah, I mean I have found it uncomfortable at first anything that like when I was in a relationship, with my mom, but after I broke into it. But that's when I was younger. Now I′m a little more … older … a little more mature so I do talk to her about it.
Sexuality was not the only issue participants felt uncomfortable discussing with parents. Participants also expressed concerns about being judged. They indicated that it was one of the motivators to seek information from health care providers; they did not want to feel as though they were being judged. Especially when you feel like you're not being judged. That should be something, like a judgment free zone, no one is judging you, you can open up, you can say how it is—cuz like even when you're talking to a health educator and doctor and you're like “oh my god, what is she going to think of me?” But no—she's heard this before. You're not the first one … you're not going to be the last one, and just being able to, when you do talk to that person, just reassuring them, and not getting straight to the point. Like, ease it—
One participant verbalized that her inability to confide in her parents, was because she was close to them and cared deeply about their opinion. Well doctors, no. Like, I have no filter, no chill, like if I′m talking to a doctor I'll tell them how it is. But I'm more censored if I'm talking to my mom or my sisters per se...because I care more about...not that I don't care about the doctor, but I care about my parents, the people that I care about, my close loves, I care about their opinion and their judgment before anybody else's. So, I would never tell my mom that I had sex, I would probably keep that til the day that I′m in my wedding dress, and be like “well, mom, I had to tell you, this awful but I'm not....”
I Just Keep Thinking of How People Can Be in My Culture–the Dominican Side… There were no interview questions related to culture, but participants brought it into the discussion spontaneously in response to a variety of questions. With this theme insider perspectives on the Dominican community and how a sexual health program would interface with this community were provided. Participants also offered cultural insights that they believed would help produce a program that would be successful in the Dominican community, when asked for suggestions about creating a health program for adolescents. These insights provided a multitude of perspectives as presented in the following excerpts. I just keep thinking of how people can be in my culture– the Dominican side anyway. I don't know if you've bumped into, I'm not stereotyping or anything just trying to put that on the table already, but I have met a … amount of people of the Dominican ethnicity that they can be stubborn, or they might joke a lot because of their discomfort, you know? Because in our culture, it does still happen from time to time, that it's not really encouraged to express certain feelings.... So they probably mask it with humor. Humor is a very popular way to mask certain discomforts and pain and stuff. So it is, I'm sure something you've come across and such, but it is still a thing.
Health Promotion Needs (Health insurance) they cut me at 18, and I get it cuz I'm not a kid anymore, I'm considered an adult in America. But, I couldn't apply for the adult one because I wasn't 21. So, for three years I didn't have health insurance … Well good thing, the Hispanic culture we have a lot of remedies for practically anything. So that's what I basically lived off of on. But, it was–it's just this awkward three-year gap that no one has health insurance. Yeah … And the, as well as the tradition behind marijuana AND hookah, because we forget to mention that. Some people think like “oh, it's cool”, but it's part of traditions for some cultures, it's not used as you know, “lemme just feel better.” I gotta think about....let's see...something helpful for the program...depends on cuz....Dominicans are hotheaded, we are hotheaded–yeah. Puerto Ricans too, but Dominicans are worse. Dominicans don't...when you give an offer, and want to help out, they be like “No″, but when you give them something they want they be like “hmm okay, let's go!” Know what I mean? Cuz you see that...you know, for example, you know like Medicaid? If you want to help out of with Medicaid they're gonna be like “no”, but when you tell them “oh, it's gonna get you medicine, it'll all be free,” they'll be like “oh yeah!”
In response to a question about where to hold the program, one young woman said … “So you know how people will be the stereotypes “Oh, he's white he must be a better doctor“. But here, in the neighborhood there is...all types of races, and it's like … “alright I can do with this”. One young women attributed her inability to discuss sexual health with her mother, to her culture. Because she is very like...follows the tradition, she likes to follow that we are supposed to have sex once we get married. And it's like … “God mom, it's the 21st century, it doesn't happen like that anymore”.
Discussion Evidence-based behavioral interventions designed for adolescent sexual health promotion may be modified for Dominican-American adolescents based upon these findings described in the themes. The quotations and themes in this paper reflect the influence that Dominican culture has on these adolescents, who spontaneously brought it up in many of their responses, despite the fact that no questions asked about it. This supports the conceptualization that “culture” and “ethnicity” matter to these adolescents. They perceived their connection to their culture as intimately important and relevant to the development of health programming. These quotations impart connection to the Dominican culture and pride in belonging. Therefore, interventions should be integrated into rather than layered upon their cultural milieu. Moreover, the topics of concern to these adolescents reflect some health issues that are particularly prevalent among Dominicans. Obesity was mentioned frequently, and with a sense of embarrassment that could be expected when
7 discussing what nurses might consider to be more personal topics such as sexuality. An interest in learning more about weight and obesity is especially notable because the rate of obesity among Dominican adolescents in the US is high and 21st tends to be more accepted among Hispanics in general (Vangeepuram et al., 2012). These adolescents evidently desired a health program that addresses weight and obesity. Clearly, this sample of adolescents brought up issues that might be expected regardless of cultural/ethnic background, including pregnancy sexually transmitted infections and drug use (Ewan, McLinden, Biro, DeJonckheere, & Vaughn, 2016). Even here, however, they mentioned issues specific to their culture such as hookah, which is especially prevalent in this population. Sixty-three percent of the adolescents in this sample reported hookah use, for example. Our study findings demonstrate that these young people were thoughtful about accessing health promotion data, and finding answers to their own health questions. Some findings were anticipated, while there were also a number of surprising results, including the importance of cultural influences on their ability to access sensitive information. Moreover, unexpectedly the adolescents were skeptical about sexual health information obtained via the Internet. While some adolescents chose sites that are reputable, i.e., Mayo Clinic website, they still sought face-to-face verification from “experts” who most often were health care professionals. The responses also suggest culturally congruent ways for nurses to address difficult subjects, for example by using humor. Difficulty discussing sexuality with parents seems to be particularly problematic for these adolescents. While none of the respondents specifically mentioned marianisma, similar to other Hispanic cultures, marianisma is prevalent in the Dominican Republic, i.e. a view of women that includes saintliness, self-sacrifice and passivity (DeSantis & Patsdaughter, 2008). This may underlie the difficulty adolescent females have in discussing sexuality with their mothers. Simply being sexually active before marriage is not consistent with the concept of saintliness. An understanding of this cultural context may be incorporated in programming to promote sexual health for this population. One young woman alluded to the difference between her own and her mother's perceptions, pointing out that “it is the 21st century”. It may be beneficial for nurses to work with adolescents and their parents – together or separately. However, this issue was not included in the interviews. Clearly, these adolescents were eager to learn more about sexual health, and had firm ideas about the areas they would like to have it addressed in health promotion programs. Their comments, incidentally provided some avenues that professionals can use to address these topics. The importance of their parental relationships was clear; although many adolescents felt they could not talk to their parents about sensitive health issues including sexual health and also obesity. More research is indicated for assessment of mechanisms to promote involvement of parents in sexual and other health promotion programs. A comparable study examining Dominican-American parents'
8 concerns about their children's health would be an important starting point. Hookah use was described as an accepted practice in the Dominican culture. The high rate of hookah use among these adolescents is of concern particularly as several cited their lack of knowledge about its use. Hookah presents serious health risks to those who smoke it, and those exposed to the smoke (Akl et al., 2010; Blank et al., 2011). Although many hookah smokers believe that hookah is not as harmful as cigarette smoking, there is evidence that it is at least as toxic, and possibly more so. Because the hookah mouthpiece is shared hookah presents the risk of spreading infectious diseases, such as influenza, herpes and hepatitis, among others (Soule, Lipato, & Eissenberg, 2015). Moreover hookah use appears to be growing rapidly among all adolescents (Barnett, Forrest, Porter, & Curbow, 2014; Smith et al., 2011). Some research suggests its use is more prevalent among Hispanic adolescents (Barnett et al., 2014), while other researchers found a higher prevalence among Whites (Smith et al., 2011).
Clinical Implications The results of this study can inform the health promotion activities of pediatric nurses who work with Dominican adolescents. The Dominican-American adolescents in this study had diverse health concerns, and sought health promotion information from a variety of sources. Importantly they primarily trusted only what they heard face-to-face from health professionals such as pediatric nurses and preferred this source. Their comments suggested that they were receptive to having a health program designed for them that would take place in person and in a familiar setting, such as the clinic. They conceptualized their health very broadly with concerns primarily about sexual health. However, substance use was also on their minds, as was anxiety about being overweight, violence and mental health issues. These adolescents spontaneously addressed cultural issues for Dominican-American adolescents as being relevant to their behaviors. Pediatric nurses may incorporate these issues into their health promotion programming; as well as other factors the adolescents mentioned such as use of humor when discussing sensitive topics.
Limitations The sample included 25 participants, all of whom were recruited from one clinic in a low income, urban neighborhood. They all were patients of record in the clinic, so all had access to the health care and anticipatory guidance that comes with primary care. Therefore, participants recruited in other settings may be less well informed or thoughtful about their health issues.
Conclusions These findings indicate that health promotion programming for Dominican-American adolescents would optimally address a broad conceptualization of health rather than focusing on only one issue. This programing would optimally incorporate
J.D. Champion and C.F. Roye Dominican cultural issues and be provided using face-to-face group or individual interventions provided by pediatric nurses in a primary care-based setting.
References Akl, E. A., Gaddam, S., Gunukula, S. K., Honeine, R., Jaoude, P. A., & Irani, J. (2010). The effects of Waterpipe tobacco smoking on health outcomes: A systematic review. International Journal of Epidemiology, 39, 834–857. Aponte, J. (2009). Addressing cultural heterogeneity among Hispanic subgroups by using Campinha-Bacote's model of cultural competency. Holistic Nursing Practice, 23, 3–12. http://dx.doi.org/10.1097/01.HNP. 0000343203.26216.c9. Barnett, T. E., Forrest, J. R., Porter, L., & Curbow, B. A. (2014). A multiyear assessment of hookah use prevalence among Florida high school students. Nicotine and Tobacco Research, 16, 373–377. http:// dx.doi.org/10.1093/ntr/ntt188. Blank, M. D., Cobb, C. O., Kilgalen, B., Austin, J., Weaver, M. F., Shihadeh, A., & Eissenberg, T. (2011). Acute effects of Waterpipe tobacco smoking: A double-blind, placebo-control study. Drug and Alcohol Dependence, 116, 102–109. Champion, J. D., & Collins, J. L. (2012). Comparison of a theory-based (AIDS risk reduction model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: Results of a randomized controlled trial. International Journal of Nursing Studies, 49, 138–150. Champion, J. D., & Roye, C. (2014). Toward an understanding of the context of anal sex behavior in ethnic minority adolescent women. Issues in Mental Health Nursing, 35, 509–516. http://dx.doi.org/10. 3109/01612840.2014.888602. Daviglus, M. L., Talavera, G. A., Avilés-Santa, M. L., Allison, M., Cai, J., Criqui, M. H., ... Stamler, J. (2012). Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA, 308, 1775–1784. http://dx.doi.org/10.1001/jama.2012.14517. DeSantis, J. P., & Patsdaughter, C. A. (2008). Hispanics in the Americas: History, health, and HIV. Journal of the Association of Nurses in AIDS Care, 19, 243–246. http://dx.doi.org/10.1016/j.jana.2008.05.003. Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. http://dx.doi.org/10.1111/j.1365-2648. 2007.04569. Ewan, L. A., McLinden, D., Biro, F., DeJonckheere, M., & Vaughn, L. M. (2016). Journal of Adolescent Health, 58, 24–32. http://dx.doi.org/10. 1016/j.jadohealth.2015.09.020 (10.1093/ntr/ntt188). Fennelly, K., Cornwell, G., & Casper, L. (1992). A comparison of the fertility of Dominican, Puerto Rican and mainland Puerto Rican adolescents. Family Planning Perspectives, 24, 107–110 (134). Ferdinand, K. C. (2005). Managing cardiovascular risk in minority patients. Journal of the National Medical Association, 97, 459–466. Gordon-Larsen, P., The, N. S., & Adair, L. S. (2010). Longitudinal trends in obesity in the United States from adolescence to the third decade of life. Obesity, 18, 1801–1804. http://dx.doi.org/10.1038/oby. 2009.451. Hamilton, B. E., Martin, J. A., Osterman, M. J. K., & Curtin, S. C. (2015). Births: final data for 2013. Hyattsville, MD: National Center for Health Statistics (Retrieved January 23, 2015, from http://www.cdc.gov/nchs/ data/nvsr/nvsr64/nvsr64_01.pdf). Heiss, G., Snyder, M. L., Teng, Y., Schneiderman, N., Llabre, M. M., Cowie, C., ... Avilés-Santa, L. (2014). Prevalence of metabolic syndrome among Hispanics/Latinos of diverse background: The Hispanic community health study/study of Latinos. Diabetes Care, 37, 2391–2399. http://dx.doi.org/10.2337/dc13-2505. Kaplan, D. (2013). Teen sexual and reproductive health in New York City. Citizens' Committee for children of NY policy briefing October 23rd, 2013. Krauss, R. C., Powell, L. M., & Wada, R. (2012). Weight misperceptions and racial and ethnic disparities in adolescent female body mass index. Journal of Obesity. http://dx.doi.org/10.1155/2012/205393.
Health Promotion Needs Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Mathews, T. J. (2013). Births: final data for 2013. National Vital Statistics Reports, 64. Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconomic status in children and adolescents: United States, 2005-2008. NCHS Data Brief, 51, 1–8. Orshan, S. A. (1999). Acculturation, perceived social support, self-esteem, and pregnancy status among Dominican adolescents. Health Care for Women International, 20, 245–257. Roye, C., Krauss, B., & Silverman, P. (2010). Prevalence and correlates of heterosexual anal intercourse among urban black and Latina female adolescents and the role of sexual relationship power. Journal of the Association of Nurses in AIDS Care, 21, 291–301. Roye, C., Silverman, P., & Krauss, B. (2007). A brief, low-cost, theorybased intervention to promote dual method use by black and Latina female adolescents: A randomized clinical trial. Health Education and Behavior, 34, 608–621.
9 Smith, J. R., Edland, S. D., Novotny, T., Hofstetter, C. R., White, M., Lindsay, S. P., & Al-Delaimy, W. (2011). Increasing hookah use in California. American Journal of Public Health, 101, 1876–1879. http:// dx.doi.org/10.2105/AJPH.2011.300196. Soule, K., Lipato, T., & Eissenberg, T. (2015). Waterpipe tobacco smoking: A new smoking epidemic among the young? Current Pulmonology Reports, 4, 163–172. Thomas, M. D., Blacksmith, J., & Reno, J. (2000). Utilizing insider-outsider research teams in qualitative research. Qualitative Health Research, 10, 819–828. Vangeepuram, N., Mervish, N., Galvez, M. P., Brenner, B., & Wolff, M. S. (2012). Dietary and physical activity behaviors of New York City children from different ethnic minority subgroups. Academic Pediatrics, 12, 481–488. http://dx.doi.org/10.1016/j.acap.2012.06.014. Wasserman, G. A., Rauh, V. A., Brunelli, S. A., Garcia-Castro, M., & Necos, B. (1990). Psycho-social attributes and life experiences of disadvantaged minority mothers: Age and ethnic variations. Child Development, 61, 566–580.
Identifying Health Promotion Needs Among Dominican-American Adolescents Jane Dimmitt Champion DNP, PhD, FNP, AH-PMH-CNS, FAANP, FAAN a,⁎, Carol F Roye EdD, RN, CPNP, FAAN b a
Lee and Joseph D. Jamail Endowed Professorship in Nursing, School of Nursing, The University of Texas at Austin, Austin, TX Pace University, College of Health Professions, Pleasantville, NY
b
Received 6 November 2015; revised 25 August 2016; accepted 17 September 2016
Key words: Adolescents; Dominican-American; Health promotion; Sexual health; Substance use; Obesity
Purpose: Immigration from the Dominican Republic to the United States has grown rapidly. Yet, although adolescent pregnancy and obesity are common concerns among Hispanics, little is known specifically about Dominican adolescent health. This study was undertaken to assess DominicanAmerican adolescents' health concerns and their perceptions about their health promotion needs. Design and methods: Dominican-American adolescents (N = 25) were recruited in a pediatric clinic in New York City which primarily serves a Dominican population. Eligibility criteria included age 13– 21 years, self-identifying as Dominican ethnicity, and able to speak and read English. They completed a questionnaire, with demographic questions and questions about their risk behaviors including sexual and substance use. After completing the questionnaire, they participated in a semi-structured interview addressing their health education experiences and suggestions for such programs. Quantitative data were analyzed using frequencies to provide a demographic and behavioral profile. Qualitative data were analyzed using thematic analysis. Results: Twenty-five adolescents, ages 13—21 years, (female N = 19, male N = 6) participated in the study. Most were in school (92%) and were sexually experienced (68%). Programmatic preferences included inperson programs rather than online. They spontaneously addressed the importance of cultural issues, and the need to address several issues in addition to sexuality, including obesity and substance use. Conclusions: Programming for this population should address a broad conceptualization of health, and incorporate Dominican cultural issues. Practice implications: Nurses working with adolescents of Dominican origin, should provide health education that incorporates the specific needs of this population, including culturally congruent face-to-face interventions. © 2016 Elsevier Inc. All rights reserved.
Purpose There is a gap in research concerning Hispanic health issues. Research assessing health behaviors of Spanish speaking populations, and health promotion programs designed for them, typically refer to “Hispanics” as a homogenous group. This is important because “Hispanics” experience multiple
⁎ Corresponding author: Jane Dimmitt Champion, DNP, PhD, FNP, AH-PMH-CNS, FAANP, FAAN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2016.09.004 0882-5963/© 2016 Elsevier Inc. All rights reserved.
health disparities. Notably, Hispanic adolescents have the highest birth rate among adolescents (Hamilton, Martin, Osterman, & Curtin, 2015). Obesity and diabetes also represent prevalent problems in this population (Daviglus et al., 2012; Ferdinand, 2005; Gordon-Larsen, The, & Adair, 2010; Heiss et al., 2014; Krauss, Powell, & Wada, 2012; Ogden, Lamb, Carroll, & Flegal, 2010). Recent research however has demonstrated that the term “Hispanic” is inadequate as there are meaningful health-related differences between Hispanic subgroups (Aponte, 2009; Daviglus et al., 2012; Heiss et al., 2014; Vangeepuram, Mervish, Galvez, Brenner, & Wolff,
2 2012). Health providers must understand these differences in order to implement tailored health promotion programs. Among Hispanic adolescents, those from the Dominican Republic have received relatively little attention however experience these health disparities. Although expansive evidence indicates that Hispanics adolescents have a high rate of obesity (Ferdinand, 2005; Gordon-Larsen et al., 2010; Krauss et al., 2012; Ogden et al., 2010), Dominican-American children and adolescents have been found to have the highest rate of obesity among Hispanics (Vangeepuram et al., 2012). Hispanics in general have a high rate of adolescent pregnancy (Fennelly, Cornwell, & Casper, 1992; Orshan, 1999; Wasserman, Rauh, Brunelli, Garcia-Castro, & Necos, 1990). Current data however concerning Dominican-American adolescent pregnancy rates is unavailable (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013) though the highest adolescent pregnancy rates have been identified in neighborhoods with higher proportions of Dominican-American populations (Kaplan, 2013). These data are of particular importance as the Dominican population in the U.S. is growing rapidly with a recent increase of 85% according to the 2010 census (Martin et al., 2013). Limited study has addressed programming of interventions to ameliorate these health disparities among DominicanAmerican adolescents. Attention should be directed at understanding health behaviors of this population so that effective health promotion interventions can be tailored to their needs. The purpose of our study was to assess Dominican-American adolescents' health concerns and perceived health education needs. This assessment will inform design of health promotion programs thus facilitating the efforts of pediatric nurses who provide care to this population.
Design and Methods The study used a mixed methods design. It was approved by the relevant institutional review board before data collection began. Study participants were recruited in a pediatric primary care clinic in the New York City Metropolitan area, where the population is primarily Dominican. The clinic has a large adolescent clientele. A research assistant approached adolescent patients in the clinic waiting room to introduce them to the study. Adolescents who indicated interest were asked to accompany the research assistant to a private area where the study was described. Study eligibility was assessed by asking the adolescents to complete an intake form to ensure that they met eligibility criteria, including age 13–21 years and self-identifying as being of Dominican ethnicity, and able to speak and read English. The study was conducted in English because funding did not allow for translation. Furthermore, the vast majority of adolescents in the clinic speak both English and Spanish. Adolescents eligible for this study were seeking sexual health and reproductive health services at the clinic. This is the reason that parental consent was not indicated for this study. Consistent with New York State law and the recommendations of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research consent was obtained
J.D. Champion and C.F. Roye from the study participants and not from parents. According to New York State Law, adolescents can receive reproductive health care without the knowledge or consent of their parents. After informed consent was obtained, participants completed a self-report questionnaire using paper and pencil. They subsequently engaged in a face-to-face interview with the RA.
Questionnaire The questionnaire is a 15-item survey, which is based on instruments developed by the investigators in previous studies. It asks about demographic factors including educational level and ethnicity; and addresses participants' risk-behaviors, including substance use, sexual behaviors and sexual health history including pregnancy and sexually transmitted infections (STIs). (Champion & Collins, 2012; Champion & Roye, 2014; Roye, Krauss, & Silverman, 2010; Roye, Silverman, & Krauss, 2007). It was amended to include behaviors which have recently come to light among Dominican adolescents, such as hookah use, but was otherwise similar to that used in earlier studies. It took participants approximately 15 minutes to complete, on average. Because the instrument had been used with a similar population, the authors did not do a pilot test for readability or reliability. There is no total score as the instrument is used to provide a behavioral profile.
Interview After completing the self-report questionnaire, participants were interviewed face-to-face by the research assistant. A semi-structured interview guide was used. The focus of the qualitative interview was for assessment of the type of health-promoting programs the adolescents had participated in; their assessment of the program, the issues they would like to address in a health program and suggestions that they had for design of a program to promote health among their peers. The interviews lasted 20–25 minutes. They were audio-recorded and transcribed by the research assistant.
Data Analysis Quantitative Descriptive statistical methods using SSPS were utilized to obtain a behavioral profile for the adolescents. These methods included frequencies, percentages, means, and standard deviations. Qualitative Content analysis of the semi-structured face-to-face interviews was conducted to assess 1) the type of health-promoting programs the adolescents had participated in, 2) their assessment of the program and 3) how they would design a program to promote health among their peers. For almost all participants, the only formal health education they had had was the mandatory school health course. In addition, the interview explored the health-related issues of concern to the participants; and revealed which professionals, friends, family and services they turn to for help. While the questioning was limited to these issues, participants brought up their own issues during the
Health Promotion Needs
3
interviews, such as embarrassment about their obesity, which provided additional data that will be helpful in designing health education programming for this population. Data were analyzed using inductive content analysis as described by Elo and Kyngäs (2008) to understand critical processes and to address meanings, intentions, consequences and context (Elo & Kyngäs, 2008). Both authors read through the data multiple times, independently, to make sense of it and broad categories were created. These categories were examined for more specific content, seeking similarities and dissimilarities in content. Content was grouped by similarities into themes in the process of abstraction. Themes were used to explain the meaning of categories. The authors had ongoing discussions of categories and themes to maintain rigor in the study design. Text descriptive of the categories was selected and new themes were created. Each interview was re-read in detail and the authors returned to the data once again to check the reliability of the themes against the data. One author is a pediatric nurse practitioner who practices with Dominican-American adolescents in New York and so brought an insider perspective to the analysis of the interviews; the other author is a family nurse practitioner who has developed sexual health promotion interventions for Mexican-American adolescents and so provided an outsider perspective. The two perspectives allowed for analytic negotiation, which brought a richer understanding to the data (Thomas, Blacksmith, & Reno, 2000). This process also revealed individual biases, allowing the authors to recognize and reduce bias in the final analysis. The identified themes provide important structural information for the development of health promotion programs for Dominican-American adolescents. We provide an extensive listing of quotations to substantiate themes as there was consistency, but also diversity in their suggestions. Additionally, we elected to preserve the linguistic context of the participants' viewpoints via use of extensive quotations rather than risking its potential loss via paraphrasing of participants' words.
hookah (63%), alcohol (41%) and marijuana use (30%). While hookah use was high, only 4% reported smoking cigarettes.
Results
This theme concerns preferences about who would be the most appropriate professional or nonprofessional person to facilitate the health promotion program. They had many suggestions concerning the type of facilitator for the health program. Overall, the participants suggested health professionals, specifically a nurse most often followed by a doctor or social worker. Those who preferred a nonprofessional displayed some ambivalence, still wanted some aspects that a professional would bring, because they wanted a very knowledgeable nonprofessional. This can be seen in the following excerpts;
Sample Twenty-five adolescents participated in the study, including 19 females and 6 males. Participants all self-reported Dominican ethnicity and ranged in age from 13–21 years (mean, 17.28; standard deviation = 2.372).
Behavioral Profile Almost all participants (N = 23, 92%) reported that they were currently in school. Sixty-eight percent (N = 17) reported having had vaginal intercourse with the opposite sex. All sexually active participants reported having ever used a method to prevent pregnancy or infections; including ever use of condoms. Four (23.5%) of those who were sexually active reported having been diagnosed with a sexually transmitted infection. One female participant reported a history of pregnancy. All the males denied having caused a girl to become pregnant. The participants disclosed high rates of
Qualitative Results Several themes pertain to the respondents' preferences for health education. The first set of responses below reflect logistical issues about a health education program, which may not be specific to the Dominican culture. It may be a reflection that Dominican adolescents share many attitudes with a large portion of American adolescents. After these themes, we present themes that are specific to the Dominican culture.
Gender Doesn't Matter…Mostly The theme “Gender doesn't matter … mostly” provides the participants' perspectives about whether or not the gender of the facilitator would make a difference for the program. All participants stated that the gender of the facilitator for the program would not make any difference to them. Yet, as can be seen from the following excerpts, there was some ambivalence. In addition, a separate suggestion was to have a man and woman co-facilitate the program for others who may not be comfortable with receiving this information from the opposite gender. I think sometimes gender does matter. Um (pause) …I know I don't care, I could talk to a boy or girl, I don't care. But other people wouldn't necessarily wanna say some things to a man that they would say to a woman. Both, because maybe a boy won't feel comfortable talking to girl, and maybe a girl won't feel comfortable talking to a boy.Well my doctor is a male so I can't really tell him when I have my period and stuff like that it's awkward.
One young man expressed a preference for a man.
Anyone Who Has Seen a Lot of Whatever It Is You're Gonna Speak of ….
A nurse, yeah....definitely. I think a nurse, or anyone who has seen a lot of whatever it is you're gonna speak of, so maybe a social worker. I dunno. I guess someone who is well-informed I'm whatever the topic is. I think most people feel comfortable with a professional compared to a college student.
4
J.D. Champion and C.F. Roye Someone who is very informed on whatever subject. Someone who has experience with the topic. Sometimes you put a random person and they say textbook things...and I can tell if you're telling me what I can read.
Two participants, however, did not think that it needed to be either a doctor or a nurse and would rather have someone who they perceived as more “relatable”. The suggestion here is for a college student. I think that it shouldn't be a doctor. It shouldn't be a nurse. I think it should be someone who can be more relatable to the individuals who are coming and then people will be like, “Oh, she is just like me”.
Several participants suggested that it would be beneficial to have more than one person who was facilitating the program. This was primarily to meet the needs of those who just want somebody to talk to.
Where Would You Go for a Health Program? The theme “Where would you go?” contains descriptions of participant preferences for location of a sexual health program. Almost all of the participants indicated that they would attend a health promotion program at their clinic. This was in part a result of their familiarity with the clinic setting as well as program content. I would recommend a clinic or health center of some kind... basically anywhere that most people would feel comfortable going to. People would come to the clinic, I think what's going on here is really cool … And it's nice to see everyone in this community and everything.
This finding has implications for implementation of adolescent health programs within primary care-based settings. Issues providers may encounter within this setting include the availability of physical space.
Face to Face The theme “Face to face” contains descriptions of the reasons that participants gave for a preference for face to face provision of health programming. The respondents overwhelmingly preferred having a face to face group intervention for delivery of health information, as opposed to an online intervention, though some suggested augmentation via a “credible” website. Well, for a group I would say, um....just health in general. Teaching people dietary, foods you should eat, things like...hygiene, things like that, that could be group and universal, and people could be like ‘Oh, well I do this when I shower,’ or ‘I do this when I eat, just to like help me’, and ‘this is what I do in the morning,’ so that people can learn from each other–things like that. But individual....”I might have an STD,’ that should be left for people by themselves.
As can be seen from this quote, the group option was desirable in part because the adolescents' felt that they could learn from each other. However they indicated consistently that they believed it would be best to also offer an option for individual interventions during which they could discuss personal sexual health questions and concerns. It was interesting that the adolescents perceived this need by others however perhaps this was indicative of their need as projected upon others.
I Did it Myself The theme “I did it myself” describes how participants learned about sexual health. Participants related learning about sexual health on their own. They did not relate receiving any health promotion programs outside of the school system. The health programs that the participants did receive through the school system were not perceived as beneficial by many participants. I mean, I think that whenever I wanted to look something up I did it myself. I don't remember learning anything that I would remember that stood out to me cuz I went somewhere. Usually I do a lot of research on everything.
This quote summarizes the experiences related by the participants. They basically sought information using their own initiative and based upon their self-identified needs.
Do Not Trust Online Information The theme “Do not trust online information” contains the participants' description of their use of the Internet to access sexual health information and also their perceptions of the utility of this information. The participants indicated that they use blogs/WebMD/Google to obtain sexual health information. However they stated that they do not trust the online information. Most said they may go online, but then verify the information with a health professional or counselor. Some indicated that they use multiple sources to validate information. But naw, to find information I'll Google, but I don't like the pictures they show. I need someone who has knowledge on the topic, because Google exaggerates and is not really reliable. Google is a go-to for me. When I have any questions that I can't see a doctor, I go to Google to get an idea, and I usually go to certified websites such as Mayo Clinic. Yeah, there are times I research stuff on the computer or on my phone, but I don't really like, I don't know, I'm not 100%...there is always a detail missing. So what I do is, I go to my counselor, I have one in my high school and I talk to her. Like sometimes I call my school and that's the only way I can talk to her now …Cuz it's better like, someone that has a lot of experience … like … she is really old, and she knows a lot, and she has been in the medical field for years. So I would rather ask her than a computer or a friend.
Health Promotion Needs Other participants indicated that they do not use the Internet to access information. Reasons they gave for this included a preference for in-person discussions about their health. One participant suggested that program leaders could use technology to send information, as described below: Nope. I know that every teen is on there for like 24/7, but I feel like it's better in person … you learn more in person … but you guys could do like an Instagram, like everyone could follow it, send motivation, send tips and be aware of things. That would be good. Yeah, if I'm like searching yeah, but I don't consider it credible until I hear it from a doctor. Like if I came today, I would ask the doctor about those things.
Several participants indicated that they used the Internet to access information because they felt it provided anonymity. One participant stated this was particularly important when embarrassed about some of the questions being asked. Sort of...I just ask like silly questions that I don't want to ask other people cuz I'm embarrassed. I think it better to be electronic because there is no proof....it's not face to face, so people can keep themselves confidentially.
The theme “Do not trust online information” exemplifies the overall preference adolescents have for face-to-face, interpersonal, individual interactions for obtaining sexual health information. A facilitator for interventions may be conceptualized as a mentor, as in many situations adolescents may not sense comfort in discussion of sexual health with their parent or guardian. The following themes reflect issues which are prevalent in Dominican-American communities and the DominicanAmerican culture. These adolescents initiated discussion of cultural issues, even though there were no specific questions about their culture or how it impacts their health behaviors or education.
I Want to Learn More About… Participants reflected on a variety of health-related topics about which they would like to learn more, including sexual health, substance use, eating issues, poverty, obesity, self-harm and abuse. Many of these issues, while perhaps of general interest to adolescents, reflect issues that are particularly cogent in Dominican communities. One participant summed it up as: “So I think having a program that has all of it combined, and focuses on the individual and what their needs are would help....” Quotations from other participants substantiate this perception with descriptions of specific topic foci. We provide an extensive listing of quotations as there was some consistency and some diversity in their suggestions.
5 I think sexual health is really important. Like even when you're having sex and after, you still don't know everything … it's very important for people to understand...like a lot of people are very naive to the way you can get diseases, and … like going deeper into how it's just not...sex...it's oral, it's like different types of sex and stuff like that. I think it should be...in a community where you see a lot of people having kids at an early age I think sex that's really up there in the education, and even dieting too, because I′m getting so big. … Obesity … It hasn't been hard to speak about....but it's been difficult, a difficult journey...to try and want to lose the weight and know the direction to take. So, yeah....I like … touch upon topics that people do know about, but they go into more depth and really like...get into your mind, like this is what is going, here are the things, the measure that you can take to prevent this, or this is what you can do if you wanna lose weight, and they give you options that are very realistic and accessible to people of the Dominican community. …life motivation … poverty is usually a reason for these alternatives [risk behaviors such as drug use]. Because, if you can't find a job, or if you're bored, you just know, go to drugs. Especially if there are no recreational activities going on. So, I think life motivation is so helpful. Especially for those who feel like they can't get a job, or those who are like me who feel like they aren't getting anywhere with their weight, or someone who is fighting an addiction. I would like to learn more about abuse–like what takes people to do that. Because I have friends, I don't know why, but it's like every time I meet someone they come from an abusive house or something and I always help them. Like, during my high school year, I had a...my best friend, she used to cut herself.... Maybe more on hookah … cuz it's something that I do once in a blue ... and they're like “it's bad for you, but it's not so bad for you because blah blah”–I dunno, the whole point is it's not clear to me.
These quotations reflect considerable insight by the participants concerning dilemmas facing adolescents maturing within this society. These dilemmas concern key decisions adolescent face regarding their personal health within their unique environment.
I Ask My…Not My Mom Participants were asked who they typically go to for health information. In the theme, “I ask my … not my mom,” participants described seeking information from their health care providers, as it provided more confidentiality and fewer questions. Importantly, they do not feel judged by their providers. It is important to note that participants used the terms “doctor” or “nurse” interchangeably to describe health care providers; going to the “doctor” meant going to the clinic for health care. Nurse practitioners provided the majority of health care to adolescents at the clinic.
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J.D. Champion and C.F. Roye It's like anytime I have questions, I just call my doctors. I tell them what's happening, what do you recommend? And she'll say “Oh, come see me, we can talk more about that”, and I just make an appointment and come. Cuz like, about my sexual life–I cannot talk about that to my mom. I just do that behind her back … … But with doctors, I'm very open to. These are the people who know, these are the people who go to school for this. I am very open to tell them how it is, but my parents ……I can't tell her anything.
Other reasons cited by participants as contributing to their reluctance to seek sexual and other health information from parents had to do with perceived lack of time or interest on the part of parents. One participant related trust as a motivator to withhold information from a parent as described in the following excerpt. Yes … sometimes I do things that I'm not gonna go to my father or my mother...my mother is like my therapist like my diary … but then again, there are things you don't even tell your own diary. Can talk to my doctors about sex stuff or birth control … I can't tell my Mom.
However, it is not only sexual health that adolescents are uncomfortable discussing with their parents. As one participant expressed “Can't talk to mom or teachers (about my obesity), but tell doctor everything because they're there to help me.” In response to a query about whether there is any health concern that is difficult to speak about with your parents, your health care providers, or maybe a teacher, one young man contextualized a problem with confiding in his parents: Maybe my mother... cuz the fact of the matter with my father … our relationship is kind of, you know...I didn't learn that Plan B, I had to learn that myself in the moment, I didn't have no Plan B. Cuz I was selling drugs in school and I got suspended, could have been a court case, could have been in jail, the world of “what ifs”. So he looks down upon me, so that relationship is no longer the same, and it feels fake. Cuz in front of the doctor he is calling me “his baby”, “his son”, and I'm just like … but you don't say that in the house. So for the world, it's like yeah, everybody has smiles. But behind doors, everybody has closed cases.
Other participants related becoming more comfortable and seeking information and guidance from parents later during adolescence. One participant anticipated being able to talk with her mother when she became older. These experiences are described in the following excerpts. Yeah, I mean I have found it uncomfortable at first anything that like when I was in a relationship, with my mom, but after I broke into it. But that's when I was younger. Now I′m a little more … older … a little more mature so I do talk to her about it.
Sexuality was not the only issue participants felt uncomfortable discussing with parents. Participants also expressed concerns about being judged. They indicated that it was one of the motivators to seek information from health care providers; they did not want to feel as though they were being judged. Especially when you feel like you're not being judged. That should be something, like a judgment free zone, no one is judging you, you can open up, you can say how it is—cuz like even when you're talking to a health educator and doctor and you're like “oh my god, what is she going to think of me?” But no—she's heard this before. You're not the first one … you're not going to be the last one, and just being able to, when you do talk to that person, just reassuring them, and not getting straight to the point. Like, ease it—
One participant verbalized that her inability to confide in her parents, was because she was close to them and cared deeply about their opinion. Well doctors, no. Like, I have no filter, no chill, like if I′m talking to a doctor I'll tell them how it is. But I'm more censored if I'm talking to my mom or my sisters per se...because I care more about...not that I don't care about the doctor, but I care about my parents, the people that I care about, my close loves, I care about their opinion and their judgment before anybody else's. So, I would never tell my mom that I had sex, I would probably keep that til the day that I′m in my wedding dress, and be like “well, mom, I had to tell you, this awful but I'm not....”
I Just Keep Thinking of How People Can Be in My Culture–the Dominican Side… There were no interview questions related to culture, but participants brought it into the discussion spontaneously in response to a variety of questions. With this theme insider perspectives on the Dominican community and how a sexual health program would interface with this community were provided. Participants also offered cultural insights that they believed would help produce a program that would be successful in the Dominican community, when asked for suggestions about creating a health program for adolescents. These insights provided a multitude of perspectives as presented in the following excerpts. I just keep thinking of how people can be in my culture– the Dominican side anyway. I don't know if you've bumped into, I'm not stereotyping or anything just trying to put that on the table already, but I have met a … amount of people of the Dominican ethnicity that they can be stubborn, or they might joke a lot because of their discomfort, you know? Because in our culture, it does still happen from time to time, that it's not really encouraged to express certain feelings.... So they probably mask it with humor. Humor is a very popular way to mask certain discomforts and pain and stuff. So it is, I'm sure something you've come across and such, but it is still a thing.
Health Promotion Needs (Health insurance) they cut me at 18, and I get it cuz I'm not a kid anymore, I'm considered an adult in America. But, I couldn't apply for the adult one because I wasn't 21. So, for three years I didn't have health insurance … Well good thing, the Hispanic culture we have a lot of remedies for practically anything. So that's what I basically lived off of on. But, it was–it's just this awkward three-year gap that no one has health insurance. Yeah … And the, as well as the tradition behind marijuana AND hookah, because we forget to mention that. Some people think like “oh, it's cool”, but it's part of traditions for some cultures, it's not used as you know, “lemme just feel better.” I gotta think about....let's see...something helpful for the program...depends on cuz....Dominicans are hotheaded, we are hotheaded–yeah. Puerto Ricans too, but Dominicans are worse. Dominicans don't...when you give an offer, and want to help out, they be like “No″, but when you give them something they want they be like “hmm okay, let's go!” Know what I mean? Cuz you see that...you know, for example, you know like Medicaid? If you want to help out of with Medicaid they're gonna be like “no”, but when you tell them “oh, it's gonna get you medicine, it'll all be free,” they'll be like “oh yeah!”
In response to a question about where to hold the program, one young woman said … “So you know how people will be the stereotypes “Oh, he's white he must be a better doctor“. But here, in the neighborhood there is...all types of races, and it's like … “alright I can do with this”. One young women attributed her inability to discuss sexual health with her mother, to her culture. Because she is very like...follows the tradition, she likes to follow that we are supposed to have sex once we get married. And it's like … “God mom, it's the 21st century, it doesn't happen like that anymore”.
Discussion Evidence-based behavioral interventions designed for adolescent sexual health promotion may be modified for Dominican-American adolescents based upon these findings described in the themes. The quotations and themes in this paper reflect the influence that Dominican culture has on these adolescents, who spontaneously brought it up in many of their responses, despite the fact that no questions asked about it. This supports the conceptualization that “culture” and “ethnicity” matter to these adolescents. They perceived their connection to their culture as intimately important and relevant to the development of health programming. These quotations impart connection to the Dominican culture and pride in belonging. Therefore, interventions should be integrated into rather than layered upon their cultural milieu. Moreover, the topics of concern to these adolescents reflect some health issues that are particularly prevalent among Dominicans. Obesity was mentioned frequently, and with a sense of embarrassment that could be expected when
7 discussing what nurses might consider to be more personal topics such as sexuality. An interest in learning more about weight and obesity is especially notable because the rate of obesity among Dominican adolescents in the US is high and 21st tends to be more accepted among Hispanics in general (Vangeepuram et al., 2012). These adolescents evidently desired a health program that addresses weight and obesity. Clearly, this sample of adolescents brought up issues that might be expected regardless of cultural/ethnic background, including pregnancy sexually transmitted infections and drug use (Ewan, McLinden, Biro, DeJonckheere, & Vaughn, 2016). Even here, however, they mentioned issues specific to their culture such as hookah, which is especially prevalent in this population. Sixty-three percent of the adolescents in this sample reported hookah use, for example. Our study findings demonstrate that these young people were thoughtful about accessing health promotion data, and finding answers to their own health questions. Some findings were anticipated, while there were also a number of surprising results, including the importance of cultural influences on their ability to access sensitive information. Moreover, unexpectedly the adolescents were skeptical about sexual health information obtained via the Internet. While some adolescents chose sites that are reputable, i.e., Mayo Clinic website, they still sought face-to-face verification from “experts” who most often were health care professionals. The responses also suggest culturally congruent ways for nurses to address difficult subjects, for example by using humor. Difficulty discussing sexuality with parents seems to be particularly problematic for these adolescents. While none of the respondents specifically mentioned marianisma, similar to other Hispanic cultures, marianisma is prevalent in the Dominican Republic, i.e. a view of women that includes saintliness, self-sacrifice and passivity (DeSantis & Patsdaughter, 2008). This may underlie the difficulty adolescent females have in discussing sexuality with their mothers. Simply being sexually active before marriage is not consistent with the concept of saintliness. An understanding of this cultural context may be incorporated in programming to promote sexual health for this population. One young woman alluded to the difference between her own and her mother's perceptions, pointing out that “it is the 21st century”. It may be beneficial for nurses to work with adolescents and their parents – together or separately. However, this issue was not included in the interviews. Clearly, these adolescents were eager to learn more about sexual health, and had firm ideas about the areas they would like to have it addressed in health promotion programs. Their comments, incidentally provided some avenues that professionals can use to address these topics. The importance of their parental relationships was clear; although many adolescents felt they could not talk to their parents about sensitive health issues including sexual health and also obesity. More research is indicated for assessment of mechanisms to promote involvement of parents in sexual and other health promotion programs. A comparable study examining Dominican-American parents'
8 concerns about their children's health would be an important starting point. Hookah use was described as an accepted practice in the Dominican culture. The high rate of hookah use among these adolescents is of concern particularly as several cited their lack of knowledge about its use. Hookah presents serious health risks to those who smoke it, and those exposed to the smoke (Akl et al., 2010; Blank et al., 2011). Although many hookah smokers believe that hookah is not as harmful as cigarette smoking, there is evidence that it is at least as toxic, and possibly more so. Because the hookah mouthpiece is shared hookah presents the risk of spreading infectious diseases, such as influenza, herpes and hepatitis, among others (Soule, Lipato, & Eissenberg, 2015). Moreover hookah use appears to be growing rapidly among all adolescents (Barnett, Forrest, Porter, & Curbow, 2014; Smith et al., 2011). Some research suggests its use is more prevalent among Hispanic adolescents (Barnett et al., 2014), while other researchers found a higher prevalence among Whites (Smith et al., 2011).
Clinical Implications The results of this study can inform the health promotion activities of pediatric nurses who work with Dominican adolescents. The Dominican-American adolescents in this study had diverse health concerns, and sought health promotion information from a variety of sources. Importantly they primarily trusted only what they heard face-to-face from health professionals such as pediatric nurses and preferred this source. Their comments suggested that they were receptive to having a health program designed for them that would take place in person and in a familiar setting, such as the clinic. They conceptualized their health very broadly with concerns primarily about sexual health. However, substance use was also on their minds, as was anxiety about being overweight, violence and mental health issues. These adolescents spontaneously addressed cultural issues for Dominican-American adolescents as being relevant to their behaviors. Pediatric nurses may incorporate these issues into their health promotion programming; as well as other factors the adolescents mentioned such as use of humor when discussing sensitive topics.
Limitations The sample included 25 participants, all of whom were recruited from one clinic in a low income, urban neighborhood. They all were patients of record in the clinic, so all had access to the health care and anticipatory guidance that comes with primary care. Therefore, participants recruited in other settings may be less well informed or thoughtful about their health issues.
Conclusions These findings indicate that health promotion programming for Dominican-American adolescents would optimally address a broad conceptualization of health rather than focusing on only one issue. This programing would optimally incorporate
J.D. Champion and C.F. Roye Dominican cultural issues and be provided using face-to-face group or individual interventions provided by pediatric nurses in a primary care-based setting.
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