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Nursing News HighlightsAdvancing Culturally Competent Care

Overcoming Obstacles to Develop Specialized Patient Interventions

Unique approaches to care and research are not always accepted at first, and nurse innovators everywhere often overcome many obstacles to obtain the resources and credibility needed to implement life-changing ideas and programs. This is true for Antonia M. Villarruel, PhD, RN, FAAN, professor and the Margaret Bond Simon Dean of Nursing at The University of Pennsylvania School of Nursing (Penn Nursing), who developed the successful ¡Cuídate! or “Take Care of Yourself” program.

Even with her extensive background in health promotion and health disparities research and practice, Dr. Villarruel experienced pushback in developing the ¡Cuídate! program, a culturally-based curriculum designed to reduce HIV risk among Latino youth. In a recent interview with Johnson & Johnson Nursing, Dr. Villarruel discussed the challenges and triumphs of bringing this program to life, as well as her role as a nurse leader in reducing health disparities.

J&J: Can you share a little bit about your nursing background and your career journey? Who or what inspired you to become a nurse?
Dr. Villarruel: As the only daughter in a working-class Mexican family, there were two choices for my continued education and, ultimately, career: become a teacher or a nurse. While I had limited options in choosing a career – I am now in a career where the options are limitless.

My nursing career began working at two facilities in Michigan as a clinician at a migrant health center and as a residential psychiatric nurse in a transitional care home. I then worked at Children’s Hospital of Michigan (CHM) for 15 years in many positions as part of an interdisciplinary team that developed the first in-patient rehabilitation center in the hospital. I was inspired to become a nurse researcher through participating in various research efforts to assess and manage children’s pain with nursing colleagues. At CHM, we added pain as a fifth vital sign to our assessments, quickly changing how kids were being medicated. That experience of affecting direct, rapid change had me hooked on research – so I decided to pursue a PhD.
J&J: What led you to focus your research on promoting health and reducing disparities in the Hispanic community and the development of the intervention that became ¡Cuídate!?
Dr. Villarruel: My own background guided my population focus. As a bilingual Mexican-American, I am in a unique position to focus on research that can benefit and impact my community. I wanted to focus on health promotion and health disparities in my community because there was a need for research in this area. I was also inspired by Latino community-focused leaders’ personal investment in the community.

I came to Penn Nursing as faculty in 1995, when HIV was emerging as a major health concern among minority populations. We partnered with community members who were working on similar issues, as well as our colleagues, doctors Loretta and John Jemmott, who developed an intervention to reduce sexual risk behaviors among black youth. Additionally, we worked to adapt and tailor the intervention for Latino youth by incorporating salient aspects of Latino culture into the approach.
J&J: What types of barriers/challenges did you face in securing support for ¡Cuídate!?
Dr. Villarruel: The earlier challenges were related to funding, specifically to support the adaptation and testing of the curriculum. The proposal was rejected many times because reviewers didn’t believe Latino parents would engage in research, nor allow researchers to talk to their adolescents about sex or condom use. This was uncharted territory at the time, as no one had yet developed or tested approaches to reduce sexual risk behavior among Latino youth. The lack of Latino researchers who could evaluate our research proposals played a big part in this gap. But I persisted.

I made sure I had the evidence, I made the case, and I sought and received honest critiques of my work. In 1999, I received funding from the National Institutes of Health (NIH) to conduct a randomized controlled trial to evaluate the effectiveness of ¡Cuídate!. It was shown to reduce the number of sexual partners of participants, reduce their rate of unprotected sex, and increase the age at which they first had sex; it was also proven to be sustainable over time.
J&J: Why is it important for public health initiatives to take cultural differences into consideration? In what ways do traditional programs often fall short of serving minority communities?
Dr. Villarruel: Traditional programs often assume that “one size fits all.” We know better now! We’ve come a long way in knowing successful public health initiatives must take into consideration the values, norms, and preferences of the population, and include community members in the design, implementation, and testing of such approaches. Importantly, communities are much more selective in choosing research partners. They are tired of the “swoop in, get your data, and swoop out” mentality, and are looking for partners who will work side by side in using and evaluating data to solve problems they see as priorities.
J&J: How does your research help to highlight the importance of cultural competency within the healthcare community?
Dr. Villarruel: ¡Cuídate! was a success because it was an intervention geared toward a specific population, incorporating the cultural attitudes, beliefs, and norms of that population. As our program was disseminated, we provided a framework and guides to best adapt the intervention to local needs – without affecting the components that we knew to be effective. Additionally, I was available to work with community groups and trainers to help solve issues never encountered during the research phase, resulting in community members taking ownership of ¡Cuídate! because they experienced the positive reactions of youth and families, and believed they were having a positive impact in their roles.
J&J: What role do nurses play in reducing healthcare disparities within minority and underserved communities?
Dr. Villarruel: The roles we can play in reducing healthcare disparities are endless! As providers, we have opportunities to intervene at the point of care. As educators, we can work with communities to provide a learning context for students to understand how social determinants of health affect individuals, families, and communities. As researchers, we can work with communities to design and evaluate programs and use data to make informed decisions. Playing each of these roles is our opportunity to advocate for programs and policies to sustain individual programs and interactions.
J&J: In what ways do you foresee this work becoming impactful to the nursing community?
Dr. Villarruel: The impact to the nursing community on health and healthcare disparities is not the focus of why we do (or should do) this work. Rather, as part of addressing the care of individuals, families, and communities, we must address the multitude of factors that affect health. Nurses are not just concerned with healthcare. Nurses – more than any other health profession – have always been concerned with context and addressing the environment to support optimal health. Addressing health disparities is part of nursing’s social mission.
J&J: What advice do you have for nurses (or nursing students) who want to improve their cultural competency skills?
Dr. Villarruel: Cultural competency isn’t improved by just being in a classroom, or in a healthcare setting. Nurses and nursing students need to be familiar with the context in which care is provided and in which their clientele live, work, play, pray, and worship. Look for opportunities to put yourself in the surrounding neighborhoods; get involved in outreach activities like volunteer opportunities; and find yourself a “community mentor” who can help guide and teach you about the community history and norms. Importantly, ask for feedback in your interactions as a way of understanding how your messages are received.
J&J: Is there anything else that you would like to add?
Dr. Villarruel: This is a great time to be a nurse! The opportunities to positively impact individuals, families, and communities are endless. As the most trusted group of health professionals, we must use our voice to promote health for all.
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