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Nurs Clin North Am. Author manuscript; available in PMC 2023 May 2.
Published in final edited form as:
Nurs Clin North Am. 2022 Sep; 57(3): 393–411.
Published online 2022 Aug 2. doi:10.1016/j.cnur.2022.04.006
PMCID: PMC10153429
NIHMSID: NIHMS1890779
PMID: 35985727
Rosa M. Gonzalez-Guarda, PhD, MPH, RN, CPH, FAAN,a,b,* Irene C. Felsman, DNP, MPH, RN,a,c and Rosa M. Solorzano, MPH, MDa,d
Author information Article notes Copyright and License information PMC Disclaimer
The publisher's final edited version of this article is available at Nurs Clin North Am
INTRODUCTION
The Latinx (gender inclusive term for individuals of Hispanic or Latin American descent)1 population is a heterogenous community representing a large segment of the US population.2 This ethnic minoritized group represents diverse racial identities, languages (including indigenous languages), heritages, immigration status, acculturation levels, and other social determinants that influence their health. As a whole, the Latinx community represents 18.7% of the total US population,3,4 with Mexican (61.5%), Puerto Rican (9.7%), Cuban (3.9%), Salvadoran (3.9%), and Dominican Republic (3.4%), representing the largest subgroups based on origin. Latinxs are among the fastest growing minoritized groups in the United States and are expected to represent 60% of the population by 2060.5 In order to advance population health in the United States, it is imperative that nurses address the unique needs and strengths of this population. Schools of nursing across the country can play a unique role in leading efforts to promote health and well-being in this population through preparing a culturally humble nursing workforce, research that informs interventions and policies promoting health equity for this population, and providing direct services that are responsive to the needs, preferences, and strengths of the community. The purpose of this article is to describe a model used by a school of nursing for engaging and promoting health equity among the Latinx community in North Carolina.
HEALTH DISPARITIES IN THE LATINX COMMUNITY
The Latinx community in the United States experiences significant health disparities related to a myriad of health conditions. For example, when comparted with Non-Latinx White individuals, Latinx people are 23% more likely to be obese,6 2.5 more likely to have undiagnosed diabetes,7 35% more likely to have chronic liver disease,8 and 3.6 times more likely to acquire human immunodificiency virus (HIV).9 These health disparities are exacerbated by the fact that this group has the highest uninsurance rates in the United States,10 significantly limiting access to needed preventative services and lifesaving treatments. For example, although Latinx individuals are less likely to have heart disease, they are more likely to have uncontrolled hypertension.6 Latinx individuals also have lower cancer screening behaviors, placing them at risk for detecting cancer at later stages in progression.6,11,12 Lack of insurance, interacts with other social factors such as low education levels, high rates of poverty, exposure to poor working conditions, and experiences with discrimination to place this community at a disproportionate risk for poor health.6,13 Disparities experienced by the Latinx community became very apparent during the COVID-19 pandemic because they were 3 times more likely to acquire the infection and 2 times more likely to die than their non-Latinx White counterparts. In fact, the Latinx community has experienced a higher decline in life expectancy than non-Latinx Black and non-Latinx White individuals (3.88,3.25, and 1.36 years, respectively) during the past 2 years.14 If disparities among the Latinx community are not addressed, these will only continue to grow alongside the growth in this population.
Health care in the United States is not typically designed to meet the needs of the Latinx community. Not only are services often out of reach for Latinx families due to lack of insurance or proximity of these service15,16 but they are often not culturally and linguistically tailored for this population. For example, only 7.4% of registered nurses and 6.5% of physicians are Latinx, and only a small segment of health-care providers speak Spanish, the most common language spoken by individual with Limited English Proficiency (LEP).17–20 Although access to interpreters are required through the Culturally and Linguistically Appropriate Services (CLAS) standards, Latinx patients with LEP often have to rely on family, friends, or other untrained individuals as interpreters.20,21 Additionally, core cultural norms and experiences are often not considered. For example, although acculturative stress, the stress associated with being Latinx in the United States and adapting to a new context, and the acculturation gaps between parents and children are key social determinants of health for Latinx families, they are rarely considered in a clinical encounter or in population health approaches targeting this population.22–24
The Latinx community in the US South is particularly marginalized due to systemic causes. Because the US South is a more recent immigrant-receiving region, there are less resources available for immigrants, the vast majority who are Latinx.25 Additionally, states in the US South are among those with the highest uninsurance rates, which is in part due to the states not expanding Medicaid expansion.16,26 Additionally, hostility toward immigrant and Latinx populations, and the adoption of community-based immigration and custom enforcement programs has contributed to fear in this populations and reluctance of Latinx immigrants to access needed health and social services.27–31 Given this context, it is imperative that nurses go beyond the walls of their institutions to address the evolving needs of the Latinx community, leveraging strengths that exist in the culture and local context. Partnerships with trusted community-based organizations (CBOs) and faith-based organizations (FBOs) are essential in meeting the needs of this population. Duke University School of Nursing (DUSON) provides a model that is responsive to the recommendation from The Future of Nursing 2020–2030 Charting a Path to Achieve Health Equity17 report and provides an exemplar of nurses leading health equity for the Latinx community.
THE DUKE UNIVERSITY SCHOOL OF NURSING LATINX ENGAGEMENT AND EQUITY MODEL
Principles
The DUSON Latinx Engagement and Equity model is built on the principles of community engagement, including principles of community engaged research (CEnR) that have been demonstrated to have an impact on promoting health equity in historically marginalized populations.32,33
Collaborative partnerships with diverse community organizations and leaders to address historically marginalized Latinx groups across the life span.
DUSON has developed partnership with several community organizations (Table 1) that spans over 25 years to mirror Latinx population growth in Durham, NC, where Duke University is located (Fig. 1). These partnerships were developed with the intention of reaching the most historically marginalized groups in the Latinx community, such as families with a low income, uninsured individuals, and undocumented individuals who often do not seek health care within the walls of Duke Health. These organizations include both CBO and FBO, as well as community-based health-care institutions such as federally qualified health centers that provide direct clinical care. DUSON works in partnership with these organizations, never on their own, to reach a diverse population of Latinx communities across the life span and through diverse health delivery models.
Fig. 1.
History of DUSON’s Engagement with the Latinx community.
Table 1
Summary of Community Organizations Duke University School of Nursing has partnered with to engaged the Latinx population
| Organization | Population | Service Provided | Description of Partnership Activities |
|---|---|---|---|
| Church World Services | Immigrants and refugees | Relocation support; job preparation | • DUSON student volunteers provide safety inspection on new housing, first aid kits, and assisting families to access health care |
| Curamericas | Mothers and children in Latin America; Latinx in NC | Global and public health services | • Partnered on a CEnR application to test a multilevel intervention addressing acculturative stress and resilience in the Latinx immigrant population • ABSN student placements contribute to global missions and local COVID-19 response |
| Durham Public Schools | Latinx children | Learning together program | • ABSN clinical placements provide health education and health fairs |
| El Centro Hispano | Uninsured Latinx population | Health and social services, advocacy, education, English literacy | • Partner on CEnR studies to examine the effects of acculturative stress and resilience on Latinx immigrant health and to develop and test CHW delivered interventions • ABSN clinical placements contribute to their health programming |
| EL Futuro | Uninsured Latinx populations | Mental health services | • Placed Psychiatric Mental Health Nursing Students for clinical placements • Partnered on a CEnR application to improve the participation of Latinx in clinical trials • Faculty and staff volunteered at events and served on the board of directors |
| Iglesia la Semilla | Methodist Latinx community | Religious services; health ministry | • DUSON collaborates in COVID-19 response to provide education, testing, and vaccination • Partnered on a CEnR application to improve the participation of Latinx in clinical trials • Collaborating to develop training for CHWs and medical Spanish for students |
| Immaculate Conception Church | Catholic Latinx community | Religious services; health ministry; community outreach | • ABSN clinical placements and provide health education and screening after masses and facilitate support groups; CPR and first aid training for ushers. |
| Lincoln Community Health Center | Uninsured Latinx population | Primary health care | • D-CHIPP scholars address prioritized areas for quality improvement • Diabetes support groups in Spanish Certified Diabetes Health Educator (ADA certified) • Direct clinical care by DUSON faculty |
| Mexican Consulate | Mexican immigrants | Consulate services to citizens of Mexico | • ABSN students placements contribute to “la ventanilla de salud/the health window” providing health education and screening |
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Note: CEnR, community engaged research; CHW, community health workers; DUSON, Duke University School of Nursing; D-CHIPP, Community Health Improvement Partnership Program; ABSN, Accelerated Bachelor of Science in Nursing.
Ongoing engagement that is responsive to evolving needs and opportunities.
DUSON has had a long history of engaging with the Latinx community that began in 1997 in collaboration with El Centro Hispano, the first Latinx serving CBO in the region as depicted in see Fig. 1. This ongoing engagement has been responsive to the evolving needs of the population by making sure to (1) prioritize addressing health conditions that disproportionately impact the Latinx community, (2) being responsive to priorities identified by community organizations and coalitions, and (3) leveraging the community leaders, organizations, and networks that already exist to address these issues. For example, DUSON faculty, staff, and students engage in several health education and community-screening activities in collaboration with CBO and FBO partners to address the high levels of obesity and diabetes in the community, conditions that are not only documented to disproportionately impact the Latinx community15 but also identified as a local community priority.34 When the COVID-19 pandemic affected the globe and was at its peak, affecting 3 times as many Latinx individuals than non-Latinx whites,35 DUSON responded to this disparity by deploying bilingual/bicultural nursing students as part of the contact tracers in partnerships with organization who were leading this such a Curamerica, conducting research to understand drivers of this disparities and potential solutions through an existing study funded through the National Institutes of Health (R01MD012249), and partnered with a coalition of multiple stakeholder to advocate for Latinx health equity during the pandemic. The ongoing engagement of DUSON with the Latinx community, prepandemic, facilitated the success of advocacy efforts.
Spanning the tripartite mission of education, research, and service to enhance mutual benefits.
The DUSON model intentionally spans the academic missions of education, research, and service. This has helped ensure that there is mutual benefit from both the community and academic stakeholder and created a balance between research and action. For example, faculty and staff meet monthly with leaders from El Centro Hispano’s health program. In those meetings, faculty and staff check in on the progress related to a collaborative CEnR study, plan community, and public health clinical activities that are responsive to the organization’s and community needs and assess organizational needs from both the community and academic perspective. The clinical placements of student at El Centro allows DUSON to offer assistance to El Centro in meeting their goals for their health program through the support of the students, providing a benefit for El Centro and a service for the community while simultaneously providing training experiences for students. The provision of health services such as evidence-based education and screening while data are still being collected and analyzed from a separate research study allows DUSON to provide care while new interventions are being developed and tested through research. Partner needs are also addressed and have resulted in mutual benefits. For example, El Centro has asked DUSON faculty and staff to provide training to their staff (eg, mental health education for community health workers [CHWs]) and DUSON faculty and staff have asked El Centro to conduct trainings on the local Latinx community for learners.
Diverse representation from both Latinx and non-Latinx nurses and interdisciplinary partners that fosters cultural humility.
The DUSON model intentionally engages faculty, students, and staff from diverse heritages, immigration and generational experiences, racial and gender identities, and language preferences in addressing the needs to the Latinx community. The model intentionally engages both bilingual and bicultural health care providers and individuals from non-Latinx identities in this study, recognizing the importance for all health-care providers to have a level of awareness of the needs and strengths of the Latinx community. The diverse learning and working environment helps to foster the actions that come from the Rainbow Model of Cultural Humility (eg, openness, self-awareness, flexibility, recognition of power imbalance),36 to support each other to tailor responses to the population, avoid stereotypes and biases, and serve as advocates for change in health-care institutions. For example, in the Medical Spanish courses that are provided, learners from diverse personal identities and disciplines to engage in bidirectional learning in partnership with community partners who contribute to an understanding of how the local context shapes the experience of diverse local Latinx communities and helps inform tailored approaches that are responsive.
Respeto and Carino as Core values.
Respeto (respect) and Carino (love) are core values for many Latinx communities that are vital for health promoting interactions with health-care providers.37,38 The DUSON Model intentionally incorporates these values in our approach through specific behaviors demonstrated to the community. Respect is operationalized in a multitude ways. DUSON faculty, staff, and students do not engage with the Latinx community without a CBO or FBO partner that has established trustworthiness in the community. Value is also placed on the lived experience of the community and their expertise. For example, DUSON faculty, staff, and students often work with CHWs to design, implement, and evaluate health initiatives. Every individual is treated with the dignity they deserve and services are provided despite access to documents that are often required in health care such as a license and a health insurance card. For example, in a CEnR research study led by DUSON addressing the Latinx community, investigators were able to get a waiver for collecting social security numbers or tax identification to compensate participants for their participation. Carino is approached through communicating warmth as interpersonal relationships are established and care is provided. This can be demonstrated by gestures that can range from asking for aspects of the individual’s personal life such as their family demonstrating a connection such as a common heritage, providing a card with a personal message (eg, birthday cards for research participants), and expressing affection during interactions such as engaging in an embrace when a patient expressed gratitude for providing health service. These culturally responsive strategies are foundational to establishing trustworthiness with this population.39
Institutional support for Latinx Engagement.
Institutional support by DUSON and the broader Duke University community has helped facilitate meaningful and sustainable engagement with the Latinx community. DUSON’s Office of Global and Community Health Affairs facilitated early engagement with the Latinx community, both locally and globally. In 2017, the DUSON Community Health Improvement Partnership Program (D-CHIPP) was established and provided additional infrastructure and funding to support local community engagement as a result of the implementation of the school strategic plan. For example, through funding provided by D-CHIPP, DUSON was able to purchase hemoglobin A1C screening materials to expand diabetes screening in the Latinx community and in accordance to established guidelines.40 DUSON’s Center for Nursing Research has helped provide training for community partners in submitting grants and supported an institutional license to be able to make the collaborative institutional training initiative (CITI)41 available in Spanish. The Community Engaged Research Initiative (CERI) of the Duke Clinical Translational Institute provides additional support through consultations, education/training, providing funding, supporting community coalitions, and advocacy to support CEnR. For example, CERI has helped facilitate community consultation studios for DUSON faculty. These consultation studios are on the engagement studio model42 and have provided opportunities for DUSON faculty engaged in research with the Latinx community to receive their input on their research ideas and protocols. DUSON has also worked with Duke’s Office of Civic Engagement to broker relationships between Duke University and Latinx serving organizations to respond to emerging needs such as the mental health crises that has been exacerbated in the Latinx community by the pandemic. This tapestry of services provides a rich environment for engagement.
Core Programs and Activities
DUSON has core programs with a specific focus on engagement with the Latinx community that builds on its academic, research, and service missions. These programs are integrated in the 5 academic programs: Accelerated Bachelor of Science in Nursing (ABSN); Master of Science in Nursing (MSN), which include 8 advanced practice nursing specialties and 3 nonclinical majors; Doctor of Nursing Practice (DNP), inclusive of a Certified Registered Nurse Anesthetists (CRNA) tract, and a PhD program. Three of these are onsite (ABSN, CRNA, PhD), allowing for the opportunity for students to be immersed in work in the local Latinx community.
ABSN Local Community Clinical Immersion Experiences. The ABSN program includes a community and public health required course with 56 hours of clinical immersion. Groups of 6–10 students are imbedded in various CBOs and FBOs with long-standing engagement with DUSON (see Table 1). Students with Spanish language ability (beginner, proficient, or native speakers) work with bilingual/bicultural instructors to (1) conduct a community assessment (windshield/walking surveys; key informant interviews; focus groups surveys), identifying assets and needs; (2) determine mutual goals and objectives with community partners; (3) plan an intervention; (4) and finally evaluating the success of the programming. Examples of areas of intervention include hypertension, diabetes, obesity, nutrition and food insecurity, infectious disease (HIV and COVID-19), hygiene, women’s health, and stress and resilience, all health disparities prioritized by the Latinx local community.
ABSN Global Clinical Immersion Experiences.
A percentage of ABSN students opt to fulfill their community and public health clinical hours through a global immersion program offered as an alternative to the local experience. Groups of up to 10 students travel with an experienced clinical instructor to one of several Latin American countries, including Nicaragua, Guatemala, and Honduras, regions that represent the origins of a significant proportion of the local Latinx community in Durham, NC. Students in the Global Immersion carrying out similar activities as the local immersion, however, within the context of a different health system and culture that helps facilitate their understanding of the lived experiences of immigrants in the United States as they encounter a new context.
Masters, PhD, and DNP Student Clinical Placements and Engagement.
Graduate level students often leverage the faculty’s long-standing community partnerships with the Latinx community for research and quality improvement projects. For example, one longitudinal study of Latinx young adults has allowed students in several programs to learn about CEnR and contribute to data collection, analyses, and dissemination. These have been used as Directed Scholarship opportunities (independent studies), research practicum, and dissertation research. In addition, through a university wide funding source [Bass connections], students from the undergraduate to PhD levels have had the opportunity to work with faculty and postdoctoral fellows on several focused research projects pertaining to the Latinx community. When MSN students are local, they can be placed in local settings serving the Latinx community such as clinical placement at El Futuro for students in the Psychiatric Mental Health Nursing postmasters certificate program. Several DNP quality improvement scholarly projects have focused on the Latinx population, in South America and in North Carolina. Two projects in Bolivia addressed triage protocols in an outpatient clinic and another on appropriate diagnosis of bacterial infection and antibiotic prescription.43 An NC project focused on diabetes peer education within the Latinx community.
Volunteer Opportunities.
Outside of the formal academic program, nursing students at all levels have several volunteer service opportunities that they may choose to be involved in. In the local community, an annual Latinx health fair is organized by El Centro Hispano with support from DUSON and other community partners. Nursing students and other learners (eg, Medical Spanish) participate in screenings, health education, and triage activities. Throughout the pandemic, students have volunteered in COVID testing and vaccination efforts through various community-organized events. A student club, Nursing Students Without Borders, engages in service to the Latinx community, both locally and globally. They partner with a local resettlement organization (Church World Service) to prepare housing for new immigrant families, including doing a safety inspection, providing first aid kits, and assisting families to access health care. Students collaborate with a faculty advisor to organize an annual service trip to the Guatemalan highlands to work with midwives and health workers in a remote community-based health center focused on maternal-child survival. Nursing alumni, as well as other health professional students often join students on this trip.
Interprofessional Courses in Medical Spanish.
Medical Spanish and Cultural Competence courses started at DUSON in 1998 as an interprofessional initiative funded by the Duke Endowment that also engaged different departments at Duke (Physician Assistant, Physical Therapy, and Medical Students, Residency Programs), the Linguistic Center at El Centro Hispano, and Lincoln Community Center. These courses have evolved from evening classes offered at El Centro Hispano for no credit, to a series of courses that are offered for credit that includes distance-based components delivered through synchronous and asynchronous activities. Currently, Medical Spanish courses are offered through 2 3-credit hour elective courses tailored for both beginners and advanced learners (see curriculum on Table 2). Nursing students from different levels of experience and across academic programs at DUSON bring their unique perspectives to embrace cultural diversity, respect the unique perspectives of other disciplines within their own body of practice, whereas contributing to the needs of the team. Such a meaningful collaboration allows students to engage others through joint didactic classwork, which permits them to delineate individuals’ roles and responsibilities serving as a model for future patient care to maintain their own competence in their profession.40
Table 2
Medical Spanish and cultural competence curriculum
| Introduction to Medical Spanish and Cultural Competence Level I and II | Advanced Medical Spanish and Cultural Competence Levels I and II | |
|---|---|---|
| Course Description | Designed to help health-care professionals and learners develop basic languages skills in Medical Spanish to enhance their cultural competence when caring for Latinx patients. Aspects of Latin American culture—especially those most pertinent to health care—are included in each lesson | Designed to help students achieve fluency when engaged in health-related interactions with Latin American populations. Aspects of Latin American culture—especially those most pertinent to health care—are addresses as students engage in more complex or emotionally charged interactions with the Latinx population |
| Delivery | 12 sessions 1:45 min synchronous/1:45 min asynchronous work | 12 sessions 1:45 min synchronous/1:45 min asynchronous work |
| Objectives | 1. Use basic sentences in present tense, past and future tenses of regular and irregular verbs for common health-related patient care issues 2. Use medical Spanish vocabulary in patient-related situations, such as intake or health history interviews, conducting a physical examination or providing health-related education to Latinx populations 3. Explain unique considerations health providers must make to respect cultural beliefs and practices when conducting intake or health history interviews with Latin American patients/families 4. Explain unique considerations health providers must make to respect cultural beliefs and practices | 1. Communicate in Spanish using fluent language skills (written, oral, reading, listening) incorporating the present tense, present perfect, past, imperfect mood of the past and future tenses of regular verbs and other common health related reflexive and irregular verbs 2. Engage in dialog with Latinx patients/families about health-related issues or decisions using fluent Spanish language skills and medical vocabulary 3. Explain unique considerations health providers must make to respect cultural beliefs and practices when engaging in dialogue about health-related issues or decisions with Latin American patients/families 4. Use medical Spanish vocabulary in the context of simulated patient care scenarios on nursing care skills 5. Correctly convey Spanish speaking Latin American patient’s questions and concerns about health care to non-Spanish speaking health providers 6. Explain unique considerations health providers must make to respect cultural beliefs and practices when performing nursing care skills and using an interpreter with Latin American patients/families |
| Content | Level 1 • Verbs: To be (Ser and Estar), to have (tener), to hurt/pain (dolor/ doler) • Grammar: Verbs in present tense, regular verbs and some irregular verbs, past participate as an adjective, basic sentence structure, making questions • Vocabulary: Medical professions and specialties, countries of origin, symptoms, injuries, body parts and organs, days of the week, numbers, clinic items, vital signs, family, pharmacy, taking a basic interview-intake form • Cultural Competence: basics, family, attitudes toward health care, impact on effective communication with healthcare providers, social drivers of health Level II • Verbs: Verbs gustar, querer, preferir, deber, regular verbs for the physical examination • Grammar: present tense, future tense, past tense, direct and indirect object pronoun Vocabulary: Diet and Nutrition, health history, physical examination, illnesses and symptoms, cardiovascular, maternity, mental health, infectious diseases • Cultural Competence: Cultural thoughts and attitudes toward traditional medicine, nutrition, mental health, and childbearing. Practicing interview models applying concepts of humility, respect, and personalism relevant to the Latino culture. Roles of the interpreter/patient/provider | Level 1 • Verbs: To be (Ser and Estar), to have (tener), Pain (dolor/doler) • Grammar. Verbs in present tense, regular and some irregular verbs, past participate, future sentence, basic sentence structure, elaborating questions • Vocabulary: Medical Professions and specialties, Countries of origin, symptoms, injuries, body parts and organs, days of the week, clinic items, vital signs, family, pharmacy, conducting a medical interview-intake form, introduction to the physical examination, some illnesses • Oral Skills: Conduct a medical interview using numbers, day of the week, key question, and commands for physical examination. Provide education about and medications in Spanish • Cultural Competence: basics principles of cultural competence, family, pharmacy/traditional medicine and attitudes toward health care Level II • Verbs: reflexive verbs, regular, and irregular verbs, commands • Grammar: past and present perfect tense, imperfect mood of the past tense, future tense • Vocabulary: Nutrition, Physical examination, test and procedures, hospital admissions and presurgery care, illnesses and review of systems, how to become an interpreter, basics skills in nursing • Oral Skills: Conduct a complete health interview using symptoms, diseases, systems, medical procedures. Provide education about nutrition, medications, maternity, trauma, mental health. Conduct basic nursing skills with focus on giving education in Spanish using the simulation laboratory • Cultural Competence: Cultural thoughts and attitudes toward traditional medicine, nutrition, mental health, and childbearing. Practicing interview models applying concepts of humility, respect, and personalism relevant to the Latino culture. Roles of the interpreter/patient/provider |
| Evaluation methods | • Homework • Quizzes/Examinations • Oral video recordings • Class Participation | • Homework • Quizzes/Examinations • Oral video recordings • Class Participation • Essays |
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A myriad of teaching and learning strategies are integrated with synchronous and asynchronous strategies to enhance competency in Medial Spanish and interprofessional care for Spanish-speaking communities. Simulation activities (eg, providing labor and delivery and postpartum care to a family) are integrated into the course, and students are allowed to apply their medical Spanish speaking skills to gain confidence and receive appropriate feedback when errors ensue within the context of their role on the interprofessional team. Distance-based students are able to participate through video conference throughout the simulation. These courses also offer students local and global opportunities where students can practice in “real world” settings through community experiences such as participating in a health fair in collaboration with El Centro Hispano or participating in a global immersion trip. Finally, students are paired with students from la Universidad Politécnica de Nicaragua/the Polytechnical University of Nicaragua University, Nicaragua and engage in 3 conversations, were they share experiences about their culture, nursing profession while practicing their Spanish oral skills. DUSON students also have the opportunity to participate every year in the interprofessional course and clinical outreach Exploring Medicine: Cross-Cultural Challenges to Health in the 21 Century-Honduras. The team consists of faculty, staff, and students from the Schools of Nursing and Medicine. During the course and outreach, students learn about how culture influences the delivery ofhealth care, provide health education, and basic clinical and dental care to a rural Honduran community. The team works very closely with the Honduran health system and CBO whom identify their needs. Lessons learned from the trip are translated to their care of Latinx families in the local communities.
Research addressing Latinx Health Equity.
In 2017, the SER (Salud, Estrés, y Resiliencia/Stress, Health and Resilience) Hispano study was funded by the National Institute on Minority Health and Health Disparities (R01MD012249, PI: Gonzalez-Guarda, R.M.) to examine the impact of acculturative stress and resilience on the syndemic outcome of substance abuse, violence, HIV, and mental health as well as stress biomarkers. This was the first research study at DUSON specifically addressing health equity in the local Latinx community. This initial funding was leveraged to enhance the scope of this research to include examining the impact of the political climate on the health (Bass Connections Grant; PIs: Stafford, A., Nagy, G., & Felsman, I.), to engage the community in identifying needs and preferences for interventions addressing acculturative stress (diversity supplement, Nagy, G.), and pilot different approaches using a multitude of funding available through Duke. CEnR strategies were integrated throughout these studies and included community partners as coin-vestigators and members of the research team, consultants of the research (eg, community consultation studios, advisory boards), the use of bicultural and bilingual members of the local community such as CHWs as interventionists, and a focus on returning the results to the participants through newsletters and events that allowed participants and health and social providers to come together, entitled “Access to Immigrants.” Research from this team has helped advocate for the Latinx community during the COVID-19 pandemic, and served as a source of training for learners from a range of disciplines (eg, nursing, medicine, psychology, global health, anthropology) and levels of training (eg, undergraduate to postdoctoral). A Latinx health equity laboratory has also been established at DUSON to support a growing community of scholars that are addressing diverse health equity topics in their research in partnership with Latinx communities.
The Latinx Advocacy and Interdisciplinary Network for COVID-19 (LATIN-19).
DUSON faculty, staff, and students have been key leaders of LATIN-19, is a coalition of more than 700 registrants that have convened since the onset of the COVID-19 pandemic to focus on strategies for reducing health disparities in the Latinx community during COVID-19.44 Members of LATIN-19 represent diverse sectors including health care, public health, CBOs, FBOs, education, government, media, and others. Members of the DUSON community collaborate with this extensive network through their service on the executive team, helping to lead events such as vaccination clinics, supporting staffing events with trained bilingual/bicultural student volunteers (eg, ABSN students with local and global placements serving the Latinx community; Medical Spanish students), and leading research and evaluation efforts for the coalition.
The coalition leverages the strength of preexisting community partnerships and fosters new collaborations among community members with a commitment to the Latinx population.13 About 60 to 100 participants meet weekly via a virtual platform. The weekly meeting allows for information sharing from diverse perspective, opportunities to network and collaborate, and the opportunity for individuals in leadership positions to listen directly from community members on their lived experiences during the pandemic. Hearing stories directly from community members has been a key driver to promote change and action around issues regarding the health of the Latinx community. Simultaneous interpretation is provided in English and Spanish. The LATIN-19 approach uses the principles of the socio-ecological model (eg, intrapersonal, interpersonal, community levels, and so forth) of health and community engagement to respond to the unique needs of the Latinx community.45 Interventions by Latin-19 include creation and dissemination of health promotion materials through partner organizations, coordination of testing and vaccine clinics, production of public service announcements, engagement with media across multiple platforms to create awareness of health disparities affecting the community, and advocacy for systems changes to promote health equity in this community.
IMPACT
DUSON’s Model for Latinx Engagement and Health Equity is far reaching and has an impact on a learners, faculty and staff, and the broader community.
Learners
DUSON’s increasing efforts to engage students in addressing the needs of the Latinx community through an equity lens have had several benefits for learners. Not the least of these is to highlight through real-time experience the importance of cultural intelligence when working with diverse individuals and families, both in their countries of origin and in their chosen country of resettlement, the United States (Buchanan and colleagues 2021). Didactic learning, coupled with clinical immersion experience, allows for integration of concepts and skills. Students learn through immersive experience essential concepts regarding global socio-political issues pertaining to the Latinx population, both locally and globally (Clarke and colleagues, 2016). Through faculty and clinical instructor guidance, students are prompted to reflect on personal expectations and cultural perspectives regarding community members and professional colleagues they interact with during immersion experiences (Onasu, 2021) and gain skills and confidence in intercultural interactions. Interprofessional learning is another benefit, illustrated by this DUSON alumni comment,
“My time in Honduras was an invaluable experience that I will never forget. I learned how to work on a team of inter-professional health-care members and contribute towards a diagnosis and treatment plan.”
Faculty and Staff
The long history of Latinx engagement at DUSON has helped recruit Latinx faculty, staff, and students at DUSON, demonstrating a clear commitment to promoting health equity in this population. For example, in 2016, a Latinx faculty was attracted to DUSON because an expanded strategic focus on community and population health at DUSON and an ongoing educational and service initiatives serving the Latinx population. Shortly thereafter, she received funding through NIMHD for the SER Hispano study and hired a total of 5 new staff at DUSON during the course of the project, 4 of whom continue to work at Duke through different research and clinical activities. Working in an institution that has other members of the Latinx community has helped provide a community of colleagues with similar interest, a support structure, and helped promote a sense of belonging and well-being at the school. It also serves as an approach to help begin changing practices and structures to be more inclusive. For example, as a result of the SER Hispano research team advocating for research training in Spanish (eg, CITI), the Center of Nursing Research at DUSON bought the institutional license for the modules in Spanish, allowing the entire Duke community access to these.
Community
It is the mission of DUSON faculty to work toward mutual benefit for students and community through community engaged programs, both locally and globally. Faculty members are active on boards and health department committees that carry out important clinical and public health functions (eg, inform direct mental health clinical care; community health assessments) and advance policies and enhance organizational responsiveness to the Latinx community through advocacy. DUSON’s engagement with the Latinx community has grown proportionately as the Latinx population has grown during the past 30 years. Since the onset of the COVID-19 pandemic, this relationship has strengthened dramatically due to faculty, staff, and student response to efforts to mitigate the health and socioeconomic effects on this community. This engagement has not only contributed to community health improvement that resulted from changes in health-care practices (eg, more inclusive care for Latinx and Spanish speaking patients in the ICU) but also closed important gaps in vaccine inequities that existed when these first became available but then mitigated through hyperlocal strategies led by LATIN-19.46
CLINICS CARE POINTS
Below is a list of key strategies clinicians can implement to promote health equity in the Latinx community:
Go beyond the walls of health-care institutions to partner with trusted CBOs and FBOs who are serving the local Latinx community.
Assess the social determinants of health when providing care to the Latinx community, including their experiences of acculturative stress.
Connect Latinx individuals and families with existing services in the community that address the social determinants of health.
Ensure that referral services are available in the preferred language of your patient (eg, Spanish or indigenous language) and that those being referred are eligible for receipt of services (eg, required driver’s license; health insurance).
Advocate for Latinx and immigrant friendly environments in your practice setting, including the availability of CLAS.
SUMMARY
In order to improve population health, it is becoming increasingly vital to address evolving health disparities experienced by the Latinx community, the largest racial and ethnic minoritized community in the United States. Schools of Nursing are uniquely positioned to promote health equity in this population through their education, research, and service missions. The DUSON Model for Latinx Community Engagement and Health Equity is a comprehensive model that is responsive to the recommendations of The Future of Nursing Report 2020–203017 and include key principles of community engagement that have a strong evidence based in promoting health equity among historically marginalized communities.33 Through innovative local and global immersion programs, service provided through volunteer work, innovative interprofessional training in Medical Spanish, CEnR to inform interventions that promote health equity, and partnerships with diverse stakeholders and sectors that go beyond health care, DUSON is having an impact on learners, the DUSON and university community, the Latinx community being served, and population health more broadly. This model could be disseminated throughout other schools of nursing to inform a responsive strategy promoting health equity.
DISCLOSURE
Funding for projects being reported in this paper included research supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD012249 and research infrastructure supported through the National Center Advancing Translation Science under Award Number 5UL1TR002553. Additional support was provided by Duke University School of Nursing and the Duke University COVID Philanthropic fund. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Duke University. The authors also wish to acknowledge the important contributions of the community organizations mentioned in this paper and the faculty, staff, students and community partners involved in the initiatives described.
KEY POINTS
The Latinx population in the United States is the largest racial and ethnic minoritized group in the United States that experiences significant health disparities.
Schools of nursing can play an important role in promoting health equity among Latinx communities through their academic missions of education, research, and service.
Principles of community engagement can be implemented and combined with the cultural values important to partnering Latinx communities to foster trustworthiness.
Programs and activities that provide learners with opportunities to partner with community and faith-based organizations to address prioritized health needs and develop skills in Spanish and cultural humility, community engaged research that informs interventions to promote health equity, and partnerships with multiple stakeholders can be led by schools of nurses to promote health equity and population health.
Abbreviations
| HIV | Human Immunodificiency Virus |
| COVID-19 | SARS-CoV2 |
| LATIN-19 | Latinx Advocacy Team and Interdisciplinary Network for COVID-19 |
| SER | Salud/Health, Estres/Stress, y/and Resiliencia/Resilience |
| ICU | Intensive Care Unit |
| CPR | Cardiopulmonary resuscitation |
| ADA | American Diabetes Association |
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