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Keywords:

  • culture;
  • health counselling;
  • prevention of lifestyle-related diseases;
  • public health nursing;
  • validation study

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

This study evaluates culturally appropriate health counselling to prevent lifestyle-related diseases and suggests modifications of the method for practical use.

Semi-structured interviews were conducted with 13 public health nurses (PHNs) in seven cities with different cultural backgrounds. Data were analysed qualitatively with the following research questions: Do we need to add other cultural factors to the previous six categories or to improve their expression for practical use? Are the methods for using cultural factors valid and expressed in appropriate language for practical use?

The original factors were re-categorized into three classifications—Values, Styles and Relationships—using colloquial expressions. The original methods of using cultural factors were re-categorized and modified into five phases: Assessment, Acceptance, Awareness, Balance and Connection. The names of the methods were also modified.

Modified culturally appropriate health counselling is easily understandable by any PHN and highlights the unique Japanese culture and style of public health nurses.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

Lifestyle-related diseases are a serious issue in both Western and Eastern countries.[1] Lifestyle factors including values or beliefs are influenced by the local culture. Although Japan is a small country and most people are of Japanese origin, cultural factors such as food habits, norms or beliefs developed differently in each region, owing to its topographic features and historical background.[2, 3] Therefore, health-care providers like public health nurses (PHNs) have to consider regional cultural factors.

Globally, public health nurses play a crucial role in the prevention of lifestyle-related diseases with community residents in their home areas. Either unconsciously or intentionally, PHNs take into consideration a resident's culture, including beliefs, values and lifestyle,[4-6] when providing care. Therefore, understanding the local culture enables PHNs to understand the meaning of residents' unconscious behaviours or values and provide health counselling consistent with the residents' culture. It is difficult for new PHNs to offer cultural sensitive or appropriate health counselling. In Japan, the skills are handed down to new PHNs when they begin to work with expert PHNs in health centres. Recently, such transmission of culturally competent care has become difficult because expert PHNs are working in places other than health centres and have the challenge of complicated health problems.[7]Thus, there is a growing need to clarify empirical knowledge of culturally appropriate health counselling. We defined ‘culturally appropriate health counselling’ as ‘health counselling that respect the resident's culture, including beliefs, values, and lifestyle’.

Culture and cultural issues related to nursing interventions were explored in various studies; however, most research focused on specific ethnic cultures and assessed factors such as aboriginal healing traditions,[8] the positive meaning of gender role responsibilities for Lebanese Muslims[9] or Arab Americans' perception of disrobing in the hospital.[10] Multiple cultures have been investigated simultaneously.[11] Studies have also focused on the native cultures such as empirically grounded self-management and people's eating behaviours.[12, 13] In addition, cultural care such as considering the specific dietary habits of Chinese Americans[14] and Mexican Americans[15] or considering language,[16] in order to facilitate behavioural changes to prevent or control lifestyle-related diseases, has been evaluated. However, no study clarifies Japanese PHNs' understanding of how to use cultural knowledge during health counselling to prevent lifestyle-related diseases.

Japanese researchers alert that Japanese traditional healthy lifestyles were replaced by urban unhealthy lifestyle[17] and the whole nation has been trying to possible means to lifestyle-related diseases. Given that, various health counselling methods were developed; however, most of them do not respect counselees' culture but focus on efficient persuading.[18, 19]

Therefore, we developed a new method of health counselling, ‘culturally appropriate health counselling to prevent lifestyle-related diseases’, in our previous two studies conducted in Japanese rural areas.[20, 21] This counselling method requires PHNs to consider cultural factors according to the methods described in Table 1. Using this method, PHNs enable community residents who are at risk of contracting lifestyle-related diseases to be encouraged to comfortably adopt healthy behaviours. The development process of this new counselling method is described in Figure 1. We first conducted study 1[20] and then enriched its findings with study 2.[21] The method was evaluated by 12 public health nursing scholars and practitioners in a 1 hour round table session at the conference of 13th Japan Academy of Community Health Nursing in 2010. Although every attendee at the session approved of the method, two challenges were proposed: Could the PHNs use this method in not only rural but also other areas? Could we modify this method for actual use?

figure

Figure 1. Development process of this study.

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Table 1. Culturally appropriate health counselling to prevent lifestyle-related diseases
Contents of health counsellingCategory
  1. PHN, public health nurse.

Cultural factors considered in health counselling to prevent lifestyle-related diseasesPractice while including values of daily living, work and self-care specific to a generation
Practice while including values of daily living and work specific to an occupation/local industry
Relationship with family or neighbours, influenced by the population composition
Activity influenced by the conditions of climate, topography or public transportation
Relationship with the PHNs influenced by the condition of population or medical resources
Dissemination of new healthy practices among the community
Methods for using cultural factors in health counselling to prevent lifestyle-related diseasesStarting health counselling with familiar topics according to the relationship with PHNs in order to obtain information more easily
Assessing health risks while feigning to chat about common topics related to eating habits or working style
Not judging the counselees' favourite lifestyles or self-care including values, even though they may be health risks, in order to encourage them to open up to the PHNs
Helping them to be aware of the health risks in unconscious behaviours, using familiar examples
Accepting the conflicts/efforts in relation to changes in customs or family relationships
Suggesting self-care methods which are balanced between medical models and familiar lifestyles with consideration for sustainability
Suggesting self-care methods which are balanced between medical models and familiar styles with consideration for changeability
Approving efforts to change behaviours and encouraging to maintain efforts for achieving the purpose of life
Encouraging to undertake new healthy practices by connecting to the preciousness of life

The purpose of this paper is to present the results of a project to evaluate the method of ‘culturally appropriate health counselling to prevent lifestyle-related diseases’ developed in our previous study and describe the modification for practical use as the new ABC Model of culturally appropriate counselling for Japanese PHNs.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

This study employed semi-structured interviews to elicit the PHNs' opinions about authors' method of ‘culturally appropriate health counselling to prevent lifestyle-related diseases’ developed in our previous study. We were not aiming for consensus but rather needed the PHNs' evaluation on the counselling method developed in our previous study for the possibility of adjustment to various areas and improvement for practical use. To examine each category of cultural factors and methods on Table 1, PHNs were required to reflect on their cultural knowledge and skills of health counselling for lifestyle-related diseases. It is said that being aware of the culture is difficult for insiders. Therefore, semi-structured interviews enabled the PHNs to report their experiences in a holistic context through the recall of clinical examples. This, in turn, enabled the interviewers to collect in-depth data appropriate to the aims of the study.[20]

Participants

Snowball sampling was used and participants were 13 PHNs in seven cities (Table 2). All were Japanese females with an average work experience of 19 years (range: 15–24 years). The inclusion criterion was as follows: working for more than 5 years as a PHN in a city reported in refereed Japanese public health nursing journals as providing excellent prevention measurements for lifestyle-related diseases. We asked the head PHNs to introduce PHNs who are familiar with the area and provide culturally appropriate health counselling. The interviews were conducted immediately after getting written informed consent.

Table 2. Overview of the cities
 City ACity BCity CCity DCity ECity FCity G
Total population760040 60081 600113 600473 900549 000654 500

Population density

(/km)

22028013806500824016 01017 450
IndustryFarming and retail shopsFarming, fishing and retail shopsBusiness, retail shops and a little farming around the cityBusiness, retail shops and a little farming around the cityBusiness, retail shops, manufacturing and a little farming around the cityBusiness and retail shopsBusiness and retail shops

Ethical considerations

The study protocol was approved by the committee for research ethics of Chiba Prefectural University of Health Sciences. In addition, written informed consent was obtained from the participating PHNs. The researchers gave full explanations of the purpose, voluntary terms of participation, potential risks/benefits of the study, security of individual information and how the results of the interviews would be used.

Data collection

Between November 2010 and September 2011, after obtaining informed consent, we explained to the study's participants the ‘culturally appropriate health counselling to prevent lifestyle-related diseases’ by showing them Table 1. Following the explanation, we conducted semi-structured interviews for 60–90 min to individual participant with the following three questions:

  1. What do you think about the cultural factors listed in Table 1? Please explain by citing concrete cultural factors in your community.
  2. What do you think about the methods for using cultural factors listed in Table 1? Please explain by citing concrete counselling methods employed in your daily practice.
  3. Do you have any other opinion about the counselling methods developed in our previous study?

From the eight participants additional questions were asked (as the new idea emerged from previous interviews), like ‘what do you think about with new categories of values, styles and relationships?’

Data analysis

The interview transcripts were analysed qualitatively on basis of the following research questions: Do we need to add other cultural factors to the previous six factors or improve the expression of the categories of cultural factors listed in Table 1 for practical use? Are the methods of using cultural factors valid and expressed in language appropriate for practical use?

First, codes for opinions about cultural factors were created from interview transcripts and categorized according to the similarity of meaning. The categories were used to revise the original cultural factors listed in Table 1. Second, codes for opinions about the methods for using cultural factors were similarly created and categorized and the categories were used to revise the original methods for using cultural factors listed in Table 1. Finally, codes for other opinions about the counselling methods developed in our previous study were created and categorized and the categories were used to revise the counselling methods.

Data analysis was conducted immediately after interview by authors. The results were shown to community health nursing researchers and PHNs, and examined by them during the analysing process.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

Three types of opinion about the ‘culturally appropriate health counselling to prevent lifestyle-related diseases’ are described in Table 3: opinions about (i) the original cultural factors listed in Table 1; (ii) the methods for using the cultural factors listed in Table 1; and (iii) the name of the counselling method.

Table 3. Opinions about original cultural factors and methods
 CategorySubcategory
Opinions about the original cultural factorsRe-categorizing the original six categories into three main classifications: values, styles and relationshipsSeparating the styles of practices from values to make them easily understandable
Separating relationships from styles of practices because they are more important than other cultural factors
Setting values ahead of styles and relationships
Separating the concrete items of culture, the specificity of or influence on culture from the original categories of cultural factorsSeparating the concrete items of culture from the original categories of cultural factors and describing them using subtitles
Separating the specificity of or influence on culture from the original categories of cultural factors and describing them using subtitles
Opinions about the methods for using the cultural factors listed in Table 1Setting headings for intentions and breaking down into actionsSeparating intention from what the PHNs say and do
Setting headings for intention and breaking them down into details
Expressing simple stylesExpressing each method simply
Adding the meaning of support for pleasure/purpose of life to behavioural change
Opinion about the name of the health counselling methodExpress the name of the counselling method in terms of the classification of culture such as value/style for ease of understanding

Opinions about the cultural factors listed in Table 1

All the PHN participants confirmed that the cultural factors listed in Table 1 were appropriate in the context of the health counselling that the factors contribute to preventing lifestyle-related diseases. They mentioned no additional cultural factors.

Opinions about the cultural factors considered in health counselling are categorized in Table 3. According to these opinions, the original cultural factors listed in Table 1 were modified according to the process described in Figure 2a.

figure

Figure 2. (a) The procedure for modifying the cultural factors considered in health counselling. Stage 1: Re-categorizing the original cultural factors of Table 1 into three major classifications. (b) Procedure of modifying cultural factors considered in health counselling. Stage 2: Dividing the main categories into ‘main categories’, ‘concrete items’, ‘specificities’ and ‘influence’. PHN, public health nurse.

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In the first stage, after examining the contents of the original culture, we re-categorized the original cultural factors in Table 1 into three major classifications focused on ‘Values’, ‘Styles’ and ‘Relationships’. For example, category 1 was divided into the major classifications of ‘Values’ and ‘Practice’. Hence, the ‘Values of daily living, work and self-care specific to a generation’ in the original category 1 was re-categorized into the ‘Values of daily living, work and self-care specific to a generation, occupation or local industry’, as described in Figure 2b. Similarly, the ‘Practice of daily living, work and self-care specific to a generation’ in the original category 1 was re-categorized into the ‘Styles of daily living, work and self-care specific to a generation, occupation or local industry, influenced by the conditions of climate, topography or public transportation’. The original category 2 was also re-categorized into the major classifications of ‘Values’ and ‘Practice’. Categories 3 and 5 were re-categorized into ‘Relationships with neighbourhoods/PHNs, influenced by the population or condition of medical resources’. Categories 4 and 6 were re-categorized into the ‘Styles of daily living, work and self-care specific to a generation, occupation or local industry, influenced by the conditions of climate, topography or public transportation’.

In the second stage, we used the opinions in Table 3 to divide the main categories of ‘Values’, ‘Styles’ and ‘Relationships’ into four parts: ‘main categories’, ‘concrete items’, ‘specificity’ and ‘influence’ (see Stage 2 of Fig. 2). For example, the major classification of the ‘Values of daily living, work and self-care specific to a generation, occupation or local industry’ was divided into ‘Value’ as main category, the concrete items and the specificity. The concrete items reflect the details of value such as value of eating habits. The specificity describes what the values are observed in characteristically, for example eating habits specific to generation. The concrete items and specific qualifiers came from the codes generated from the raw data. Similarly, the major classification ‘Styles of daily living, work and self-care specific to a generation, occupation or local industry, influenced by the conditions of climate, topography or public transportation’ was separated into ‘Styles’ as the main category and followed by the concrete items, specificity and influences. Influence indicates which concrete styles have been formed by. For example, farmers work before sunrise especially in summer because it is very heated climate. The third major classification, ‘Relationships with neighbourhoods/PHNs influenced by population or medical resources condition’, was separated into ‘Relationships’ as main category with embellishment, the concrete items and influence. For example, relationships with neighbors are so closed that the farmers become well known throughout the area when they are neglectful of the farming.

Each of the three types of main categories, concrete items, specificities and influences were rewritten in a colloquial manner. These are shown in Table 4 as ‘Practical expression of cultural factors’.

Table 4. Practical expression of cultural factors
  1. PHN, public health nurse.

What values do people have?

About eating habits, daily schedule, working style, activity, leisure or self-care

Are the above values specific to generation, occupation or local industry?

What styles do people have?

About eating habits, daily schedule, working style, activity, leisure or self-care

Are the above styles specific to generation, occupation or local industry?

Are the above styles influenced by the natural/social environment?

What types of relationships do people have?

Between people and family members, neighbours or PHNs

Are the above types influenced by census/vital statistics or healthcare participation rates?

Opinions about the methods for using the cultural factors listed in Table 1

The original methods for using the cultural factors were modified according to the categories described in Table 3. Although those categories emerged from all interviews, most participants agreed with the original methods for using the cultural factors in Table 1. Therefore, few opinions were gained to modify the original methods. Researchers and participants consulted again in this process. First, each method was separated into intention and action, as described in Figure 3, according to the opinion ‘Setting headings for intentions and breaking them down into actions’. We examined similarity/difference of intentions and actions between nine methods for using cultural factors and reorganized them. For example, the original methods of ‘Starting health counselling with familiar topics according to the relationship with the PHNs’ and ‘Assessing health risks while feigning to chat about common topics related to eating habits or working style’ were divided into headings for intention and two actions that are described in Figure 3. The headings for intention that were common between methods 1 and 2 were considered to represent ‘Assessing health risks while encouraging the counselees to report daily life events while using cultural factors’. Therefore, this brief head of intention was separated from the two actions of ‘Prioritizing topics according to counselees' interests or relationships with PHNs in order to obtain information more easily’ and ‘Obtaining information and assessing health risks in the daily life by identifying lifestyles/working styles that are familiar and tend to be health risks in the area’. We similarly rewrote the remaining seven methods.

figure

Figure 3. The procedure for modifying the methods for using the cultural factors. PHN, public health nurse.

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The modified methods were expressed in a colloquial style by identifying key words such as ‘assessing’, as described in Table 5.

Table 5. Modified methods for using cultural factors
  1. PHN, public health nurse.

Assessment: assess health risks while encouraging the counselees to report on daily life using cultural factors
Prioritizing topics according to the counselees' interests or relationships with the PHNs in order to obtain information more easily
Obtaining information and assessing health risks in daily life by identifying lifestyles/working styles that are familiar and tend to be health risks in the area
Acceptance: Accepting favourite lifestyles or conflicts/efforts relating to the changes in customs or relationships for the purpose of allowing the counselees to open up to the PHNs
Not judging favourite lifestyles, including values, even though they may be health risks, in order to encourage the counselees to open up to the PHNs
Accepting the conflicts/efforts relating to changes in familiar lifestyles or relationships
Awareness: Helping the counselees to be aware of the health risks in their daily lives using familiar examples
Helping the counselees to be aware that their unconscious behaviours may be health risks, using familiar diet habits or values
Balance: Balancing healthy lifestyles with familiar lifestyles with consideration for sustainability
Suggesting self-care methods that do not spoil relationships between counselees and family/neighbourhood
Suggesting self-care methods that are balanced between medical models and daily lifestyles or working styles
Connection: Connecting changing behaviour with the aim/preciousness of life, to enhance autonomy
Approving efforts to change behaviours and encouraging their maintenance for the values/relationships
Encouraging to undertake new healthy customs by connecting to work or family considerations

Opinions about the name of the health counselling method

The name of the health counselling method was changed to ‘Health counselling considering Values, Styles and Relationships: ABC’, according to the opinion shown at the bottom of Table 3. The ‘Values, Styles and Relationships’ part in the name was derived from the main categories of cultural factors shown in Table 4. ‘ABC’ in the new name expresses the initials of ‘Assessment’, ‘Acceptance’, ‘Awareness’, ‘Balance’ and ‘Connection’, which are described under the ‘Modified methods for using cultural factors’ in Table 5.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

Practical expression of cultural factors

In the present study, practical expressions of the cultural factors were modified in order to make the factors more understandable and useful for Japanese PHNs working in rural and urban settings. In our previous study, cultural factors were categorized inductively, focusing on their commonness. The expert PHNs who participated in our previous study understood culture not as a cluster of discrete factors but as interweaving phenomena, as shown in Table 1. By contrast, in the present study, the original cultural factors identified in the previous study were segmented deductively. The PHNs who participated in the present study offered their suggestions from the perspective of ease of understanding and usefulness to all PHNs, including new recruits. It is said that insiders of a culture, including health-care providers, find it difficult to consciously express the culture. Therefore, the original cultural factors were re-categorized into three simple classifications, followed by concrete questions, to provide an efficient means for health-care providers to understand their culture.

There are some unique findings concerning practical expressions of the cultural factors. The first unique point is the setting of value as the top classification. In most of the literature, value was placed as a component of cultural factors.[23, 24] In the present study, it is emphasized that every practical aspect, including relationships, is based on values. A second unique point is the separation of relationships from other factors. Relationships are more important than independence for Japanese people,[25] and consideration of relationships is especially important for the prevention of lifestyle-related diseases. For example, people tend to feel guilty when refusing alcohol offered by their co-workers because they do not want to offend the person offering alcohol.

Modified methods for using cultural factors

The modified methods for using cultural factors described in Table 5 are similar to the LEARN Model[26] and ETHNIC Model.[27] Both were developed to assist health-care providers to conduct cultural care. The ‘Assessment’ phase of our modified methods for using cultural factors is similar to the process of ‘listening’ in the LEARN Model and ‘Explanation’, ‘Treatment’ and ‘Healers’ in the ETHNIC Model because the PHNs who provide culturally appropriate health counselling actively listened to the counselees and obtained information about lifestyle, including self-care or folk remedies. ‘Acceptance’ is similar to ‘acknowledging’ and ‘Awareness’ is similar to ‘explaining’ in the LEARN Model. ‘Balance’ is similar to ‘recommending and negotiating’ in the LEARN Model and ‘Negotiate’, ‘Intervention’ and ‘Collaboration’ in the ETHNIC Model, in relation to addressing ambivalence.

However, neither LEARN nor ETHNIC model mentions the last phase: ‘Connection’. The PHNs in our study connected the purpose of behavioural changes to the aim or preciousness of life, which is unique to the health counselling method described in the present study. This attribute comes from the aim of Japanese public health nursing. Japanese PHNs always strive not only to improve the quality of life of each resident but also to nurture caring among all community residents.

The name of the health counselling method

The name of the health counselling method was changed to focus more on the essential features of culture (Table 5). A person's values direct him/her towards healthy or unhealthy lifestyle. Therefore, separating ‘Values’ from ‘Styles’ and setting ‘Values’ at the top of the name are rational choices. The separation of ‘Relationships’ from ‘Styles’ is a characteristic feature of Japanese culture because Japanese people respect relationships between family, colleagues and neighbourhoods as much as their own health promotion.

Summary

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

Many studies investigate efficient educational methods of transcultural nursing.[28] However, no previous Japanese study clarifies the educational methods of health counselling considered within its own culture The conspicuous features of Japanese culturally appropriate health counselling methods were clarified in this study so as to make future use of these methods more efficient. This aim of public health nursing must influence health counselling methods; therefore, the PHNs must consider values or relationships common to community residents.

Limitations

This study reports the analysis of interviews from a small sample. The modified health counselling method needs further study using this method with a larger sample that includes counselees from diverse cultural background. This will enable us to investigate whether the present study's findings can be generalized and used in practical health counselling sessions.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References

The authors thank all the PHNs who participated in this study.

References

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Summary
  8. Acknowledgements
  9. Disclosures
  10. References
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