Culture Class Module 2 Assignment Family Traditions

Table of Contents

Culture Class

Familial Health Traditions

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  1. Read and follow the directions on pages 160 and 161.
  2. Conduct an interview with an older family member.
  3. Summarize your findings regarding familial and social changes, and your ethnocultural and religiousheritage. (Include one example)
  4. Your paper should be:
    • One (1) page
    • Typed according to APA style for margins, formating and spacing standards 
      • See NUR3045 – Library (located on left-side on menu) for tutorial Using APA Style
    • Typed into a Microsoft Word document, save the file, and then upload the file.

Cultural Diversity in Health and Illness


There is something that transcends all of this I am I . . . You are you Yet. I and you Do connect Somehow, sometime.

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To understand the “cultural” needs Samenesses and differences of people Needs an open being See—Hear—Feel With no judgment or interpretation Reach out Maybe with that physical touch Or eyes, or aura You exhibit your openness and willingness to Listen and learn And, you tell and share In so doing—you share humanness It is acknowledged and shared Something happens— Mutual understanding

—Rachel E. Spector

Cultural Diversity in Health and Illness


Rachel E. Spector, PhD, RN, CTN-A, FAAN Needham, MA 02494

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ISBN-13: 978-0-13-284006-4 ISBN-10: 0-13-284006-5

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Culture Class

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Library of Congress Cataloging-in-Publication Data Spector, Rachel E. Cultural diversity in health and illness/Rachel E. Spector.—8th ed. p. cm. Includes bibliographical references and index. ISBN-13: 978-0-13-284006-4 ISBN-10: 0-13-284006-5 1. Transcultural medical care—United States. 2. Health attitudes—United States. 3. Transcultural nursing—United States. I. Title. RA418.5.T73S64 2013 610—dc23 2012012708

10 9 8 7 6 5 4 3 2 1

I would like to dedicate this text to

My husband, Manny; Sam, Hilary, Julia, and Emma; Becky, Perry, Naomi, Rose, and Miriam; the memory of my parents, Joseph J. and Freda F. Needleman, and my in-laws, Sam and Margaret Spector; and the memory of my beloved mentor, Irving Kenneth Zola.

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Chapter 1 Building Cultural and Linguistic Competence 3 National Standards for Culturally and Linguistically

Appropriate Services in Health Care 8 Cultural Competence 11 Linguistic Competence 11 Institutional Mandates 12 CULTURALCARE 13

Chapter 2 Cultural Heritage and History 19 Heritage Consistency 20 Acculturation Themes 29 Ethnocultural Life Trajectories 32 Commingling Variables 34 Cultural Conflict 36 Cultural Phenomena Affecting Health 37

Chapter 3 Diversity 43 Census 2010 45 Immigration 48 Poverty 54

Chapter 4 Health and Illness 62 Health 63 Illness 74


Chapter 5 HEALTH Traditions 89 HEALTH and ILLNESS 91 HEALTH Traditions Model 92 HEALTH Protection 95 Health/HEALTH Care Choices 102


viii ■ Contents

Folk Medicine 104 Health/HEALTH Care Philosophies 108

Chapter 6 HEALING Traditions 120 HEALING 121 Ancient Forms of HEALING 123 Religion and HEALING 124 HEALING and Today’s Beliefs 136 Ancient Rituals Related to the Life Cycle 138

Chapter 7 Familial HEALTH Traditions 158 Familial Health/HEALTH Traditions 160 Consciousness Raising 171

Chapter 8 Health and Illness in Modern Health Care 178 The Health Care Provider’s Culture 179 Health Care Costs 182 Trends in Development of the Health Care System 187 Common Problems in Health Care Delivery 191 Pathways to Health Services 195 Barriers to Health Care 197 Medicine as an Institution of Social Control 199


Chapter 9 HEALTH and ILLNESS in the American Indian and Alaska Native Population 210 Background 211 Traditional Definitions of HEALTH and ILLNESS 213 Traditional Methods of HEALING 215 Current Health Care Problems 222 The Indian Health Service 228

Chapter 10 HEALTH and ILLNESS in the Asian Populations 238 Background 239 Traditional Definitions of HEALTH and ILLNESS 241 Traditional Methods of HEALTH Maintenance

and Protection 246 Traditional Methods of HEALTH Restoration 247 Current Health Problems 257

Chapter 11 HEALTH and ILLNESS in the Black Population 265 Background 266 Traditional Definitions of HEALTH and ILLNESS 270 Traditional Methods of HEALTH Maintenance

and Protection 271

Contents ■ ix

Traditional Methods of HEALTH Restoration 272 Current Health Problems 279

Chapter 12 HEALTH and ILLNESS in the Hispanic Populations 291 Background 292 Mexicans 294 Puerto Ricans 308

Chapter 13 HEALTH and ILLNESS in the White Populations 323 Background 324 German Americans 326 Italian Americans 330 Polish Americans 334 Health Status of the White Population 339


Appendix A Selected Key Terms Related to Cultural Diversity in Health and Illness 354

Appendix B Calendar: Cultural and Religious Holidays That Change Dates 364

Appendix C Suggested Course Outline 367

Appendix D Suggested Course Activity—Urban Hiking 373

Appendix E Heritage Assessment Tool 376

Appendix F Quick Guide for CULTURALCARE 379

Appendix G Data Resources 381



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Every book, every volume you see here, has a soul. The soul of the person who wrote it and of those who read it and lived and dreamed with it.

—Carlos Ruiz Zafon, The Shadow of the Wind, 2001

In 1977—more than 35 years ago—I prepared the first edition of Cultural Diversity in Health and Illness. Now, as I begin the eighth edition of this book— the sixth revision—I realize that this is an opportunity to reflect on an endeavor that has filled a good deal of my life for the past 30 years. I believe this book has a soul and it, in turn, has become an integral part of my soul. I have lived—through practice, teaching, and research—this material since 1974 and have developed many ways of presenting this content. In addition, I have tracked for 40 years:

1. the United States Census; 2. immigration—numbers and policies; 3. poverty—figures and policies; 4. health care—costs and policies; 5. morbidity and mortality rates; 6. nursing and other health care manpower issues; and 7. the emergence and growth of the concepts of health disparities and

cultural and linguistic competence.

My metaphors are HEALTH, defined as “the balance of the person, both within one’s being—physical, mental, and spiritual—and in the outside world— natural, communal, and metaphysical”; ILLNESS, “the imbalance of the person, both within one’s being—physical, mental, and spiritual—and in the outside world—natural, communal, and metaphysical”; and HEALING, “the restoration of balance, both within one’s being—physical, mental, and spiritual—and in the outside world—natural, communal, and metaphysical.”

I have learned over these years that within many traditional heritages (defined as “old,” not con- temporary or modern) people tend to define HEALTH, ILLNESS, and HEALING in this manner. Imagine a kaleidoscope—the tube can represent HEALTH. The ob- jects reflected within the kaleidoscope reflect the traditional tools used to care for a given person’s HEALTH. If you love kaleidoscopes, you know what I am describing and that the patterns that emerge are infinite.

xii ■ Preface

In addition, I have had the unique opportunity to travel to countless places in the United States and abroad. I make it a practice to visit the tra- ditional markets, pharmacies, and shrines and dialogue with the people who work in or patronize the settings, and I have gathered invaluable knowledge and unique items and images.

My tourist dollars are invested in amulets and remedies and my collection is large. Digital photography has changed my eyes; I may be a “digital immigrant,” rather than a “digital native,” but the camera has proven to be my most treasured companion. I have been able to use the im- ages of sacred objects and sacred places to create HEALTH Traditions Imagery.

The opening images for each chapter and countless images within the chapters are the results of these explorations. Given that there are times when we do not completely understand a concept or an image, several images are slightly blurred or dark to represent this wonderment.

The first edition of this book was the outcome of a promesa—a promise— I once made. The promise was made to a group of Asian, Black, and Hispanic students I taught in a medical sociology course in 1973. In this course, the students wound up being the teachers, and they taught me to see the world of health care delivery through the eyes of the health care consumer rather than through my own well-intentioned eyes. What I came to see I did not al- ways like.

I did not realize how much I did not know; I believed I knew a lot. I promised the students that I would take that which they taught me regarding HEALTH and teach it to students and colleagues. I have held on to the promesa, and my experiences over the years have been incredible. I have met people and traveled. At all times I have held on to the idea and goal of attempting to help nurses and other health care providers be aware of and sensitive to the HEALTH, ILLNESS, and HEALING beliefs and needs of their patients.

I know that looking inside closed doors carries with it a risk. I know that people prefer to think that our society is a melting pot and that the traditional beliefs and practices have vanished with the expected acculturation and assimi- lation into mainstream North American modern life. Many people, however, have continued to carry on the traditional customs and culture from their na- tive lands and heritage, and HEALTH, ILLNESS, and HEALING beliefs are deeply entwined within the cultural and social beliefs that people have. To understand HEALTH and ILLNESS beliefs and practices, it is necessary to see each person in his or her unique sociocultural world. The theoretical knowledge that has evolved for the development of this text is cumulative and much of the “old” material is relevant today as many HEALTH, ILLNESS, and HEALING beliefs do not change. However, many beliefs and practices do go underground.

The purpose of each edition has been to increase awareness of the dimen- sions and complexities involved in caring for people from diverse cultural back- grounds. I wished to share my personal experiences and thoughts concerning the introduction of cultural concepts into the education of health care profes- sionals. The books represented my answers to the questions:

■ “How does one effectively expose a student to cultural diversity?” ■ “How does one examine health care issues and perceptions from a

broad social viewpoint?”

Preface ■ xiii

As I have done in the classroom over the years, I attempt to bring you, the reader, into direct contact with the interaction between providers of care within the North American health care system and the consumers of health care. The staggering issues of health care delivery are explored and contrasted with the choices that people may make in attempting to deal with health care issues.

When I began this journey in nursing, there were limited resources avail- able to answer my questions and to support me in my passion for knowledge. The situation has dramatically changed and today there is nearly more informa- tion than one can absorb! Not only is this information being sought by nurses, all stakeholders in the health care industry are struggling with this concept. The de- mographics of America, and the world, have changed and perhaps this challenge of building bridges between cultural groups can be seen as a way to open op- portunities to do this in many disciplines. Indeed, the content is readily available:

■ Countless books and articles have been published in nursing, medicine, public health, and the popular media over the past 40 years that con- tain invaluable information relevant to CULTURALCOMPETENCY.

■ Innumerable workshops and meetings have been available where the content is presented and discussed.

■ “Self-study” programs on the Internet have been developed that pro- vide continuing education credits to nurses, physicians, and other providers.

However, the process of becoming CULTURALLYCOMPETENT is not generally provided for. Issues persist, such as:

Demographic disparity exists in the profile of health care providers and in health status.

■ Patient needs, such as modesty, space, and gender-specific care, are not universally met.

■ Religious-specific needs are not met in terms of meal planning, proce- dural planning, conference planning, and so forth.

■ Communication and language barriers exist.

As this knowledge is built, you are on the way to CULTURALCOMPETENCY. As it matures and grows, you become an advocate of CULTURALCARE, as it will be described in Chapter 1.

■ Overview Unit I focuses on the background knowledge one must recognize as the foun- dation for developing CULTURALCOMPETENCY.

■ Chapter 1 presents an overview of the significant content related to the on-going development of the concepts of cultural and linguistic com- petency as it is described by several different organizations.

■ Chapter 2 explores the concept of cultural heritage and history and the roles they play in one’s perception of health and illness. This exploration

xiv ■ Preface

is first outlined in general terms: What is culture? How is it transmit- ted? What is ethnicity? What is religion? How do they affect a person’s health? What major sociocultural events occurred during the life trajec- tory of a person that may influence his or her personal health beliefs and practices?

■ Chapter 3 presents a discussion of the diversity—demographic, im- migration, and poverty—that impacts on the delivery of and access to health care. The backgrounds of each of the U.S. Census Bureau’s cat- egories of the population, an overview of immigration, and an overview of issues relevant to poverty are presented.

■ Chapter 4 reviews the provider’s knowledge of his or her own percep- tions, needs, and understanding of health and illness.

Unit II explores the domains of HEALTH, blends them with one’s personal heritage, and contrasts them with the Allopathic Philosophy.

■ Chapter 5 introduces the concept of HEALTH and develops the con- cept in broad and general terms. The HEALTH Traditions Model is pre- sented, as are natural methods of HEALTH maintenance and protection.

■ Chapter 6 explores the concept of HEALTH restoration or HEALING and the role that faith plays in the context of HEALING, or magico-religious, traditions. This is an increasingly important issue, which is evolving to a point where the health care provider must have some understanding of this phenomenon.

■ Chapter 7 discusses family heritage and explores personal and familial HEALTH traditions. It includes an array of familial health/HEALTH be- liefs and practices shared by people from many different heritages.

■ Chapter 8 focuses on the health care provider culture and the allopathic health care delivery system.

Once the study of each of these components has been completed, Unit III (Chapters 9 to 13) moves on to explore selected population groups in more de- tail, to portray a panorama of traditional HEALTH and ILLNESS beliefs and prac- tices, and to present relevant health care issues.

Chapter 14 is devoted to an overall analysis of the book’s contents and how best to apply this knowledge in health care delivery, health planning, and health education, for both the patient and the health care professional.

Each chapter in the text opens with images relevant to the chapter’s topic. They may be viewed in the CULTURALCARE Museum on the accompanying web page.

These pages cannot do full justice to the richness of any one culture or any one health/HEALTH belief system. By presenting some of the beliefs and practices and suggesting background reading, however, the book can begin to inform and sensitize the reader to the needs of a given group of people. It can also serve as a model for developing cultural knowledge of populations that are not included in this text.

There is so much to be learned. Countless books and articles have now appeared that address these problems and issues. It is not easy to alter attitudes

Preface ■ xv

and beliefs or stereotypes and prejudices, to change a person’s philosophy. Some social psychologists state that it is almost impossible to lose all of one’s prejudices, yet alterations can be made. I believe the health care provider must develop the ability to deliver CULTURALCARE and knowledge regarding per- sonal fundamental values regarding health/HEALTH and illness/ILLNESS. With acceptance of one’s own values come the framework and courage to accept the existence of differing values. This process of realization and acceptance can enable the health care provider to be instrumental in meeting the needs of the consumer in a collaborative, safe, and professional manner.

This book is written primarily for the student in basic allied health profes- sional programs, nursing, medical, social work, and other health care provider disciplines. I believe it will be helpful also for providers in all areas of practice, especially community health, long-term oncology, chronic care settings, and geri- atric and hospice centers. I am attempting to write in a direct manner and to use language that is understandable by all. The material is sensitive, yet I believe that it is presented in a sensitive manner. At no point is my intent to create a vehicle for stereotyping. I know that one person will read this book and nod, “Yes, this is how I see it,” and someone else of the same background will say, “No, this is not correct.” This is the way it is meant to be. It is incomplete by intent. It is written in the spirit of open inquiry, so that an issue may be raised and so that clarifica- tion of any given point will be sought from the patient as health care is provided. The deeper I travel into this world of cultural diversity, the more I wonder at the variety. It is wonderfully exciting. By gaining insight into the traditional attitudes that people have toward health and health care, I found my own nursing practice was enhanced, and I was better able to understand the needs of patients and their families. It is thrilling to be able to meet, to know, and to provide care to people from all over the world and every walk of life. It is the excitement of nursing. As we go forward in time, I hope that these words will help you, the reader, develop CULTURALCARE skills and help you provide the best care to all.

You don’t need a masterpiece to get the idea. —Pablo Picasso

■ Features ■ Research on Culture and Health. As evidence-based practice grows

in importance, its application is expected in all aspects of health care. This special feature spotlights how current research informs and im- pacts cultural awareness and competence.

■ Unit and Chapter Objectives. Each unit and chapter opens with ob- jectives to direct the reader when studying.

■ Unit Exercises and Activities. The beginning of each unit provides ex- ercises and activities related to the topic. Questions stimulate reflective

xvi ■ Preface

consideration of the reader’s own family and cultural history as well as to develop an awareness of one’s own biases.

■ Figures, Tables, and Boxes. Throughout the book are photographs, illustrations, tables, and boxes that exemplify and expand on informa- tion referenced in the chapter.

■ Health Traditions Imagery. These symbolic images are used to link the chapters. The images were selected to awaken you to the richness of a given heritage and the practices inherent within both modern and tra- ditional cultures, as well as the beliefs surrounding health and HEALTH. (HEALTH, when written this way, is defined as the balance of the person, both within one’s being—physical, mental, spiritual—and in the outside world—natural, familial and communal, metaphysical.)

■ Keeping Up. Selected resources that present information that is fre- quently published in a timely manner to keep you abreast of data, on such topics as poverty, income, immigration, and so forth, as the facts and figures change. This is a new feature for this edition.

■ Supplemental Resources

■ CulturalCare Guide. Previously available as a separate booklet, the contents of this helpful guide are now available for downloading on the Companion Website. The guide includes the Heritage Assess- ment Tool, Cultural Phenomena Affecting Health Care, CulturalCare Etiquette, and other assessment tools and guides.

■ Companion Website. The Companion Website includes a wealth of supplemental material to accompany each chapter. In addition to the complete contents of the CulturalCare Guide, the site presents chapter-related review questions, case studies, exercises, and MediaLinks to provide additional information. Panorama of Health and Illness videos accompany many chapters, and a glossary of terms appears for each chapter. Also included is a collection of the author’s photographs and culturally significant images in the CULTURAL- CARE Museum.

■ Instructor’s Resource Center. Available to instructors adopting the book are PowerPoint Lecture Slides and a complete testbank available for downloading from the Instructor’s Resource Center, which can be accessed through the online catalog.

■ Online Course Management. Built to accompany Cultural Diversity in Health and Illness are online course management systems available for Blackboard, WebCT, Moodle, Angel, and other platforms. For more information, contact your Pearson Education sales

About the Author

Dr. Rachel E. Spector has been a student of culturally diverse HEALTH and ILLNESS beliefs and practices for 40 years and has researched and taught courses on culture and HEALTH care for the same time span. Dr. Spector has had the opportunity to work in many different communities, including the American Indian and Hispanic communities in Boston, Massachusetts. Her studies have taken her to many places: most of the United States, Canada, and Mexico; several European countries, including Denmark, England, Greece, Finland, Iceland, Italy, France, Russia, Spain, and Switzerland; Israel and Pakistan; and Australia and New Zealand. She was fortunate enough to collect traditional amulets and remedies from many of these diverse communities, visit shrines, and meet practitioners of traditional HEALTH care in several places. She was in- strumental in the creation and presentation of the exhibit “Immigrant HEALTH Traditions” at the Ellis Island Immigration Museum, May 1994 through January 1995. She has exhibited HEALTH-related objects in several other set- tings. Recently, she served as a Colaboradora Honorifica (Honorary Collabora- tor) in the University of Alicante in Alicante, Spain, and Tamaulipas, Mexico. In 2006, she was a Lady Davis Fellow in the Henrietta Zold-Hadassah Hebrew University School of Nursing in Jerusalem, Israel. This text was translated into Spanish by Maria Munoz and published in Madrid by Prentice Hall as Las Cul- turas de la SALUD in 2003 and into Chinese in 2010. She is a Fellow in the American Academy of Nursing and a Scholar in Transcultural Nursing Society. The Massachusetts Association of Registered Nurses, the state organization of the American Nurses’ Association, honored her as a “Living Legend” in 2007. In 2008 she received the Honorary Human Rights Award from the American Nurses Association. This award recognized her contributions and accomplish- ments that have been of national significance to human rights and have influ- enced health care and nursing practice.



I have had a 35-year adventure of studying the forces of culture, ethnicity, and religion and their profound influence on HEALTH, ILLNESS, and HEALING beliefs and practices. Many, many people have contributed generously to the knowledge I have acquired over this time as I have tried to serve as a voice for traditional people and the HEALTH, ILLNESS, and HEALING beliefs and prac- tices derived from their given heritage. It has been a continuous struggle to in- sure that this information be included not only in nursing education but in the educational content of all helping professions—including medicine, the allied health professions, and social work.

I particularly wish to thank the following people for their guidance, professional support, and encouragement over the 32 years that this book, now in its eighth edition, has been an integral part of my life. They are peo- ple from many walks of life and have touched me in many ways. The people from Appleton-Century-Crofts, which became Appleton & Lang, then became Prentice Hall, and now Pearson. They include Kim Mortimer, Patrick Walsh, and countless people involved in the production of the text. My first encounter with publishing was with Leslie Boyer, an acquisition editor from Appleton- Century-Crofts, who simply said “write a book” in 1976. The experience of preparing this eighth edition has been a formidable one. Most of the new con- tent has been gathered via the World Wide Web. However, the most exciting aspect of this project has been working with people in India throughout the copyediting phase. I was living in Honolulu, Hawaii; the Senior Project Man- ager, Saraswathi Muralidhar, was in India. We were thousands of miles apart, there was a fifteen and one half-hour difference in time; yet, we have completed this challenge in a most timely manner. Yes, the World Wide Web is an amaz- ing asset. In 1976, when the first edition of this book was conceived, I never dreamt that this is where it would be in 2012. In addition, for this edition I have worked closely with Yagnesh Jani, the development editor in the United States. Without their help, this book would not be here today.

The many people who helped with advice and guidance to resources over the years include Elsi Basque, Billye Brown, Louise Buchanan, Julian Castillo, Leonel J. Castillo, Jenny Chan, Dr. P. K. Chan, Joe Colorado, Miriam Cook, Elizabeth Cucchiaro, Norine Dresser, Marjory Gordon, Orlando Isaza, Henry and Pandora Law, S. Dale McLemore, Anita Noble, Carl Rutberg, Sister Mary Nicholas Vincelli, David Warner, and the late Hawk Littlejohn, Father Richard McCabe, and Irving K. Zola.

I wish to thank my friends and family, who have tolerated my absence at countless social functions, and the many people who have provided the


Acknowledgments ■ xix


numerous support services necessary for the completion of an undertaking such as this. My husband, Manny, has been the rock who has sustained and sup- ported me through all these years–most of all, I can never thank him enough.

A lot has happened in my life since the first edition of this book was pub- lished in 1979. My family has shrunk with the deaths of all four parents, and it has greatly expanded with a new daughter, Hilary, and a new son, Perry, and five granddaughters—Julia, Emma, Naomi, Rose, and Miriam. The generations have gone, and come.

■ Reviewers Michelle Gagnon, BS, RUT, RDCS Bunker Hill Community College Boston, MA

Marie Gates, PhD WMU Bronson School of Nursing Kalamazoo, MI

Janette McCrory, MSN Delta State University Cleveland, MS

Anita Noble, DNSc Hebrew University School of Nursing, Henrietta Zold-Hadassah School of Nursing Jerusalem, Israel

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Cultural Foundations

Unit I creates the foundation for this book and enables you to become aware of the importance of developing knowledge in the topics of (1) cultural and linguistic competency; (2) cultural heritage and history—both your own and those of other people; (3) diversity—demographic, immigration, and economic; and (4) the standard concepts of health and illness.

The chapters in Unit I will present an overview of relevant historical and contemporary theoretical content that will help you climb the first three steps to CULTURALCOMPETENCY. You will:

1. Understand the compelling need for the development of cultural and lin- guistic competency.

2. Identify and discuss the factors that contribute to heritage consistency— culture, ethnicity, religion, acculturation, and socialization.

3. Identify and discuss sociocultural events that may influence the life trajec- tory of a given person.

4. Understand diversity in the population of the United States by observing ■ Census 2010 and the demographic changes in the population of the

United States over several decades; ■ immigration patterns and issues; and ■ economic issues relevant to poverty.

5. Understand health and illness and the sociocultural and historical phenom- ena that affect them.


2 ■ Unit 1

6. Reexamine and redefine the concepts of health and illness. 7. Understand the multiple relationships between health and illness.

Before you read Unit I, please answer the following questions:

1. Do you speak a language other than English? 2. What is your sociocultural heritage? 3. What major sociocultural events have occurred in your lifetime? 4. What is the demographic profile of the community you grew up in? Has it

changed; if so, how has it changed? 5. How would you acquire economic help if necessary? 6. How do you define health? 7. How do you define illness? 8. What do you do to maintain and protect your health? 9. What do you do when you experience a noticeable change in your health? 10. Do you diagnose your own health problems? If yes, how do you do so? If

no, why not? 11. From whom do you seek health care? 12. What do you do to restore your health? Give examples.


Chapter 1 Building Cultural and

Linguistic Competence

When there is a very dense cultural barrier, you do the best you can, and if something happens despite that, you have to be satisfied with little success instead of total successes. You have to give up total control. . . .

—Anne Fadiman (2001)

■ Objectives

1. Discuss the underpinnings of the need for cultural and linguistic competence. 2. Describe the National Standards for Culturally and Linguistically Appropri-

ate Services in Health Care. 3. Describe institutional mandates regarding cultural and linguistic

competence. 4. Articulate the attributes of CULTURALCOMPETENCY and CULTURALCARE.

The opening images for this chapter depict the foundations for the building of CULTURALCOMPETENCE. The first image is that of a dandelion that has gone to seed (Figure 1–1). All of the seeds are united, yet each is a discrete entity—they represent the numerous facets necessary for cultural competence. Figure 1–2 is that of a “fake door” in Vejer de la Frontera, Spain. It is a reminder of personal beliefs that shut out all other arguments and ways of understanding people. Figure 1–3 is a translucent door in Avila, Spain, where it is possible to look into a different reality and because it is not locked—one can open it and recognize

Figure 1–1 Figure 1–2 Figure 1–3 Figure 1–4

4 ■ Chapter 1

the view of others. Figure 1–4 represents the steps to cultural competency. A more detailed discussion of each image follows in the forthcoming text.

In May 1988, Anne Fadiman, editor of The American Scholar, met the Lee family of Merced, California. Her subsequent book, The Spirit Catches You and You Fall Down, published in 1997, tells the compelling story of the Lees and their daughter, Lia, and their tragic encounter with the American health care delivery system. This book has now become a classic and is used by many health care educators and providers in situations where there is an effort to demonstrate the need for developing cultural competence.

When Lia was 3 months old, she was taken to the emergency room of the county hospital with epileptic seizures. The family was unable to communicate in English; the hospital staff did not include competent Hmong interpreters. From the parents’ point of view, Lia was experiencing “the fleeing of her soul from her body and the soul had become lost.” They knew these symptoms to be quag dab peg—“the spirit catches you and you fall down.” The Hmong re- garded this experience with ambivalence, yet they knew that it was serious and potentially dangerous, as it was epilepsy. It was also an illness that evokes a sense of both concern and pride.

The parents and the health care providers both wanted the best for Lia, yet a complex and dense trajectory of misunderstanding and misinterpreting was set in motion. The tragic cultural conflict lasted for several years and caused considerable pain to each party (Fadiman, 2001). This moving incident exem- plifies the extreme events that can occur when two antithetical cultural belief systems collide within the overall environment of the health care delivery sys- tem. Each party comes to a health care event with a set notion of what ought to happen—and, unless each is able to understand the view of the other, complex difficulties can arise.

The catastrophic events of September 11, 2001; the wars in Iraq, Afghanistan, and Libya; the countless natural disasters such as Hurricane Katrina and the earthquakes in Haiti and Japan; and our preoccupation with terrorist threats have pierced the consciousness of all Americans in general and health care providers in particular. Now, more than ever, providers must be- come informed about and sensitive to the culturally diverse subjective meanings of health/HEALTH,1 illness/ILLNESS, caring, and curing/HEALING practices. Cultural diversity and pluralism are a core part of the social and economic en- gines that drive the country, and their impact at this time has significant impli- cations for health care delivery and policymaking throughout the United States (Office of Minority Health, 2001, p. 25).

1This style of combining terms, such as health/HEALTH, will be used throughout the text to con- vey that there is a blending of modern and traditional connotations for the terms. The terms are de- fined within the text and in the glossary. Furthermore, when terms such as CULTURALCOMPETENCY and CULTURALCARE and others are written in all capital letters, it is done so to imply that they are referring to a holistic philosophy, rather than a dualistic philosophy.

Building Cultural and Linguistic Competence ■ 5

In all clinical practice areas—from institutional settings, such as acute and long-term care settings, to community-based settings, such as nurse practitioners’ and doctors’ offices and clinics, schools and universities, pub- lic health, and occupational settings—one observes diversity every day. The undeniable need for culturally and linguistically competent health care services for diverse populations has attracted increased attention from health care pro- viders and those who judge their quality and efficiency for many years. The mainstream health care provider is treating a more diverse patient population as a result of demographic changes and participation in insurance programs, and the interest in designing culturally and linguistically appropriate services that lead to improved health care outcomes, efficiency, and patient satisfaction has increased.

One’s personal cultural background, heritage, and language have a con- siderable impact on both how patients access and respond to health care services and how the providers practice within the system. Cultural and linguistic com- petence suggests an ability of health care providers and health care organiza- tions to understand and respond effectively to the cultural and linguistic needs brought to the health care experience. This is a phenomenon that recognizes the diversity that exists among the patients, physicians, nurses, and caregivers. This phenomenon is not limited to the changes in the patient population in that it also embraces the members of the workforce—including providers from other countries. Many of the people in the workforce are new immigrants and/or are from ethnocultural backgrounds that are different from that of the dominant culture.

In addition, health and illness can be interpreted and explained in terms of personal experience and expectations. We can define our own health or illness and determine what these states mean to us in our daily lives. We learn from our own cultural and ethnic backgrounds how to be healthy, how to recognize illness, and how to be ill. Furthermore, the meanings we attach to the notions of health and illness are related to the basic, culture-bound values by which we define a given experience and perception.

It is now imperative, according to the most recent policies of the Joint Commission of Hospital Accreditation and the Centers for Medicare & Med- icaid Services, that all health care providers be “culturally competent.” In this context, cultural competency implies that within the delivery of care the health care provider understands and attends to the total context of the patient’s situa- tion; it is a complex combination of knowledge, attitudes, and skills, yet

■ How do you really inspire people to hear the content? ■ How do you motivate providers to see the worldview and lived experi-

ence of the patient? ■ How do you assist providers to really bear witness to the living condi-

tions and lifeways of patients? ■ How do you liberate providers from the burdens of prejudice, xenopho-

bia, the “isms”—racism, ethnocentrism—and the “antis” such as anti- Semitism, anti-Catholicism, anti-Islamism, anti-immigrant, and so forth?

6 ■ Chapter 1

■ How do you inspire philosophical changes from dualistic thinking to holistic thinking?

It can be argued that the development of CULTURALCOMPETENCY does not occur in a short encounter with programs on cultural diversity but that it takes time to develop the skills, knowledge, and attitudes to safely and sat- isfactorily become “CULTURALLYCOMPETENT” and to deliver CULTURALCARE. Indeed, the reality of becoming “CULTURALLYCOMPETENT” is a complex process—it is time consuming, difficult, frustrating, and extremely interesting. It is a philosophical change wherein the CULTURALLYCOMPETENT person is able to hear, understand, and respect the nonverbal and/or non-articulated needs and perspectives of a given patient.

CULTURALCOMPETENCY embraces the premise that all things are con- nected. Look again at the dandelion that has gone to seed. Each seed is a dis- crete entity, yet each is linked to the other (Figure 1–1). Each facet discussed in this text—heritage, culture, ethnicity, religion, socialization, and identity— is connected to diversity, demographic change, population, immigration, and poverty. These facets are connected to health/HEALTH, illness/ILLNESS, curing/HEALING, and beliefs and practices, modern and traditional. All of these facets are connected to the health care delivery system—the culture, costs, and politics of health care, the internal and external political issues, public health is- sues, and housing and other infrastructure issues. In order to fully understand a person’s health/HEALTH beliefs and practices, each of these topics must be in the background of a provider’s mind.

I have had the opportunity to live and teach in Spain and to explore many areas, including Cadiz and the surrounding small villages. There was a fake door within the walls of a small village, Vejer de la Frontera (Figure 1–2), that appeared to be bolted shut. The door was placed there during the early 14th century to fool the Barbary pirates. The people were able to vanquish them while they tried to pry the door open. It reminded me of the attempt to keep other ideas and people away and not open up to new and different ideas. Another door (Figure 1–3), found in Avila, Spain, was made of translu- cent glass. Here, the person has a choice—peer through the door and view the garden behind it or open it and actually go into the garden for a finite walk. This reminded me of people who are able to understand the needs of others and return to their own life and heritage when work is completed. This polarity represents the challenges of “CULTURALCOMPETENCY.”

The way to CULTURALCOMPETENCY is complex, but I have learned over the years that there are five steps (Figure 1–4) to climb to begin to achieve this goal:

1. Personal heritage—Who are you? What is your heritage? What are your health/HEALTH beliefs?

2. Heritage of others—demographics—Who is the other? Family? Community?

3. Health and HEALTH beliefs and practices—competing philosophies 4. Health care culture and system—all the issues and problems

Building Cultural and Linguistic Competence ■ 7

5. Traditional HEALTH care systems—the way HEALTH was for most and the way HEALTH still is for many

Once you have reached the sixth step, CULTURALCOMPETENCY, you are ready to open the door to CULTURALCARE.

Each step represents a discrete unit of study, each building upon the one below it. The steps have been constructed with “bricks,” and they represent the fundamental terms, or language, of the content. Table 1–1 lists many examples

Table 1–1 Bricks: Selected CULTURALCARE Terms

Access Acupuncture Ageism Alien Allopathic philosophy Amulet Apparel Assimilation Bankes Borders Calendar Care Census Citizen CLAS Community Costs Cultural conflict CULTURALCARE CULTURALCOMPETENCY Culturally appropriate Culturally competent Culturally sensitive Culture Curandera/o Customs Cycle of poverty Demographic disparity Demographic parity Demography Diagnosis Diversity Documentation Education Empacho Envidia Ethics Ethnicity Ethnicity Ethnocentrism Evil eye Family Financing Food Garments Gender specific care Green Card Gris-gris Habits Halal HEALING Health HEALTH Health care system Health disparities HEALTH Traditions Healthy People 2020 Herbalist Heritage Heritage consistency Heritage inconsistency

Heterosexism Hex Homeland security

Homeopathic philosophy

Homophobia Iatrogenic Illness

ILLNESS Immigration Kosher Language Law Legal Permanent

Resident (LPR) Life trajectory Limpia

Linguistic competence Literacy Mal ojo Manpower Meridians Migrant labor Milagros Modern Modesty Morbidity Mortality Naturalization Office of Minority Health

Orisha Osteopathy Partera

Pasmo Politics Poverty Poverty guidelines Powwow Procedures Promesa Quag dab peg Racism Reflexology Refugee Religion Remedies Sacred objects Sacred places Sacred practices Sacred spaces Sacred times Santera/o Senoria Sexism Silence Silence Singer Socialization Spell Spirits Spiritual Spirituality Title VI Traditional Undocumented person Visitors Voodoo Vulnerability Welfare Worldview Xenophobia Yin &Yang Yoruba

8 ■ Chapter 1

of the bricks and the terms are used in the following chapters as appropriate and most are defined in the Key Terms list in Appendix A. These selected terms and many more are the evolving language or jargon of CULTURALCARE.

The railings represent “responsibility and resiliency”—for it is the respon- sibility of health care providers to be CULTURALLYCOMPETENT and, if this is not met, the consequences will be dire. The resiliency of providers and patients will be further compromised and we will all become more vulnerable. Contrary to popular belief and practice, CULTURALCOMPETENCY is not a “condition” that is rapidly achieved. Rather, it is an ongoing process of growth and the develop- ment of knowledge that takes a considerable amount of time to ingest, digest, assimilate, circulate, and master. It is, for many, a philosophical change in that they develop the skills to understand where a person from a different cultural background than theirs is coming from.

This discussion now presents an overview of the significant content re- lated to the ongoing development of the concepts of cultural and linguistic competency as they are described by several different organizations. Presently, there has been a proliferation of resources related to this content and a discus- sion of selected items is included here. Box 1–2, at the conclusion of the chap- ter, lists numerous resources.

■ National Standards for Culturally and Linguistically Appropriate Services in Health Care

In 1997, the Office of Minority Health undertook the development of national standards to provide a much needed alternative to the patchwork that has been undertaken in the field of cultural diversity. It developed the National Stan- dards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. These 14 standards (Box 1–1) must be met by most health care-related agencies. The standards are based on an analytical review of key laws, regula- tions, contracts, and standards currently in use by federal and state agencies and other national organizations. Published in 2001, the standards were developed with input from a national advisory committee of policymakers, health care pro- viders, and researchers. The CLAS standards are primarily directed at health care organizations. The principles and activities of culturally and linguistically appropriate services must be integrated throughout an organization and imple- mented in partnership with the communities being served. Enhanced standards are currently being developed but are not yet available. The new standards, National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Pol- icy and Practice will be available at

Accreditation and credentialing agencies can assess and compare provid- ers who say they provide culturally competent services and assure quality care for diverse populations. This includes the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); the National Committee on Quality

Building Cultural and Linguistic Competence ■ 9

Box 1–1

Office of Minority Health’s Recommended* National Standards for

Culturally and Linguistically Appropriate Services in Health Care

The Fundamentals of Culturally Competent Care 1. Health care organizations should ensure that patients/consumers receive

from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguisti- cally appropriate service delivery.

Speaking of Culturally Competent Care 4. Health care organizations must offer and provide language assistance

services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

5. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

6. Health care organizations must assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to pro- vide interpretation services (except on request by the patient/consumer).

7. Health care organizations must make available easily understood patient- related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

8. Health care organizations should develop, implement, and promote a writ- ten strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

Structuring Culturally Competent Care 9. Health care organizations should conduct initial and ongoing organizational

self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence–related measures into their internal au- dits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.


10 ■ Chapter 1

Assurance; professional organizations, such as the American Medical Associa- tion and the American Nurses Association; the Transcultural Nursing Society; and quality review organizations, such as peer review organizations.

In order to ensure both equal access to quality health care by diverse populations and a secure work environment, all health care providers must “promote and support the attitudes, behaviors, knowledge, and skills necessary for staff to work respectfully and effectively with patients and each other in a culturally diverse work environment” (Office of Minority Health, 2001, p. 7). This is the first and fundamental standard of the 14 standards that have been recommended as national standards for CLAS in health care.

10. Health care organizations should ensure that data on the individual patient’s/ consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

11. Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

12. Health care organizations should develop participatory, collaborative part- nerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.

13. Health care organizations should ensure that conflict and grievance resolu- tion processes are culturally and linguistically sensitive and capable of iden- tifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.

14. Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

*CLAS standards are non-regulatory and therefore do not have the force and effect of law. The standards are not mandatory but they greatly assist health care providers and organiza- tions in responding effectively to their patients’ cultural and linguistic needs. Compliance with Title VI of the Civil Rights Act of 1964 is mandatory and requires health care providers and or- ganizations that receive federal financial assistance to take reasonable steps to ensure Limited English Proficiency (LEP) persons have meaningful access to services.

CLAS standards use the term patients/consumers to refer to “individuals, including accompa- nying family members, guardians, or companions, seeking physical or mental health care ser- vices, or other health-related services” (p. 5 of the comprehensive final report; see http://

Source: National Standards for Culturally and Linguistically Appropriate Services in Health Care. Final Report. Washington, DC, March 2001. browse.aspx?lvl=2&lvlID=15, accessed April 6, 2011.

Box 1–1 Continued

Building Cultural and Linguistic Competence ■ 11

■ Cultural Competence Cultural competence implies that professional health care must be developed to be culturally sensitive, culturally appropriate, and culturally competent. Cultur- ally competent care is critical to meet the complex culture-bound health care needs of a given person, family, and community. It is the provision of health care across cultural boundaries and takes into account the context in which the pa- tient lives, as well as the situations in which the patient’s health problems arise.

■ Culturally competent—within the delivered care, the provider under- stands and attends to the total context of the patient’s situation and this is a complex combination of knowledge, attitudes, and skills.

■ Culturally appropriate—the provider applies the underlying back- ground knowledge that must be possessed to provide a patient with the best possible health/HEALTH care.

■ Culturally sensitive—the provider possesses some basic knowledge of and constructive attitudes toward the health/HEALTH traditions ob- served among the diverse cultural groups found in the setting in which he or she is practicing.

■ Linguistic Competence Title VI of the Civil Rights Act of 1964 states, “No person in the United States shall, on ground of race, color, or national origin, be excluded from participa- tion in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance” (Dirksen Congressio- nal Center, 2011).

To avoid discrimination based on national origin, Title VI and its imple- menting regulations require recipients of federal financial assistance to take rea- sonable steps to provide meaningful access to Limited English Proficiency (LEP) persons. Therefore, under the provisions of Title VI of the Civil Rights Act of 1964, when people with LEP seek health care in health care settings such as hospitals, nursing homes, clinics, day care centers, and mental health centers, services cannot be denied to them. It is said that “language barriers have a del- eterious effect on health care and patients are less likely to have a usual source of health care, and have an increased risk if non-adherence to medication regi- mens” (Flores, 2006, p. 230).

The United States is home to millions of people from many national ori- gins. Currently, because there are growing concerns about racial, ethnic, and lan- guage disparities in health and health care and the need for health care systems to accommodate increasingly diverse patient populations, language access ser- vices (LAS) have become more and more a matter of national importance. This need has become increasingly pertinent given the continued growth in language diversity within the United States. English is the predominant language of the United States and according to the 2010 American Community Survey estimates it is spoken at home by 79.4% of its residents over 5 years of age (U.S. Census Bureau, 2012a). In the total of over 13 million Spanish-speaking households,

12 ■ Chapter 1

there are 3.2 million households where no one over 14 speaks English only or speaks English “very well.” There are over 5.2 million Indo-European and over 3.7 million Asian and Pacific Island households where no one over 14 speaks English only or speaks English “very well.” (U.S. Census Bureau, 2012b). The most common, non-English languages spoken by people over 5 at home are Spanish, Chinese, French, German, and Tagalog. Vietnamese, Italian, Korean, and Russian and Polish are next among the top 10 languages (U.S. Census Bureau, 2012c).

People who are limited in their ability to speak, read, write, and under- stand the English language experience countless language barriers that can result in limiting their access to critical public health, hospital, and other medical and social services to which they are legally entitled. Many health and social service programs provide information about their services in English only. When LEP persons seek health care at hospitals or medical clinics, they are frequently faced with receptionists, nurses, and doctors who speak English only. The language barrier faced by LEP persons in need of medical care and/or social services se- verely limits the ability to gain access to these services and to participate in these programs. In addition, the language barrier often results in the denial of medi- cal care or social services, delays in the receipt of such care and services, or the provision of care and services based on inaccurate or incomplete information. Services denied, delayed, or provided under such circumstances could have seri- ous consequences for an LEP patient as well as for a provider of medical care. Some states, for example California, Massachusetts, and New York, recognize the seriousness of the problem and require providers to offer language assis- tance to patients in health care settings. Language access services are especially relevant to racial and ethnic disparities in health care. A report by the Institute of Medicine (IOM) on racial and ethnic disparities in health care documented through substantial research that minorities, as compared to their White Ameri- can counterparts, receive lower quality of care across a wide range of medical conditions, resulting in poorer health outcomes and lower health statuses. The research conducted by the IOM showed that language barriers can cause poor, abbreviated, or erroneous communication and poor decision making on the part of both providers and patients (Smedley, B. D., A. Y. Stith, and A. R. Nelson, 2004, p. 3). Each patient must be carefully assessed to determine his or her language needs, and information must be delivered in a manner that is under- standable by the patient. When a patient does not understand English, compe- tent interpreters or language resources must be available.

■ Institutional Mandates Since 2003, the Joint Commission has been actively pursuing a course that en- sures that cultural and linguistic competency standards become a part of their accreditation requirements. Since this time, they have published several docu- ments relevant to this topic and in 2010 they published a monograph, Advanc- ing Effective Communication, Cultural Competence, and Patient and Family

Building Cultural and Linguistic Competence ■ 13

Centered Care: A Roadmap for Hospitals. The monograph provides checklists to improve effective communication during the admission, assessment, treatment, end-of-life, and discharge and transfer stages of a given patient’s hospitalization trajectory. They strongly state that:

Every patient that enters the hospital has a unique set of needs—clinical symptoms that require medical attention and issues specific to the individ- ual that can affect his or her care. (The Joint Commission, 2010, p. 1)

They implicitly recognize that when a given person moves through the hospital- ization continuum, he or she not only requires medical and nursing intervention, but they also require care that addresses the spectrum of each person’s demo- graphic and personal characteristics. The Joint Commission has made many ef- forts to understand personal needs and then provide guidance to organizations to address those needs. They initially focused on studying language, culture, and health literacy needs and presently (as of 2011), they are focusing on effective communication, cultural competence, and patient- and family-centered care.

The Joint Commission defines cultural competency as:

the ability of health care providers and health care organizations to under- stand and respond effectively to the cultural and language needs brought by the patient to the health care encounter. (2010, p. 91)

They further recognize that:

cultural competence requires organizations and their personnel to: (1) value diversity; (2) assess themselves; (3) manage the dynamics of difference; (4) acquire and institutionalize cultural knowledge; and (5) adapt to diver- sity and the cultural contexts of individuals and communities served. (The Joint Commission, 2010, p. 91)

These principles apply to each segment of the institutional experience from admission to discharge or end of life, and for each facet there are specific actions that must be undertaken. These actions include informing patients of their rights, assessing communication needs, and involving the patient and family in care plans. Each segment is accompanied by a checklist for activities; for example, there is a checklist to Improve Effective Communication, Cultural Competence, and Patient- and Family-Centered Care during admission (The Joint Commis- sion, p. 9).

■ CULTURALCARE The term CULTURALCARE expresses all that is inherent in the development of health care delivery to meet the mandates of the CLAS standards and other cul- tural competency mandates. CULTURALCARE is holistic care. There are countless conflicts in the health care delivery arenas that are predicated on cultural misun- derstandings. Although many of these misunderstandings are related to universal situations—such as verbal and nonverbal language misunderstandings, the con- ventions of courtesy, the sequencing of interactions, the phasing of interactions,

14 ■ Chapter 1

and objectivity—many cultural misunderstandings are unique to the delivery of health care. The need to provide CULTURALCARE is essential, and providers must be able to assess and interpret a patient’s health beliefs and practices and cultural and linguistic needs. CULTURALCARE alters the perspective of health care delivery as it enables the provider to understand, from a cultural perspective, the mani- festations of the patient’s cultural heritage and life trajectory. The provider must serve as a bridge in the health care setting between the given institution, the pa- tient, and people who are from different cultural backgrounds.

In conclusion, cultural and linguistic competency must be understood to be the foundations of a new health care philosophy. It is comprised of countless facets—each of which is a topic for study. CULTURALCOMPETENCY is a philosophy that appreciates and values holistic perspectives rather than, or in addition to, du- alistic—modern and technological—viewpoints. CULTURALCOMPETENCY is more than a “willingness”—it is a philosophy that must be part of an institution’s and a professional’s mission and goal statement. Within the philosophy of cultural competency, HEALTH, ILLNESS, and HEALING are understood holistically.

There are countless interrelated facets that include but are not limited to:

1. Language and the regulations of Title VI 2. Demography 3. Gender issues such as gender specific care and modesty 4. Faith and the roles religions play in HEALTH 5. Dietary practices 6. Income—both low and high 7. Heritage 8. Education 9. Social status 10. Spatial factors 11. Immigration—legal and illegal 12. Environmental issues 13. Unnatural causes of diseases 14. Health disparities 15. Manners 16. Socialization—both into the dominant society and into the profes-

sional practice disciplines 17. Traditional HEALTH beliefs and practices 18. Use of traditional healers and medicines 19. The human right of a given person/family/community to choose

and select the type of health/HEALTH care (modern, traditional, or both) he or she prefers.

20. Dissonance—when a practitioner provides culturally and linguisti- cally competent care and this care is not in harmony with his or her allopathic and/or institutional care beliefs and practices.

Building Cultural and Linguistic Competence ■ 15

Each of these topics will be further discussed in various chapters in the remain- der of this text.

Indeed, the development of CULTURALCOMPETENCE is an ongoing, life- long endeavor. This is a topic that requires deep study, reflection, and time. The days when a “bagged lunch” with an hour’s lecture or discussion have passed and hours—even a lifetime—must be dedicated to the topics, and countless others, this book presents. A critical question must be asked: “Are health care providers institutional advocates? Modern health care advocates? Or, patient advocates?”

Go to the Student Resource Site at for chapter-related review questions, case studies, and activities. Contents of the CULTURALCARE Guide and CULTURALCARE Museum can also be found on the Student Resource Site. Click on Chapter 1 to select the activities for this chapter.

Explore MediaLink

Box 1–2: Keeping Up

There are countless references that are published weekly, monthly, annually, and periodically, which may be accessed to maintain currency in the domains of cul- tural and linguistic competency and with professional organizations concerned with this specialty area of practice. The following are selected suggestions:

American Association of Colleges of Nursing (AACN) The AACN’s Toolkit for Cultural Competent Education provides extensive resources including content and teaching-learning activities.

Health and Human Services (HHS) Data Council The HHS Data Council coordinates all health and human services data collection and analysis activities of the Department of Health and Human Services, including integrated data collection strategy, coordination of health data standards and health and human services, and privacy policy activities.

Kaiser FamilyFund Kaiser Fast Facts provides direct access to facts, data, and slides about the nation’s health care system and programs, in an easy-to-use format.


16 ■ Chapter 1 The Kaiser Family Foundation has launched a new Internet resource, State Health Facts Online, that offers comprehensive and current health infor- mation for all 50 states, the District of Columbia, and U.S. territories. State Health Facts Online offers health policy information on a broad range of issues such as managed care, health insurance coverage and the uninsured, Medicaid, Medicare, women’s health, minority health, and data and slides about the nation’s health care system and programs, in an easy-to-use format.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) NBCCEDP provides access to critical breast and cervical cancer screen- ing services for underserved women in the United States, the District of Columbia, 4 U.S. territories, and 13 American Indian/Alaska Native organizations.

Office of Minority Health (OMH) The OMH was created in 1986 and is one of the most significant outcomes of the 1985 Secretary’s Task Force Report on Black and Minority Health. The Office is dedicated to improving the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities. The OMH was reauthorized by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148). In addition the new standards, National Standards for Culturally and Linguisti- cally Appropriate Services in Health and Health Care: A Blueprint for Advanc- ing and Sustaining CLAS Policy and Practice will be available at https://www.

Robert Wood Johnson The Robert Wood Johnson Foundation has launched an online tool that ranks state counties by health status, taking into account clinical care, socio- economic and environmental factors.

The National Center for Health Statistics (NCHS) The NCHS provides quick and easy access to the wide range of informa- tion and data available, including HHS surveys and data collection systems.

Box 1–2 Continued

Building Cultural and Linguistic Competence ■ 17

The Joint Commission Since 2007, the Joint Commission has been working toward improv- ing access to care for all patients at our accredited organizations through better communication, cultural competence, and patient- and family- centered care.

Transcultural Nursing Society

The Transcultural Nursing Society has developed a core curriculum in Transcultural Nursing that can be found at ref=nb_sb_noss?url=search-alias%3Dstripbooks&field-keywords=core +curriculum+for+transcultural+nursing Douglas, M. K., Editor-in-Chief and Pacquiao, D. F., Senior Editor. (2010). Core Curriculum for Transcultural Nursing and Health Care is available here.

The Transcultural Nursing Society has also developed Standards for Culturally Competent Nursing Care and they can be found at Douglas, M. K., Pierce, J.U., Rosenkoetter, M., et al. (2011). Standards of Practice for Culturally Competent Care. Journal of Transcultural Nursing, 22(4), 318.

University of Michigan Health System: The Cultural Competency Division. The Cultural Competency Division plays a vital role in implementing cul- tural competency in the UMHS and in promoting good community health care practices. This is an excellent website with links to numerous sites.

The Online Journal of Cultural Competence in Nursing and Healthcare

This journal’s first issue appeared online in January 2011. It is a free quarterly peer-reviewed publication that provides a forum for discussion of the issues, trends, theory, research, evidence-based, and best practices in the provision of culturally congruent and competent nursing and healthcare. The address is

■ Internet Sources American Institutes for Research. (2005). A Patient-Centered Guide to Imple-

menting Language Access Services in Healthcare Organizations. Washington, DC: Office of Minority Health/U.S. Department of Health and Human Ser- vices. Retrieved from, August 2011.

18 ■ Chapter 1

Dirksen Congressional Center. (2011). Major Features of the Civil Rights Act of 1964, Public Law 88–352, §601, 78 Stat 252 (42 USC 2000d). Retrieved from 64text.htm, November 28, 2011.

The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospi- tals. Oakbrook Terrace, IL: The Joint Commission. Retrieved from http://, July 2011.

United States Census Bureau. (2010a). American Community Survey Language Spoken at Home. Retrieved from tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_GCT1601. US01PR&prodType=table, April 11, 2012.

United States Census Bureau. (2010b). American Community Survey Lan- guage Spoken at Home. Retrieved from faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_ B16002&prodType=table, April 11, 2012.

United States Census Bureau. (2010c) American Community Survey Lan- guage Spoken at Home. Retrieved from faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_ B16001&prodType=tables, April 11, 2012.

■ References American Institutes for Research. (2005). A patient-centered guide to implementing

language access services in healthcare organizations. Washington, DC: Office of Minority Health/U.S. Department of Health and Human Services.

Civil Rights Act of 1964, Public Law 88–352, §601, 78 Stat 252 (42 USC 2000d). Fadiman, A. (2001). The spirit catches you and you fall down. NY: Farrar, Straus,

and Giroux. Flores, G. (2006). Language barriers to health care in the United States. New

England Journal of Medicine, 355(3), 229–231. Smedley B. D., A. Y. Stith, and A. R. Nelson. (2004). Unequal treatment: con-

fronting racial and ethnic health disparities in health care. Institute of Medicine Report. Washington, DC: National Academy Press.


Chapter 2 Cultural Heritage and History

Samoans, remember your culture.

■ Objectives

1. Explain the factors that contribute to heritage consistency—culture, ethnicity, religion, and socialization.

2. Explain acculturation themes. 3. Determine and discuss sociocultural events that may influence the life

trajectory of a given person. 4. Explain the factors involved in the cultural phenomena affecting health.

The image of a banner (Figure 2–1) was photographed at the International Parade in Honolulu, Hawaii, on March 13, 2011. It admonished Samoans— “remember YOUR culture”—a searing message for each of us to hear. This banner deeply resonated in me and made me aware of how important it is for me to know my culture and heritage—for all of us to know our culture and heritage. The opening images for this chapter depict critical aspects of the heri- tage I am a member of and are examples of the places and icons that were a part of my socialization as a child and teenager in the New England, American soci- ety of the mid-1950s. Figure 2–2 is that of Temple Shalom, the synagogue my family belonged to in Salem, Massachusetts. Here, I learned to read and write Hebrew, the history of the Jewish people, and the norms and expectations of be- ing a Jewish American. Figure 2–3 is my high school, where I learned the skills to advance in life and experienced the roller coaster ride of the teenaged years. Last, my class ring (Figure 2–4), a cherished icon—I graduated from Salem

Figure 2–4Figure 2–3Figure 2–2Figure 2–1

20 ■ Chapter 2

(Massachusetts) High School in 1958. These are examples of the highlights of my socialization—the places and icons representative of my cultural heritage and history. What are the places and icons of your generation and culture? If you had to choose 4 images to blend together as cornerstones of your cultural heritage, what would you choose?

Who are you? What is your cultural, ethnic, and religious heritage? How and where were you socialized to the roles and rules of your family, commu- nity, and occupation? Who is the person next to you? What is this person’s cul- tural, ethnic, and religious heritage? How and where was this person socialized to the roles and rules of his or her family, community, and occupation? Are you this person’s health care provider, instructor, colleague, or supervisor? The foundation for cultural competency rests in the knowledge and understanding of heritage, not only of yours but also of others with whom you are interacting.

This second chapter presents an overview of the salient content and com- plex theoretical content related to one’s heritage and its impact on health beliefs and practices. Two sets of theories are presented, the first of which analyzes the degree to which people have maintained their traditional heritage; the second, and opposite, set of theories relates to socialization and acculturation and the quasi creation of a melting pot or some other common threads that are part of an American whole. It then becomes possible to analyze health beliefs by deter- mining a person’s ties to his or her traditional heritage, rather than to signs of acculturation. The assumption is that there is a relationship between people with strong identities—either with their heritage or the level at which they are accul- turated into the American culture—and their health beliefs and practices. Hand in hand with the concept of ethnocultural heritage is that of a person’s ethnocul- tural history; the journey a person has experienced predicated on the historical sociocultural events that have touched his or her life directly or indirectly.

■ Heritage Consistency Heritage consistency is a concept developed by Estes and Zitzow (1980, p. 1) to describe “the degree to which one’s lifestyle reflects his or her respective tribal culture.” The theory has been expanded in an attempt to study the degree to which a person’s lifestyle reflects his or her traditional culture, such as European, Asian, African, or Hispanic. The values indicating heritage consistency exist on a continuum, and a person can possess value characteristics of both a consistent heritage (traditional) and an inconsistent heritage (acculturated). The concept of heritage consistency includes a determination of one’s cultural, ethnic, and religious background (Figure 2–5). It has been found over time that the greater a given person identifies with his or her traditional heritage, that is, his or her culture, ethnicity, and religion, the greater the chance that the person’s health and illness beliefs and practices may vary from those of the mainstream soci- ety and modern health care providers. For example, Estes and Zitzow observed that when people who identified highly with their tribal culture were treated for alcoholism by a medicine man, the outcome was more favorable than with treatment in the modern culture. Other research found that people with a high

Cultural Heritage and History ■ 21

level of heritage consistency frequented health care sources not used by modern providers. The Heritage Assessment Tool, Appendix E, is a screening tool to assess for a person’s level of heritage consistency and is a useful tool in research development.


The word culture showed 1,550,000,000 results on February 23, 2012, on the Internet. An overview of the content on selected sites, however, is certainly in harmony with the forthcoming discussion. There is no single definition of culture, and all too often definitions omit salient aspects of culture or are too general to have any real meaning. Of the countless ideas of the meaning of this term, some are of particular note. The classical definition by Fejos (1959, p. 43) describes culture as “the sum total of socially inherited characteristics of a human group that comprises everything which one generation can tell, convey, or hand down to the next; in other words, the nonphysically inherited traits we possess.” Another way of understanding the concept of culture is to picture it as the luggage that each of us carries around for our lifetime. It is

Figure 2–5 Model of heritage consistency.

22 ■ Chapter 2

the sum of beliefs, practices, habits, likes, dislikes, norms, customs, rituals, and so forth that we learned from our families during the years of socialization. In turn, we transmit cultural luggage to our children. A third way of defining culture is the behaviors and beliefs characteristic of a particular social, ethnic, or age group (, n.d.) and, lastly, one that is most relevant in areas of traditional health is that culture is a “metacommunication system,” wherein not only the spoken words have meaning but everything else does as well (Matsumoto, 1989, p. 14).

All facets of human behavior can be interpreted through the lens of cul- ture, and everything can be related to and from this context. Culture includes all the following characteristics:

1. Culture is the medium of personhood and social relationships. 2. Only part of culture is conscious. 3. Culture can be likened to a prosthetic device because it is an exten-

sion of biological capabilities. 4. Culture is an interlinked web of symbols. 5. Culture is a device for creating and limiting human choices. 6. Culture can be in two places at once—it is found in a person’s mind

and exists in the environment in such form as the spoken word or an artifact. (Bohannan, 1992, p. 12)

Culture is a complex whole in which each part is related to every other part. It is learned, and the capacity to learn culture is genetic, but the subject matter is not genetic and must be learned by each person in a family and social commu- nity. Culture also depends on an underlying social matrix, and included in this social matrix are knowledge, beliefs, art, law, morals, and customs (Bohannan, 1992, p. 13).

Culture is learned in that people learn the ways to see their environment— that is, they learn from the environment how to see and interpret what they see. People learn to speak, and they learn to learn. Culture, as the medium of our individuality, is the way in which we express ourselves. It is the medium of human social relationships, in that culture must be shared and creates social relationships. The symbols of culture—sound and acts—form the basis of all lan- guages. Symbols are everywhere—in religion, politics, and gender; these are cul- tural symbols, the meanings of which vary between and within cultural groups (Bohannan, 1992, pp. 11–14). The society in which we live, and political, eco- nomic, and social forces tend to alter the way in which some aspects of a culture are transmitted and maintained. Many of the essential components of a culture, however, pass from one generation to the next unaltered. Consequently, our cultural background determines much of what we believe, think, and do, both consciously and unconsciously. In this way, culture and ethnicity are handed down from one generation to another. These classic definitions of culture con- tinue to serve as a basis for understanding the term in the present time. In fact, the recent definition developed by the Joint Commission in 2010 defines culture as “integrated patterns of human behavior that include the language,

Cultural Heritage and History ■ 23

thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (p. 91).


The word ethnicity showed 23,600,000 results on February 23, 2012, on the Internet. A random exploration of selected sites did not provide information different from the classical information in the following discussion.

Cultural background is a fundamental component of one’s ethnic back- ground. Before we proceed with this discussion, though, we need to define some terms, so that we can proceed from the same point of reference. The classic ref- erence defines ethnic as an adjective “of or pertaining to a social group within a cultural and social system that claims or is accorded special status on the basis of complex, often variable traits including religious, linguistic, ancestral, or physical characteristics” (Davies, 1976, p. 247). The contemporary definition applied by the Office of Minority Health is that of “a group of people that share a com- mon and distinctive racial, national, religious, linguistic, or cultural heritage” (Office of Minority Health, 2001, p. 131). O’Neil (2008) described ethnicity as selected cultural and sometimes physical characteristics used to classify people into groups or categories considered to be significantly different from others.

The term ethnic has for some time aroused strongly negative feelings and is often rejected by the general population. One can speculate that the upsurge in the use of the term stems from the recent interest of people in discovering their personal backgrounds, a fact used by some politicians who overtly court “the ethnics.” Paradoxically, in a nation as large as the United States and comprising as many different peoples as it does—with the American Indians being the only true native population—we find ourselves still reluctant to speak of ethnicity and ethnic differences. This stance stems from the fact that most foreign groups that come to this land often shed the ways of the “old country” and quickly attempt to assimilate themselves into the mainstream, or the so-called melting pot (Novak, 1973). Other terms related to ethnic include:

■ Ethnicity: Identity with or membership in a particular racial, national, or cultural group and observance of that group’s customs, beliefs, and language (, n.d.)

■ Ethnocentrism: (1) belief in the superiority of one’s own ethnic group; (2) overriding concern with race

■ Xenophobia: a morbid fear of strangers ■ Xenophobe: a person unduly fearful or contemptuous of strangers or

foreigners, especially as reflected in his or her political or cultural views

The behavioral manifestations of these phenomena occur in response to people’s needs, especially when they are foreign born and must find a way to function (1) before they are assimilated into the mainstream and (2) in order to accept themselves. The people cluster together against the majority, who in turn may be discriminating against them.

24 ■ Chapter 2

Indeed, the phenomenon of ethnicity is “complex, ambivalent, paradoxi- cal, and elusive” (Senior, 1965, p. 21). Ethnicity is indicative of the following characteristics a group may share in some combination:

1. Geographic origin 2. Migratory status 3. Race 4. Language and dialect 5. Religious faith or faiths 6. Ties that transcend kinship, neighborhood, and community boundaries 7. Traditions, values, and symbols 8. Literature, folklore, and music 9. Food preferences 10. Settlement and employment patterns 11. Special interest, with regard to politics, in the homeland and in the

United States 12. Institutions that specifically serve and maintain the group 13. An internal sense of distinctiveness 14. An external perception of distinctiveness

There are at least 106 ethnic groups and more than 500 American Indian Nations in the United States that meet many of these criteria. People from every country in the world have immigrated to this country. Some nations, such as Germany, England, Wales, and Ireland, are heavily represented; others, such as Japan, the Philippines, and Greece, have smaller numbers of people living here (Thernstrom, 1980, p. vii). People continue to immigrate to the United States, with the present influx coming from Haiti, Mexico, South and Central America, India, and China.


The third major component of heritage consistency is religion. The word religion showed 170,000,000 results on February 23, 2012, on the Internet. Again, a random review of the material yielded information that was similar to existing data. One way to understand religion is that it is “the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe; it is a system of beliefs, practices, and ethical values.” Religion is a major reason for the development of ethnicity (Abramson, 1980, pp. 869–875). Another way is to see religion as, “a set of beliefs concerning the cause, nature, and purpose of the universe, especially when considered as the creation of a superhuman agency or agencies, usually involving devotional and ritual ob- servances, and often containing a moral code governing the conduct of human affairs and a specific fundamental set of beliefs and practices generally agreed upon by a number of persons or sects” (, n.d.).

Cultural Heritage and History ■ 25

The Office of Minority Health has adopted the definition of religion as “a set of beliefs, values, and practices based on the teachings of a spiritual leader” (Office of Minority Health, 2001, p. 132). The practice of religion is revealed in numerous cults, sects, denominations, and churches. Ethnicity and religion are clearly related, and one’s religion quite often determines one’s ethnic group. Religion gives a person a frame of reference and a perspective with which to organize information. Religious teachings in relation to health help present a meaningful philosophy and system of practices within a system of social controls having specific values, norms, and ethics. These are related to health in that ad- herence to a religious code is conducive to spiritual harmony and health. Illness is sometimes seen as a punishment for the violation of religious codes and morals.

Religion plays a fundamental and vital role in the health beliefs and prac- tices of many people. The following are general examples of the influences reli- gion has on health practices:

1. Meditating 2. Being vaccinated 3. Being willing to have the body examined 4. Maintaining family viability 5. Hoping for recovery 6. Coping with stress 7. Caring for children.

Specific examples of a religious tradition and its influence on health include:

1. Judaism is rich in health-related proscriptions—from diet to activity to human relations and so forth.

2. The Catholic religion forbids abortion. 3. The Jehovah’s Witnesses forbid blood transfusions. 4. The Mormons and Seventh Day Adventists prohibit the use of caf-

feine and tobacco.

An additional way of understanding the relationship of religion to health is to conceptualize religion as

1. particular churches or organized religious institutions; 2. a scholarly field of study; and 3. the domain of life that deals with things of the spirit and matters of

“ultimate concern.”

In addition, religious affiliation and membership benefit health by pro- moting healthy behavior and lifestyles in the following ways:

1. Regular religious fellowship benefits health by offering support that buffers and affects stress and isolation.

2. Participation in worship and prayer benefits health through the phys- iological effects of positive emotions.

26 ■ Chapter 2

3. Religious beliefs benefit health by their similarity to health promot- ing beliefs and personality styles.

4. Simple faith benefits health by leading to thoughts of hope, optimism, and positive expectation.

5. Mystical experiences benefit health by activating a healing bioenergy or life force or altered state of consciousness.

6. Absent prayer for others is capable of healing by paranormal means or by divine intervention (Levin, 2001, p. 9).

Unlike some countries, the United States does not include a question about religion in its census and has not done so for over 50 years. Religious adher- ent statistics in the United States are obtained from surveys and organizational reporting. However, it is also noteworthy that “ ‘we the people’ of the United States now form the most profusely religious nation on earth” (Eck, 2001, p. 4). In 2006, Putnam and Campbell again found that Americans are a highly religious people. We have high rates of belonging, behaving, and believing, and when compared to other industrialized nations the United States ranks 7th in the rate of weekly attendance at religious services. Jordan, Indonesia, and Brazil are ahead of us. They also found that Mormons, Black Protestants, and Evan- gelicals are the most religiously observant groups in America; and that the deep south, Utah, and the Mississippi Valley are the most religious regions of the country (2010, pp. 7–23).

One source of religious preference is the Pew Forum on Religion and Public Life. (2011). The Forum delivers timely, impartial information on issues at the intersection of religion and public affairs. Table 2–1 illustrates the find- ings in the Statistical Abstracts, a government publication, regarding religious preferences in the United States (see Box 2–1).

Table 2–1 Self Described Religious Identification of the Adult Population: 2008

Religious Group

Estimate (In thousands (175,440 represents


Christian 173,402 Jewish 2,680 Buddhist 1,189 Muslim 1,349 Hindu 582 Other Unclassified 1,030 No religion specified 34,169

Source: Adapted from U.S. Census Bureau, Statistical Abstract of the United States: 2012. Population. p. 61. Retrieved from 11/28/11

Cultural Heritage and History ■ 27

Examples of Heritage Consistency

The factors that constitute heritage consistency are listed in Table 2–2. The fol- lowing are examples of each factor:

1. The person’s childhood development occurred in the person’s coun- try of origin or in an immigrant neighborhood in the United States of like ethnic group. The person was raised in a specific ethnic neighborhood, such as Italian, Black, Hispanic, or Jewish, in a given part of a city and was exposed to only the culture, language, foods, and customs of that group.

2. Extended family members encouraged participation in traditional religious and cultural activities. The parents sent the person to religious school, and most social activities were church-related.

3. The individual engages in frequent visits to the country of origin or returns to the “old neighborhood” in the United States. The desire to return to the old country or to the old neighborhood is prevalent in many people; however, many people, for various reasons, cannot return. The people who came here to escape religious persecution or whose families were killed during world wars or the Holocaust may not want to return to Euro- pean homelands. Other reasons people may not return to their native country include political conditions in the homeland and lack of relatives or friends in that land.

Table 2–2 Factors Indicating Heritage Consistency

1. The person’s childhood development occurred in the person’s country of origin or in an immigrant neighborhood in the United States of like ethnic group.

2. Extended family members encouraged participation in traditional religious or cultural activities.

3. The individual engages in frequent visits to the country of origin or returns to the “old neighborhood” in the United States.

4. The individual’s family home is within the ethnic community. 5. The individual participates in ethnic cultural events, such as religious festivals or

national holidays, sometimes with singing, dancing, and special garments. 6. The individual was raised in an extended family setting. 7. The individual maintains regular contact with the extended family. 8. The individual’s name has not been Americanized. 9. The individual was educated in a parochial (nonpublic) school with a religious or

ethnic philosophy similar to the family’s background. 10. The individual engages in social activities primarily with others of the same ethnic

background. 11. The individual has knowledge of the culture and language of origin. 12. The individual possesses elements of personal pride about heritage.

28 ■ Chapter 2

4. The individual’s family home is within the ethnic community of which he or she is a member. As an adult, the person has elected to live with family in an ethnic neighborhood.

5. The individual participates in ethnic cultural events, such as religious festivals or national holidays, sometimes with singing, dancing, and costumes. The person holds membership in ethno- or religious-specific organizations and primarily participates in activities with the groups.

6. The individual was raised in an extended family setting. When the person was growing up, there may have been grandparents living in the same household, or aunts and uncles living in the same house or close by. The person’s social frame of reference was the family.

7. The individual maintains regular contact with the extended family. The person maintains close ties with members of the same generation, the surviv- ing members of the older generation, and members of the younger generation who are family members.

8. The individual’s name has not been Americanized. The person has restored the family name to its European original if it had been changed by immigration authorities at the time the family immigrated or if the family changed the name at a later time in an attempt to assimilate more fully.

9. The individual was educated in a parochial (nonpublic) school with a religious or ethnic philosophy similar to the family’s background. The person’s education plays an enormous role in socialization, and the major purpose of education is to socialize a person into the dominant cul- ture. Children learn English and the customs and norms of American life in the schools. In the parochial schools, they not only learn English but also are socialized in the culture and norms of the religious or ethnic group that is sponsoring the school.

10. The individual engages in social activities primarily with others of the same religious or ethnic background. The major portion of the person’s personal time is spent with primary structural groups.

11. The individual has knowledge of the culture and language of origin. The person has been socialized in the traditional ways of the family and expresses this as a central theme of life.

12. The individual expresses pride in his or her heritage. The person may identify him- or herself as ethnic American and be supportive of ethnic activities to a great extent.

It is not possible to isolate the aspects of culture, religion, and ethnicity that shape a person’s worldview. Each is part of the other, and all three are united within the person. When one writes of religion, one cannot eliminate culture or ethnicity, but descriptions and comparisons can be made. Referring to Figure 2–5 and Figures 2–6A and 2–6B to assess heritage consistency can help deter- mine ethnic group differences in health beliefs and practices. Understanding

Cultural Heritage and History ■ 29

such differences can help enhance your understanding of the needs of patients and their families and the support systems that people may have or need.

■ Acculturation Themes Several facets are relevant to the overall experience of acculturation. Acculturation is the broad term used to describe the process of adapting to and becoming absorbed into the dominant social culture. The overall process of acculturation into a new society is extremely difficult. Have you ever moved to a new community? Imagine moving to a new country and society where you

Figure 2–6A Matrix of heritage consistency.

30 ■ Chapter 2

are unable to communicate, do not know your way around, and do not know know the “rules.” The three facets to the process of overall acculturation are socialization, acculturation, and assimilation.


Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Education—be it pre-school, elementary school, high school, college, or a health care provider program—is a form of

Figure 2–6B Matrix of heritage consistency, continued.

Cultural Heritage and History ■ 31

socialization. For many people who have been socialized within the bound- aries of a “traditional culture” or a non-Western culture, modern American culture becomes a second cultural identity. Those who immigrate here, legally or illegally, from non-Western or non-modern countries may find socializa- tion into the American culture, whether in schools or in society at large, to be an extremely difficult and painful process. They may experience bicultural- ism, which is a dual pattern of identification and one often of divided loyalty (LaFrombose, Coleman, & Gerton, 1993).

Understanding culturally determined health and illness beliefs and practices from different heritages requires moving away from linear models of process to more complex patterns of cultural beliefs and interrelationships.


While becoming a competent participant in the dominant culture, a member of the nondominant culture is always identified as a member of the original culture. The process of acculturation is involuntary, and a member of the non- dominant cultural group is forced to learn the new culture to survive. Indi- viduals experience second-culture acquisition when they must live within or between cultures (LaFrombose et al., 1993). Acculturation also refers to cultural or behavioral assimilation and may be defined as the changes of one’s cultural patterns to those of the host society. In the United States, people assume that the usual course of acculturation takes three generations; hence, the adult grandchild of an immigrant is considered fully Americanized.


Acculturation also may be referred to as assimilation, the process by which an individual develops a new cultural identity. Assimilation means becoming in all ways like the members of the dominant culture. The process of assimilation encompasses various aspects, such as cultural or behavioral, marital, identifica- tion, and civic. The underlying assumption is that the person from a given cul- tural group loses this cultural identity to acquire the new one. In fact, this is not always possible, and the process may cause stress and anxiety (LaFrombose et al., 1993). Assimilation can be described as a collection of subprocesses: a process of inclusion through which a person gradually ceases to conform to any standard of life that differs from the dominant group standards and, at the same time, a process through which the person learns to conform to all the dominant group standards. The process of assimilation is considered complete when the foreigner is fully merged into the dominant cultural group (McLemore, 1980, p. 4).

There are four forms of assimilation: cultural, marital, primary structural, and secondary structural. One example of cultural assimilation is the ability to speak excellent American English. It is interesting to note that, according to the 2010 American Community Survey estimates, 79.4% of the American population over 5 years old speak only English; and 20.6% speak a language other than English (U.S. Census Bureau, 2010). Marital assimilation occurs when members of one group intermarry with members of another group. The third and fourth forms of

32 ■ Chapter 2

assimilation, those of structural assimilation, determine the extent to which social mingling and friendships occur between groups. In primary structural assimila- tion, the relationships between people are warm, personal interactions between group members in the home, the church, and social groups. In secondary struc- tural assimilation, there is nondiscriminatory sharing—often of a cold, impersonal nature—between groups in settings such as schools and workplaces (McLemore, 1980, p. 39).

The concepts of socialization, assimilation, and acculturation are complex and sensitive. The dominant society expects that all immigrants are in the pro- cess of acculturation and assimilation and that the worldview we share as health care practitioners is shared by our patients. Because we live in a pluralistic society, however, many variations of health beliefs and practices exist.

The debate still rages between those who believe that America is a melt- ing pot and that all groups of immigrants must be acculturated and assimilated to an American norm, and those who dispute theories of acculturation and believe that the various groups maintain their own identities within the Ameri- can whole. The concept of heritage consistency is one way of exploring whether people are maintaining their traditional heritage and of determining the depth of a person’s traditional cultural heritage.

■ Ethnocultural Life Trajectories Generational differences have been described as deep and gut-level ways of experiencing and looking at the cultural events that surround us. “The differences between generations—and the determination of who we are—are more than distinct ways of looking at problems and developing solutions for problems” (Hicks & Hicks, 1999, p. 4). Changes in the past several decades have created cultural barriers that openly or more subtly create misunderstandings, tensions, and often conflicts between family members, co-workers, and other individuals— as well as between patients and caregivers, especially in the practice of gerontology. The cycle of our lives is an ethnocultural journey and many of the aspects of this journey are derived from the social, religious, and cultural context in which we grew up. Factors that imprint our lives are the characters and events that we interacted with at 10 years of age, more or less (Hicks & Hicks, 1999, p. 25). Table 2–3 provides examples of seminal events that occurred from 1928–2001 and examples of workplace ethics, lifestyle, and social values of various generations.

One example of generational conflict between health care providers and patients is within institutional settings where the patients are cared for not only by people who are immigrants but also by those who are much younger and have limited knowledge as to what has been a patient’s life trajectory. The patient may also be an immigrant who experienced a much different life trajectory than others of the same age and the caregivers. Imagine your life today and what it may have been like to live without a computer, a cell phone, an iPod, or an iPad. Many people may see today’s commonplace objects as “strangers” rather than “friends,” and could be “digital immigrants,” not “digital natives.”

Cultural Heritage and History ■ 33

Table 2–3 Selected Seminal Sociocultural Events of the Past 75 Years, Workplace Ethos, Lifestyle, and Social Values


Seminal Events

Workplace Ethos


Social Values

The Silent Generation

The Great Depression

Traditional work ethic

Work first Community service

WWII Employer loyalty Conformist Vote b. 1928–1945 Hiroshima Born to lead Expect to lead Family first 10:* 1938–1955 World’s first

electronic computer assembled

Conventional Believe in mission

Care for religion Buy decent home

The Baby Boomers

Television— I Love Lucy

Money/work Work/play hard Reluctant community service

Expect to lead Religion acceptable

Vote only if convenient

b. 1946–1964 What do others think?

Buy most house you can

Family and friends

TV dinners Lip service to mission

10: 1956–1974 Elvis Presley Marilyn Monroe Rosa Parks Sputnik

Generation X Kent State Money/principle Work/play hard I do not give Watergate Lead and follow Religion a

hobby Vote if you want to

Nixon resigned

Independent and care what others think

Do I need a house?

Family and friends

b. 1965–1980 Vietnam Memorial Wall

Care about mission

HIV/AIDS epidemic

Principle/ satisfaction

Work hard if it does not interfere

May donate

Challenger explosion

Lifestyle first What is religion?

Vote privately

10: 1975–1990 Loyal to skills Gentrify inner city

Friends are family

Must have mission Individual first


34 ■ Chapter 2

■ Commingling Variables Five commingling variables relate to this overall situation of social and genera- tional divisions as they are potential sources of conflict:

1. Decade of birth. People’s life experiences vary greatly, depend- ing on the events of the decades in which they were born and the cultural values and norms of the times. People who tend to be heritage consistent—that is, have a high level of identification and association with a traditional heritage—tend to be less caught up in the secular fads of the time and popular sociocultural events.

2. Generation in United States. Worldviews differ greatly between the immigrant generation and subsequent generations, and people who score high as heritage consistent and mainstream people who may score low on the heritage consistency assessment and have been born into families who have resided in the United States for multiple generations.

3. Class. Social class is an important factor. The analysis of one’s edu- cation, economics, and background is an important observation of people. There are countless differences among people predicated on class. The United States Department of Labor produces employment and wage estimates for over 800 occupations (Table 2–4). These are estimates of the number of people employed in certain occupations,

Table 2–3 continued


Seminal Events

Workplace Ethos


Social Values

Millennial Generation (First generation to come of age in new millennium)

Tiananmen Square

Desert Storm

Principle/ satisfaction

Lifestyle first

Make others pay

Comparative religions

Community service equals punishment

Vote my issues

b. 1981–1992 President Clinton impeached

Must have a mission

Live with parents

Want extended families

September 11, 2001

Individual first

10: 1991–2001 Afghanistan Iraq Hurricane Katrina

*Generational names are the inherent work of popular culture. The names are derived from 1. a historic event, 2. rapid social or demographic change, or 3. a turn in the calendar. “10” marks the decade when a person turns 10. This is the decade (10–19 years of age) that influences a person’s socio/cultural identity.

Sources: Taylor, P. and Keeter, S. (2010). MILLENNIALS A protrait of generation next: Confident. Connnected. Open to change. PEW RESEARCH CENTER.; Hicks, R., & Hicks, K. (1999). Boomers, Xers, and other strangers. Wheaton, IL: Tyndale House; Jennings, P. (1998). The century. Copyright 1998 by ABC Television.

Cultural Heritage and History ■ 35

and estimates of the wages paid to them. Self-employed persons are not included in the estimates.

The unemployment rate in February 2011 was 9% (Bartash, 2011); in January 2008 it was 4.9% (U.S. Department of Labor). This has had an impact on the delivery of health care.

These figures, too, demonstrate the differences in economic class and play heavily in relation to issues of health care access and insurance coverage.

4. Language. There are frequent misunderstandings, as discussed in Chapter 1, when people who do not understand English must help and care for or take direction from English speakers. There are also countless conflicts when people who are hard of hearing attempt to understand people with limited English-speaking skills, and many cultural and social misunderstandings can develop.

5. Education. Increasing percentages of students have completed high school, from 69% in 1980 to 85.3% in 2009 (http://factfinder. “Every child in America deserves a world-class education.” With these words, President Obama signed A Blueprint for Reform: The Reauthorization of the Elementary and Secondary Education Act in March, 2010. This blueprint challenges the nation to embrace education standards that would put America back on a path to global leadership in education. It provides incen- tives for states to adopt academic standards that prepare students to succeed in college and the workplace, and create accountability systems that measure student growth toward meeting the goal that all children graduate and succeed in college. It has three key priorities:

• Raising standards for all students—every student should gradu- ate from high school ready for college and a career, regardless of income, race, ethnic or language background, or disability status

Table 2–4 May 2010 National Occupational Employment and Wage Estimates for Selected Major Occupational Groups

Major Occupational Group

Employment Estimate (number of employed)

Mean Annual Wage (dollars)

Management 6,022,860 105,400 Legal occupations 999,650 96,940 Computer and mathematical 3,283,950 77,230 Architecture and engineering 2,305,530 75,550 Health care practitioners and technical occupations

7,346,580 71,280

Registered nurses 2,655,020 67,720 Health care support occupations 3,962,930 26,920 Production occupations 8,236,130 33,770

Source: U.S. Department of Labor Statistics. Washington DC: United States Department of Labor. May 2010. National Occupational Employment and Wage Estimates. Retrieved from htm#51-0000, February 23, 2012.

36 ■ Chapter 2

• Better assessments—the development and use of a new generation of assessments that are aligned with college- and career-ready standards

• Effective teachers and principals—to elevate the teaching profes- sion to focus on recognizing, encouraging, and rewarding excel- lence (U.S. Department of Education, 2010).

■ Cultural Conflict Hunter (1994) describes cultural conflicts as events that occur when there is polarization between two groups and the differences are intensified by the way they are perceived. The struggles are centered on the control of the symbols of culture. In the case of the conflict between the Lee family and the health care system, discussed in Chapter 1, the scope of the conflict is readily apparent and lends itself to further analysis. Hunter describes the fields of conflict as found in family, education, media and the arts, law, and electoral politics. Health care is a sixth field, and the conflict is between those who actively participate in tra- ditional health care practices—that is, the practices of their given ethnocultural heritage—and those who are progressive and see the answers to contemporary health problems in the science and technology of the present.

When cultures clash, many misanthropic feelings, or “isms,” can enter into a person’s consciousness (Table 2–5). Just as Hunter proclaimed that the “differences” must be confronted, so, too, must stereotypes, prejudice, and dis- crimination. It is impossible to describe traditional beliefs without a temptation to stereotype, but each person is an individual; therefore, levels of heritage con- sistency differ within and between ethnic groups, as do health beliefs.

Another issue that manifests itself in this arena is prejudice. Prejudice oc- curs either because the person making the judgment does not understand the

Table 2–5 Common “Isms” Plus One Non-“Ism”

Belief Definition

Racism The belief that members of one race are superior to those of other races

Sexism The belief that members of one gender are superior to the other gender

Heterosexism The belief that everyone is or should be heterosexual and that heterosexuality is best, normal, and superior

Ageism The belief that members of one age group are superior to those of other ages

Ethnocentrism The belief that one’s own cultural, ethnic, or professional group is superior to that of others; one judges others by one’s “yardstick” and is unable or unwilling to see what the other group is really about— “My group is best!”

Xenophobia The morbid fear of strangers

Source: American Nurses’ Association. (1993). Proceedings of the invitational meeting, multicultural issues in the nursing workforce and workplace. Washington, DC: Author.

Cultural Heritage and History ■ 37

given person or his or her heritage, or because the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discrimination occurs when a person acts on prejudice and denies another person one or more of his or her fundamental rights.

■ Cultural Phenomena Affecting Health Giger and Davidhizar (1995) have identified six cultural phenomena that vary among cultural groups and affect health care: time orientation, space, commu- nication, social organization, biological variations, and environmental control.

Time Orientation

The viewing of time in the present, past, or future varies among cultural groups. Certain cultures in the United States and Canada tend to be future-oriented. People who are future-oriented are concerned with long-range goals and with health care measures in the present to prevent the occurrence of illness in the future. Others are oriented more to the present than the future and may be late for appointments because they are less concerned about planning to be on time. This difference in time orientation may become important in health care measures such as long-term planning and explanations of medication schedules.


Personal space refers to people’s behaviors and attitudes toward the space around themselves. Territoriality is the behavior and attitude people exhibit about an area they have claimed and defend or react emotionally to when others encroach on it. Both personal space and territoriality are influenced by culture, and thus different ethnocultural groups have varying norms related to the use of space.


Communication differences present themselves in many ways, including lan- guage differences, verbal and nonverbal behaviors, and silence. Language dif- ferences are possibly the most important obstacle to providing multicultural health care because they affect all stages of the patient-caregiver relationship.

Social Organization

The social environment in which people grow up and live plays an essential role in their cultural development and identification. Children learn their culture’s re- sponses to life events from the family and its ethnoreligious group. This socialization process is an inherent part of heritage—cultural, religious, and ethnic background.

Biological Variations

The several ways in which people from one cultural group differ biologically (i.e., physically and genetically) from members of other cultural groups constitute their

38 ■ Chapter 2

biological variations; for example, body build and structure, including specific bone and structural differences between groups, such as the smaller stature of Asians and skin color, including variations in tone, texture, healing abilities, and hair follicles.

Environmental Control

Environmental control is the ability of members of a particular cultural group to plan activities that control nature or direct environmental factors. Included in this concept are the complex systems of traditional health and illness beliefs, the practice of folk medicine, and the use of traditional healers.

Figure 2–7 illustrates how a person, with a unique ethnic, religious, and cultural background, is affected by cultural phenomena. The discussions in

Figure 2–7 Personal health traditions of a unique cultural being.

Cultural Heritage and History ■ 39

Table 2–6 Examples of Etiquette as Related to Selected Cultural Phenomena

Time Visiting Inform person when you are coming Being on time Avoid surprises

Explain your expectations about time Taboo times Ask people from other regions and cultures

what they expect Be familiar with the times and meanings of person’s ethnic and religious holidays

Space Body language and distances

Know cultural and/or religious customs regarding contact, such as eye and touch, from many perspectives

Communication Greetings Know the proper forms of address for people from a given culture and the ways by which people welcome one another

Know when touch, such as an embrace or a handshake, is expected and when physical contact is prohibited

Gestures Gestures do not have universal meaning; what is acceptable to one cultural group is taboo with another

Smiling Smiles may be indicative of friendliness to some, taboo to others

Eye contact Avoiding eye contact may be a sign of respect

Social organization

Holidays Know what dates are important and why, whether to give gifts, what to wear to special events, and what the customs and beliefs are

Special events Births Weddings Funerals

Know how the event is celebrated, the meaning of colors used for gifts, and expected rituals at home or religious services


Chapters 9 through 13 highlight these phenomena, and relevant examples are presented within the text and in tabular form. The examples used in the text to illustrate health traditions in different cultures are not intended to be stereotyp- ical. With careful listening, observing, and questioning, the provider should be able to sort out the traditions of a given person. Table 2–6 suggests examples of etiquette relevant to each of the cultural phenomena.

This chapter has served as the foundation that delineates the multiple, interrelating phenomena that underlie the cultural conflict that occurs between health care providers and patients, many of whom have difficulty interacting with the health care providers and system. It has presented both classical and contemporary definitions and explanations relevant to the foundation of this conflict and sets the stage for further discussion.

40 ■ Chapter 2

Go to the Student Resource Site at for chapter-related review questions, case studies, and activities. Contents of the CULTURALCARE Guide and CULTURALCARE Museum can also be found on the Student Resource Site. Click on Chapter 2 to select the activities for this chapter.

Explore MediaLink

Biological variations

Food customs Know what can be eaten for certain events, what foods may be eaten together or are forbidden, and what and how utensils are used

Environmental control

Health practices and remedies

Know what the general health traditions are for person and question observations for validity

Source: Adapted from Dresser, N. (1996). Multicultural manners. New York: Wiley. Copyright © 1996 John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons. Inc.

Table 2–6 continued

Box 2–1: Keeping Up

The following resource will be helpful in maintaining current information related to religious participation.

Pew Research Center

■  Internet Sources Bartash, J. (2011). Digging Up U.S. Economic Trends Not Easy. Mar-

ket Watch. Retrieved from forecast-for-us-economy-obscured-by-poor-weather-2011-02-06?reflink= MW_news_stmp, February 23, 2011.

culture. (n.d.). The American Heritage New Dictionary of Cultural Literacy, Third Edition. Retrieved from browse/culture, January 31, 2011.

ethnicity. (n.d.). The American Heritage New Dictionary of Cultural Literacy, Third Edition. Retrieved from http://dictionary.reference. com/browse/ethnicity, January 31, 2011.

O’Neil, D. (2008). Ethnicity and Race: An Introduction to the Nature of Social Group Differentiation and Inequality. San Marcos, CA: Palomar College. Retrieved from, February 18, 2008.

religion. (n.d.). The American Heritage New Dictionary of Cultural Literacy, Third Edition. Retrieved from http://dictionary. reference. com/browse/religion, January 31, 2011.

Cultural Heritage and History ■ 41

Taylor, P. and Keeter, S. (2011). MILLENNIALS: A Portrait of Generation Next: Confident. Connected. Open to change. Pew Research Center. Retrieved from, February 23, 2011.

The Pew Forum on Religion and Public Life. (2011). U.S. Religious Landscape Sur- vey. (2010). Recovered from, April 2011.

United States Census Bureau. (2012). Statistical Abstract of the United States. Population, p. 61. Retrieved from statab/, November 28, 2011.

United States Census Bureau. (2010). American Community Survey Lan- guage Spoken at Home. Retrieved from faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_ S1601&prodType=table, February 23, 2011.

United States Department of Education. (2007). No Child Left Behind – High School Facts at a Glance. Retrieved from list/ovae/pi/hs/hsfacts.html, October 18, 2007.

United States Department of Education. (2010). A Blueprint for Reform: The Re- authorization of the Elementary and Secondary Education Act. Retrieved from, February 23, 2012.

United States Department of Health and Human Services. Fact Sheet – Your rights under Title VI of the Civil Rights Act. Retrieved from ocr/generalinfo.html, July 15, 2007.

United States Department of Labor Statistics. (2010). National Occupational Em- ployment and Wage Estimates. Washington, DC: United States Department of Labor. Retrieved from 0000, February 23, 2012.

■  References Abramson, H. J. (1980). Religion. In S. Thernstrom (Ed.), Harvard encyclopedia

of American ethnic groups. Cambridge: Harvard University Press. American Heritage Dictionary. (1976). Boston: Houghton Mifflin. American Nurses’ Association. (1993). Proceedings of the invitational meeting,

multicultural issues in the nursing workforce and workplace. Washington, DC: Author.

Bohannan, P. (1992). We, the alien—An introduction to cultural anthropology. Prospect Heights, IL: Waveland Press.

Carroll, J. (2003). Harley-Davidson: The living legend. Edison, NJ: Edison Books. culture. (n.d.). The American heritage new dictionary of cultural literacy, third

edition. Retrieved from browse/culture, January 31, 2011.

Davies, P. (Ed). (1976). The American heritage dictionary of the English language, Paperback edition. NY: Dell.

Dresser, N. (1996). Multicultural manners. New York: John Wiley & Sons, Inc. Eck, D. L. (2001). A new religious America: How a “Christian country” has become

the world’s most religious diverse nation. San Francisco: Harper. ethnicity. (n.d.). The American heritage new dictionary of cultural literacy, third

edition. Retrieved from browse/ethnicity, January 31, 2011.

42 ■ Chapter 2

Estes, G., & Zitzow, D. (1980, November). Heritage consistency as a consideration in counseling Native Americans. Paper read at the National Indian Education Association Convention, Dallas, TX.

Fadiman A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus, Giroux.

Fejos, P. (1959). Man, magic, and medicine. In L. Goldston (Ed.), Medicine and anthropology. New York: International University Press.

Giger, J. N., & Davidhizar, R. E. (1995). Transcultural nursing assessment and intervention (2nd ed.). St. Louis: Mosby-Year Book.

Hicks, R., & Hicks, K. (1999). Boomers, Xers, and other strangers. Wheaton, IL: Tyndale House.

Hunter, J. D. (1994). Before the shooting begins—Searching for democracy in America’s culture wars. New York: Free Press.

LaFrombose, T., Coleman, L. K., & Gerton, J. (1993). Psychological impact of biculturalism: Evidence and theory. Psychological Bulletin, 114(3), 395.

Levin, J. (2001). God, faith, and health. New York: John Wiley & Sons. Matsumoto, M. (1989). The unspoken way. Tokyo: Kodahsha International. McLemore, S. D. (1980). Racial and ethnic relations in America. Boston: Allyn

& Bacon. Novak, M. (1973). How American are you if your grandparents came from Serbia

in 1888? In S. Te Selle (Ed.), The rediscovery of ethnicity: Its implications for culture and politics in America. New York: Harper & Row.

Office of Minority Health. (2001). National standards for culturally and linguisti- cally appropriate services in health care. Washington, DC: U.S. Department of Health and Human Services.

Putnam, R. D., & D. E. Campbell. (2010) American grace: How religion divides and unites us. New York: Simon and Schuster.

religion. (n.d.). The American heritage new dictionary of cultural literacy, third edition. Retrieved from browse/religion, January 31, 2011.

Senior, C. (1965). The Puerto Ricans: Strangers then neighbors. Chicago: Quad- rangle Books.

The Joint Commission. (2010). Advancing effective communication, cultural com- petence, and patient- and family-centered care: A roadmap for hospitals. Oak- brook Terrace, IL: Author.

Thernstrom, S. (Ed.). (1980). Harvard encyclopedia of American ethnic groups. Cambridge: Harvard University Press.

Chapter 3 Diversity

… Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!

—Emma Lazarus, The New Colossus (1886)

■ Objectives

1. Describe the total population characteristics of the United States as pre- sented in Census 2010.

2. Compare the population characteristics of the United States in 2000 and 2010.

3. Discuss the changes in points of origin of recent and past immigrants. 4. Discuss the meanings of terms related to immigration, such as citizen, refugee,

legal permanent resident, and naturalization. 5. Discuss the facets of poverty. 6. Describe poverty guidelines. 7. Analyze the cycle of poverty.

The opening images for this chapter are representative of the demographic and socioeconomic diversity that exists in countless communities in this nation. The first figure, 3–1, is that of the Statue of Liberty—a reminder that most of the


Figure 3–4Figure 3–3Figure 3–2Figure 3–1

44 ■ Chapter 3

people who live in the United States of America are the descendants of immi- grants or are themselves immigrants. Figures 3–2 and 3–3 depict places where people are able to purchase food and other necessities from their homelands—a Mexican market and other stores in San Juan Capistrano, California, and a shelf of canned goods in an Indian grocery store in Waltham, Massachusetts. Fig- ure 3–4 depicts the poverty in this land of plenty—a homeless woman, guard- ing her cart of possessions while rummaging through the trash on a street in Brooklyn, New York. An infinite number of images could be placed in this chapter’s opening. What comes to your mind when you think about the demo- graphic diversity in your home community? What are your images of poverty and homelessness?

Health care providers are entangled in the revolutionary consequences of the enormous demographic, social, and cultural changes that have occurred in the United States. Many of these changes are playing a dramatic role both in the delivery of health care to patients, their families, and communi- ties, and in the workforce and environment in which the provider practices. Table 3–1 demonstrates the growth of the emerging majority—people of color—that constituted 30.9% of the population in 2000; grew to 36.3% in the 2010 census (Humes, Jones, Ramirez, 2011 p. 6). The comments and data presented in this chapter are designed to provide you with an impression of the demographic features, derived from Census 2010 and other recent data from the Census Bureau and recent immigration, labor, and economic backgrounds of the American population.

Table 3–1 Population by Hispanic or Latino Origin and by Race for the United States: 2000 and 2010

Hispanic or Latino Origin and Race 2000 2010

Total population 281,421,906 308,745,538

Percentage of Total Population

Percentage of Total Population

Hispanic or Latino 12.5 16.3 Not Hispanic or Latino 87.5 83.7 White alone 69.1 63.7 Race One race 97.6 97.1 White 75.1 72.4 Black or African American 12.3 12.6 American Indian and Alaska Native 0.9 0.9 Asian 3.6 4.8 Native Hawaiian and other Pacific Islander 0.1 0.2 Some other race 5.5 6.2 Two or more races 2.4 2.9

Source: Humes, et al. (2011). Overview of Race and Hispanic Origin: 2010. Census Briefs. p. 4. Retrieved from, June 26, 2011. p. 6.

Diversity ■ 45

In order to understand the profound changes that are taking place in the health care system, both in the delivery of services and in the profile of the peo- ple who are receiving and delivering services, we must look at the changes in the American population. The White majority is aging and shrinking; the Black, Hispanic, Asian, and American Indian populations are young and growing. It is imperative for those who deliver health care to be understanding of and sensi- tive to cultural differences, and the effect of the differences on a person’s health and illness beliefs and practices and health care needs.

■ Census 2010 Every census adapts to the decade in which it is conducted. One of the most important changes to Census 2010 was the revision of the questions that were asked regarding race and Hispanic origin. The federal government considers race and Hispanic origin to be two separate concepts and the questions on race and Hispanic origin were asked of all people living in the United States. The changes were developed to reflect the country’s growing diversity. The respon- dents were given the option of selecting one or more race categories to indicate their racial identities. A factor that presents confusion is that people were free to define themselves as belonging to many groups. However, the overwhelming majority of the population reported one race.

In 1997, the Office of Management and Budget established federal guide- lines to collect and present data on race and Hispanic origin. Census 2010 ad- hered to the guidelines, and added “some other race.” Data on race has been collected since the first census in 1790. The present categories are as follows:

1. White—refers to a person having origins in any of the original peo- ples of Europe, the Middle East, or North Africa. It includes people who indicated their race(s) as “White” or reported entries such as Irish, German, Italian, Lebanese, Arab, Moroccan, or Caucasian.

2. Black or African American—refers to a person having origins in any of the Black racial groups of Africa. It includes people who indicated their race(s) as “Black, African American, or Negro” or reported en- tries such as African American, Kenyan, Nigerian, or Haitian.

3. American Indian or Alaska Native—refers to a person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. This category includes people who indicated their race(s) as “American Indian or Alaska Native” or reported their enrolled or principal tribe, such as Navajo, Black- feet, Inupiat, Yup’ik, Central American Indian groups, or South American Indian groups.

4. Asian—refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, includ- ing, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. It includes

46 ■ Chapter 3

people who indicated their race(s) as “Asian” or reported entries such as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japa- nese,” “Vietnamese,” and “Other Asian,” or provided other detailed Asian responses.

5. Native Hawaiian or Other Pacific Islander—refers to a person hav- ing origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicated their race(s) as “Pacific Islander” or reported entries such as “Native Ha- waiian,” “Guamanian or Chamorro,” “Samoan,” and “Other Pacific Islander,” or provided other detailed Pacific Islander responses.

6. Some Other Race—includes all other responses not included in the White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander race categories described above. Respondents reporting entries such as multiracial, mixed, interracial, or a Hispanic or Latino group (for example, Mexi- can, Puerto Rican, Cuban, or Spanish) in response to the race ques- tion are included in this category.

7. Hispanic or Latino—refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race (Humes et al., 2011, p. 2).

These terms of classification will be used throughout this chapter and the text. The census does not break down the population by gender except to ask if the respondent is male or female. It questions neither gender preference nor if a person is abled or disabled. This text will follow census categories and not di- rectly include the homosexual and diasabled populations in its discussions.

Total Population Characteristics

The 2010 census percentages are compared with the 2000 census percentages in Table 3–1. The figures demonstrate both the growth of the American population in general and the growth of people of color specifically. The changes are as follows:

Age. The age classification is based on the age of the person in complete years as of April 1, 2010. The age was derived from the date of birth information requested on the census form. It is critical to note the following points regarding age in 2010:

■ The number of people under age 18 was 74.2 million (24% of the total population). Between 2000 and 2010, the population under the age of 18 grew at a rate of 2.6%.

■ The population between 18 and 64 comprised 62.9% of the population. ■ The younger working-age population, ages 18 to 44, represented

112.8 million persons (36.5%). ■ The older working-age population, ages 45 to 64, made up 81.5 million

persons (26.4%).

Diversity ■ 47

■ The 65 and over population was 40.3 million persons (13%). ■ The median age for the total population was 37.2 years. (Howden &

Meyer, 2011, p. 1.)

American Indian, Aleut, and Eskimo Populations (Alone). The American Indian, Eskimo, and Aleut populations alone in the United States constituted 0.9% of the total population in 2010. The median age of the population was 27.7 years in 2000 and 31.0 years in 2010 (see Table 3–2).

Asian/Pacific Islander Population (Alone). Members of the Asian/Pacific Island communities made up 3.6% of the population in 2000 and 4.8% in 2010. The median age of the Asian/Pacific Island population was 32.5 years in 2000 and the Asian alone population in 2010 was 35.5 years.

Black Population (Alone). The Black population alone in the United States constituted 12.3% of the total population in 2000 and 12.6% in 2010. The median age of the Black population was 30.0 years in 2000 and 32.5 years in 2010.

Hispanic Population (of Any Race). Hispanic Americans (of any race) made up 12.5% of the total population in 2000 and 16.8% in 2010. The median age of the Hispanic population was 25.8 years in 2000 and 27.2 years in 2010.

White Population (Alone). In 2000, the White population in the United States constituted 72.1% of the total population and 63.2% in 2010. The median age of the population was 38.6 years in 2000 and 39.8 years in 2010 (U.S. Census Bureau, 2010).

The U.S. Census Bureau produces estimates of the resident population for the United States on an annual basis. It revises the estimates time series each year as final input data become available. These postcensal estimates from

Table 3–2 Median Ages of the Population, 2000 and 2010

Population Group Median Age

2000 Census 2010 Census

American Indian alone 27.7 years 31.0 years Asian alone 32.5 years 35.5 years Black alone 30.0 years 32.5 years Hispanic 25.8 years 27.2 years White alone—not of Hispanic heritage 38.6 years 39.8 years Native Hawaiian and other Pacific Islanders 26.8 years 28.6 years 2 or more races 19.8 years 19.7 years Total Population 35.3 years 36.5 years

Source: U.S. Census Bureau. (2001). Retrieved from asrh.html, December 16, 2011; U.S. Census Bureau. (2010). American Community Survey. Retrieved from http://, December 16, 2011.

48 ■ Chapter 3

April 1, 2000 through July 1, 2006 supersede all previous estimates produced since Census 2000. On March 30, 2007, the U.S. Census Bureau submitted to Congress the subjects it planed to address in the 2010 Census, which include gender, age, race, ethnicity, relationship, and whether you own or rent your home. It was estimated that the questions will take less than 10 minutes to complete. The 2010 Census was one of the shortest and easiest to complete since the nation’s first census in 1790. There is also a yearly American Com- munity Survey, which eliminates the need for a long-form questionnaire and provides key socioeconomic and housing data about the nation’s rapidly chang- ing population. The information required for the census was to be mailed in by April 1, 2010. A census enumerator interviewed the residents who did not sub- mit their census forms during the months of May and June 2010. This measure was taken in order to ensure as complete a count as possible.

■ Immigration Immigrants and their descendants constitute most of the population of the United States, and Americans who are not themselves immigrants have ances- tors who came to the United States from elsewhere. The only people consid- ered native to this land are the American Indians, the Aleuts, and the Inuit (or Eskimos), for they migrated here thousands of years before the Europeans (Thernstrom, 1980, p. vii).

Immigrants come to the United States seeking religious and political free- dom and economic opportunities. The life of the immigrant is fraught with difficulties—going from an “old” to a “new” way of life, learning a new lan- guage, and adapting to a new climate, new foods, and a new culture. Socializa- tion of immigrants occurs in American public schools, and Americanization, according to Greeley (1978), is for some a process of “vast psychic repression,” wherein one’s language and other familiar trappings are shed. In part, the con- cept of the melting pot has been created in schools, where children learn Eng- lish, reject family traditions, and attempt to take on the values of the dominant culture and “pass” as Americans (Novak, 1973). This difficult experience, as noted and described by Greeley and Novak in the 1970s, continues today.

A citizen of the United States is a native-born, foreign-born child of citi- zens, or a naturalized person who owes allegiance to the United States and who is entitled to its protection. All persons born or naturalized in the United States, are citizens of the United States and of the state wherein they reside. A refugee is any person who is outside his or her country of nationality and who is unable or unwilling to return to that country because of persecution or a well- founded fear of persecution. Persecution or the fear thereof must be based on the alien’s race, religion, nationality, membership in a particular social group, or political opinion. People with no nationality must generally be outside their country of last habitual residence to qualify as a refugee. Refugees are subject to ceilings by geographic area set annually by the president in consultation with Congress and are eligible to adjust to lawful permanent resident status after 1 year of continuous presence in the United States. A permanent resident alien

Diversity ■ 49

is an alien admitted to the United States as a lawful permanent resident. A “green card” provides official immigration status (lawful permanent residency) in the United States. Immigrants are now referred to as Legal Permanent Resi- dents; however, the Immigration and Nationality Act (INA) broadly defines an immigrant as “any alien in the United States, except one legally admitted under specific nonimmigrant categories.” An illegal alien, or undocumented person, who entered the United States without inspection, for example, would be strictly defined as an immigrant under the INA but is not a Legal Permanent Resident. Legal Permanent Residents (LPRs) are legally accorded the privilege of residing permanently in the United States. Naturalization is the process by which United States citizenship is conferred upon foreign citizens or nationals after fulfilling the requirements established by Congress. Box 3–1 contains an

Box 3–1

Sample Questions and Answers for the Naturalization Test

1. What is one responsibility that is only for United States citizens? 2. What is the supreme law of the land? 3. What do we call the first ten amendments to the Constitution? 4. How many amendments does the Constitution have? 5. Who makes federal laws? 6. What is the highest court in the United States? 7. How many justices are on the Supreme Court? 8. Under our Constitution, what powers belong to the states? 9. How old do citizens have to be to vote for President? 10. What did Susan B. Anthony do?

Answers 1. serve on a jury, vote in a federal election 2. the Constitution 3. the Bill of Rights 4. twenty-seven (27) 5. Congress, Senate and House (of Representatives), (U.S. or national)

legislature 6. the Supreme Court 7. nine (9) 8. provide schooling and education, provide protection (police), provide safety

(fire departments), give a driver’s license, approve zoning and land use 9. eighteen (18) and older 10. fought for women’s rights, fought for civil rights

Source: U.S. Department of Homeland Security. (2011). Learn about the United States: Quick Civics Lessons for the Naturalization Test. Retrieved from, July 7,

50 ■ Chapter 3

example of the questions a person is asked when taking the examination for naturalization. They are able to obtain a civics book to study about our govern- ment and some history. The person is now also interviewed to determine Eng- lish language competency and expected to meet other requirements.

In 2010, a total of 1,042,625 people became Legal Permanent Residents of the United States. The majority, 54%, already resided here. Among the LPRs, Mexico (13%), China (7%), and India (7%) were the leading countries of birth (Monger & Yankay, 2011, p. 1). In 1970, the highest percentage of people was from Europe whereas in 2010, people from Mexico, China, and India were the highest in percentage. In 2010, 619,913 people were naturalized. The largest percentage came from Asia (Lee, 2010, p. 2).

Table 3–3 lists the primary metropolitan areas for Legal Permanent Resi- dents in 2010, and Table 3–4 lists the top 10 states where Legal Permanent

Table 3–3 Five Leading Legal Permanent Resident Flow Metropolitan Areas of Residence: 2010

1. New York, northern New Jersey–Long Island: 17.8% 2. Los Angeles–Long Beach–Santa Ana, California: 8.4% 3. Miami–Fort Lauderdale–Miami Beach, Florida: 6.7% 4. Washington, DC–Maryland–Virginia: 4.0% 5. Chicago–Naperville-Joliet, Illinois, Indiana, Wisconsin: 3.4%

Source: Monger, R., & Yankay, J. (2011). U.S. Legal Permanent Residents: 2010. p. 3. Washington, DC: Department of Homeland Security. Retrieved from http://www.dhs. gov/ximgtn/statistics/publications/index.shtm, May 24, 2011.

Table 3–4 Permanent Resident Flow by State of Residence: 2010

1. California 20.0% 2. New York 14.2% 3. Florida 10.3% 4. Texas 8.4% 5. New Jersey 5.5% 6. Illinois 3.6% 7. Massachusetts 3.0% 8. Virginia 2.7% 9. Maryland 2.5% 10. Georgia 2.4% Other states 27.4%

Source: Monger, R., & Yankay, J. (2011). U.S. Legal Permanent Residents: 2010. Washington, DC: Department of Homeland Security. p. 4. Retrieved from http://www.dhs. gov/ximgtn/statistics/publications/index.shtm, May 24, 2011.

Diversity ■ 51

Table 3–5 Leading 10 Countries of Origin for Legal Permanent Resident Flow by Country of Birth: 2010

Country Legal Permanent Residents (%)

1. Mexico 13.3 2. People’s Republic of China 6.8 3. India 6.6 4. Philippines 5.6 5. Dominican Republic 5.2 6. Cuba 3.2 7. Vietnam 2.9 8. Haiti 2.2 9. Colombia 2.1 10. Korea 2.1

Source: Monger, R., & Yankay, J. (2011). U.S. Legal Permanent Residents: 2010. Washington, DC: Department of Homeland Security. p. 4. Retrieved from http://www.dhs. gov/ximgtn/ statistics/publications/index.shtm, May 24, 2011.

Table 3–6 Selected Characteristics of the Native and Foreign-Born Populations: 2005–2009

Characteristic Native Population

Foreign Born

Naturalized Citizens

Not a U.S. Citizen

Population 264.1 million 37.3 million 15.9 million 21.4 million Median age 35.6 years 40.1 48.6 years 34.5 years Asian 1.7% 23.5% 31.1% 17.9% Hispanic 10.6% 47.0% 31.2% 58.7% Population 25 years and older, less than high school

12.3% 32.2% 22.5% 40.7%

Speak language other than English

9.7% 84.2% 78.3% 88.7 %

Speak English less than well 2.0% 52.1% 38.8% 62.0% Family poverty rates 8.9% 15.1% 8.7% 21.9% Poverty status below 100% of poverty level

13.0% 16.4% 9.8% 21.3%

Renting household unit 31.1% 46.1% 31.1% 62.2% Vehicle unavailable 8.1% 13.4% 11.5% 15.3% No telephone service 4.2% 4.7% 2.5% 7.0%

Source: American Fact Finder. Selected Characteristics of the Native and Foreign-Born Population (2005–2009). American Community Survey. Retrieved from ACS_2009_5YR_G00_S0501&-ds_name=ACS_2009_5YR_G00_&-redoLog=false, July 7, 2011.

Residents are residing. Table 3–5 shows the leading 10 countries of origin for Legal Permanent Residents flow by country of birth in 2010. Table 3–6 compares selected characteristics of the native and foreign-born populations in 2005. The following are examples:

52 ■ Chapter 3

■ Fewer foreign-born people are likely to have a vehicle than native-born residents.

■ More foreign-born people are likely to graduate from high school than natives.

■ More foreign-born people are likely to speak English less than well. ■ More foreign-born people are likely to be unemployed. ■ More foreign-born people are likely to earn less than natives. ■ More foreign-born people are likely to live in poverty than natives.

There are estimated (as of 2007) to be 12 million undocumented people living in the United States. It is extremely difficult to count the number of peo- ple who are hiding because they are not documented. It is widely recognized that the population is growing by about 275,000 people each year. California is the leading state of residence for undocumented people. Other states include Texas, New York, and Florida.

There has been an effort by the government to tighten both immigration and travel access to the United States since the terrorist attacks in September 2001. On July 22, 2002, the Justice Department announced that it would use criminal penalties against immigrants and foreign visitors who fail to notify the government of change of address within 10 days. This requirement is not a new one, but it has not been strictly enforced. This will have an impact on at least 11 million people and visitors who stay in the United States for more than 30 days (Davis & Furtado, 2002, p. A2). In addition, this will have an impact on the health care system and on providers of health care both directly and indirectly. For example, it will be more difficult for people to work here and to visit family members who are ill. In addition, the passage of Proposition 187 in California in November 1994, and earlier laws relating to bilingual education in Texas, demonstrates that many citizens are no longer willing to provide basic human services, such as health care and education, to new residents in general and those who are undocumented specifically. Thus far, the implementation of these laws has been held up in the courts. Despite such efforts, however, it is evident that immigration to this country will continue. It is predicted that by the year 2020, immigration will be a major source of new people for the United States and will be responsible for whatever growth occurs in the United States after 2030. The United States will continue to attract about two-thirds of the world’s immigrants, and 85% will be from Central and South America. Other immigration events are noted in Box 3–2.

On May 17, 2007, the U.S. president and a bipartisan group of senators reached bipartisan agreement on comprehensive immigration reform. The pro- posal included the following points:

1. Putting border security and enforcement first. 2. Providing tools for employers to verify the eligibility of the workers

they hire. 3. Creating a temporary worker program. 4. No amnesty for illegal immigrants.

Diversity ■ 53

Box 3–2

Highlights of Immigration History: 1798–2007

Year Event

1790 Naturalization Act passed 1798 Alien and Sedition Acts passed 1808 African slave trade prohibited 1819 First immigrant data collected 1824 Naturalization set at 2 years 1846 Potato famine in Ireland results in massive Irish influx 1862 Homestead Act opens land to immigrants 1870 Naturalization extended to Africans 1875 Federal government regulates immigration 1882–1943 Chinese Exclusion Act passed 1886 Statue of Liberty opens 1892 Ellis Island Immigration Station opens 1898 Immigrants classified by “race” 1903 Political radicals banned from entering the United States

Call for rules governing entry into this country from Mexico 1907 Immigration Act to stem the flow of immigrants from Mexico

1,004,756 people—a record—pass through Ellis Island 1908 “Gentleman’s Agreement” restricts Japanese immigration 1910 Entrance barred to criminals, paupers, and the diseased 1917 Literacy required for immigrants over 16 1924 Annual racial quotas established; Border Patrol established 1940 Alien Registration Act—predecessor to the Green Card—passed 1942–1964 Bracero Program allows entry to temporary workers 1975 Vietnam War ends; Indochinese refugee program implemented 1980 Mariel boatlift from Cuba of 125,000 people occurs 1986 Amnesty for illegal aliens granted 1990 Ellis Island Immigration Museum opens 1996 Illegal Immigration Reform and Immigrant Responsibility Act of

1996 passed 1996 Personal Responsibility and Work Opportunity Reconciliation

Act of 1996 passed 1996 Antiterrorism and Effective Death Penalty Act of 1996 passed 1999 Nursing Relief for Disadvantaged Areas Act of 1999 passed 2001 USA Patriot Act of 2001 passed 2002 Family Sponsor Immigration Act of 2002 passed 2002 Enhanced Security and Visa Entry Reform Act of 2002 passed 2003 Extension of the Special Immigrant Religious Worker Program passed 2003 Department of Homeland Security begins 2005 Disadvantaged Areas Reauthorization Act passed


54 ■ Chapter 3

5. Strengthening the assimilation of new immigrants: the proposal declares that English is the language of the United States.

6. Establishing a merit system for future immigration. 7. Ending chain migration. 8. Clearing the family backlog in 8 years (Homeland Security, 2007).

This legislation did not pass, however, and will not be addressed until after the 2012 presidential election. As of this writing, the issue has not been resolved. Individual states have imposed their own laws regulating the residency of un- documented people but most of these laws have been struck down by the courts.

The need for strict enforcement of Title VI and the Culturally and Lin- guistically Appropriate Services (CLAS) standards becomes self evident when you realize the high numbers of people who do not understand and speak English, as seen in Table 3–6.

■ Poverty There are countless ways to answer the question “What is poverty?” Poverty may be viewed through many lenses and from anthropological, cultural, de- mographic, economical, educational, environmental, historical, medical, phil- osophical, policy, political, racial, sexual, sociological, and theological points of view. The consequences of poverty are ubiquitous. They include, but are not limited to, battering, bullying, child abuse, gaming, obesity, spousal abuse, substance abuse, and violence. Poverty may also be viewed in a “holistic” way. Here, the physical, mental, and spiritual aspects of poverty are self-evident. Examples include, but are not limited to,

■ physical—substandard housing, no telephone or vehicle, limited access to health care;

■ mental—inadequate education, poor opportunity; and ■ spiritual—despair, the experience of being disparaged.

Year Event

2006 Secure Fence Act passed 2006 National Defense Authorization Act for Fiscal Year 2006 passed 2007 Failure of immigration reform

Sources: Lefcowitz, E. (1990). The United States immigration history timeline. New York: Terra Firma Press. Reprinted with permission; RapidImmigration. (2012). Significant Historic Dates in U.S. Immigration. Retrieved from history.html, February 25, 2011; Homeland Security. (2010). Retrieved from http://www.dhsgov/ index.shtm.

Box 3–2 Continued

Diversity ■ 55

In 2005–2009, 39.5 million people, approximately 13.5% of the popula- tion, lived below the poverty level (American Fact Finder 2010). Poverty rates differ by age, gender, race, and ethnicity. For example, the rates of poverty in 2005–2009 were

■ 25.1% for Blacks; ■ 21.9% for Hispanics; ■ 10.8% for non-Hispanic Whites; ■ 18.6% for children under 18; ■ 9.8% for adults over 65.

The federal government has an extensive history of efforts to improve the conditions of people living with limited incomes and material resources. Since the 1850s, there have been countless initiatives enacted to help citizens who were “poor.” The programs described in Table 3–7 are examples of federal cash assistance programs available to low-income families.

Other ways of answering the question “what is poverty” include:

1. Using the description provided by the U.S. Bureau of Labor Statis- tics, which counts the poor and describes them by age, education, location, race, family composition, and employment status.

2. Using the federal government’s definition of the poverty threshold. This poverty threshold, developed in 1965, is based on pretax in- come only, excluding capital gains, and does not include the value of

Table 3–7 Selected Examples of Federal Poverty Programs

Purpose Program Description

Cash aid Temporary Assistance for Needy Families (TANF)

Basic cash aid through state Requires work

Food and nutrition Food Stamps Provides, depending on need, funding for food

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Provides benefits for low-income mothers, infants, and children considered to be “at risk”

Medical Medicaid Provides payments to health care providers in full or in a co-pay for eligible low-income families and individuals, and for long-term care to those eligible who are aged or disabled

Housing Section 8 Low-Income Housing Assistance

Provides rental assistance through vouchers or rental subsidies to eligible low-income families

Source: Nilsen, S. (2007). Poverty in America—Report to Congressional Requesters. Washington, DC: United States Government Accountability Office.

56 ■ Chapter 3

noncash benefits, such as employer-provided health insurance, food stamps, or Medicaid. The poverty-level figures are used by programs, such as Head Start, Low-Income Home Energy, and National School Lunch, to determine eligibility (U.S. Census Bureau, 2011).

3. Determining the poverty status, for people not living in families, by comparing the individual’s income to his or her threshold. The poverty thresholds are updated annually to allow for changes in the cost of living using the Consumer Price Index (Bishaw & Macartney, 2010, p. 1).

The poverty threshold for an average family of four was $23,018 in 2011. Table 3–8 lists the poverty weighted threshold for persons in a household

for selected years. The association between socioeconomic status and the health status of

a person or family may be explained in part by the reduced access to health care among those with lower socioeconomic status. Income may be related to health because it

■ increases access to health care; ■ enables the person or family to live in a better neighborhood; ■ enables the person or family to afford better housing; ■ enables the person or family to reside in locations not abutting known

environmentally degraded locations (heavy industrial pollution or known hazardous waste sites); and

■ increases the opportunity to engage in health promoting behaviors.

Health also may affect income by restricting the type and amount of employment a person may seek or by preventing a person from working.

Table 3–8 Poverty Weighted Average Thresholds for the Years 1986–2011 by Persons in Household

Year First Person Two Persons Four Persons

1986 $5,572 $7,138 $11,203

1990 6,652 8,509 13,359

1994 7,547 9,661 15,141

1998 8,316 10,634 16,660

2002 9,183 11,756 18,392

2006 10,294 13,167 20,614

2010 11,139 14,218 22,314

2011 11,491 14,667 23,018

Sources: U.S. Census Bureau. Retrieved from html;; poverty/data/threshld/thresh94.html;; http://; threshld/thresh06.html; and, April 12, 2012; Federal Register 63, no. 36. (1998, February 24), 9235–9238, and (2002, February 14), 6931–6933; U.S. Census Bureau. (2006, August 29).

Diversity ■ 57

There has been an increase in earning inequality over the last 25 years. The income for all races rose, then dipped, in this time period. For Blacks and Hispanics, it was much lower than for Whites and Asians and for people from the Pacific Islands. Much of this change and inequality was due to technologi- cal changes that increased income to highly skilled labor. At the same time, less skilled workers saw their wages decrease or stagnate. The other factors respon- sible for this phenomenon include

■ globalization of the economy; ■ decline in the real minimum wage; ■ decline in unionization; ■ increase in immigration; and ■ increase in families headed by women (from 10% in 1970 to 18% in

1996 and 24.7% in 2000—households headed by women generally have lower incomes). In fact, in households headed by women, with no husband present, the percentage below the poverty level was 9.7% in 2009.

The following are compelling examples of the poverty in the United States:

■ Nationally, 13.8% of the U.S. population was in poverty during the 5 years, 2006–2010, according to the estimate from the 5-year American Community Survey’s data. (Bishaw, A. (2011) Areas With Concentrated Poverty: 2006–2010 American Community Survey Re- trieved from pdf February 26, 2011).

■ In 2009 alone, 43.6 million people were in poverty, up from 39.8 mil- lion in 2008—the third consecutive annual increase in the number of people in poverty.

■ The poverty rate in 2009 (14.3%) was the highest poverty rate since 1994 but was 8.1 percentage points lower than the poverty rate in 1959, the first year for which poverty estimates are available.

■ The number of people in poverty in 2009 (43.6 million) is the larg- est number in the 51 years for which poverty estimates have been published.

■ Between 2008 and 2009, the poverty rate increased for children under the age of 18 (from 19.0% to 20.7%) and people aged 18 to 64 (from 11.7% to 12.9%), but decreased for people aged 65 and older (from 9.7% to 8.9%) (DeNavas-Walt, Proctor, & Smith, 2011, p. 14).

The poverty status of people between 2005 and 2009 for

■ Blacks was 22.1%; ■ Non-Hispanic Whites was 10.8%; ■ American Indians and Alaska natives was 25.9%;

58 ■ Chapter 3

■ Non-Hispanic Whites was 7.5%; ■ Asians was 10.9%; ■ Hispanics was 21.9%; and ■ people 65 years old and over was 10.2% (Bishaw & Macartney, S. (2010)).

Cycle of Poverty

Poverty is more than the absence of money. One way of analyzing the phe- nomenon is by observing the effects of the “cycle of poverty,” as illustrated in Figure 3–5. In this cycle, the person lives in a situation that may create poor intellectual and physical development and poor economic production, and in which the birth rate is high; this living situation in turn, causes numerous social problems and lower employment abilities, which creates insufficient salaries and a subsistence economy that often forces the person to reside in densely popu- lated areas or remotely located rural areas where adequate shelter and potable

Figure 3–5 The Cycle of Poverty.

Poor intellectual and physical development

Poor economic production

Important role of high human reproduction

High cost of health care needs

High incidence of illness

Lack of preventive care

Increased sickness

Poor production

Lack of potable water

Poor nutrition

Poor and densely populated housing

Insufficient salaries

Subsistence economy

Diversity ■ 59

water are scarce, and the person suffers from chronically poor nutrition. These conditions all too often lead to high morbidity and accident rates, precipitating high health care costs, which, in turn, prevent the person from seeking health care services. Thus, there is an increase in sickness and poor production, in a cycle that has yet to be broken. Other barriers that are interrelated to this cycle are the lack of access to health care services, language issues, and transportation issues (Spector, 1979, pp. 148–152).

The issues of overcrowded housing, poor sanitation, inadequate nutrition, homelessness, and so forth that are part of the cycle of poverty have a profound and prolonged impact on the health status of people and in future generations.

This chapter has presented an overview of the major phenomena contribut- ing to the profound diversity existing within the United States— demographic; population and immigration; and poverty. Additional issues will be explored in more depth in the chapters relating to each of the major population groups described in Census 2010.

Go to the Student Resource Site at for chapter-related review questions, case studies, and activities. Contents of the CULTURALCARE Guide and CULTURALCARE Museum can also be found on the Student Resource Site. Click on Chapter 3 to select the activities for this chapter.

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