Great Cultural and Linguistic Competence

Building Cultural and Linguistic Competence

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, public 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 providers 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.

Linguistic Competence
Linguistic Competence

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.

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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 CULTURAL COMPETENCY 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 satisfactorily become “CULTURALLY COMPETENT” and to deliver CULTURAL CARE. Indeed, the reality of becoming “CULTURALLY COMPETENT” is a complex process—it is time consuming, difficult, frustrating, and extremely interesting. It is a philosophical change wherein the CULTURALLY COMPETENT person is able to hear, understand, and respect the nonverbal and/or non-articulated needs and perspectives of a given patient.

CULTURAL COMPETENCY 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

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

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 audits, 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

■ 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

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

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

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

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