Introduction to Multicultural Health
Evidence based practice questions in Nursing
Lois A. Ritter, EdD, MS, MA, MS-HCA, PMP
Consultant, Health and Education
Donald H. Graham, JD, MA Attorney and Consultant, Human Services
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Library of Congress Cataloging-in-Publication Data Names: Ritter, Lois A., author. | Graham, Donald H., author. Title: Multicultural health / Lois A. Ritter, Donald H. Graham. Description: Second edition. | Burlington, MA : Jones & Bartlett Learning,  | Includes
bibliographical references and index. Identifiers: LCCN 2015048787 | ISBN 9781284021028 (pbk. : alk. paper) Subjects: | MESH: Cultural Competency | Culturally Competent Care | Cross-Cultural
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About the Authors
UNIT I The Foundations
Chapter 1 Introduction to Multicultural Health Key Concepts and Terms Diversity Within the United States Cultural Adaptation Health Disparities Causes of Health Disparities Legal Protections for Ethnic Minorities Personal Health Decisions Ethical Considerations Summary Review Activity Case Study References
Chapter 2 Theories and Models Related to
Multicultural Health Theories of Health and Illness Pathways to Care Cultural Competence Promoting Cultural Competence Summary Review Activity Case Study References
Chapter 3 Worldview and Health Decisions Worldview Worldview and Medical Decisions Worldview and Response to Illness Summary Review Activity Case Study References
Chapter 4 Complementary and Alternative Medicine History of Complementary and Alternative Medicine Complementary and Alternative Health Care Modalities Laws Affecting Cultural Practices and Health Summary Review Activity Case Study References
Chapter 5 Religion, Rituals, and Health Religion in the United States Religion and Health Behaviors Religion and Health Outcomes Religion and Well-Being Rituals Summary Review Activity Case Study References
Chapter 6 Communication and Health Promotion in Diverse Societies Health Communication Delivering Your Health Message Printed Materials Public Health Programs Evaluating Your Multicultural Health Program Summary Review Activity Case Study References
UNIT II Specific Cultural Groups
Chapter 7 Hispanic and Latino American Populations Introduction Terminology
History of Hispanics in the United States General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavioral Risk Factors and Common Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the Hispanic Population Summary Review Activity Case Study References
Chapter 8 American Indian and Alaskan Native Populations Introduction Terminology History of American Indians and Alaska Natives in the United States American Indian and Alaskan Native Populations in the United States American Indian and Alaskan Native General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavior Risk Factors and Prevalent Health Problems Considerations for Health Promotion and Program Planning Tips for Working With American Indian and Alaskan Native Populations
Summary Review Activity Case Study References
Chapter 9 African American Populations Introduction Terminology History of African Americans in the United States African Americans in the United States General Philosophy About Disease Prevention and Health Maintenance Healing Traditions Behavior Risk Factors and Prevalent Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the African American Population Summary Review Activity Case Study References
Chapter 10 Asian American Populations Introduction Terminology History of Asian Americans in the United States Asian Americans in the United States
General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavioral Risk Factors and Common Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the Asian American Population Summary Review Activities Case Study References
Chapter 11 European and Mediterranean American Populations Introduction Terminology History of European and Mediterranean Americans in the United States European and Mediterranean Americans in the United States General Philosophy About Disease Prevention and Health Maintenance History, Healing Practices, and Risk Factors for Three Subcultures Behavior Risk Factors and Prevalent Health Problems for European and Mediterranean Americans Tips for Working With European and Mediterranean American Populations Summary Review
Activity Case Studies References
Chapter 12 Nonethnic Cultures Introduction Introduction to the “Culture of People Suffering Discrimination” History of Gay Americans in the United States Introduction to People With Disabilities Introduction to the Culture of Commerce Consumers Farmworkers Introduction to People Who Are Recent Immigrants or Refugees Summary Review Activities Case Study References
UNIT III Looking Ahead
Chapter 13 Closing the Gap: Strategies for Eliminating Health Disparities Strategies for Reducing or Eliminating Health Disparities Summary Review Activities
Case Study References
To Gary and Samantha, for creating countless hours of laughter—lr
Your mind is like a parachute . . . it functions only when open. ~ Author unknown
Health care professionals work in a diverse society that presents both opportunities and challenges, so being culturally competent is essential to their role. Although knowing about every culture is not possible, having an understanding of various cultures can improve effectiveness. Multicultural Health provides an introduction and overview to some of the major cultural variations related to health.
Throughout this text, those engaged in health care can acquire knowledge necessary to improve their effectiveness when working with diverse groups, regardless of the predominant culture of the community in which they live or work. The content of this book is useful when working in the field on both individual and community levels. It serves as a guide to the concepts and theories related to cultural issues in health and as a primer on health issues and practices specific to certain cultures and ethnic groups.
New to This Edition
NEW! A Student Activity is added to each chapter to challenge student comprehension.
NEW! Two new Feature Boxes appear in each chapter—What Do You Think? and Did You Know?—to engage readers and enhance critical thinking.
NEW! Chapter 3, Worldview and Health Decisions, provides
information about the ways that worldview and communication affect health, the provision of health services, health care decisions, and communication.
Expanded! Reiki has been added to Chapter 4, Complementary and Alternative Medicine. Chiropractic care, homeopathy, hypnosis, and hydro-therapy, although important treatment modalities, were removed to keep the chapter focused on culturally based CAM modalities.
Expanded! In Chapter 5, Religion, Rituals, and Health, a section was added about the clinical implications of the relationships among religion, spirituality, and health.
Expanded! In Chapter 6, Communication and Health Promotion in Diverse Societies, tips for communicating with people with limited English proficiency have been added.
Expanded! Chapters 7 through 12 have new sections on worldview, pregnancy, mental health, and death and dying as they relate to the cultural group discussed in each chapter.
Expanded! Chapter 12, Nonethnic Cultures, has been expanded to include people with disabilities, immigrants and refugees, and the culture of commerce.
Expanded! In Chapter 13, Closing the Gap: Strategies for Eliminating Health Disparities, information about the Health and Humans Services Action Plan to reduce racial and ethnic health disparities and the National Stakeholder Strategy for Achieving Health Equality have been added.
Revised! Laws and ethics material is now integrated throughout where appropriate.
Revised! The model programs have been removed from Chapters 7 through 12 and an activity has been added for learners to conduct research and identify a model program themselves.
About This Book
Multicultural Health is divided into three units.
UNIT I, The Foundations, includes Chapters 1 through 6 and focuses on the context of culture, cultural beliefs regarding health and illness, health disparities, models for cross-cultural health and communication, and approaches to culturally appropriate health promotion programs and evaluation.
Chapter 1, Introduction to Multicultural Health, discusses the reasons for becoming knowledgeable about the cultural impact of health practices. It defines terminology and key concepts that set the foundation for the remainder of the text. The chapter addresses diversity in the United States and the racial makeup of the country, health disparities and their causes, and issues related to medical care in the context of culture.
Chapter 2, Theories and Models Related to Multicultural Health, addresses theories regarding the occurrence of illness and its treatment. Terms and theoretical models related to cultural competence are provided. Individual and organizational cultural competence assessments are included.
Chapter 3, Worldview and Health Decisions, explores the concept of worldview on illness and treatment and cultural influences that affect health. Differences in worldview and how that affects perceptions about health, health behaviors, and interactions with health care providers are described. Verbal and nonverbal communication considerations are explained. The chapter closes with discussions about how worldview and communication influence specific areas of health, such as the use of birth control.
Chapter 4, Complementary and Alternative Medicine, provides an introduction to complementary and alternative medicine and health practices. It explores the major non-Western medicine modalities of
care, including Ayurvedic medicine, traditional Chinese medicine, herbal medicine, and holistic and naturopathic medicine. The history, theories, and beliefs regarding the source of illness and treatment modalities are described.
Chapter 5, Religion, Rituals, and Health, explores the role of religion and spiritual beliefs in health and health behavior. The similarities and differences between religion and rituals are described. The chapter integrates examples of religious beliefs in the United States and their impact on health decisions and behaviors.
Chapter 6, Communication and Health Promotion in Diverse Societies, includes information about culturally sensitive communication strategies used in public health. Considerations to making health care campaigns using various communication channels, such as social media, appropriate for diverse audiences are explained. A section on health literacy is included.
UNIT II, Specific Cultural Groups, includes Chapters 7 through 12 and addresses the history of specific cultural groups in the United States, beliefs regarding the causes of health and illness, healing traditions and practices, common health problems, and health promotion and program planning for the various cultural groups. These points are applied to specific cultural groups as follows:
Chapter 7, Hispanic and Latino American Populations
Chapter 8, American Indian and Alaskan Native Populations
Chapter 9, African American Populations
Chapter 10, Asian American Populations
Chapter 11, European and Mediterranean American Populations
Chapter 12, Nonethnic Cultures
UNIT III, Looking Ahead, outlines priority areas in health disparities and strategies to eliminate health disparities.
Chapter 13, Closing the Gap: Strategies for Eliminating Health Disparities, explores the implications of the growth of diversity in the United States in relation to future disease prevention and treatment. It further addresses diversity in the health care workforce and its impact on care, as well as the need for ongoing education in cultural competence for health care practitioners.
Features and Benefits
Each chapter includes a “Did You Know?” and “What Do You Think?” section to stimulate critical thinking and classroom discussions. Also included are chapter review questions, related activities, and a case study. Key concepts are listed and their definitions are provided in the glossary.
We hope the information contained in Multicultural Health will introduce you to the rich and fascinating cultural landscape in the United States and the diverse health practices and beliefs of various cultural groups. This book is not intended to be an end point; rather, it is a starting point in the journey to becoming culturally competent in health care.
For the Instructor
Instructor resources, including Power-Point presentations, Instructor’s Manual, and test bank questions, are available. Contact your sales representative or visit go.jblearning.com/Ritter2e for access.
We would like to express gratitude to the many dedicated people whose contributions made this book possible. We extend a special thanks to those who provided us with permission to reprint their work. We also are grateful to the Jones & Bartlett Learning team who assisted with the editing, design, and marketing of the book. We would like to particularly acknowledge Sara J. Peterson and Cathy Esperti at Jones & Bartlett Learning for their efforts. Cherilyn Aranzamendez and Jessica Ross, we appreciate your efforts to locate research on the topic of multicultural health. We are also indebted to the reviewers for their thoughtful and valuable suggestions:
First Edition Patricia Coleman Burns, PhD, University of Michigan Maureen J. Dunn, RN, Pennsylvania State University, Shenango Campus Mary Hysell Lynd, PhD, Wright State University Sharon B. McLaughlin, MS, ATC, CSCS, Mesa Community College Melba I. Ovalle, MD, Nova Southeastern University
Second Edition William C. Andress, DrPH, MCHES, La Sierra University Debra L. Fetherman, PhD, CHES, ACSMHFS, University of Scranton Carmel D. Joseph, MPH, Nova Southeastern University Kirsten Lupinski, PhD, Albany State University Hendrika Maltby, PhD, RN, University of Vermont Cindy K. Manjounes, MSHA, EdD, Linden-wood University–Belleville Mary P. Martinasek, PhD, University of Tampa
To our family, friends, and colleagues, we want to express our gratitude because you provided continued encouragement, support, and recognition throughout the process.
About the Authors
Lois A. Ritter earned a doctorate in education and master’s degrees in health science, health care administration, and cultural and social anthropology. She has taught at the university level for approximately 20 years and has led national and regional research studies on a broad range of health topics.
Donald H. Graham is an attorney and holds a master’s degree in urban affairs. He has developed and managed client-centered and culturally appropriate health and human service programs for more than 30 years.
CHAPTER 1 Introduction to Multicultural Health
CHAPTER 2 Theories and Models Related to Multicultural Health
CHAPTER 3 Worldview and Health Decisions
CHAPTER 4 Complementary and Alternative Medicine
CHAPTER 5 Religion, Rituals, and Health
CHAPTER 6 Communication and Health Promotion in Diverse Societies
Courtesy of David Bartholomew
Introduction to Multicultural Health
We have become not a melting pot but a beautiful mosaic. —Jimmy Carter
One day our descendants will think it incredible that we paid so much attention
to things like the amount of melanin in our skin or the shape of our eyes or our gender instead of the unique identities of each of us as complex human beings.
Multicultural health Cultural competence Culture Dominant culture Race Racism Discrimination Ethnicity Cultural ethnocentricity Cultural relativism Cultural adaptation Acculturation Minority Assimilation Heritage consistency Health disparity Healthy People 2020 Hill-Burton Act Ethics Morality Autonomy Respect Veracity
Fidelity Beneficence Nonmaleficence Justice
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After reading this chapter, you should be able to:
1. Explain why cultural considerations are important in health care.
2. Describe the processes of acculturation and assimilation.
3. Define race, culture, ethnicity, ethnocentricity, and cultural relativism.
4. Explain what cultural adaptation is and why it is important in health care.
5. Explain what health disparities are and their related causes.
6. List the five elements of the determinants of health and describe how they relate to health disparities.
7. Explain key legislation related to health and minority rights.
Why do we need to study multicultural health? Why is culture important if we all have the same basic biological makeup? Isn’t health all about science? Shouldn’t people from different cultural backgrounds just adapt to the way we provide health care in the United States if they are in this country?
For decades, the role that culture plays in health was virtually ignored, but the links have now become more apparent. As a result, the focus on the need to educate health care professionals about the important role
that culture plays in health has escalated. Health is influenced by factors such as genetics, the environment, and socioeconomic status, as well as by other cultural and social forces. Culture affects people’s perception of health and illness, how they pursue and adhere to treatment, their health behaviors, beliefs about why people become ill, how symptoms and concerns about the problem are expressed, what is considered to be a health problem, and ways to maintain and restore health. Recognizing cultural similarities and differences is an essential component for delivering effective health care services. To provide quality care, health care professionals need to provide services within a cultural context, which is the focus of multicultural health.
Multicultural health is the phrase used to reflect the need to provide health care services in a sensitive, knowledgeable, and nonjudgmental manner with respect for people’s health beliefs and practices when they are different from our own. It entails challenging our own assumptions, asking the right questions, and working with the patient and the community in a manner that respects the patient’s lifestyle and approach to maintaining health and treating illness. Multicultural health integrates different approaches to care and incorporates the culture and belief system of the health care recipient while providing care within the legal, ethical, and medically sound practices of the practitioner’s medical system.
Knowing the health practices and cultures of all groups is not possible, but becoming familiar with various groups’ general health beliefs and preferences can be very beneficial and improve the effectiveness of health care services. In this text, generalizations about cultural groups are provided, but it is important to realize that many subcultures exist within those cultures, and people vary in the degree to which they identify with the beliefs and practices of their culture of origin. Awareness of general differences can help health care professionals provide services within a cultural context, but it is important to distinguish between stereotyping (the mistaken assumption that everyone in a given culture is alike) and generalizations (awareness of cultural norms) (Juckett, 2005). Generalizations can serve as a starting point but do not preclude factoring
in individual characteristics such as education, nationality, faith, and level of cultural adaptation. Stereotypes and assumptions can be problematic and can lead to errors and ineffective care. Remember, every person is unique, but understanding the generalizations can be beneficial because it moves people in the direction of becoming culturally competent.
Cultural competence refers to an individual’s or an agency’s ability to work effectively with people from diverse backgrounds. Culture refers to a group’s integrated patterns of behavior, and competency is the capacity to function effectively. Cultural competence occurs on a continuum, and this text is geared toward helping you progress along the cultural competence continuum.
Specific terms related to multicultural health, such as race and acculturation, need to be clarified, and this chapter begins by defining some of these terms. Following that is a discussion of the demographic landscape of the U.S. population and how it is changing, types and degrees of cultural adaptation, and health disparities and their causes. The chapter concludes with an analysis of the legislation related to health care that is designed to protect minorities.
Key Concepts and Terms
Some of the terminology related to multicultural health can be confusing because the differences can be subtle. This section clarifies the meaning of terms such as culture, race, ethnicity, ethnocentricity, and cultural relativism.
Culture There are countless definitions of culture. The short explanation is that culture is everything that makes us who we are. E. B. Tylor (1924/1871), who is considered to be the founder of cultural anthropology, provided the classical definition of culture. Tylor stated in 1871, “Culture, or civilization, taken in its broad, ethnographic sense, is that complex whole
which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society” (p. 1). Tylor’s definition is still widely cited today. A modern definition of culture is the “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Office of Minority Health, 2013).
Culture is learned, changes over time, and is passed on from generation to generation. It is a very complex system, and many subcultures exist within each culture. For example, universities, businesses, neighborhoods, age groups, homosexuals, athletic teams, and musicians are subcultures of the dominant American culture. Dominant culture refers to the primary or predominant culture of a region and does not indicate superiority. People simultaneously belong to numerous subcultures because we can be students, fathers or mothers, and bowling enthusiasts at the same time.
Race and Ethnicity Race refers to a person’s physical characteristics and genetic or biological makeup, but race is not a scientific construct. Race is a social construct that was developed to categorize people, and it was based on the notion that some “races” are superior to others. Many professionals in the fields of biology, sociology, and anthropology have determined that race is a social construct and not a biological one because not one characteristic, trait, or gene distinguishes all the members of one so-called race from all the members of another so-called race. “There is more genetic variation within races than between them, and racial categories do not capture biological distinctiveness” (Williams, Lavizzo-Mourey, & Warren, 1994).
Why is race important if it does not really exist? Race is important because society makes it important. Race shapes social, cultural, political, ideological, and legal functions in society. Race is an institutionalized concept that has had devastating consequences. Race has been the basis for deaths from wars and murders and suffering caused by discrimination,
violence, torture, and hate crimes. The ideology of race has been the root of suffering and death for centuries even though it has little scientific merit.
The 2010 U.S. Census questions related to ethnicity and race can be found in Figure 1.1 and Figure 1.2. Box 1.1 explains how these terms were defined in the 2010 census. The U.S. government declared that Hispanics and Latinos are an ethnicity and not a race.
FIGURE 1.1 U.S. Census origin question, 2010. Source: Population Reference Bureau (2013).
FIGURE 1.2 U.S. Census race question, 2010. Source: Population Reference Bureau (2013).
It is important to note that there is great variation within each of the racial and ethnic categories. For example, American Indians are grouped together even though there are variations between the tribes. It is essential to be aware of the differences that occur within these groups and not to stereotype people. Stereotyping people by their race and ethnicity is racism. Racism is the belief that some races are superior to others by nature. Discrimination occurs when people act on that belief and treat people differently as a result. Discrimination can occur because of beliefs related to factors such as race, sexual orientation, dialect, religion, or gender.
Ethnicity is the socially defined characteristic of a group of people who share common cultural factors such as race, history, national origin, religious belief, or language. So how is ethnicity different from race? Race is primarily based on physical characteristics, whereas ethnicity is based on social and cultural identities. For example, consider these terms in relation to a person born in Korea to Korean parents but adopted by a French family in France as an infant. Ethnically, the person may feel French: she or he eats French food, speaks French, celebrates French holidays, and learns French history and culture. This person knows nothing about Korean history and culture, but in the United States she or he would likely be treated racially as Asian. Let’s consider another example. The physical characteristics of Caucasians (a race) are typically light skin and eyes, narrow noses, thin lips, and straight or wavy hair. A person whose appearance matches these characteristics is said to be a Caucasian. However, there are many ethnicities within the Caucasian race such as Dutch, Irish, Greek, German, French, and so on. What differentiates these Caucasian ethnic groups from one another is their country of origin, language, cultural heritage and traditions, beliefs, and rituals.