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CULTURES COVERED IN THE TEXT

People of African American Heritage The Amish People of Appalachian Heritage People of Arab Heritage People of Chinese Heritage People of Guatemalan Heritage People of Egyptian Heritage People of Filipino Heritage People of French Canadian Heritage People of German Heritage People of Haitian Heritage People of Iranian Heritage People of Japanese Heritage People of Jewish Heritage People of Korean Heritage People of Mexican Heritage People of Russian Heritage People of Polish Heritage People of Thai Heritage

CULTURES COVERED ON THE DavisPlus WEB SITE (http://davisplus.fadavis.com)

People of Baltic Heritage: Estonians, Latvians, and Lithuanians People of Brazilian Heritage People of Greek Heritage People of Cuban Heritage People of Hindu Heritage People of Irish Heritage People of Italian Heritage People of Puerto Rican Heritage Navajo Indians People of Turkish Heritage People of Vietnamese Heritage

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Transcultural Health Care A Culturally Competent Approach Third Edition

Betty J. Paulanka, EdD, RN Professor and Dean College of Health Sciences University of Delaware Newark, Delaware

Larry D. Purnell, PhD, RN, FAAN Professor College of Health Sciences University of Delaware Newark, Delaware

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2008 by F. A. Davis Company

Copyright © 2003, 1998 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

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Library of Congress Cataloging-in-Publication Data

Transcultural health care : a culturally competent approach / [edited by] Larry D. Purnell, Betty J. Paulanka. — 3rd ed.

p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1865-7 ISBN-10: 0-8036-1865-4

1. Transcultural medical care—United States. 2. Transcultural medical care—Canada. I. Purnell, Larry D. II. Paulanka, Betty J.

[DNLM: 1. Delivery of Health Care—North America. 2. Cross-Cultural Comparison—North America. 3. Ethnic Groups—North America. W 84 DA2 T7 2008]

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v

The rise in concern for cultural competence has become one of the most important developments in American health care over the past decade. Medicine and health more generally have moved beyond their traditional equanimous approach of application of scientific rational- ity to clinical problems to one that promotes an easier inte- gration of clinical science with empathy. This development has occurred with a rising tide of the diversity of the popu- lation of the United States. Some of this is driven by actual numbers of immigrants, but other dimensions of this awareness come from the visibility of the “new” ethnics and the waning of the social ideology of the melting pot. Beyond all of this is a younger generation that is much more attuned to diversity as part of their cultural landscape and their comfort with the globalization of perspectives resulting from technological and economic change.

From within health care, the advocacy for culturally competent approaches is driven in part by the dawning recognition of the danger to patient safety and overall inadequacy in the quality of outcomes in what we do. The literature around the disparities of outcomes across ethnic, social, and economic groups provides a com- pelling case to ensure that health care is attentive to these differences. But there is also attention to the costs that are driven up by health care that is not culturally competent and discourages compliance. The excess expenditures are associated with poor communication, the failure to use culturally responsive methods, and ineffective attempts to transfer treatment modalities to make the system cost efficient. Finally, as the health system makes its glacial move to more consumer and individual responsiveness, the system is recognizing that a cultural perspective is essential to provide services that earn high levels of con- sumer satisfaction.

Much of the activity aimed at advancing cultural com- petence has been centered on regulations and mandates. However, a generational change that begins with the edu- cation of each new practitioner is needed to bring about a culturally informed and competent professional commu- nity.

This edition of Transcultural Health Care provides the critical lessons to introduce students and practitioners to

how different cultures construct the social world and the dramatic impact that culture has on how health care, medicine, community, and family interact. These insights into the rich variety of human culture are only small steps toward developing real wisdom regarding culture compe- tence.

The first step in such a transformation is awareness of the other. Most young students and many seasoned prac- titioners simply do not have an appreciation of the vari- ety of backgrounds and perspectives that people bring to an encounter with the health-care system. They have the expectation that the patient or consumer will “fit” into their clinic or admission process. Moreover, much of what is done in health care follows a “procedure,” which implies that there are predetermined steps by which any one receiving the care or service must fit. For an increas- ingly large part of the population, nothing could be fur- ther from the truth. The care-seeking behavior, the atti- tude toward authority, the comfort with middle-class America culture that makes up so much of the health-care social world, and the relationship between genders are just a few of the literally hundreds of places at which a disconnect between the individual and the system can occur. When disconnects occur, the efforts by the system to maintain or return health may fail.

The second step after awareness is knowledge. What is it that we must know as practitioners in a system of care to reach the other person and overcome the cultural barri- ers? And it is essential that this knowledge pass both ways. What do they need to know about us in order to be an equal part of a team-focused plan to address a prob- lem? Knowledge also speaks to the need for every practi- tioner to be aware of his/her own attitudes, bias, and pre- judices. Everyone has such prejudices; they are not the issue. Awareness of them and the wisdom and insight to adjust care to provide nonjudgmental and supportive interventions is the challenge.

A culturally competent practitioner must also have a sense of comfort with the experiential process of engaging others from different cultures. This is perhaps the most difficult of all skills to teach and may only be learned through the practice of engaging others and being able to

Preface

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reflect critically on the experience and its impact on the patient as well as on the provider. This process is a famil- iar one, of course, as it is the core of clinical education. But students must come to value the variety of life and learn how to adapt their clinical expertise to different cul- tures and the individual unique development in a multi- cultural context.

As we focus on cultural competence, one fear is that we will make the knowledge more transactional than transfor- mational. It needs to be the latter. For the patient or con- sumer, health care presented in a culturally competent way must blend the traditions of the older culture with the promise and resources of modern health care. For the prac- titioner or health-care institution, new patterns of service and organization of care must be transformed using the experience with the new culture. Such a critical perspec- tive of cultural humility is essential for all practitioners in all dimensions of health care and is a vital part of devel- oping into a truly culturally competent provider.

This will be greatly assisted as care delivery moves from profession-specific models of care to more interpro- fessional and team-based approaches. This has long been a hope of many involved in efforts to reform health care. If one is truly committed in becoming culturally compe- tent, then one important lesson to learn is how to expand competence and the facility from the culture of nursing to an interdisciplinary culture that includes pharmacy, medicine, and the allied health professions. This seems obvious, but without these skills of closer adaptation and accommodation among all health profes- sions, how can you imagine practitioners adapting to cultures that are more alien than those we encounter on a routine basis?

Synthesizing cultural adaptations within the health pro- fessional perspectives and offering adapted care to patients may not be sufficient to guarantee individual cultural com- petence. Practitioners who achieve such skill will need to change their orientation from one that is focused on the profession and its clinical world to one that is patient-centric. This is easy to affirm but very difficult to deliver because of the power and cultural hegemony of the clinical world. This cultural blindness serves neither the patient nor the practi- tioner. It is also a source of much of the dysfunction of the current system of care, both in terms of costs and quality.

The final stage in cultural competency is the ability to balance self-awareness with other-awareness. Such a balance is the hallmark of an outstanding clinician and is also the basis of all true cultural competence. This value allows for a response ability that transcends the simple knowledge of all practitioners knowing every detail about particular cul- tures and allows a different relationship to emerge between the provider of service and the recipient. In this way, the work toward developing the skills of a culturally compe- tent practitioner assists in the broader goal of becoming an outstanding clinician in any setting. This edition of Transcultural Health Care provides an outstanding guide to the journey of becoming just such a practitioner.

EDWARD O’NEIL, MPA, PHD, FAAN Professor

Departments of Family and Community Medicine, Preventive and Restorative Dental Sciences and

Social and Behavioral Sciences, and Director of the Center for the Health Professions

University of California, San Francisco San Francisco, California

vi • PREFACE

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The editors would like to thank all those who helped in the preparation of the third edition of this book. We espe- cially thank acquisitions editor, Jonathan D. Joyce, and associate acquisitions editor, Thomas A. Ciavarella, at F. A. Davis for their support and enthusiasm for the project; and Julie Catagnus, developmental editor, for her atten- tion to detail, timeliness, and patience during the editing

process. We thank the copyeditors at F. A. Davis for their assistance in bringing the book to completion. Most importantly, we want to thank the many multicultural populations and health professionals who are the impe- tus for this book. Finally, we thank our families, friends, and colleagues for their patience and support during the preparation of the book.

Acknowledgments

vii

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Diane Alain, Med, RN Teacher La Cité Collégiale University of Ottawa Ottawa, Ontario, Canada

Josepha Campinha-Bacote, PhD, MAR, APRN, BC, CNS, CTN, FAAN

Clinical Assistant Professor Case Western Reserve University Cleveland, Ohio President, Transcultural C.A.R.E. Associates Cincinnati, Ohio

Marga Simon Coler, EdD, APRN-C, FAAN Professor Emeritus University of Connecticut Storrs, Connecticut Adjunct Professor University of Massachusetts Amherst, Massachusetts Collaborating Professor Federal University of Paraíba Paraíba, Brazil

Jessie M. Colin, PhD, RN Professor Barry University School of Nursing Miami Shores, Florida

Ginette Coutu-Wakulczyk, RN, MSc, PhD Associate Professor School of Nursing Faculty of Health Sciences University of Ottawa Ottawa, Ontario, Canada

Tina A. Ellis, RN, MSN, CTN Nursing Instructor Florida Gulf Coast University Fort Myers, Florida

Rauda Gelazis, RN, PhD, CS, CTN Associate Professor Ursuline College Pepper Pike, Ohio

Divina Grossman, PhD, RN, FAAN Dean College of Nursing and Health Sciences Florida International University Miami, Florida

Homeyra Hafizi, RN, MS, LHRM Occupational Health Dynamac Corporation Kennedy Space Center, Florida

Sandra M. Hillman, PhD, MS, BSN Professor Nelson Mandela Metropolitan University Port Elizabeth, South Africa

David Hodgins, MSN, RN, CEN Indian Health Service Shiprock, New Mexico

Olivia Hodgins, RN, PhD, MSA, BSN Map Instructor and Nurse Executive Indian Health Service San Fidel, New Mexico

Kathleen W. Huttlinger, PhD, RN Associate Director for Research and Interim Director of Graduate Programs School of Nursing New Mexico State University Las Cruces, New Mexico

Eun-Ok Im, PhD, MPH, FAAN Professor The University of Texas at Austin Austin, Texas

ix

Contributors

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Misae Ito, MSN, RN, NMW Associate Professor, Fundamental Nursing Department of Nursing, Faculty of Health Sciences Yamaguchi University School of Medicine Yamaguchi-Ken, Japan

Anahid Dervartanian Kulwicki, RN, DNS, FAAN Deputy Director Wayne County Health and Human Services Detroit, Michigan Professor Oakland University Rochester, Michigan

Juliene G. Lipson, RN, PhD, FAAN Professor Emerita University of California, San Francisco School of

Nursing Mill Valley, California

Afaf Ibrahim Meleis, PhD, DrPS(hon), FAAN Margaret Bond Simon Dean of Nursing Professor of Nursing and Sociology University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Mahmoud Hanafi Meleis, PhD, PE Retired Nuclear Engineer Philadelphia, Pennsylvania

Denise Moreau, PhD, MSc, RN Assistant Professor and Lecturer University of Ottawa Ottawa, Ontario, Canada

Dula F. Pacquiao, EdD, RN, CTN Associate Professor and Director Bergen Center for Multicultural Education,

Research and Practice School of Nursing University of Medicine and Dentistry of New Jersey Newark, New Jersey

Irena Papadopoulos, PhD, MA, RN, RM, DipNEd, NDN Cert

Professor of Transcultural Health and Nursing Middlesex University, United Kingdom Highgate Hill, London

Ghislaine Paperwalla, BSN, RN Research Nurse in Immunology Veterans Administration Medical Center Miami, Florida

Henry M. Plawecki, RN, PhD Professor of Nursing Purdue University Calumet School of Nursing Hammond, Indiana

Judith A. Plawecki, RN, PhD Professor University of South Florida Tampa, Florida

Lawrence H. Plawecki, RN, JD, LLM Health Law Consultant Plawecki Consultants, LLC Highland, Indiana

Martin H. Plawecki, PhD, MD Faculty Indiana University School of Medicine Indianapolis, Indiana

Jeffrey Ross, BFA, MA, MAT Graphic Designer and Language Arts Teacher Archbishop Hoban High School Akron, Ohio

Ratchneewan Ross, PhD, MSc, RN, Certificate in Midwifery

Assistant Professor College of Nursing Kent State University Kent, Ohio

Maryam Sayyedi, PhD Adjunct Professor Department of Counseling California State University, Fullerton Fullerton, California

Janice Selekman, DNSc, RN Professor University of Delaware Newark, Delaware

Linda S. Smith, MS, DSN, RN, CLNC Associate Professor and Director Idaho State University Pocatello, Idaho

Jessica A. Steckler, MS, RNBC National Program Manager Employee Education System, VHA Erie, Pennsylvania

Gulbu Tortumluoglu, PhD Assistant Professor Nursing Department Chief Yuksekokulu, Canakkale, Turkey

Susan Turale, DEd, MNStud, BN, DApSci(AdvPsychNurs), RN, RPN, FRCNA, FANZCMHN

Professor of International Nursing Department of Nursing, Faculty of Health Sciences Yamaguchi University School of Medicine Yamaguchi-Ken, Japan

Yan Wang, MSN, RN-BC Nursing Informatics System Specialist III Duke University Health System Duke Health Technology Solutions Durham, North Carolina

x • CONTRIBUTORS

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Anna Frances Z. Wenger, PhD, RN, CTN, FAAN Professor and Director of Nursing Emerita Goshen College Goshen, Indiana Senior Scholar Interfaith Health Program School of Public Health Emory University Program Consultant Ethiopia Public Health Training Initiative The Carter Center Atlanta, Georgia

Marion R. Wenger, PhD Retired Professor of Foreign Languages and Linguistics Emory University Atlanta, Georgia

Sarah A. Wilson, PhD, RN Associate Professor Director, Institute for End of Life Care Education Marquette University College of Nursing Milwaukee, Wisconsin

Cecilia A. Zamarripa, RN, CWON Wound, Ostomy, and Continence Nurse University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Rick Zoucha, APRN, BC, DNSc, CTN Associate Professor Duquesne University School of Nursing Pittsburgh, Pennsylvania

CONTRIBUTORS • xi

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Introduction ........................................................................................................ xvii

Chapter 1 Transcultural Diversity and Health Care ........................................ 1 LARRY D. PURNELL

Chapter 2 The Purnell Model for Cultural Competence .............................. 19 LARRY D. PURNELL

Chapter 3 People of African American Heritage ............................................ 56 JOSEPHA CAMPINHA-BACOTE

Chapter 4 The Amish ........................................................................................ 75 ANNA FRANCES Z. WENGER and MARION R. WENGER

Chapter 5 People of Appalachian Heritage .................................................... 95 KATHLEEN W. HUTTLINGER and LARRY D. PURNELL

Chapter 6 People of Arab Heritage ................................................................ 113 ANAHID DERVARTANIAN KULWICKI

Chapter 7 People of Chinese Heritage .......................................................... 129 YAN WANG and LARRY D. PURNELL

Chapter 8 People of Guatemalan Heritage .................................................... 145 TINA A. ELLIS and LARRY D. PURNELL

Chapter 9 People of Egyptian Heritage.......................................................... 157 AFAF IBRAHIM MELEIS and MAHMOUD HANAFI MELEIS

Chapter 10 People of Filipino Heritage .......................................................... 175 DULA F. PACQUIAO

Chapter 11 People of French Canadian Heritage............................................ 196 GINETTE COUTU-WAKULCZYK, DENISE MOREAU, and DIANE ALAIN

Chapter 12 People of German Heritage .......................................................... 213 JESSICA A. STECKLER

Chapter 13 People of Haitian Heritage ............................................................ 231 JESSIE M. COLIN and GHISLAINE PAPERWALLA

Chapter 14 People of Iranian Heritage ............................................................ 248 HOMEYRA HAFIZI, MARYAM SAYYEDI, and JULIENE G. LIPSON

Contents

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Chapter 15 People of Japanese Heritage .......................................................... 260 SUSAN TURALE and MISAE ITO

Chapter 16 People of Jewish Heritage ............................................................ 278 LARRY D. PURNELL and JANICE SELEKMAN

Chapter 17 People of Korean Heritage ............................................................ 293 EUN-OK IM

Chapter 18 People of Mexican Heritage .......................................................... 309 RICK ZOUCHA and CECILIA A. ZAMARRIPA

Chapter 19 People of Russian Heritage ............................................................ 325 LINDA S. SMITH

Chapter 20 People of Polish Heritage .............................................................. 337 HENRY M. PLAWECKI, LAWRENCE H. PLAWECKI, JUDITH A. PLAWECKI, and MARTIN H. PLAWECKI

Chapter 21 People of Thai Heritage ................................................................ 355 RATCHNEEWAN ROSS and JEFFREY ROSS

Appendix Cultural, Ethnic, and Racial Diseases and Illnesses.................... 373

Abstracts People of Baltic Heritage: Estonians, Latvians, and Lithuanians ............................................................................ 381 RAUDA GELAZIS

People of Brazilian Heritage.......................................................... 383 MARGA SIMON COLER

People of Greek Ancestry ..............................................................385 IRENA PAPADOPOULOS and LARRY D. PURNELL

People of Cuban Heritage.............................................................. 387 DIVINA GROSSMAN and LARRY D. PURNELL

People of Hindu Heritage .............................................................. 389 LARRY D. PURNELL

People of Irish Heritage ................................................................ 391 SARAH A. WILSON

People of Italian Heritage.............................................................. 393 SANDRA M. HILLMAN

People of Puerto Rican Heritage .................................................. 395 LARRY D. PURNELL

Navajo Indians ................................................................................397 OLIVIA HODGINS and DAVID HODGINS

People of Turkish Heritage ............................................................399 GULBU TORTUMLUOGLU

People of Vietnamese Heritage .................................................... 401 LARRY D. PURNELL

Glossary................................................................................................................ 403

Index .................................................................................................................... 411

xiv • CONTENTS

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People of Baltic Heritage: Estonians, Latvians, and Lithuanians RAUDA GELAZIS

People of Brazilian Heritage MARGA SIMON COLER and MARIA ADRIANA FELIX COLER

People of Greek Heritage IRENA PAPADOPOULOS and LARRY D. PURNELL

People of Cuban Heritage DIVINA GROSSMAN and LARRY D. PURNELL

People of Hindu Heritage LARRY D. PURNELL

People of Irish Heritage SARAH A. WILSON

People of Italian Heritage SANDRA M. HILLMAN

People of Puerto Rican Heritage LARRY D. PURNELL

Navajo Indians OLIVIA HODGINS and DAVID HODGINS

People of Turkish Heritage GULBU TORTUMLUOGLU

People of Vietnamese Heritage LARRY D. PURNELL

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Contents – DavisPlus

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The Purnell Model for Cultural Competence and its accompanying organizing framework has been used in education, clinical practice, administration, and research, giving credence to its usefulness for healthcare providers. They have been translated into Spanish, French, Flemish, Portuguese, Turkish, and Korean. Healthcare organiza- tions have adapted the organizing framework as a cultural assessment tool and numerous students have used the Model to guide research for theses and dissertations in the United States and overseas. The Model’s usefulness has been established in the global arena, recognizing and including the client’s culture in assessment, healthcare planning, interventions, and evaluation. The Model is now being used more with organizational cultural com- petence as well.

The third edition of Transcultural Health Care: A Culturally Competent Approach has been revised based upon response from students and practicing healthcare professionals such as nurses, physicians, physical thera- pists, emergency medical technicians, and nutritionists to name a few as well as educators from associate degree, baccalaureate, masters, and doctoral programs in nursing. We appreciate their review and suggestions.

Chapter 1 has three important changes: (a) a more extensive section on health disparities, (b) a more exten- sive section on organizational cultural competence, and (c) a section on evidence-based practice as it relates to cul- ture care. We have made a concerted effort to use non- stereotypical language when describing cultural attributes of specific cultures, recognizing that there are exceptions to every description provided and that the differences within a cultural group may be greater than the diversity between and among different cultural groups. We have also tried to include both the sociological and anthropo- logical perspectives of culture.

Chapter 2 expands the description of the Purnell Model for Cultural Competence to include application of the domains and concepts of culture to the dominant American Culture in a cross-cultural fashion. Chapters 1 and 2 have critical thinking questions dispersed throughout each chapter. The glossary remains as it did in the second

edition because users have noted its importance. Cultural specific chapters have changes based on users’ suggestions. Instead of one large case study at the end of each chapter, shorter vignettes covering several domains with study questions are dispersed throughout each chapter.

Given the world diversity and the diversity within cul- tural groups, it is impossible to cover each group more extensively. Space and cost concerns limit the number of chapters that are included in the book; therefore, additional cultural groups, PowerPoint slides, test banks, useful web sites, and additional case studies are include on DavisPlus.

Specific criteria were used for identifying the groups represented in the book and those included in electronic format. Groups included in the book were selected based on any of the six criteria that follow.

• The group has a large population in North America, such as people of Appalachian, Mexican, German, and African American heritage.

• The group is relatively new in its migration status, such as people of Haitian, Cuban, and Arab her- itage.

• The group is widely dispersed throughout North America, such as people of Iranian, Korean, and Filipino heritage.

• The group has little written about it in the health- care literature, such as people of Guatemalan, Russian, and Thai heritage.

• The group holds significant disenfranchised sta- tus, such as people of Navajo heritage, a large American Indian group.

• The group was of particular interest to readers in the second edition, such as people from Amish heritage.

Again, we have strived to portray each culture posi- tively and without stereotyping. We hope you enjoy our book and are as excited about the content as we are.

Larry D. Purnell Betty J. Paulanka

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1

Transcultural Diversity and Health Care

Chapter 1

LARRY D. PURNELL

The Need for Culturally Competent Health Care Cultural competence in multicultural societies continues as a major initiative for business, health-care, and educational organizations in the United States and throughout most of the world. The mass media, health-care policy makers, the Office of Minority Health, and other Governmental organi- zations, professional organizations, the workplace, and health insurance payers are addressing the need for individ- uals to understand and become culturally competent as one strategy to improve quality and eliminate racial, ethnic, and gender disparities in health care. Educational institutions from elementary schools to colleges and universities also address cultural diversity and cultural competency as they relate to disparities and health promotion and wellness.

Many countries are now recognizing the need for addressing the diversity of their society, including the client base, the provider base, and the organization. Societies that used to be rather homogeneous, such as Portugal, Norway, Sweden, Korea, and selected areas in the United States and the United Kingdom, are now facing sig- nificant internal and external migration, resulting in eth- nocultural diversity that did not previously exist, at least not to the degree it does now. As commissioned by the U.K. Presidency of the European Union, several European countries—such as Denmark, Italy, Poland, the Czech Republic, Latvia, the United Kingdom, Sweden, Norway, Finland, Italy, Spain, Portugal, Hungary, Belgium, Greece, Germany, the Netherlands, and France—either have in place or are developing national programs to address the value of cultural competence in reducing health dispari- ties (Health Inequities: A Challenge for Europe, 2005).

Whether people are internal migrants, immigrants, or vacationers, they have the right to expect the health-care system to respect their personal beliefs, values, and health-care practices. Culturally competent health care from providers and the system, regardless of the setting in which care is delivered, is becoming a concern and expec- tation among consumers. Diversity also includes having a diverse workforce that more closely represents the popu- lation the organization serves.

Health-care personnel provide care to people of diverse cultures in long-term-care facilities, acute-care facilities, clinics, communities, and clients’ homes. All health-care providers—physicians, nurses, nutritionists, therapists, technicians, home health aides, and other caregivers— need similar culturally specific information. For example, all health-care providers engage in verbal and nonverbal communication; therefore, all health-care professionals and ancillary staff need to have similar information and skill development to communicate appropriately with diverse populations. The manner in which the informa- tion is used may differ significantly based on the disci- pline, individual experiences, and specific circumstances of the client and provider.

Culturally competent staff and organizations are essen- tial ingredients in increasing clients’ satisfaction with health care and reducing multifactor reasons for gender, racial, and ethnic disparities and complications in health care. If providers and the system are competent, most clients will access the health-care system when problems are first recognized, thereby reducing the length of stay, decreasing complications, and reducing overall costs.

A lack of knowledge of clients’ language abilities and cultural beliefs and values can result in serious threats to life and quality of care for all individuals. Organizations

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and individuals who understand their clients’ cultural values, beliefs, and practices are in a better position to be coparticipants with their clients in providing culturally acceptable care. Having ethnocultural specific knowledge, understanding, and assessment skills to work with cultur- ally diverse clients assures that the health-care provider knows what questions to ask. Providers who know ethno- culturally specific knowledge are less likely to demon- strate negative attitudes, behaviors, ethnocentrism, stereotyping, and racism. Accordingly, there will be improved opportunities for health promotion and well- ness; illness, disease, and injury prevention; and health maintenance and restoration. The onus for cultural com- petence is on the health-care provider and the delivery system in which care is provided. To this end, health-care providers need both general and specific cultural knowl- edge to help reduce gender and ethnic and racial dispari- ties in health care.

World Diversity and Migration The world’s population reached 6.5 billion people in the year 2005 and is expected to approach 7.6 billion by 2020 and 9.3 billion by 2050. The estimated population growth rate is 1.14 percent, with 20.05 births per 1000 popula- tion, 8.6 deaths per 1000 population, and an infant mor- tality rate of 48.87 per 1000 population. Worldwide, life expectancy at birth is currently 64.77 years, with males at 63.17 years and females at 66.47 years (CIA, 2007).

As a first language, Mandarin Chinese is the most popu- lar, spoken by 13.59 percent of the world’s population, fol- lowed by Spanish at 5.05 percent, English at 4.8 percent, Hindi at 2.82 percent, Portuguese at 2.77 percent, Bengali at 2.68 percent, Russian at 2.27 percent, Japanese at 1.99 percent, German at 1.49 percent, and Wu Chinese at 1.21 percent. Only 82 percent of the world population is liter- ate. When technology is examined, more people now have a cell phone than a landline: 1.72 billion versus 1.2 billion. Slightly over 1 billion people are Internet users (CIA, 2007).

We currently live in a global society, a trend that is expected to continue into the future. According to the United Nations High Commissioner for Refugees, there is a global population of 9.2 million refugees, the lowest num- ber in 25 years, and as many as 25 million internally dis- placed persons. Migrants represent 2.9 percent or approxi- mately 190 million people of the world population, up from 175 million in the year 2000. Moreover, international migration is decreasing while internal migration is increas- ing, especially in Asian countries. Only two countries in the world are seeing an increase in their migrant stock— North America and the former USSR (CIA, 2007).

The International Organization for Migration com- pleted the first-ever comprehensive study looking at the costs and benefits of international migration. According to the report, ample evidence exists that migration brings both costs and benefits for sending and receiving coun- tries, although these are not shared equally. Trends sug- gest a greater movement toward circular migration with substantial benefits to both home and host countries. The perception that migrants are more of a burden on, than a benefit to, the host country is not substantiated by

research. For example, in the Home Office Study (2002) in the United Kingdom, migrants contributed U.S. $4 billion more in taxes than they received in benefits. In the United States, the National Research Council (1998) esti- mated that national income had expanded by U.S. $8 bil- lion because of immigration. Thus, because migrants pay taxes, they are not likely to put a greater burden on health and welfare services than the host population. However, undocumented migrants run the highest health risks because they are less likely to seek health care. This not only poses risks for migrants but also fuels sentiments of xenophobia and discrimination against all migrants.

2 • CHAPTER 1

What evidence do you see in your community that migrants have added to the economic base of the community? Who would be doing their work if they were not available?

UNITED STATES POPULATION AND CENSUS DATA

As of 2006, the U.S. population was over 300 million, an increase of 16 million since the 2000 census. The most recent census data estimates that 74.7 percent are white, 14.5 percent are Hispanic/Latino (of any race), 12.1 per- cent are black or African American, 0.8 percent are American Indian or Alaskan Native, 4.3 percent are Asian, 0.1 percent are Native Hawaiian or other Pacific Islander, 6 percent are some other race, and only 1.9 percent are of two or more races. Please note: These figures total more than 100 percent because the federal government consid- ers race and Hispanic origin to be two separate and dis- tinct categories. The categories as used in Census 2000 are

1. White refers to people having origins in any of the original peoples of Europe, the Near East, and the Middle East, and North Africa. This cate- gory includes Irish, German, Italian, Lebanese, Turkish, Arab, and Polish.

2. Black or African American refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any per- son who self-designates this category regardless of origin.

3. American Indian and Alaskan Native refer to people having origins in any of the original peoples of North, South, or Central America and who main- tain tribal affiliation or community attachment.

4. Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This category includes the terms Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, and Thai.

5. Native Hawaiian and other Pacific Islander refer to people having origins in any of the original peo- ples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands, and Chuuk.

6. Some other race was included for people who are unable to identify with the other categories.

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7. In addition, the respondent could identify, as a write-in, with two races (U.S. Bureau of the Census, 2006).

The Hispanic/Latino and Asian populations continue to rise in numbers and in percentage of the overall popula- tion; although the black/African American, Native Hawaiian and Pacific Islanders, Native American and Alaskan Natives groups continue to increase in overall numbers, their percentage of the population has decreased. Of the Hispanic/Latino population, most are Mexicans, followed by Puerto Ricans, Cubans, Central Americans, South Americans, and lastly, Dominicans. Salvadorans are the largest group from Central America. Three-quarters of Hispanics live in the West or South, with 50 percent of the Hispanics living in just two states, California and Texas. The median age for the entire U.S. population is 35.3 years, and the median age for Hispanics is 25.9 years (U.S. Bureau of the Census, 2006). The young age of Hispanics in the United States makes them ideal candidates for recruitment into the health professions, an area with crisis-level shortages of person- nel, especially of minority representation.

Before 1940, most immigrants to the United States came from Europe, especially Germany, the United Kingdom, Ireland, the former Union of Soviet Socialist Republics, Latvia, Austria, and Hungary. Since 1940, immigration patterns to the United States have changed: Most are from Mexico, the Philippines, China, India, Brazil, Russia, Pakistan, Japan, Turkey, Egypt, and Thailand. People from each of these countries bring their own culture with them and increase the cultural mosaic of the United States. Many of these groups have strong ethnic identities and maintain their values, beliefs, prac- tices, and languages long after their arrival. Individuals who speak only their indigenous language are more likely to adhere to traditional practices and live in ethnic enclaves and are less likely to assimilate into their new society. The inability of immigrants to speak the language of their new country creates additional challenges for health-care providers working with these populations. Other countries in the world face similar immigration challenges and opportunities for diversity enrichment. However, space does not permit a comprehensive analysis of migration patterns.

the Secretary’s Task Force’s report on Black and Minority Health (Perspectives on Disease Prevention and Health Promotion, 1985). Two goals from Healthy People 2010 are to increase quality and years of healthy life and eliminate health disparities (Healthy People 2010, 2005). In 2005, the Agency for Healthcare Research and Quality (AHRQ) released the Third National Healthcare Disparities Report (Agency for Healthcare Research and Quality [AHRQ], 2005) that provides a comprehensive overview of health disparities in ethnic, racial, and socioeconomic groups in the United States. This report is a companion document to the National Healthcare Quality Report (NHQR) that is an overview of quality health care in the United States. These two documents highlight four themes: (1) Disparities still exist, (2) some disparities are diminishing, (3) opportunities for improvement still exist, and (4) information about disparities is improving. These docu- ments address the importance of clinicians, administra- tors, educators, and policymakers in cultural competence. Disparities are observed in almost all aspects of health- care, including

1. Effectiveness, patient safety, timeliness, and patient centeredness.

2. Facilitators and barriers to care and health-care utilization.

3. Preventive care, treatment of acute conditions, and management of chronic disease.

4. Clinical conditions such as cancer, diabetes, end- stage renal disease, heart disease, HIV disease, mental health and substance abuse, and respira- tory diseases.

5. Women, children, elderly, rural residency, and individuals with disabilities and other special health-care needs.

6. Minorities and the financially poor receive a lower quality of care (AHRQ, 2005).

When ethnocultural specific populations are exam- ined, although some disparities have shown improve- ment, many have not improved and some have wors- ened. With whites as the comparison group, the report shows:

1. Blacks were 10 times more likely to be diagnosed with AIDS, 59 percent less likely to be given antibiotics for the common cold, 9 percent more likely to receive poorer quality care, 17 percent more likely to lack health insurance, 7 percent less likely to report difficulties in getting care, and 10 percent more likely to have worse access to care.

2. Non-white Hispanics/Latinos were 3.7 times more likely to be diagnosed with AIDS, 16 per- cent more likely to receive poorer quality care, 2.9 times for under age 65 to lack health insur- ance, 18 percent less likely to report difficulties or delays getting care, and 87 percent more likely to have worse access. However, they were 40 per- cent less likely to die of breast cancer.

3. Asians were 57 percent more likely to report com- munication problems with the child’s provider,

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 3

What changes in ethnic and cultural diversity have you seen in your community over the last 5 years? Over the last 10 years? Have you had the opportu- nity to interact with newer groups?

Racial and Ethnic Disparities in Health Care A number of organizations have developed documents addressing the need for cultural competence as one strat- egy for eliminating racial and ethnic disparities. In 1985, the Department of Health and Human Services released

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40 percent less likely to report difficulties or delays in getting care, and 20 percent more likely to have worse access to care.

4. American Indians and Alaskan Natives were twice as likely to lack early prenatal care, 67 per- cent less likely to develop late-stage breast can- cer, 8 percent more likely to receive poorer qual- ity care, twice as likely for the under-age-65 group to not have health insurance, 23 percent more likely to lack a primary-care provider, and 4 percent more likely to have worse access to care.

5. Data for Native Hawaiians and other Pacific Islanders were not available for this report but will be in future reports (AHRQ, 2005).

The health of the lesbian, gay, bisexual, and transgen- der populations has not been addressed in the Healthy People 2010 document or in other government publica- tions. However, the Gay and Lesbian Medical Association (www.glma.org) in 2001 developed Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. Salient disparities are noted in this publication. Gays and lesbians are more likely than their heterosexual cohort groups to have higher rates of tobacco, alcohol, and recreational drug use. Sexually transmitted infections, HIV (especially for men), suicide and suicide ideation, depression, being a victim of street violence (especially for men) and home violence (espe- cially for women), sexual abuse among men, hate crimes, and psychological and emotional disorders are higher among these groups. They are also more likely to be dis- criminated against by health-care providers owing to homophobia. Because of the stigma that alternative iden- tity gender discrimination brings, especially among racially and ethnically diverse populations (Purnell, 2003), these populations were less likely to disclose their sexual orientations. They are also less likely to have health insurance, have a primary-care provider, or take part in prevention programs; in fact, 57 percent of trans- gender people do not have health insurance (Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, Transgender Health, 2001; Purnell, 2003). To help combat violence and crimes against lesbians, gays, and transgender people, several cities such as Washington, D.C.; Fargo, North Dakota; and Missoula, Montana, in the United States have initiated Gay and Lesbian Crime Units (Police Unit Reaches Out to Gay Community, Inspires Others, 2006).

ethnic disparities in other countries. However, documents that include other countries, conditions, and policies are listed as a resource herein. Additional information on the role of cultural competence on eliminating racial and ethnic disparities includes:

1. Transcultural Nursing Society, International (www.tcns.org)

2. U.S. Department of Health and Human Services Office of Minority Health: Physician’s Toolkit and Curriculum (http://www.omhrc.gov/assets/ pdf/checked/toolkit.pdf)

3. Institute of Medicine’s Unequal Treatment study (http://www.iom.edu/?id=4475)

4. The Commonwealth Fund Report on Health Care Quality (http://www.cmwf.org/)

5. Delivering Race Equality: A Framework for Action (http://www.londondevelopmentcentre. org/silo/files/577.pdf)

6. Protecting Vulnerable Populations (www.wcc- assembly.info/en/news-media/news/english)

7. Canadian Institutes of Health Research: Reducing Health Disparities and Promoting Equity for Vulnerable Populations (www.cihr-irsc. gc.ca/e/19739.html)

8. American Physical Therapy Association’s docu- ment and monographs on cultural competence (www.apta.org)

9. Health Inequalities: A Challenge for Europe that includes health policies for the Czech Republic, England, Denmark, Finland, Greece, Germany, Hungary, Ireland, Latvia, the Netherlands, Northern Ireland, Poland Portugal, Scotland, Spain, Sweden, and Wales (www.fco.gov.uk/ Files/kfile/HI_EU_Challenge,0.pdf)

10. American Academy of Family Physicians docu- ments on health disparities and cultural com- petence (http://www.aafp.org)

11. American Academy of Physician Assistants doc- ument The Four Layers of Diversity (http:// www.aapa.org/)

12. Health Resources and Services Administration publication “Indicators of Cultural Competence in Health Care Delivery Organizations” and Cultural Competence Works (www.hrsa.gov)

13. American Student Medical Association Culture and Diversity Curriculum (http://www.amsa.org/ programs/diversitycurriculum.cfm)

14. American Academy of Nursing Standards of Cultural Competence (in press).

15. Diversity Rx (www.diversityRx.org)

Self-Awareness and Health Professionals Culture has a powerful unconscious impact on health professionals. Each health-care provider adds a new and

4 • CHAPTER 1

What health disparities have you observed in your community? To what do you attribute these dispar- ities? What can you do as a professional to help decrease these disparities?

Only broad categories of health disparities are addressed in this chapter. More specific data are included in individual chapters on cultural groups. As can be seen by the overwhelming data, much more work needs to be accomplished to improve the health of the nation. Space does not permit an extensive discourse on racial and

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unique dimension to the complexity of providing cultur- ally competent care. The way health-care providers per- ceive themselves as competent providers is often reflected in the way they communicate with clients. Thus, it is essential for health professionals to think about their cul- tures, their behaviors, and their communication styles in relation to their perceptions of cultural differences. They should also examine the impact their beliefs have on oth- ers, including clients and coworkers, who are culturally diverse. Before addressing the multicultural backgrounds and unique individual perspectives of each client, health- care professionals must first address their own personal and professional knowledge, values, beliefs, ethics, and life experiences in a manner that optimizes interactions and assessment of culturally diverse individuals.

Self-knowledge and understanding promote strong professional perceptions that free health-care profession- als from prejudice and allow them to interact with others in a manner that preserves personal integrity and respects uniqueness and differences among individual clients. The process of professional development and diversity com- petence begins with self-awareness, sometimes referred to as self-exploration. Although the literature provides numerous definitions of self-awareness, discussion of research integrating the concept of self-awareness with multicultural competence is minimal. Many theorists and diversity trainers imply that self-examination or aware- ness of personal prejudices and biases is an important step in the cognitive process of developing cultural compe- tence (Andrews & Boyle, 2005; Campinha-Bacote, 2006; Giger & Davidhizar, 2008). However, discussions of emo- tional feelings elicited by this cognitive awareness are somewhat limited, given the potential impact of emo- tions and conscious feelings on behavioral outcomes.

Culture and Essential Terminology CULTURE DEFINED

Anthropologists and sociologists have proposed many definitions of culture. For the purposes of this book, cul- ture is defined as the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life- ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making. Health and health-care beliefs and values are assumed in this definition. These patterns may be explicit or implicit, are primarily learned and transmitted within the family, are shared by most (but not all) members of the culture, and are emergent phenomena that change in response to global phenom- ena. Culture, a combined anthropological and social con- struct, can be seen as having three levels: (1) a tertiary level that is visible to outsiders, such as things that can be seen, worn, or otherwise observed; (2) a secondary level, in which only members know the rules of behavior and can articulate them; and (3) a primary level that repre- sents the deepest level in which rules are known by all, observed by all, implicit, and taken for granted (Koffman, 2006). Culture is largely unconscious and has powerful influences on health and illness. Health-care providers must recognize, respect, and integrate clients’ cultural beliefs and practices into health prescriptions.

An important concept to understand is that cultural beliefs, values, and practices are learned from birth: first at home, then in the church and other places where people congregate, and then in educational settings. Therefore, a 3-month-old male child from Korea adopted by an African American family and reared in an African American environment will have an African American worldview. However, that child’s “race” would be Asian, and if that child had a tendency toward genetic/hereditary conditions, they would come from his Korean ancestry, not from African American genetics.

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 5

In your opinion, why is there conflict about work- ing with culturally diverse clients? What attitudes are necessary to deliver quality care to clients whose culture is different from yours?

Self-awareness in cultural competence is a deliberate and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional knowledge standards, your ethics, and the impact of these factors on the various roles you play when interacting with individuals different from yourself. The ability to understand oneself sets the stage for integrating new knowledge related to cultural differ- ences into the professional’s knowledge base and percep- tions of health interventions.

What have you done in the last 5 to 10 years to increase your self-awareness? Has increasing your self-awareness resulted in an increased apprecia- tion for cultural diversity? How might you increase your knowledge about the diversity in your community? In your school?

Who in your family had the most influence in teaching you cultural values and practices? Outside the family, where else did you learn about your cultural values and beliefs? What cultural practices did you learn in your family that you no longer practice?

When individuals of dissimilar cultural orientations meet in a work or a therapeutic environment, the likeli- hood for developing a mutually satisfying relationship is improved if both parties attempt to learn about each other’s culture. Moreover, race and culture are not syn- onymous and should not be confused. For example, most people who self-identify as African American have vary- ing degrees of dark skin, but some may have white skin. However, as a cultural term, African American means that the person takes pride in having ancestry from both Africa and the United States; thus, a person with white skin could self-identify as African American.

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IMPORTANT TERMS RELATED TO CULTURE

Attitude is a state of mind or feeling about some matter of a culture. Attitudes are learned; for example, some peo- ple think that one culture is better than another. One cul- ture is not better than another; the two are just different, although many patterns are shared among cultures. A belief is something that is accepted as true, especially as a tenet or a body of tenets accepted by people in an eth- nocultural group. A belief among some cultures is that if a pregnant woman craves a particular food substance, strawberries, for example, and does not satisfy the crav- ing, the baby will be born with a birthmark in the shape of the craving. Attitudes and beliefs do not have to be proven; they are unconsciously accepted as truths. Ideology consists of the thoughts and beliefs that reflect the social needs and aspirations of an individual or an ethnocultural group. For example, some people believe that health care is a right of all people, whereas others see health care as a privilege.

The literature reports many definitions for the terms cultural awareness, cultural sensitivity, and cultural com- petence. Sometimes, these definitions are used inter- changeably. However, cultural awareness has more to do with an appreciation of the external signs of diversity, such as arts, music, dress, and physical characteristics. Cultural sensitivity has more to do with personal atti- tudes and not saying things that might be offensive to someone from a cultural or ethnic background different from the health-care provider’s. Cultural competence in health care is having the knowledge, abilities, and skills to deliver care congruent with the client’s cultural beliefs and practices. Increasing one’s consciousness of cultural diversity improves the possibilities for health-care practi- tioners to provide culturally competent care.

as the humanities. An understanding of one’s own culture and personal values and the ability to detach oneself from “excess baggage” associated with personal views are essential to cultural competence. Even then, traces of eth- nocentrism may unconsciously pervade one’s attitudes and behavior. Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, act- ing, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally com- petent care. Ethnocentrism, a concept that most people practice to some degree, perpetuates an attitude in which beliefs that differ greatly from one’s own are strange, bizarre, or unenlightened and, therefore, wrong. Values are principles and standards that are important and have meaning and worth to an individual, family, group, or community. For example, the dominant U.S. culture places high value on youth, technology, and money. The extent to which one’s cultural values are internalized influences the tendency toward ethnocentrism. The more one’s values are internalized, the more difficult it is to avoid the tendency toward ethnocentrism.

6 • CHAPTER 1

What activity have you done to increase your cul- tural awareness and competence? How do you demonstrate that you are culturally sensitive?

One progresses from unconscious incompetence (not being aware that one is lacking knowledge about another culture), to conscious incompetence (being aware that one is lacking knowledge about another culture), to con- scious competence (learning about the client’s culture, verifying generalizations about the client’s culture, and providing cultural specific interventions), and finally, to unconscious competence (automatically providing cul- turally congruent care to clients of diverse cultures). Unconscious competence is difficult to accomplish and potentially dangerous because individual differences exist within specific cultural groups. To be even minimally effective, culturally competent care must have the assur- ance of continuation after the original impetus is with- drawn; it must be integrated into, and valued by, the cul- ture that is to benefit from the interventions.

Developing mutually satisfying relationships with diverse cultural groups involves good interpersonal skills and the application of knowledge and techniques learned from the physical, biological, and social sciences as well

Given that everyone is ethnocentric to some degree, what do you do to become less ethnocen- tric? If you were to rate yourself on a scale of 1 to 10, with 1 being less ethnocentric and 10 being very ethnocentric, what score would you give yourself? What score would your friends give you? What score would you give your closest friends?

The Human Genome Project provides evidence that all human beings share a genetic code that is over 99 percent identical. However, the controversial term race must still be addressed when learning about culture. Race is genetic in origin and includes physical characteristics that are sim- ilar among members of the group, such as skin color, blood type, and hair and eye color. Although there is less than a 1 percent difference, this difference is significant when conducting physical assessments and prescribing medication, as outlined in culturally specific chapters that follow. People from a given racial group may, but do not necessarily, share a common culture. Race as a social con- cept is just as important, and sometimes more important, than race as a biological concept. Race has social meaning, assigns status, limits or increases opportunities, and influ- ences interactions between patients and clinicians. Racism has been described as prejudice combined with power (Abrums, 2004). The International Convention on the Elimination of All Forms of Racial Discrimination defines racism (1965) as “Any distinction, exclusion, restriction, or preference based on race, colour, descent, or national or ethnic origin which has the purpose or effect of nullifying or impairing the recognition, enjoyment, or exercise, on equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural, or any other field of public life.” Racism may be overt or covert. Recent antidiscrimination laws make racism illegal, but the laws do not eliminate racist attitudes; thus, people are just less likely to express racist attitudes openly. Moreover, one

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must remember that even though one might have a racist attitude, it is not always recognized because it is ingrained during socialization and leads to ethnocentrism.

culture. Some of these differences may include socioeco- nomic status, ethnic background, residence, religion, edu- cation, or other factors that functionally unify the group and act collectively on each member with a conscious awareness of these differences. Subcultures differ from the dominant ethnic group and share beliefs according to the primary and secondary characteristics of culture.

Primary and Secondary Characteristics of Culture Great diversity exists within a cultural group. Major influences that shape peoples’ worldview and the degree to which they identify with their cultural group of origin are called the primary and secondary characteristics of culture. The primary characteristics are things that a person cannot easily change, but if they do, a stigma may occur for themselves, their families, or the society in which they live. The primary characteristics of culture include nationality, race, color, gender, age, and religious affiliation. For example, consider two people with these primary characteristics: one is a 75-year-old devout Islamic female from Saudi Arabia; the other is a 19-year-old African American fundamentalist Baptist male from Louisiana. Obviously, the two do not look alike, and they probably have very different worldviews and beliefs, many of which come from their religious tenets and country of origin.

TRANSCULTURAL DIVERSITY AND HEALTH CARE • 7

How do you define race? What other terms do you use besides race to describe people? In what cate- gory did you classify yourself on the last census? What categories would you add to the current census classifications?

Worldview is the way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them. Worldview includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics.

Any generalization—reducing numerous character- istics of an individual or group of people to a general form that renders them indistinguishable—made about the behaviors of any individual or large group of people is almost certain to be an oversimplification. When a gener- alization relates less to the actual observed behavior than to the motives thought to underlie the behavior (i.e., the why of the behavior), it is likely to be oversimplified. Thus, generalizations can lead to stereotyping, an over- simplified conception, opinion, or belief about some aspect of an individual or group. Generalization and stereotyping are similar, but functionally, they are very different. Stereotyping is an endpoint; generalization is a starting point. For example, knowing whether the person comes from an individualistic versus a collectivistic cul- ture is important. Remember, individualism and collec- tivism exist to some degree in all cultures, but one pattern tends to dominate. People identifying with a collectivist culture, such as most Asians, are more likely to place a higher value on the family than on the individual, harmony, and solidarity. However, people who identify with an individualistic culture, such as the dominant American and Scandinavian cultures, are more likely to place a higher value on the individual, independence, autonomy, and achievement. The health-care provider must specifically ask questions to determine these values and avoid stereotypical views of clients.

Everyone engages in stereotypical behavior to some degree. We could not function otherwise. If someone asked you to think of a nurse, what image do you have? Is the nurse male or female? How old is the nurse? How is the nurse dressed? Is the nurse wearing a hat? How do you distinguish a stereotype from a generalization?

Even in relatively homogeneous cultures, subcultures and ethnic groups exist that may not hold all the values of their dominant culture. Subcultures, ethnic groups, or ethnocultural populations are groups of people who have experiences different from those of the dominant

What are your primary characteristics of culture? How has each one influenced you and your world- view? How has your worldview changed as your primary characteristics have changed? How is each of these a subculture?

The secondary characteristics include educational status, socioeconomic status, occupation, military experi- ence, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented status), and length of time away from the country of ori- gin. For example, the secondary cultural characteristics of being a single transsexual urban business executive will most likely evolve into a different worldview from that of a married heterosexual rural secretary who has two teenagers. In another case, a migrant farm worker from the highlands of Guatemala, who has an undocumented status, has a different perspective than an immigrant from Mexico who has lived in New York City for 10 years. People who live in ethnic enclaves and get their work, shopping, and business needs met without learning the language and customs of their host country may be more traditional than people in their home country. Such was the case for a Japanese man who lived in a Japanese eth- nic enclave in San Francisco. When he returned to Japan after 20 years to visit relatives, he was criticized for being too traditional. Japanese society had changed, while he had not.

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Immigration status influences a person’s worldview. For example, people who voluntarily migrate generally acculturate more willingly; that is, they have given up most traits from the culture of origin as a result of contact with another culture. A number of acculturation scales exist; some are generic for any population, whereas others are specific to a particular culture such as Chinese, Korean, or Filipino. Yet, others are specific to an age group such as teenagers and older people. More traditional peo- ple adhere, and sometimes tenaciously, to most of the traits of their culture of origin. Similarly, assimilation is gradually adopting and incorporating the majority of the characteristics of the prevailing culture. Many people who migrate become bicultural; they are able to function equally well in their dominant and their host cultures. Marginalized people seem to have few traits from their dominant or host culture. People who voluntarily immi- grate assimilate and acculturate more easily than people who immigrate unwillingly or as sojourners. Sojourners, who immigrate with the intention of remaining in their new homeland only a short time, or refugees, who think they may return to their home country, may not identify a need to acculturate or assimilate. In addition, undocu- mented individuals (illegal aliens) may have a different worldview from those who have arrived legally with work visas or as “legal immigrants.”

The debate regarding the precise definition and differ- ences among the terms transcultural, cross-cultural, and intercultural continues. Many authors and texts define the terms differently. This book uses the terms interchange- ably to mean “crossing,” “spanning,” or “interacting” with a culture other than one’s own. When people interact with individuals whose cultures are different from their own, they are engaged in cultural diversity. Awareness of the differences and similarities among ethnocultural groups results in a broadened multicultural worldview.

Ethics Across Cultures As globalization grows and population diversity with nations increases, health-care providers are increasingly confronted with ethical issues related to cultural diversity. At the extremes stand those who favor multiculturalism and postmodernism versus those who favor humanism. Internationally, multiculturalism asserts that no com- mon moral principles are shared by all cultures; post- modernism asserts a similar claim against all universal standards, both moral and nonmoral. Postmodernism holds the stance that everything is social construction, which leads to the contention that context is all- important (Baker, 1998). The concern is that universal standards provide a disguise whereas dominant cultures destroy or eradicate traditional cultures.

Humanism asserts that all human beings are equal in worth, that they have common resources and problems, and that they are alike in fundamental ways (Macklin, 1999). Humanism does not put aside the many circum- stances that make individuals’ lives different around the world. Many similarities exist as to what people need to live well. Humanism says that there are human rights that should not be violated. Macklin (1998) asserts that uni- versal applicability of moral principles is required, not universal acceptability. Beaucamp (1998) concurs that fundamental principles of morality and human rights allow for cross-cultural judgments of immoral conduct. Of course, there is a middle ground.

Throughout the world, practices are claimed to be cul- tural, traditional, and beneficial, even when they are exploitive and harmful. For example, the practice of female circumcision, a traditional cultural practice, is seen by some as exploiting women. In many cases, the practice is harmful and can even lead to death. Whereas empirical anthropological research has shown that differ- ent cultures and historical eras contain different moral beliefs and practices, it is far from certain that what is right or wrong can be determined only by the beliefs and practices within a particular culture or subculture. Slavery and apartheid are examples of civil rights violations.

Accordingly, codes of ethics are open to interpretation and are not value-free. Furthermore, ethics belong to the society, not to professional groups. Ethics and ethical decision making are culturally bound. The Western ethical principles of patient autonomy, self-determina- tion, justice, do no harm, truth telling, and promise keeping are not interpreted or shared by some non- Western societies. In the dominant American culture, truth telling, promise keeping, and not cheating on examinations are highly valued. However, not all cultures place such high regard on these values. For example, in Russia, the truth is optional, people are expected to break their promise, and most students cheat on examinations. Cheating on a business deal is not necessarily dishonor- able (Birch, 2006).

In health organizations in the United States, advance directives give patients the opportunity to decide about their care, and staff members are required to ask patients about this upon admission to a health-care facility. Western ethics, with its stress on individualism, asks this question directly of the patient. However, in collectivist societies, such as among ethnic Chinese and Japanese, the preferred person to ask may be a family member. In most collectivist societies, a person does not stand alone, but rather is defined in relation to another unit, such as the family or work group. In addition, translating these forms into another language can be troublesome because a direct translation can be confusing. For example, “informed consent” may be translated to mean that the person relinquishes his or her right to decision making.