Module 2
Cultural Foundations
A. National Standards for Culturally and Linguistically Appropriate Services in
Health Care
In May 1988, Anne Fadiman, editor of The American Scholar, met the Lee family
of Merced, California. Her subsequent book, The Spirit Catches You and You Fall Down,
published in 1997, tells the compelling story of the Lees and their daughter, Lia, and their
tragic encounter with the American health care delivery system. This book has now
become a classic and is used by many health care educators and providers in situations
where there is an effort to demonstrate the need for developing cultural competence.
When Lia was 3 months old, she was taken to the emergency room of the county hospital
with epileptic seizures. The family was unable to communicate in English; the hospital
staff did not include competent Hmong interpreters. From the parents’ point of view, Lia
was experiencing “the fleeing of her soul from her body and the soul had become lost.”
They knew these symptoms to be quag dab peg—“the spirit catches you and you fall
down.” The Hmong regarded this experience with ambivalence, yet they knew that it was
serious and potentially dangerous, as it was epilepsy. It was also an illness that evokes a
sense of both concern and pride.
The parents and the health care providers both wanted the best for Lia, yet a
complex and dense trajectory of misunderstanding and misinterpreting was set in motion.
The tragic cultural conflict lasted for several years and caused considerable pain to each
party (Fadiman, 2001). This moving incident exemplifies the extreme events that can
occur when two antithetical cultural belief systems collide within the overall environment
of the health care delivery system. Each party comes to a health care event with a set
notion of what ought to happen—and, unless each is able to understand the view of the
other, complex difficulties can arise. The catastrophic events of September 11, 2001; the
wars in Iraq, Afghanistan, and Libya; the countless natural disasters such as Hurricane
Katrina and the earthquakes in Haiti and Japan; and our preoccupation with terrorist
threats have pierced the consciousness of all Americans in general and health care
providers in particular. Now, more than ever, providers must become informed about and
sensitive to the culturally diverse subjective meanings of health/HEALTH, 1
illness/ILLNESS, caring, and curing/HEALING practices. Cultural diversity and
pluralism are a core part of the social and economic engines that drive the country, and
their impact at this time has significant implications for health care delivery and
policymaking throughout the United States.
In all clinical practice areas—from institutional settings, such as acute and long-
term care settings, to community-based settings, such as nurse practitioners’ and doctors’
offices and clinics, schools and universities, public health, and occupational settings—
one observes diversity every day. The undeniable need for culturally and linguistically
competent health care services for diverse populations has attracted increased attention
from health care providers and those who judge their quality and efficiency for many
years. The mainstream health care provider is treating a more diverse patient population
as a result of demographic changes and participation in insurance programs, and the
interest in designing culturally and linguistically appropriate services that lead to
improved health care outcomes, efficiency, and patient satisfaction has increased.
One’s personal cultural background, heritage, and language have a considerable
impact on both how patients access and respond to health care services and how the
providers practice within the system. Cultural and linguistic competence suggests an
ability of health care providers and health care organizations to understand and respond
effectively to the cultural and linguistic needs brought to the health care experience. This
is a phenomenon that recognizes the diversity that exists among the patients, physicians,
nurses, and caregivers. This phenomenon is not limited to the changes in the patient
population in that it also embraces the members of the workforce—including providers
from other countries. Many of the people in the workforce are new immigrants and/or are
from ethnocultural backgrounds that are different from that of the dominant culture.
CULTURALCOMPETENCY embraces the premise that all things are connected.
Look again at the dandelion that has gone to seed. Each seed is a discrete entity, yet each
is linked to the other (Figure 1–1). Each facet discussed in this text—heritage, culture,
ethnicity, religion, socialization, and identity— is connected to diversity, demographic
change, population, immigration, and poverty. These facets are connected to
health/HEALTH, illness/ILLNESS, curing/HEALING, and beliefs and practices, modern
and traditional. All of these facets are connected to the health care delivery system—the
culture, costs, and politics of health care, the internal and external political issues, public
health issues, and housing and other infrastructure issues. In order to fully understand a
person’s health/HEALTH beliefs and practices, each of these topics must be in the
background of a provider’s mind.
The railings represent “responsibility and resiliency”—for it is the responsibility
of health care providers to be CULTURALLYCOMPETENT and, if this is not met, the
consequences will be dire. The resiliency of providers and patients will be further
compromised and we will all become more vulnerable. Contrary to popular belief and
practice, CULTURALCOMPETENCY is not a “condition” that is rapidly achieved.
Rather, it is an ongoing process of growth and the development of knowledge that takes a
considerable amount of time to ingest, digest, assimilate, circulate, and master. It is, for
many, a philosophical change in that they develop the skills to understand where a person
from a different cultural background than theirs is coming from.
In 1997, the Office of Minority Health undertook the development of national
standards to provide a much needed alternative to the patchwork that has been undertaken
in the field of cultural diversity. It developed the National Standards for Culturally and
Linguistically Appropriate Services (CLAS) in Health Care. These 14 standards (Box 1–
1) must be met by most health care-related agencies. The standards are based on an
analytical review of key laws, regulations, contracts, and standards currently in use by
federal and state agencies and other national organizations. Published in 2001, the
standards were developed with input from a national advisory committee of
policymakers, health care providers, and researchers. The CLAS standards are primarily
directed at health care organizations. The principles and activities of culturally and
linguistically appropriate services must be integrated throughout an organization and
implemented in partnership with the communities being served. Enhanced standards are
currently being developed but are not yet available.
In order to ensure both equal access to quality health care by diverse populations
and a secure work environment, all health care providers must “promote and support the
attitudes, behaviors, knowledge, and skills necessary for staff to work respectfully and
effectively with patients and each other in a culturally diverse work environment” (Office
of Minority Health, 2001, p. 7). This is the first and fundamental standard of the 14
standards that have been recommended as national standards for CLAS in health care.
B. Cultural and Linguistic Competence
Cultural competence implies that professional health care must be developed to be
culturally sensitive, culturally appropriate, and culturally competent. Culturally
competent care is critical to meet the complex culture-bound health care needs of a given
person, family, and community. It is the provision of health care across cultural
boundaries and takes into account the context in which the patient lives, as well as the
situations in which the patient’s health problems arise.
Title VI of the Civil Rights Act of 1964 states, “No person in the United States
shall, on ground of race, color, or national origin, be excluded from participation in, be
denied the benefits of, or be subjected to discrimination under any program or activity
receiving Federal financial assistance”. To avoid discrimination based on national origin,
Title VI and its implementing regulations require recipients of federal financial assistance
to take reasonable steps to provide meaningful access to Limited English Proficiency
(LEP) persons. Therefore, under the provisions of Title VI of the Civil Rights Act of
1964, when people with LEP seek health care in health care settings such as hospitals,
nursing homes, clinics, day care centers, and mental health centers, services cannot be
denied to them. It is said that “language barriers have a deleterious effect on health care
and patients are less likely to have a usual source of health care, and have an increased
risk if non-adherence to medication regimens”.
People who are limited in their ability to speak, read, write, and understand the
English language experience countless language barriers that can result in limiting their
access to critical public health, hospital, and other medical and social services to which
they are legally entitled. Many health and social service programs provide information
about their services in English only. When LEP persons seek health care at hospitals or
medical clinics, they are frequently faced with receptionists, nurses, and doctors who
speak English only. The language barrier faced by LEP persons in need of medical care
and/or social services severely limits the ability to gain access to these services and to
participate in these programs. In addition, the language barrier often results in the denial
of medical care or social services, delays in the receipt of such care and services, or the
provision of care and services based on inaccurate or incomplete information. Services
denied, delayed, or provided under such circumstances could have serious consequences
for an LEP patient as well as for a provider of medical care. Some states, for example
California, Massachusetts, and New York, recognize the seriousness of the problem and
require providers to offer language assistance to patients in health care settings. Language
access services are especially relevant to racial and ethnic disparities in health care. A
report by the Institute of Medicine (IOM) on racial and ethnic disparities in health care
documented through substantial research that minorities, as compared to their White
American counterparts, receive lower quality of care across a wide range of medical
conditions, resulting in poorer health outcomes and lower health statuses. The research
conducted by the IOM showed that language barriers can cause poor, abbreviated, or
erroneous communication and poor decision making on the part of both providers and
patients (Smedley, B. D., A. Y. Stith, and A. R. Nelson, 2004, p. 3). Each patient must be
carefully assessed to determine his or her language needs, and information must be
delivered in a manner that is understandable by the patient. When a patient does not
understand English, competent interpreters or language resources must be available.
C. Institutional Mandates
Since 2003, the Joint Commission has been actively pursuing a course that
ensures that cultural and linguistic competency standards become a part of their
accreditation requirements. Since this time, they have published several documents
relevant to this topic and in 2010 they published a monograph, Advancing Effective
Communication, Cultural Competence, and Patient and Family Centered Care: A
Roadmap for Hospitals. The monograph provides checklists to improve effective
communication during the admission, assessment, treatment, end-of-life, and discharge
and transfer stages of a given patient’s hospitalization trajectory.
The term CULTURALCARE expresses all that is inherent in the development of
health care delivery to meet the mandates of the CLAS standards and other cultural
competency mandates. CULTURALCARE is holistic care. There are countless conflicts
in the health care delivery arenas that are predicated on cultural misunderstandings.
Although many of these misunderstandings are related to universal situations—such as
verbal and nonverbal language misunderstandings, the conventions of courtesy, the
sequencing of interactions, the phasing of interactions, and objectivity—many cultural
misunderstandings are unique to the delivery of health care. The need to provide
CULTURALCARE is essential, and providers must be able to assess and interpret a
patient’s health beliefs and practices and cultural and linguistic needs.
CULTURALCARE alters the perspective of health care delivery as it enables the
provider to understand, from a cultural perspective, the manifestations of the patient’s
cultural heritage and life trajectory. The provider must serve as a bridge in the health care
setting between the given institution, the patient, and people who are from different
cultural backgrounds.
D. Heritage Consistency
It admonished Samoans— “remember YOUR culture”—a searing message for
each of us to hear. This banner deeply resonated in me and made me aware of how
important it is for me to know my culture and heritage—for all of us to know our culture
and heritage. The opening images for this chapter depict critical aspects of the heritage I
am a member of and are examples of the places and icons that were a part of my
socialization as a child and teenager in the New England, American society of the mid-
1950s. Figure 2–2 is that of Temple Shalom, the synagogue my family belonged to in
Salem, Massachusetts. Here, I learned to read and write Hebrew, the history of the Jewish
people, and the norms and expectations of being a Jewish American.
Who are you? What is your cultural, ethnic, and religious heritage? How and
where were you socialized to the roles and rules of your family, community, and
occupation? Who is the person next to you? What is this person’s cultural, ethnic, and
religious heritage? How and where was this person socialized to the roles and rules of his
or her family, community, and occupation? Are you this person’s health care provider,
instructor, colleague, or supervisor? The foundation for cultural competency rests in the
knowledge and understanding of heritage, not only of yours but also of others with whom
you are interacting.
Who are you? What is your cultural, ethnic, and religious heritage? How and
where were you socialized to the roles and rules of your family, community, and
occupation? Who is the person next to you? What is this person’s cultural, ethnic, and
religious heritage? How and where was this person socialized to the roles and rules of his
or her family, community, and occupation? Are you this person’s health care provider,
instructor, colleague, or supervisor? The foundation for cultural competency rests in the
knowledge and understanding of heritage, not only of yours but also of others with whom
you are interacting.
The word culture showed 1,550,000,000 results on February 23, 2012, on the
Internet. An overview of the content on selected sites, however, is certainly in harmony
with the forthcoming discussion. There is no single definition of culture, and all too often
definitions omit salient aspects of culture or are too general to have any real meaning. Of
the countless ideas of the meaning of this term, some are of particular note. The classical
definition by Fejos (1959, p.K43) describes culture as “the sum total of socially inherited
characteristics of a human group that comprises everything which one generation can tell,
convey, or hand down to the next; in other words, the nonphysically inherited traits we
possess.” Another way of understanding the concept of culture is to picture it as the
luggage that each of us carries around for our lifetime. It is the sum of beliefs, practices,
habits, likes, dislikes, norms, customs, rituals, and so forth that we learned from our
families during the years of socialization. In turn, we transmit cultural luggage to our
children. A third way of defining culture is the behaviors and beliefs characteristic of a
particular social, ethnic, or age group (Dictionary.com, n.d.) and, lastly, one that is most
relevant in areas of traditional health is that culture is a “metacommunication system,”
wherein not only the spoken words have meaning but everything else does as well.
Culture is learned in that people learn the ways to see their environment— that is,
they learn from the environment how to see and interpret what they see. People learn to
speak, and they learn to learn. Culture, as the medium of our individuality, is the way in
which we express ourselves. It is the medium of human social relationships, in that
culture must be shared and creates social relationships. The symbols of culture—sound
and acts—form the basis of all languages. Symbols are everywhere—in religion, politics,
and gender; these are cultural symbols, the meanings of which vary between and within
cultural groups (Bohannan, 1992, pp. 11–14). The society in which we live, and political,
economic, and social forces tend to alter the way in which some aspects of a culture are
transmitted and maintained. Many of the essential components of a culture, however,
pass from one generation to the next unaltered. Consequently, our cultural background
determines much of what we believe, think, and do, both consciously and unconsciously.
In this way, culture and ethnicity are handed down from one generation to another. These
classic definitions of culture continue to serve as a basis for understanding the term in the
present time. In fact, the recent definition developed by the Joint Commission in 2010
defines culture as “integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of racial,
ethnic, religious, or social groups”.
The word ethnicity showed 23,600,000 results on February 23, 2012, on the
Internet. A random exploration of selected sites did not provide information different
from the classical information in the following discussion. Cultural background is a
fundamental component of one’s ethnic background. Before we proceed with this
discussion, though, we need to define some terms, so that we can proceed from the same
point of reference. The classic reference defines ethnic as an adjective “of or pertaining to
a social group within a cultural and social system that claims or is accorded special status
on the basis of complex, often variable traits including religious, linguistic, ancestral, or
physical characteristics” (Davies, 1976, p. 247). The contemporary definition applied by
the Office of Minority Health is that of “a group of people that share a common and
distinctive racial, national, religious, linguistic, or cultural heritage” (Office of Minority
Health, 2001, p. 131). O’Neil (2008) described ethnicity as selected cultural and
sometimes physical characteristics used to classify people into groups or categories
considered to be significantly different from others.
The term ethnic has for some time aroused strongly negative feelings and is often
rejected by the general population. One can speculate that the upsurge in the use of the
term stems from the recent interest of people in discovering their personal backgrounds, a
fact used by some politicians who overtly court “the ethnics.” Paradoxically, in a nation
as large as the United States and comprising as many different peoples as it does—with
the American Indians being the only true native population—we find ourselves still
reluctant to speak of ethnicity and ethnic differences. This stance stems from the fact that
most foreign groups that come to this land often shed the ways of the “old country” and
quickly attempt to assimilate themselves into the mainstream, or the so-called melting
pot.
The third major component of heritage consistency is religion. The word religion
showed 170,000,000 results on February 23, 2012, on the Internet. Again, a random
review of the material yielded information that was similar to existing data. One way to
understand religion is that it is “the belief in a divine or superhuman power or powers to
be obeyed and worshipped as the creator(s) and ruler(s) of the universe; it is a system of
beliefs, practices, and ethical values.” Religion is a major reason for the development of
ethnicity (Abramson, 1980, pp. 869–875). Another way is to see religion as, “a set of
beliefs concerning the cause, nature, and purpose of the universe, especially when
considered as the creation of a superhuman agency or agencies, usually involving
devotional and ritual observances, and often containing a moral code governing the
conduct of human affairs and a specific fundamental set of beliefs and practices generally
agreed upon by a number of persons or sects”.
E. Acculturation Themes
Several facets are relevant to the overall experience of acculturation.
Acculturation is the broad term used to describe the process of adapting to and becoming
absorbed into the dominant social culture. The overall process of acculturation into a new
society is extremely difficult. Have you ever moved to a new community? Imagine
moving to a new country and society where you are unable to communicate, do not know
your way around, and do not know the “rules.” The three facets to the process of overall
acculturation are socialization, acculturation, and assimilation.
Socialization is the process of being raised within a culture and acquiring the
characteristics of that group. Education—be it pre-school, elementary school, high
school, college, or a health care provider program—is a form of socialization. For many
people who have been socialized within the boundaries of a “traditional culture” or a non-
Western culture, modern American culture becomes a second cultural identity. Those
who immigrate here, legally or illegally, from non-Western or non-modern countries may
find socialization into the American culture, whether in schools or in society at large, to
be an extremely difficult and painful process. They may experience biculturalism, which
is a dual pattern of identification and one often of divided loyalty.
While becoming a competent participant in the dominant culture, a member of the
nondominant culture is always identified as a member of the original culture. The process
of acculturation is involuntary, and a member of the nondominant cultural group is forced
to learn the new culture to survive. Individuals experience second-culture acquisition
when they must live within or between cultures (LaFrombose et al., 1993). Acculturation
also refers to cultural or behavioral assimilation and may be defined as the changes of
one’s cultural patterns to those of the host society. In the United States, people assume
that the usual course of acculturation takes three generations; hence, the adult grandchild
of an immigrant is considered fully Americanized.
Acculturation also may be referred to as assimilation, the process by which an
individual develops a new cultural identity. Assimilation means becoming in all ways
like the members of the dominant culture. The process of assimilation encompasses
various aspects, such as cultural or behavioral, marital, identification, and civic. The
underlying assumption is that the person from a given cultural group loses this cultural
identity to acquire the new one. In fact, this is not always possible, and the process may
cause stress and anxiety (LaFrombose et al., 1993). Assimilation can be described as a
collection of subprocesses: a process of inclusion through which a person gradually
ceases to conform to any standard of life that differs from the dominant group standards
and, at the same time, a process through which the person learns to conform to all the
dominant group standards. The process of assimilation is considered complete when the
foreigner is fully merged into the dominant cultural group.
The concepts of socialization, assimilation, and acculturation are complex and
sensitive. The dominant society expects that all immigrants are in the process of
acculturation and assimilation and that the worldview we share as health care
practitioners is shared by our patients. Because we live in a pluralistic society, however,
many variations of health beliefs and practices exist. The debate still rages between those
who believe that America is a melting pot and that all groups of immigrants must be
acculturated and assimilated to an American norm, and those who dispute theories of
acculturation and believe that the various groups maintain their own identities within the
American whole. The concept of heritage consistency is one way of exploring whether
people are maintaining their traditional heritage and of determining the depth of a
person’s traditional cultural heritage.
Generational differences have been described as deep and gut-level ways of
experiencing and looking at the cultural events that surround us. “The differences
between generations—and the determination of who we are—are more than distinct ways
of looking at problems and developing solutions for problems” (Hicks & Hicks, 1999, p.
4). Changes in the past several decades have created cultural barriers that openly or more
subtly create misunderstandings, tensions, and often conflicts between family members,
co-workers, and other individuals— as well as between patients and caregivers,
especially in the practice of gerontology. The cycle of our lives is an ethnocultural
journey and many of the aspects of this journey are derived from the social, religious, and
cultural context in which we grew up. Factors that imprint our lives are the characters and
events that we interacted with at 10 years of age, more or less (Hicks & Hicks, 1999, p.
25). Table 2–3 provides examples of seminal events that occurred from 1928–2001 and
examples of workplace ethics, lifestyle, and social values of various generations.
F. Commingling Variables
People’s life experiences vary greatly, depending on the events of the decades in
which they were born and the cultural values and norms of the times. People who tend to
be heritage consistent—that is, have a high level of identification and association with a
traditional heritage—tend to be less caught up in the secular fads of the time and popular
sociocultural events. Worldviews differ greatly between the immigrant generation and
subsequent generations, and people who score high as heritage consistent and mainstream
people who may score low on the heritage consistency assessment and have been born
into families who have resided in the United States for multiple generations.
Social class is an important factor. The analysis of one’s education, economics,
and background is an important observation of people. There are countless differences
among people predicated on class. The United States Department of Labor produces
employment and wage estimates for over 800 occupations (Table 2–4). These are
estimates of the number of people employed in certain occupations, and estimates of the
wages paid to them. Self-employed persons are not included in the estimates.
There are frequent misunderstandings, as discussed in Chapter 1, when people
who do not understand English must help and care for or take direction from English
speakers. There are also countless conflicts when people who are hard of hearing attempt
to understand people with limited English-speaking skills, and many cultural and social
misunderstandings can develop. Raising standards for all students—every student should
graduate from high school ready for college and a career, regardless of income, race,
ethnic or language background, or disability status.
G. Cultural Phenomena Affecting Health
Hunter (1994) describes cultural conflicts as events that occur when there is
polarization between two groups and the differences are intensified by the way they are
perceived. The struggles are centered on the control of the symbols of culture. In the case
of the conflict between the Lee family and the health care system, discussed in Chapter 1,
the scope of the conflict is readily apparent and lends itself to further analysis. Hunter
describes the fields of conflict as found in family, education, media and the arts, law, and
electoral politics. Health care is a sixth field, and the conflict is between those who
actively participate in traditional health care practices—that is, the practices of their
given ethnocultural heritage—and those who are progressive and see the answers to
contemporary health problems in the science and technology of the present.
The viewing of time in the present, past, or future varies among cultural groups.
Certain cultures in the United States and Canada tend to be future-oriented. People who
are future-oriented are concerned with long-range goals and with health care measures in
the present to prevent the occurrence of illness in the future. Others are oriented more to
the present than the future and may be late for appointments because they are less
concerned about planning to be on time. This difference in time orientation may become
important in health care measures such as long-term planning and explanations of
medication schedules.
Personal space refers to people’s behaviors and attitudes toward the space around
themselves. Territoriality is the behavior and attitude people exhibit about an area they
have claimed and defend or react emotionally to when others encroach on it. Both
personal space and territoriality are influenced by culture, and thus different ethnocultural
groups have varying norms related to the use of space. Communication differences
present themselves in many ways, including language differences, verbal and nonverbal
behaviors, and silence. Language differences are possibly the most important obstacle to
providing multicultural health care because they affect all stages of the patient-caregiver
relationship.
The social environment in which people grow up and live plays an essential role
in their cultural development and identification. Children learn their culture’s responses
to life events from the family and its ethnoreligious group. This socialization process is
an inherent part of heritage—cultural, religious, and ethnic background. The several ways
in which people from one cultural group differ biologically (i.e., physically and
genetically) from members of other cultural groups constitute their biological variations;
for example, body build and structure, including specific bone and structural differences
between groups, such as the smaller stature of Asians and skin color, including variations
in tone, texture, healing abilities, and hair follicles. Environmental control is the ability of
members of a particular cultural group to plan activities that control nature or direct
environmental factors. Included in this concept are the complex systems of traditional
health and illness beliefs, the practice of folk medicine, and the use of traditional healers.
H. Diversity
Health care providers are entangled in the revolutionary consequences of the
enormous demographic, social, and cultural changes that have occurred in the United
States. Many of these changes are playing a dramatic role both in the delivery of health
care to patients, their families, and communities, and in the workforce and environment
in which the provider practices. In order to understand the profound changes that are
taking place in the health care system, both in the delivery of services and in the profile
of the people who are receiving and delivering services, we must look at the changes in
the American population. The White majority is aging and shrinking; the Black,
Hispanic, Asian, and American Indian populations are young and growing. It is
imperative for those who deliver health care to be understanding of and sensitive to
cultural differences, and the effect of the differences on a person’s health and illness
beliefs and practices and health care needs.
Every census adapts to the decade in which it is conducted. One of the most
important changes to Census 2010 was the revision of the questions that were asked
regarding race and Hispanic origin. The federal government considers race and Hispanic
origin to be two separate concepts and the questions on race and Hispanic origin were
asked of all people living in the United States. The changes were developed to reflect the
country’s growing diversity. The respondents were given the option of selecting one or
more race categories to indicate their racial identities. A factor that presents confusion is
that people were free to define themselves as belonging to many groups. However, the
overwhelming majority of the population reported one race.
White—refers to a person having origins in any of the original peoples of Europe,
the Middle East, or North Africa. It includes people who indicated their race(s) as
“White” or reported entries such as Irish, German, Italian, Lebanese, Arab, Moroccan, or
Caucasian. Black or African American—refers to a person having origins in any of the
Black racial groups of Africa. It includes people who indicated their race(s) as “Black,
African American, or Negro” or reported entries such as African American, Kenyan,
Nigerian, or Haitian.
American Indian or Alaska Native—refers to a person having origins in any of the
original peoples of North and South America (including Central America) and who
maintains tribal affiliation or community attachment. This category includes people who
indicated their race(s) as “American Indian or Alaska Native” or reported their enrolled
or principal tribe, such as Navajo, Blackfeet, Inupiat, Yup’ik, Central American Indian
groups, or South American Indian groups.
Asian—refers to a person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam. It includes people who indicated their race(s) as “Asian” or reported entries
such as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and
“Other Asian,” or provided other detailed Asian responses.
Native Hawaiian or Other Pacific Islander—refers to a person having origins in
any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes
people who indicated their race(s) as “Pacific Islander” or reported entries such as
“Native Hawaiian,” “Guamanian or Chamorro,” “Samoan,” and “Other Pacific Islander,”
or provided other detailed Pacific Islander responses. Hispanic or Latino—refers to a
person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race.
The U.S. Census Bureau produces estimates of the resident population for the
United States on an annual basis. It revises the estimates time series each year as final
input data become available. These postcensal estimates from AprilK1, 2000 through July
1, 2006 supersede all previous estimates produced since Census 2000. On March 30,
2007, the U.S. Census Bureau submitted to Congress the subjects it planed to address in
the 2010 Census, which include gender, age, race, ethnicity, relationship, and whether
you own or rent your home. It was estimated that the questions will take less than 10
minutes to complete. The 2010 Census was one of the shortest and easiest to complete
since the nation’s first census in 1790. There is also a yearly American Community
Survey, which eliminates the need for a long-form questionnaire and provides key
socioeconomic and housing data about the nation’s rapidly changing population. The
information required for the census was to be mailed in by April 1, 2010. A census
enumerator interviewed the residents who did not submit their census forms during the
months of May and June 2010. This measure was taken in order to ensure as complete a
count as possible.
I. Immigration
Immigrants and their descendants constitute most of the population of the United
States, and Americans who are not themselves immigrants have ancestors who came to
the United States from elsewhere. The only people considered native to this land are the
American Indians, the Aleuts, and the Inuit (or Eskimos), for they migrated here
thousands of years before the Europeans. Immigrants come to the United States seeking
religious and political freedom and economic opportunities. The life of the immigrant is
fraught with difficulties—going from an “old” to a “new” way of life, learning a new
language, and adapting to a new climate, new foods, and a new culture. Socialization of
immigrants occurs in American public schools, and Americanization, according to
Greeley (1978), is for some a process of “vast psychic repression,” wherein one’s
language and other familiar trappings are shed. In part, the concept of the melting pot has
been created in schools, where children learn English, reject family traditions, and
attempt to take on the values of the dominant culture and “pass” as Americans (Novak,
1973). This difficult experience, as noted and described by Greeley and Novak in the
1970s, continues today.
A citizen of the United States is a native-born, foreign-born child of citizens, or a
naturalized person who owes allegiance to the United States and who is entitled to its
protection. All persons born or naturalized in the United States, are citizens of the United
States and of the state wherein they reside. A refugee is any person who is outside his or
her country of nationality and who is unable or unwilling to return to that country
because of persecution or a wellfounded fear of persecution. Persecution or the fear
thereof must be based on the alien’s race, religion, nationality, membership in a particular
social group, or political opinion. People with no nationality must generally be outside
their country of last habitual residence to qualify as a refugee. Refugees are subject to
ceilings by geographic area set annually by the president in consultation with Congress
and are eligible to adjust to lawful permanent resident status after 1Kyear of continuous
presence in the United States. A permanent resident alien is an alien admitted to the
United States as a lawful permanent resident. A “green card” provides official
immigration status (lawful permanent residency) in the United States. Immigrants are
now referred to as Legal Permanent Residents; however, the Immigration and Nationality
Act (INA) broadly defines an immigrant as “any alien in the United States, except one
legally admitted under specific nonimmigrant categories.” An illegal alien, or
undocumented person, who entered the United States without inspection, for example,
would be strictly defined as an immigrant under the INA but is not a Legal Permanent
Resident. Legal Permanent Residents (LPRs) are legally accorded the privilege of
residing permanently in the United States.
There has been an effort by the government to tighten both immigration and travel
access to the United States since the terrorist attacks in September 2001. On July 22,
2002, the Justice Department announced that it would use criminal penalties against
immigrants and foreign visitors who fail to notify the government of change of address
within 10 days. This requirement is not a new one, but it has not been strictly enforced.
This will have an impact on at least 11 million people and visitors who stay in the United
States for more than 30 days (Davis & Furtado, 2002, p. A2). In addition, this will have
an impact on the health care system and on providers of health care both directly and
indirectly. For example, it will be more difficult for people to work here and to visit
family members who are ill. In addition, the passage of Proposition 187 in California in
November 1994, and earlier laws relating to bilingual education in Texas, demonstrates
that many citizens are no longer willing to provide basic human services, such as health
care and education, to new residents in general and those who are undocumented
specifically. Thus far, the implementation of these laws has been held up in the courts.
Despite such efforts, however, it is evident that immigration to this country will continue.
It is predicted that by the year 2020, immigration will be a major source of new people
for the United States and will be responsible for whatever growth occurs in the United
States after 2030. The United States will continue to attract about two-thirds of the
world’s immigrants, and 85% will be from Central and South America.
J. Poverty
There are countless ways to answer the question “What is poverty?” Poverty may
be viewed through many lenses and from anthropological, cultural, demographic,
economical, educational, environmental, historical, medical, philosophical, policy,
political, racial, sexual, sociological, and theological points of view. The consequences of
poverty are ubiquitous. They include, but are not limited to, battering, bullying, child
abuse, gaming, obesity, spousal abuse, substance abuse, and violence. Poverty may also
be viewed in a “holistic” way. Here, the physical, mental, and spiritual aspects of poverty
are self-evident.
There has been an increase in earning inequality over the last 25 years. The
income for all races rose, then dipped, in this time period. For Blacks and Hispanics, it
was much lower than for Whites and Asians and for people from the Pacific Islands.
Much of this change and inequality was due to technological changes that increased
income to highly skilled labor. At the same time, less skilled workers saw their wages
decrease or stagnate. Poverty is more than the absence of money.
One way of analyzing the phenomenon is by observing the effects of the “cycle of
poverty,” as illustrated in Figure 3–5. In this cycle, the person lives in a situation that
may create poor intellectual and physical development and poor economic production,
and in which the birth rate is high; this living situation in turn, causes numerous social
problems and lower employment abilities, which creates insufficient salaries and a
subsistence economy that often forces the person to reside in densely populated areas or
remotely located rural areas where adequate shelter and potable water are scarce, and the
person suffers from chronically poor nutrition.
These conditions all too often lead to high morbidity and accident rates,
precipitating high health care costs, which, in turn, prevent the person from seeking
health care services. Thus, there is an increase in sickness and poor production, in a cycle
that has yet to be broken. Other barriers that are interrelated to this cycle are the lack of
access to health care services, language issues, and transportation issues. The issues of
overcrowded housing, poor sanitation, inadequate nutrition, homelessness, and so forth
that are part of the cycle of poverty have a profound and prolonged impact on the health
status of people and in future generations.
K. Health
There are countless images we can use to visualize comprehensive notions of
health and illness. What do you do daily to maintain your health? Where do you go for
help? What do you do when you experience a self-limiting ailment? How are ideas of
health and illness reflected throughout the contemporary dominant culture in your family
and home community? The community you work in? If you could pick four images
relating to health and illness from your day-to-day experiences, what would they be?
The answers to the question “What is health?” are not as readily articulated as you
might assume. One response may be a flawless recitation of the World Health
Organization (WHO) definition of health as a “state of complete physical, mental, and
social well-being and not merely the absence of disease.” This answer may be recited
with great assurance—a challenge is neither expected nor welcomed but may evoke an
intense dispute in which the assumed right answer is completely torn apart. Answers such
as “homeostasis,” “kinetic energy in balance,” “optimal functioning,” and “freedom from
pain” are open to discussion. Experienced health care providers may be unable to give a
comprehensive, acceptable answer to such a seemingly simple question. It is difficult to
give a definition that makes sense without the use of some form of medical jargon. It is
also challenging to define health in terms that a layperson can understand. (We lack skill
in understanding “health” from the layperson’s perspective.) It is not unusual to hear
health care providers define health in a negative manner—“the absence of disease.”
As long ago as 1860, Florence Nightingale described health as “being well and
using one’s powers to the fullest extent.” Health is “a condition of physical, mental, and
social well-being and the absence of disease or other abnormal condition.” It is not a
static condition. Constant change and adaptation to stress result in homeostasis. René
Dubos, often quoted in nursing education, says, “The states of health or disease are the
expressions of the success or failure experienced by the organism in its efforts to respond
adaptively to environmental challenges.” Health can also be defined as high-level
wellness, homeostasis.
In analyzing these definitions, we are able to discern subtle variations in
denotation. In fact, the connotation does not essentially change over time. If this occurs in
the denotation of the word, what of the connotation? That is, are health care providers as
familiar with implicit meanings as with more explicit ones? Historically, Irwin M.
Rosenstock (1966) commented that the health professions are becoming increasingly
aware of the lack of clarity in the definition of health. This situation has not changed.
Surely, this is a contemporary and an accurate thought on the educational process, which
is indeed deficient. He concluded, “Whereas health itself is in reality an elusive concept,
in much of research, the stages involved in seeking medical care are conceived as
completely distinct” (p. 49). Furthermore, it may be argued that the connotation of health
is most frequently seen as a 2-dimensional phenomenon—body and mind—with the
larger emphasis on the body.
The framework of both education and research in the health professions continues
to rely on the more abstract definitions of the word health. When taken in a broader
context, health can be regarded not only as the absence of disease but also as a reward for
“good behavior.” In fact, a state of health is regarded by many people as the reward one
receives for “good” behavior and illness as punishment for “bad” behavior. You may
have heard something like “She is so good; no wonder she is so healthy” or a mother
admonishing her child, “If you don’t do such and such, you’ll get sick.” Situations and
experiences may be avoided for the purpose of protecting and maintaining one’s health.
Conversely, some people seek out challenging, albeit dangerous, situations with the hope
that they will experience the thrill of a challenge and still emerge in an intact state of
health. Examples of such behavior include driving at high speeds, ongoing tobacco
smoking, and not wearing seat belts.
In the initial step of the unlocking process, it begins to become clear that no single
definition fully conveys what health really is.1 We can all agree on the WHO definition,
but when asked “What does that mean?” we are unable to clarify or to simplify that
definition. As we begin to perceive a change in the connotation of the word, we may
experience dismay, as that emotional response accompanies the breaking down of ideas.
When this occurs, we begin to realize that as we were socialized into the health care
provider culture by the educational process our understanding of health changed, and we
moved a great distance from our older cultural understanding of the term. The following
list includes the definitions of health given by students at various levels of education and
experience. The students ranged in age from 19-year-old college juniors to graduate
students in both nursing and social work.
It appears that the definition becomes more abstract and technical as the student
advances in the educational program. The terms explaining health take on a more abstract
and scientific character with each year of removal from the lay mode of thinking. Can
these layers of jargon be removed, and can we help ourselves once again to view heath in
a more tangible manner? In further probing this question, let us think back to the way we
perceived health before our entrance into the educational program. I believe that the
farther back we can go in our memory of earlier concepts of health, the better. Again, the
question “What is health?” is asked over and over. Initially, the responses continue to
include such terms and phrases as “homeostasis,” “freedom from disease,” or “frame of
mind.” Slowly, and with considerable prodding, we are able to recall earlier perceptions
of health. Once again, health becomes a personal, experiential concept, and the relation of
health to being returns. The fragility and instability of this concept also are recognized as
health gradually acquires meaning in relation to the term being and is seen in a positive
light and not as “the absence of disease.”
Even this itemized description does not completely answer the question “What is
health?” The words are once again subjected to the question “What does that mean?” and
once again the terms are stripped down, and a paradox begins to emerge. For example,
shiny hair may, in fact, be present in an ill person or in a person whose hair has not been
washed for a long time, and a healthy person may not always have clean, well-groomed,
lustrous hair. It becomes clear that, no matter how much we go around in a circle in an
attempt to define health, the terms and meanings attributed to the state can be challenged.
As a result of this prolonged discussion, we never really come to an acceptable definition
of health, yet, by going through the intense unlocking process, we are able, finally, to
understand the ambiguity that surrounds the word. We are, accordingly, less likely to
view as deviant those people whose beliefs and practices concerning their own health and
health care differ from ours.
Health can be seen from many other viewpoints, and many areas of disagreement
arise with respect to how health can be defined. The preparation of health care providers
tends to organize their education from a perspective of illness. Rarely (or superficially)
does it include an in-depth study of the concept of health. The emphasis in health care
delivery has shifted from acute care to preventive care. The need for the provider of
health services to comprehend this concept is therefore crucial. As this movement for
preventive health care continues to grow, to become firmly entrenched, and to thrive,
multiple issues must be constantly addressed in answering the question “What is health?”
Unless the provider is able to understand health from the viewpoint of the patient, a
barrier of misunderstanding is perpetuated. It is difficult to reexamine complex
definitions dutifully memorized at an earlier time, yet an understanding of health from a
patient’s viewpoint is essential to the establishment of comprehensive primary health care
services inclusive of health maintenance and protection services because, as has been
discussed, the perception of health is a complex psychological process. There tends to be
no established pattern in what individuals and families see as their health needs and how
they go about practicing their own health care.
Health maintenance and protection or the prevention of illness are by no means
new concepts. As long as human beings have existed, they have used a multitude of
methods—ranging from magic and witchcraft to present-day immunization and lifestyle
changes—in an ongoing effort to maintain good health and prevent debilitating illness
and death. Logic suggests that in order to maintain health we must prevent disease, and
that is best accomplished by complying with immunization schedules, enforced by school
policies; eating balanced meals, including avoiding salt and cholesterol; exercising
regularly; and seeing a nurse practitioner, physician, or other health care provider once a
year for a checkup. The annual ritual of visiting a health care provider has been
extensively promoted by the health care establishment and is viewed as effective by
numerous laypeople, primarily those who have access to these services. A provider’s
statement of good health is often required by a person seeking employment or life
insurance. Furthermore, the annual physical examination has been advertised as the key
to good health. A “clean bill of health” is considered essential for social, emotional, and
even economic success. This clean bill of health is bestowed only by members of the
health care profession. The general public has been conditioned to believe that health is
guaranteed if a disease that may be developing is discovered early and treated with the
everincreasing varieties of modern medical technology. Although many people believe in
and practice the annual physical and screening for early detection of a disease, there are
some—both within and outside the health care professions— who do not subscribe to it.
Preventive medicine grew out of clinical practice associated either with welfare medicine
or with industrial or occupational medical practice. The approach of preventive medicine
and health maintenance is the focus of health care practice in the United States among
many segments of the population at large. However, countless disparities in overall
health, and in access and utilization of the health care delivery system, exist and these
will become increasingly evident as we progress through this text.
In 1979, the Surgeon General’s Report, Healthy People: The Surgeon General’s
Report on Health Promotion and Disease Prevention was published. This seminal report
was followed by Healthy People 1990: Promoting Health/Preventing Disease: Objectives
for the Nation—a series of concrete objectives for addressing national public health
issues. A decade later, this document was followed by Healthy People 2000: National
Health Promotion and Disease Prevention Objectives. These early documents presented
the initiative for a national strategy for significantly improving the health of the
American people in the decades preceding 2000 and the decades to follow. The
documents recognized that lifestyle and environmental factors are major determinants in
disease prevention and health promotion. They provided strategies for significantly
reducing preventable death and disability, for enhancing quality of life, and for reducing
disparities in health status among various population groups within our society. Healthy
People 2000: National Health Promotion and Disease Prevention and Objectives was a
statement of national opportunities, and was followed by Healthy People 2010 that was
adjusted to continue in this trajectory; Healthy People 2020, released in early 2011, has
been designed to continue this momentum.
The Health Belief Model (Figures 4–5A and 4–5B) is useful for transitioning
from a discussion of health to that of illness. It illustrates the patient’s perceptions of
health and illness and can be modified to reflect the viewpoint of health care providers.
When implemented from the provider’s viewpoint, the material provides a means of
reinspecting the differences between professional and lay beliefs and expectations.
Forging a link between the two helps one better understand how people perceive
themselves in relation to illness and what motivates them to seek medical help and then
follow that advice.
The perception of the degree of a problem’s seriousness varies from one person to
another. It is in some measure related to the amount of difficulty the patient believes the
condition will cause. From a background in pathophysiology, the provider knows—
within a certain range—how serious a problem is and may withhold information from the
patient. The provider may resort to euphemisms in explaining a problem. The patient may
experience fear and dread by just hearing the name of a problem, such as cancer. What
kinds of actions do people take when they feel susceptible, and what are the barriers that
prevent them from taking action? If the condition is seen as serious, they may seek help
from a doctor or some other significant person, or they may vacillate and delay seeking
and using help. Many factors enter into the decision-making process. Several factors that
may act as barriers to care are cost, availability, and the time that will be missed from
work.
The modifying factors shown in Figures 4–5A and 4–5B indicate the areas of
conflict between patient and provider. The variables of race and ethnicity are cited most
often as complex problem areas when the provider is White and middle-class (or from
one sociocultural economic class and the patient is from another) and the patient is a
member of the emerging majority. The issues are complex and include overtones of
personal and institutional racism. Such perceptions vary not only among groups but also
among individuals. Social class, peer group, and reference group pressures also vary
between the provider and patient and among different ethnic groups. For example, if the
patient’s belief about the causes of illness is “traditional” and the provider’s is “modern,”
an inevitable conflict arises between the 2 viewpoints. This conflict is even more evident
when the provider either is unaware of the patient’s traditional beliefs or is aware of the
manifestation of traditional beliefs and practices and devalues them. Quite often, class
differences exist between the patient and the provider. The reference group of the
provider may well be that of the “technological health system,” whereas the reference
group of the patient may well be that of the “traditional system” of health care and health
care deliverers.
Structural variables also differ when the provider and the patient see the problem
from different angles. Often, each is seeing the same thing but is using different terms (or
jargon) to explain it. Consequently, neither understands the other. Reference group
problems also are manifested in this area, and the news and broadcast media are an
important structural variable. In summary, this section has attempted to deal solely with
the concept of health. The multiple denotations and connotations of the word have been
explored. A method for helping you tune in to your health has been presented, a
transitional discussion illustrating the plethora of issues to be raised later in the text has
been included, and an overview of Healthy People 2020 has set the tone for the remainder
of the text, and the Health Belief Model serves to provide a context for the discussion.
L. Illness
We tend to regard illness as the absence of health, yet we demonstrated in the
preceding discussion that health is at best an elusive term that defies a specific definition.
Let us look at the present issue more closely. Is illness the opposite of health? Is it a
permanent condition or a transient condition? How do you know if you are ill? When you
google illness, the response on the World Wide Web is well over 37,500,000 results in
0.19 seconds (February 29, 2012). One basic dictionary definition for this term is an
unhealthy condition of body or mind: SICKNESS (© 2005 by Merriam-Webster
Incorporated). Another definition is found in Mosby’s Medical Dictionary: unhealthy
condition, an abnormal process in which aspects of the social, physical, emotional, or
intellectual condition and function of a person are diminished or impaired compared with
that person’s previous condition”.
Essentially, we are being pulled back in the popular direction and encouraged to
use lay terms. We initially resist this because we want to employ professional jargon.
(Why use lay terms when our knowledge is so much greater?) It is crucial that we be
called to task for using jargon. We must learn to be constantly conscious of the way in
which the laity perceive illness and health care. Another factor emerges as the word
illness is stripped down to its barest essentials. Many of the characteristics attributed to
health occur in illness, too. You may receive a rude awakening when you realize that a
person perceived as healthy by clinical assessment may then—by a given set of
symptoms— define him- or herself as ill (or vice versa). For example, in summertime,
one may see a person with a red face and assume that she has a sunburn. The person may,
in fact, have a fever. A person recently discharged from the hospital, pale and barely able
to walk, may be judged ill. That individual may consider himself well, however, because
he is much better than when he entered the hospital—now he is able to walk! Thus,
perceptions are relative and, in this instance, the eyes of the beholder have been clouded
by inadequate information. Unfortunately, at the provider’s level of practice, we do not
always ask the patient, “How do you view your state of health?” Rather, we determine
the patient’s state of health by objective and observational data.
The seminal work of Talcott Parsons (1966) helps explain the phenomenon of
“the sick role.” In our society, a person is expected to have the symptoms viewed as
illness confirmed by a member of the health care profession. In other words, the sick role
must first be legitimately conferred on this person by the keepers of this privilege. You
cannot legitimize your own illness and have your own diagnosis accepted by society at
large. There is a legitimate procedure for the definition and sanctioning of the adoption of
the sick role and it is fundamental for both the social system and the sick individual.
Thus, illness is not only a “condition” but also a social role.
The experience of an illness is determined by what illness means to the sick
person. Furthermore, illness refers to a specific status and role within a given society. Not
only must illness be sanctioned by a physician for the sick person to assume the sick role,
but it also must be sanctioned by the community or society structure of which the person
is a member. Alksen, L., Wellin, E., Suchman, E., et al. (n.d.) divide this experience into
four stages, which are sufficiently general to apply to any society or culture. The first
stage, onset, is the time when the person experiences the first symptoms of a problem.
This event can be slow and insidious or rapid and acute. When the onset is insidious, the
patient may not be conscious of symptoms or may think that the discomfort will
eventually go away. If, however, the onset is acute, the person is positive that illness has
occurred and that immediate help must be sought. This stage is seen as the prelude to
legitimization of illness. It is the time when the person with a sore throat in the preceding
discussion may have experienced some fatigue, a raspy voice, or other vague symptoms.
In the second stage of the illness experience, diagnosis, the disease is identified or
an effort is made to identify it. The person’s role is now sanctioned, and the illness is
socially recognized and identified. At this point, the health care providers make decisions
pertaining to appropriate therapy. During the period of diagnosis, the person experiences
another phenomenon: dealing with the unknown, which includes fearing what the
diagnosis will be.
During the third stage, patient status, the person adjusts to the social aspects of
being ill and gives in to the demands of his or her physical condition. The sick role
becomes that of patienthood, and the person is expected to shift into this role as society
determines it should be enacted. The person must make any necessary lifestyle
alterations, become dependent on others in some circumstances for the basic needs of
daily life, and adapt to the demands of the physical condition as well as to treatment
limitations and expectations. The environment of the patient is highly structured. The
boundaries of the patient’s world are determined by the providers of the health care
services, not by the patient. Herein lies the conflict.
The fourth stage—recovery—is generally characterized by the relinquishing of
patient status and the assumption of prepatient roles and activities. There is often a
change in the roles a person is able to play and the activities able to be performed once
recovery takes place. Often, recovery is not complete. The person may be left with an
undesirable or unexpected change in body image or in the ability to perform expected or
routine activities. One example is a woman who enters the hospital with a small lump in
her breast and who, after a surgery, returns home with only one breast. Another example
is that of a man who is a laborer and enters the hospital with a backache and returns home
after a laminectomy. When he returns to work, he cannot resume his job as a loader.
Obviously, an entire lifestyle must be altered to accommodate such newly imposed
changes.
Lastly, a way of explaining both health and illness is to explore the dynamics of
the natural history of the health-illness continuum (Figure 4–6). Here, it is possible to
follow the continuum or trajectory of a healthy state through an illness that a person may
experience. This summarizes the social science approaches that have been discussed to
answer our fundamental questions— “What is health?” and “What is illness?”—and
begins to shift our focus to the responses and experiences people have both to and with
states of health and illness. The focus now begins to move to the active role the person
plays in shaping and experiencing the course of a state of health and a given illness. For
example, the seemingly healthy person who develops an illness may experience the
following continuum: healthy state—he or she is carrying on activities of daily living,
actively participating in family life, work, other activities and so forth; an illness—the
symptoms of an illness may be acute, silent, or subtle in nature—occurs; the person may
recover spontaneously or with treatment, or comeback and resume his or her life in an
expected manner or resume his or her earlier stable status; or, the illness episode may be
more severe, and the person may become unstable or experience the illness as a chronic
condition; he or she may, over time, deteriorate; and at some point death occurs. The
person may die with the onset of the acute phase or later in the continuum. The acute
phase most often is treated in the home or an acute care setting, and the early phases of
comeback and rehabilitation occur in one of these settings.
