Chapter 1 Transcultural Diversity and Health Care
Larry D. Purnell
The Need for Culturally Competent Health Care
Cultural competence has become one of the most important initiatives in health care in the
United States and throughout most of the world. Diversity has increased in many countries due to
wars, discrimination, political strife, worldwide socioeconomic conditions, and the creation of
the European Union. Some of the diversity is driven by actual numbers of immigrants, but other
dimensions come from the visibility of the “new ethnics” and the waning of the social ideology
of the “melting pot” (O'Neil, 2008). Instead of the term melting pot, meaning everyone is
expected to blend, many believe the term salad bowl is more appropriate because people can
stand out and be seen as individuals. Health ideology and health-care providers have learned that
it is just as important to understand the patient's culture as it is to understand the physiological
responses in illness, disease, and injury. The health-care provider may be very knowledgeable
about laboratory values and standard treatments and interventions for diabetes mellitus, heart
disease, and asthma, but if the recommendations are not compatible with the patient's own health
beliefs, dietary practices, and views toward wellness, the treatment plan is less likely to be
followed (Giger et al., 2007). To this end, a number of worldwide initiatives have addressed
cultural competence as a means for improving health and health care, decreasing disparities, and
increasing patient satisfaction. These initiatives come from the U.S. Office of Minority Health,
the Institute of Medicine, Healthy People 2020, the National Quality Forum, the Joint
Commission, The American Medical Association, the American Association of Colleges of
Nursing, and other professional organizations. Educational institutions—from elementary
schools to colleges and universities—are also addressing cultural diversity and cultural
competency as they relate to disparities; health promotion and wellness; illness, disease, and
injury prevention; and health maintenance and restoration.
Many countries are now recognizing the need for addressing the diversity of their societies.
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 significant internal
and external migration, resulting in ethnic and cultural diversities that did not previously exist, at
least not to the degree they do now. 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 disparities (Judge, Platt, Costongs, & Jurczak, 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 expectation among consumers. Diversity also
includes having a diverse workforce that more closely represents the population the organization
serves. Health-care personnel provide care to people of diverse cultures in long-term-care
facilities, acute-care facilities, clinics, communities, and patients’ 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
communicate, both verbally and nonverbally; therefore, all health-care providers and ancillary
staff need to have similar information and skill development to communicate effectively with
diverse populations. The manner in which the information is used may differ significantly based
on the discipline, individual experiences, and specific circumstances of the patient, provider, and
organization. If providers and the system are competent, most patients 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 patients’ language abilities and cultural beliefs and values can result in
serious threats to life and quality of care for all individuals (Joint Commission, 2010).
Organizations and individuals who understand their patients’ cultural values, beliefs, and
practices are in a better position to be co-participants with their patients in providing culturally
acceptable care. Having ethnocultural-specific knowledge, understanding, and assessment skills
to work with culturally diverse patients ensures that the health-care provider can conduct a more
targeted assessment. Providers who know culturally specific aggregate data are less likely to
demonstrate negative attitudes, behaviors, ethnocentrism, stereotyping, and racism. The onus for
cultural competence 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 knowledge
when conducting assessments, planning care, and teaching patients about their treatments and
prescriptions.
World Diversity and Migration
As of January 2011, the world's population estimate reached 6.8 billion people, with a median
age of 27.7 years. The population is expected to approach 7.6 billion by 2020 and 9.3 billion by
2050. The estimated population growth rate remains relatively stable at 1.13 percent, with 19.86
births per 1000 population; 8.7 deaths per 1000 population; and an infant mortality rate of 44.13
per 1000 population, down from 48.87 in 2005. Worldwide life expectancy at birth is currently
66.12 years, up from 64.77 years in 2005 (CIA World Factbook, 2011). The ten largest urban
populations where significant migration occurs are Tokyo, Japan with 36.7 million; Delhi, India
with 22.2 million; São Paulo, Brazil with 20.3 million; Mexico City, Mexico with 19 million;
New York–Newark, United States with 19.4 million; Shanghai, China with 16.6 million; Kolata,
India with 15.6 million; Dhaka, Bangladesh with 14.7 million; and Karachi, Pakistan with 13.1
million (CIA World Factbook, 2011).
As a first language, Mandarin Chinese is the most popular, spoken by 12.65 percent of the
world's population, followed by Spanish at 4.93 percent, English at 4.91 percent, Arabic at 3.1
percent, Hindi at 2.73 percent, Portuguese at 2.67 percent, Bengali at 2.71 percent, Russian at
2.16 percent, Japanese at 1.83 percent, and Standard German at 1.35 percent. Only 82 percent of
the world population is literate. When technology is examined, more people have a cell phone
than a landline—with a ratio of 3:1. Over 1.6 billion people are Internet users, up by 62 percent
from 2005 (CIA World Factbook, 2011). Language literacy has serious implications for
immigration. Over two-thirds of the world's 785 million illiterate adults are found in only eight
countries: Bangladesh, China, Egypt, Ethiopia, India, Indonesia, Nigeria, and Pakistan. Of all the
illiterate adults in the world, two-thirds are women; extremely low literacy rates are concentrated
in three regions: the Arab states, South and West Asia, and Sub-Saharan Africa, where around
one-third of the men and half of all women are illiterate (2005 est.) (CIA World Factbook,
2011).
The United Nations High Commissioner for Refugees estimated in December 2006, the latest
year for which figures are available, a global population of 8.8 million registered refugees, the
lowest number in 30 years, and as many as 24.5 million internally displaced persons in more than
50 countries. The actual global population of refugees is probably closer to 10 million given the
estimated 1.5 million Iraqi refugees displaced throughout the Middle East. Migrants represent
approximately 190 million people or 2.9 percent of the world population, up from 175 million in
the year 2000. Moreover, international migration is decreasing, while internal migration is
increasing, especially in Asian countries (U.N. Refugee Agency, 2009).
In 1997, the International Organization for Migration studied the costs and benefits of
international migration. A comprehensive update has not been undertaken since that time.
According to the report, ample evidence exists that migration brings both costs and benefits for
sending and receiving countries, although these are not shared equally. Trends suggest 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 US$4 billion more in taxes than they received in benefits. In the
United States, the National Research Council (1998) estimated that national income had
expanded by US$8 billion 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.
• 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? If migrants (legal or
undocumented) were not picking vegetables (just one example), how much more do you think you
would pay for the vegetables?
U.S. Population and Census Data
As of 2010, the U.S. population was over 308 million, an increase of 16 million since the 2000
census. The 2010 census data include changes designed to more clearly distinguish Hispanic
ethnicity as not being a race. In addition, the Hispanic terms have been modified to
include Hispanic (used more heavily on the East Coast), Latino (used more heavily in California
and the West Coast), and Spanish. The most recent census data estimate that 65.1 percent of the
U.S. population are white, 15.8 percent are Hispanic/Latino, 12.9 percent are black, 4.6 percent
are Asian, 1.0 percent are American Indian or Alaskan Native, and 0.2 percent are Native
Hawaiian or other Pacific Islander. These groupings will be more specifically reported as the
census data are analyzed. The categories as used in the 2010 U.S. Census are as follows:
•
1. White refers to people having origins in any of the original peoples of Europe and includes
Middle Easterners, 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 person 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 maintain 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
peoples 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.
• 7. In addition, the respondent could identify, as a write-in, with two races (U.S. Census Bureau,
2010).
The Hispanic/Latino and Asian populations continue to rise in numbers and in percentage of the
overall population; however, although the black/African American, Native Hawaiian and Pacific
Islanders, and American Indian 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 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 41.8 years, and the
median age for Hispanics is 27.2 years (U.S. Census Bureau, 2010). 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 personnel, 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, practices, 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 healthcare 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.
• 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 opportunity to interact with these newer
groups?
Racial and Ethnic Disparities in Health Care
A number of organizations have developed documents addressing the need for cultural
competence as one strategy for eliminating racial and ethnic disparities. In 2005, the Agency for
Healthcare Research and Quality (AHRQ) released the “Third National Healthcare Disparities
Report” (AHRQ, 2005), which provided a comprehensive overview of health disparities in
ethnic, racial, and socioeconomic groups in the United States. This report was a companion
document to the “National Healthcare Quality Report” (2006), which was an overview of quality
health care in the United States. Healthy People 2010's (www.healthypeople.gov) goals were to
increase the quality and the length of a healthy life and to eliminate health disparities. Healthy
People provided science-based, 10-year national objectives for improving the health of all
Americans. For 3 decades, Healthy People has established benchmarks and monitored progress
over time in order to (1) encourage collaborations across communities and sectors, (2) empower
individuals toward making informed health decisions, and (3) measure the impact of prevention
activities (http://www.healthypeople.gov/2020/about/default.aspx).
The Healthy People 2020 (www.healthypeople2020.gov) report had a renewed focus on
identifying, measuring, tracking, and reducing health disparities through determinants of health
such as the social and economic environment, the physical environment, and the person's
individual characteristics and behaviors.
Although the term disparities is often interpreted to mean racial or ethnic disparities, many
dimensions of disparity exist in the United States, particularly in health. If a health outcome is
seen in a greater or lesser extent among different populations, a disparity exists. Race or
ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all
contribute to an individual's ability to achieve good health. During the past two decades, one
of Healthy People's overarching goals focused on disparities. Indeed, in Healthy People 2000,
the goal was to reduce health disparities among Americans; in Healthy People 2010, it was to
completely eliminate, not just reduce, health disparities; and in Healthy People 2020, the goal
was expanded to achieve health equity, eliminate disparities, and improve the health of all
groups.
Healthy People 2020 defines a health disparity as “a particular type of health difference that is
closely linked with social, economic, and/or environmental disadvantage.” Health disparities
adversely affect groups of people who have systematically experienced greater obstacles to
health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental
health; cognitive, sensory, or physical disability; sexual orientation or gender identity;
geographic location; or other characteristics historically linked to discrimination or exclusion. In
addition, powerful, complex relationships exist among health and biology, genetics, and
individual behavior, and among health and health services, socioeconomic status, the physical
environment, discrimination, racism, literacy levels, and legislative policies. These factors,
which influence an individual's or population's health, are known as determinants of health
(Healthy People 2020).
• What health disparities have you observed in your community? To what do you attribute these
disparities? What can you do as a professional to help decrease these disparities?
More specific data on ethnic and cultural groups are included in individual chapters. As can be
seen by the overwhelming data, much more work needs to be done to improve the health of the
nation. Space does not permit an extensive discourse on racial and ethnic disparities in other
countries, but documents with frequent updates that include other countries, conditions, and
policies are listed as a resource on DavisPlus.
Culture and Essential Terminology
Culture Defined
Anthropologists and sociologists have proposed many definitions of culture. For the purposes of
this book, which is primarily focused on individual cultural competence instead of the culturally
competent organization, culture is defined as the totality of socially transmitted behavioral
patterns, arts, beliefs, values, customs, lifeways, 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 phenomena. Culture, a combined anthropological and social construct, 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 represents 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.
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 female child from Russian Ashkenazi Jewish
heritage who is adopted by a European American family and reared in a dominant European
American environment will have a European American worldview. However, if that child's
heritage has a tendency toward genetic/hereditary conditions, they would come from her Russian
Jewish ancestry, not from European American genetics.
• 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 likelihood for developing a mutually satisfying relationship is improved if both parties
attempt to learn about one another's culture. Moreover, race and culture are not synonymous and
should not be confused. For example, most people who self-identify as African American have
varying 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.
Important Terms Related to Culture
Attitude is a state of mind or feeling about some aspect of a culture. Attitudes are learned; for
example, some people think that one culture is better than another. No one culture is “better”
than another; they are just different, and many different cultures share the same customs. A
belief is something that is accepted as true, especially as a tenet or a body of tenets accepted by
people in an ethnocultural group. A belief among some cultures is that if you go outside in the
cold weather with wet hair, you will catch a cold. Attitudes and beliefs do not have to be proven;
they are unconsciously accepted as truths. Ideologyconsists 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 the right of all people, whereas others see health care as a
privilege.
The literature reports many definitions of the terms cultural awareness, cultural sensitivity,
and cultural competence. Sometimes, these definitions are used interchangeably, but each has a
distinct meaning. Cultural awareness has to do with an appreciation of the external signs of
diversity, such as the arts, music, dress, foods, and physical characteristics. Cultural
sensitivity has to do with personal attitudes 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 patient's cultural beliefs and practices. Increasing one's consciousness of cultural
diversity improves the possibilities for health-care practitioners to provide culturally competent
care.
• What activities have you done to increase your cultural 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 conscious competence (learning about the patient's culture, verifying
generalizations about the patient's culture, and providing cultural-specific interventions), and,
finally, to unconscious competence (automatically providing culturally congruent care to patients
of diverse cultures). Unconscious competence is difficult to accomplish and potentially
dangerous because individual differences exist within cultural groups. To be even minimally
effective, culturally competent care must have the assurance of continuation after the original
impetus is withdrawn; it must be integrated into, and valued by, the culture 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 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 for cultural competence. Even then, traces of ethnocentrism may
unconsciously pervade one's attitudes and behavior. Ethnocentrism—the universal tendency of
human beings to think that their ways of thinking, acting, and believing are the only right,
proper, and natural ways (which most people practice to some degree)—can be a major barrier to
providing culturally competent care. Ethnocentrism 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.
• Given that everyone is ethnocentric to some degree, what do you do to become less
ethnocentric? With which groups are you more ethnocentric? If you were to rate yourself on a
scale of 1 to 10, with 1 being only a little 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 (2003) determined that 99.9 percent of all humans share the same
genes. One-tenth percent of genetic variations account for the differences among humans,
although these differences may be significant when conducting health assessments and
prescribing medications and treatments. Ignoring this small difference, however, is ignoring the
beliefs, practices, and values of a small ethnic or cultural population to whom one provides care.
However, the controversial term race must still be addressed when learning about culture. Race
is genetic in origin and includes physical characteristics that are similar among members of the
group, such as skin color, blood type, and hair and eye color (Giger et al., 2007). People from a
given racial group may, but do not necessarily, share a common culture. Race as a social concept
is sometimes more important than race as a biological concept. Race has social meaning, assigns
status, limits or increases opportunities, and influences interactions between patients and
clinicians. Some believe that race terminology was invented to assign low status to some and
privilege, power, and wealth to others (American Anthropological Association, 1998). Thus,
perhaps the most significant aspect of race is social in origin. Moreover, one 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.
• How do you define race? What other terms do you use besides race to describe people? In what
category 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 characteristics 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 generalization 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. However, generalizations can lead
to stereotyping, an oversimplified conception, opinion, or belief about some aspect of an
individual or group. Although generalization and stereotyping are similar, functionally, they are
very different. Generalization is a starting point, whereas stereotyping is an endpoint. The healthcare provider must specifically ask questions to determine these values and avoid stereotypical
views of patients. See the section on Variant Characteristics of Culture in this chapter.
• Everyone engages in stereotypical behavior to some degree. We could not function otherwise.
If someone asks 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?
Within all cultures are subcultures and ethnic groups whose values/experiences differ from those
of the dominant culture with which they identify. Indeed, subcultures share beliefs according to
the variant characteristics of culture, as described later in this chapter. In sociology,
anthropology, and cultural studies, a subculture is defined as a group of people with a culture
that differentiates them from the larger culture of which they are a part. Subcultures may be
distinct or hidden (e.g., gay, lesbian, bisexual, and transgendered populations). If the subculture
is characterized by a systematic opposition to the dominant culture, then it may be described as a
counterculture. Examples of subcultures are Goths, punks, and stoners, although popular lay
literature might call these groups cultures instead of subcultures. A counterculture would include
cults (Merriam Webster Online Dictionary, 2010).
The terms transcultural versus cross-cultural have been hotly debated among experts in several
countries but especially in the United States. Specific definitions of these terms vary. Some attest
that they are the same, whereas others say they are different. Historically, nursing seems to favor
the word transcultural. Indeed, the term has been credited to a nurse anthropologist, Madeleine
Leininger, in the 1950s (Leininger & McFarland, 2006), and it continues to be popular in the
United States, the United Kingdom, and many European countries. The term cross-cultural can
be traced to anthropologist George Murdock in the 1930s and is still a popular term used in the
social sciences, although the health sciences have used it as well. The term implies comparative
interactivity among cultures.
Cultural humility, another term found in cultural literature, focuses on the process of
intercultural exchange, paying explicit attention to clarifying the professional's values and beliefs
through self-reflection and incorporating the cultural characteristics of the professional and the
patient into a mutually beneficial and balanced relationship (Trevalon & Murray-Garcia,
1998). This term appears to be most popular with physicians and some professionals from the
social sciences.
Cultural safety is a popular term in Australia, New Zealand, and Canada, although it is used
elsewhere. Cultural safety expresses the diversity that exists within cultural groups and includes
the social determinants of health, religion, and gender, in addition to ethnicity (Guidelines for
Cultural Safety, 2005). Cultural leverage is a process whereby the principles of cultural
competence are deliberately invoked to develop interventions. It is a focused strategy for
improving the health of racial and ethnic communities by using their cultural practices, products,
philosophies, or environments to facilitate behavioral changes of the patient and professional
(Fisher et al., 2007).
Acculturation occurs when a person gives up the traits of his or her culture of origin as a result
of contact with another culture. Acculturation is not an absolute, and it has varying degrees.
Traditional people hold onto the majority of cultural traits from their culture of origin, which is
frequently seen when people live in ethnic enclaves and can get most of their needs met without
mixing with the outside world. Bicultural acculturation occurs when an individual is able to
function equally in the dominant culture and in one's own culture. People who are comfortable
working in the dominant culture and return to their ethnic enclave without taking on most of the
dominant culture's traits are usually bicultural. Marginalized individuals are not comfortable in
their new culture or their culture of origin. Assimilation is the gradual adoption and
incorporation of characteristics of the prevailing culture (Portes, 2007).
Enculturation is a natural conscious and unconscious conditioning process of learning accepted
cultural norms, values, and roles in society and achieving competence in one's culture through
socialization. Enculturation is facilitated by growing up in a particular culture, and it can be
through formal education, apprenticeships, mentorships, and role modeling (Clarke & Hofsess,
1998).
Individualism, Collectivism, and Individuality
All cultures worldwide vary along an individualism and collectivism scale and are subsets of
broad worldviews. A continuum of values for individualistic and collectivistic cultures includes
orientation to self or group, decision making, knowledge transmission, individual choice and
personal responsibility, the concept of progress, competitiveness, shame and guilt, help-seeking,
expression of identity, and interaction/communication style (Hofstede, 1991; Hofstede &
Hofstede, 2005).
Elements and the degree of individualism and collectivism exist in every culture. People from an
individualist culture will more strongly identify with the values at the individualistic end of the
scale. Moreover, individualism and collectivism fall along a continuum, and some people from
an individualistic culture will, to some degree, align themselves toward the collectivistic end of
the scale. Some people from a collectivist culture will, to some degree, hold values along the
individualistic end of the scale. Acculturation is a key component of adopting individualistic and
collectivistic values. Those who live in ethnic enclaves usually, but not always, adhere more
strongly to their dominant cultural values, sometimes to such a degree that they are more
traditional than people in their home country. Acculturation and the variant characteristics of
culture determine the degree of adherence to traditional individualistic and collectivist cultural
values, beliefs, and practices (Hofstede, 1991; Hofstede & Hofstede, 2005).
Communicating, assessing, counseling, and educating a person from an individualistic culture,
where the most important person in society is the individual, may require different techniques
than for a person in a collectivist culture where the group is seen as more important than the
individual (Hofstede & Hofstede, 2005). The professional must not confuse individualism with
individuality—the degree that varies by culture and is usually more prevalent in individualistic
countries. Individuality is the sense that each person has a separate and equal place in the
community and where individuals who are considered “eccentrics or local characters” are
tolerated (Purnell, 2010).
Some highly individualistic cultures include traditional European American (in the United
States), British, Canadian, German, Norwegian, and Swedish, to name a few. Some examples of
collectivist cultures include traditional Arabic, Amish, Chinese, Filipino, Korean, Japanese, Latin
American, Mexican, American Indians (and most other indigenous Indian groups), Taiwanese,
Thai, Turkish, and Vietnamese. Far more world cultures are collectivistic than are individualistic.
It may be difficult for a nurse who is from a highly collectivist culture to communicate with
patients and staff in highly individualistic cultures, such as the United States and Germany
(Hofstede & Hofstede, 2005).
Cultures differ in the extent to which health and information are explicit or implicit. In lowcontext cultures, great emphasis is placed on the verbal mode, and many words are used to
express a thought. Low-context cultures are individualistic. In high-context cultures, much of the
information is implicit where fewer words are used to express a thought, resulting in more of the
message being in the nonverbal mode. Great emphasis is placed on personal relationships. Highcontext cultures are collectivistic (Hofstede, 1991; 2001).
Consistent with individualism, individualistic cultures encourage self-expression. Adherents to
individualism freely express personal opinions, share many personal issues, and ask personal
questions of others to a degree that may be seen as offensive to those who come from a
collectivistic culture. Direct, straight forward questioning is usually appreciated with
individualism. However, the professional should take cues from the patient before this intrusive
approach is initiated. Small talk before getting down to business is not always appreciated.
Individualistic cultures usually tend to be more informal and frequently use first names. Ask the
patient by what name he or she prefers to be called. Questions that require a “yes” or “no”
answer are usually answered truthfully from the patient's perspective. In individualistic cultures
that value autonomy and productivity, one is expected to be a productive member of society.
Among collectivistic cultures, people with a mental or physical disability are more likely to be
hidden from society to “save face,” and the cultural norms and values of the family unit mean
that the family provides care in the home (Purnell, 2001).
Indeed, it is absolutely imperative to include the family, and sometimes the community, in health
care for effective counseling; otherwise, the treatment plan may falter. However, among many
Middle Eastern and other collectivistic cultures, family members with mental or physical
disabilities are hidden from the community for fear that children in the family might not be able
to obtain a spouse if the condition is known. For other impairments, such as HIV, the condition
may be kept from public view, not because of confidentiality rights but for fear that news of the
condition will spread to other family members and the community.
The greater the perceived cultural stigma, the more likely the delay in seeking counseling,
resulting in the condition being more severe at the time of treatment. Individualistic cultures
socialize their members to view themselves as independent, separate, distinct individuals, where
the most important person in society is self. A person feels free to change alliances and not feel
bound by any particular group (shared identity). Although they are part of a group, they are still
free to act independently within the group and less likely to engage in “groupthink.” In
individualism, competition, whether individual or group, permeates every aspect of life.
Separateness, independence, and the capacity to express one's own views and opinions are both
explicitly valued and implicitly assumed.
In individualistic cultures, a person's identity is based mainly on one's personal
accomplishments, career, and challenges. A high standard of living supports self-efficiency, selfdirection, self-advocacy, and independent living. Decisions made by elders and people in
hierarchal positions may be questioned or not followed because the ideal is that all people expect
to, and are expected to, make their own decisions about their lives. Moreover, people are
personally responsible and held accountable for their decisions. Improving self, doing “better”
than others (frequently focused on material gains), and making progress on a community or
national level are expected. If one fails, the blame and shame are on the individual alone.
In collectivistic cultures, people are socialized to view themselves as members of a larger group,
family, school, church, educational setting, workplace, and so on. They are bound through the
expectations of loyalty and personal and familial lifetime protective ties. Children are socialized
where priority is given to connections and interrelationship with others as the basis of
psychological well-being. Older people and those in hierarchical positions are respected, and
people are less likely to openly disagree with them. Parents and elders may have the final say in
their children's careers and life partners. The focus is not on the individual but on the group.
Collectivism is characterized by not drawing attention to oneself, and people are not encouraged
to ask controversial questions about themselves or others. When one fails, shame may be
extended to the family, and external explanations, spiritual, superiors, or fate may be given. To
avoid offending someone, people are expected to practice smooth interpersonal communication
by not openly disagreeing with anyone and being evasive about negative issues. Among most
collectivist cultures, disagreeing with or saying “no” to a health-care professional is considered
rude. In fact, in some languages, there is no word for “no.” If you ask a collectivist patient if she
knows what you are asking, if she understands you, and if she knows how to do something, she
will always answer “yes.” But “yes” could mean (a) I hear you, but I do not understand you; (b) I
understand you, but I do not agree with what you are saying; and (c) I know how to do that, but I
might not do it. Repeating what has been prescribed does not ensure understanding; instead, ask
for a demonstration or some other response that is more likely to determine understanding.
Variant Characteristics of Culture
Great diversity exists within a cultural group. Major influences that shape people's worldviews
and the degree to which they identify with their cultural group of origin are called the “variant
characteristics of culture.” Some variant characteristics cannot be changed, while others can.
They include but are not limited to the following:
REFLECTIVE EXERCISE 1.1
Does your cultural heritage primarily have a collectivistic or individualistic cultural worldview?
Rate your culture on a scale of 1 to 10 with 1 = collectivistic and 10 = individualistic. Is your
culture tolerant of individuality? Are you consistent with your cultural heritage? Provide some
specific behaviors to support your answer.
•
•
• Nationality: One cannot change his or her nationality, but over time many people have changed
their names to better fit into society or to decrease discrimination. For example, many Jews
changed the spelling of their last names during and after World War II to avoid discrimination.
• Race: Race cannot be changed, but people can and do make changes in their appearance, such as
with of cosmetic surgery.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• Color: Skin color cannot usually be changed on a permanent basis.
• Age: Age cannot be changed, but many people go to extensive lengths to make themselves look
younger. One's worldview changes with age. In some cultures, older people are looked upon with
reverence and increased respect. Age difference with the accompanying worldview is frequently
called the generation gap.
• Religious affiliation: People can and do change their religious affiliations or self-identify as
atheists. However, if someone changes his or her religious affiliation—for example, from Judaism
to Pentecostal or Baptist to Islam—a significant stigma may occur within their family or
community.
• Educational status: As education increases, people's worldview changes and increases their
knowledge base for decision making.
• Socioeconomic status: Socioeconomic status can change either up or down and can be a major
determinant for access to and use of health care.
• Occupation: One's occupation can change. Of course, an occupation can be a health risk if
employment is in a coal mine, on a farm, or in a high-stress position. In addition, someone who is
educated in the health professions would not have as much difficulty with health literacy.
• Military experience: People who have military experience may be more accustomed to
hierarchical decision making and rules of authority.
• Political beliefs: Political affiliation can change according to one's ideology. One of the major
reasons for migration is ideological and political beliefs.
• Urban versus rural residence: People can change their residence with concomitant changes in
ideology with different health risks and access to health care.
• Enclave identity: For people who primarily live and work in an ethnic enclave where they can
get their needs met without mixing with the world outside, they may be more traditional than
people in their home country.
• Marital status: Married people and people with partners frequently have a different worldview
than those without partners.
• Parental status: Often, when people become parents—having children, adopting, or taking
responsibility for raising a child—their worldview changes, and they usually become more
futuristic.
• Sexual orientation: Sexual orientation is usually stable over time, but some people are bisexual.
In addition, people who are incarcerated may engage in same-sex activity but return to a
heterosexual lifestyle when released from prison. Gender reassignment is now a possibility for
some, although a significant stigma may occur.
• Gender issues: Men and women may have different concerns in regards to type of work and
work hours, pay scales, and health inequalities.
• Physical characteristics: One's physical characteristics may have an effect on how people see
themselves and how others see them and can include such characteristics as height, weight, hair
color and style, and skin color.
• Immigration status (sojourner, immigrant, or undocumented status): Immigration status and
length of time away from the country of origin also affect one's worldview. People who
voluntarily immigrate generally acculturate and assimilate more easily. Sojourners who immigrate
with the intention of remaining in their new homeland for only a short time on work assignments
or refugees who think they may return to their home country may not have the need or desire to
acculturate or assimilate. Additionally, undocumented individuals (illegal immigrants) may have a
different worldview from those who have arrived legally. Many in this group remained hidden in
society so they will not be discovered and returned to their home country.
•
• Length of time away from the country of origin: Usually, the longer people are away from their
culture of origin, the less traditional they become as they acculturate and assimilate into their new
culture.
REFLECTIVE EXERCISE 1.2
What are your variant characteristics of culture? How has each one influenced you and your
worldview? How has your worldview changed as your variant characteristics have changed?
How is each of these a culture or a subculture?
Some examples of how variant cultural characteristics change one's worldview follow.
Consider two people with the following variant characteristics. One is a 75-year-old devout
Islamic female from Saudi Arabia, and 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.
The variant cultural characteristics of being a single transsexual urban business executive will
most likely have 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 with
an undocumented status has a different perspective than an immigrant from Mexico who has
lived in New York City for 10 years.
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 common moral principles are shared by all
cultures. Postmodernism asserts a similar claim against all universal standards, both moral and
immoral. 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 circumstances that make individuals’ lives different around the world. Many
similarities exist as to what people need to live well. Humanism says that certain human rights
should not be violated. Macklin (1998) asserts that universal 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 cultural, traditional, and beneficial, even when
they are exploitative and harmful. For example, 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. Although empirical, anthropological research has shown that different
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-determination, justice,
do no harm, truth telling, and promise-keeping are highly valued, but not all cultures—nonWestern societies—place such high regard on these values. For example, in Russia, the truth is
optional, people are expected to break their promises, and most students cheat on examinations.
Cheating on a business deal is not necessarily considered dishonorable (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 some ethnic Chinese and
Japanese, the preferred person to ask may be a family member. In addition, translating health
forms into other languages 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.
Some cultural situations occur that raise legal issues. For instance, in Western societies, a
competent person (or an alternative such as the spouse, if the person is married) is supposed to
sign her or his own consent for medical procedures. However, in some cultures, the eldest son is
expected to sign consent forms, not the spouse. In this case, both the organization and the family
can be satisfied if both the spouse and the son sign the informed consent.
Instead of Western ethics prevailing, some authorities advocate for universal ethics. Each culture
has its own definition of what is right or wrong and what is good or bad. Accordingly, some
health-care providers encourage international codes of ethics, such as those developed by
the International Council of Nurses (2010). These codes are intended to reflect the patient's
culture and whether the value is placed on individualism or collectivism. Most Western codes of
ethics have interpretative statements based on the Western value of individualism. International
codes of ethics do not contain interpretative statements but, rather, let each society interpret them
according to its culture. As our multicultural society increases its diversity, health-care providers
need to rely upon ethics committees that include members from the cultures they serve.
As the globalization of health-care services increases, providers must also address very crucial
issues, such as cultural imperialism, cultural relativism, and cultural imposition. Cultural
imperialism is the practice of extending the policies and practices of one group (usually the
dominant one) to disenfranchised and minority groups. An example is the U.S. government's
forced migration of Native American tribes to reservations with individual allotments of lands
(instead of group ownership), as well as forced attendance of their children at boarding schools
attended by white people. Proponents of cultural imperialism appeal to universal human rights
values and standards (Purnell, 2001).
Cultural relativism is the belief that the behaviors and practices of people should be judged
only from the context of their cultural system. Proponents of cultural relativism argue that issues
such as abortion, euthanasia, female circumcision, and physical punishment in child rearing
should be accepted as cultural values without judgment from the outside world. Opponents argue
that cultural relativism may undermine condemnation of human rights violations, and family
violence cannot be justified or excused on a cultural basis (Purnell, 2001).
Cultural imposition is the intrusive application of the majority group's cultural view upon
individuals and families (Universal Declaration of Human Rights, 2001). Prescription of
special diets without regard to patients’ cultures and limiting visitors to immediate family, a
practice of many acute-care facilities, border on cultural imposition (Purnell, 2001).
• What practices have you seen that might be considered a cultural imposition?
What practices have you seen that might be considered cultural imperialism?
What practices have you seen that might be considered cultural relativism?
What have you done to address them when you have seen them occurring?
Health-care providers must be cautious about forcefully imposing their values regarding genetic
testing and counseling. No group is spared from genetic disease. Advances in technology and
genetics have found that many diseases, such as Huntington's chorea, have a genetic basis. Some
forms of breast and colon cancers, adult-onset diabetes, Alzheimer's disease, and hypertension
are some of the newest additions. Currently, only the well-to-do can afford broad testing.
Advances in technology will provide the means for access to screening that will challenge
genetic testing and counseling. The relationship of genetics to disability, individuals with a
disability, and those with a potential disability will create moral dilemmas of new complexity
and magnitude.
Many questions surround genetic testing. Should health-care providers encourage genetic
testing? What is, or should be, done with the results? How do we approach testing for genes that
lead to disease or disability? How do we maximize health and well-being without creating a
eugenic devaluation of those who have a disability? Should employers and third-party payers be
allowed to discriminate based on genetic potential for illness? What is the purpose of prenatal
screening and genetic testing? What are the assumptions for state-mandated testing programs?
Should parents and individuals be allowed to “opt out” of testing? What if the individual does
not want to know the results? What if the results could have a deleterious outcome to the infant
or the mother? What if the results got into the hands of insurance companies that then denied
payment or refused to provide coverage? Should public policy support genetic testing, which
may improve health and health care for the masses of society? Should multiple births from
fertility drugs be restricted because of the burden of cost, education, and health of the family?
Should public policy encourage limiting family size in the contexts of the mother's health,
religious and personal preferences, and the availability of sufficient natural resources (such as
water and food) for future survival? What effect do these issues have on a nation with an aging
population, a decrease in family size, and decreases in the numbers and percentages of younger
people? What effect will these issues have on the ability of countries to provide health care for
their citizens? Health-care providers must understand these three concepts and the ethical issues
involved because they will increasingly encounter situations in which they must balance the
patient's cultural practices and behaviors with health promotion and wellness, as well as illness,
disease, and injury prevention activities for the good of the patient, the family, and society. Other
international issues that may be less controversial include sustainable environments, pacification,
and poverty (Purnell, 2001).
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