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
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,
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
• 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,
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
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
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
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
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
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 ...
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