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Multicultural Health

Second Edition

Lois A. Ritter, EdD, MS, MA, MS-HCA,
PMP

Consultant, Health and Education

Donald H. Graham, JD, MA
Attorney and Consultant, Human Services

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Library of Congress Cataloging-in-Publication Data
Names: Ritter, Lois A., author. | Graham, Donald H., author.
Title: Multicultural health / Lois A. Ritter, Donald H. Graham.
Description: Second edition. | Burlington, MA : Jones & Bartlett Learning, [2017] | Includes

bibliographical references and index.
Identifiers: LCCN 2015048787 | ISBN 9781284021028 (pbk. : alk. paper)
Subjects: | MESH: Cultural Competency | Culturally Competent Care | Cross-Cultural

Comparison | Ethnic Groups | United States
Classification: LCC RA418.5.T73 | NLM W 21 | DDC 362.1089—dc23 LC record
available at http://lccn.loc.gov/2015048787

6048

Printed in the United States of America
20 19 18 17 16 10 9 8 7 6 5 4 3 2 1

CONTENTS

Dedication

Preface

Acknowledgments

About the Authors

UNIT I The Foundations

Chapter 1 Introduction to Multicultural Health
Key Concepts and Terms
Diversity Within the United States
Cultural Adaptation
Health Disparities
Causes of Health Disparities
Legal Protections for Ethnic Minorities
Personal Health Decisions
Ethical Considerations
Summary
Review
Activity
Case Study
References

Chapter 2 Theories and Models Related to

Multicultural Health
Theories of Health and Illness
Pathways to Care
Cultural Competence
Promoting Cultural Competence
Summary
Review
Activity
Case Study
References

Chapter 3 Worldview and Health Decisions
Worldview
Worldview and Medical Decisions
Worldview and Response to Illness
Summary
Review
Activity
Case Study
References

Chapter 4 Complementary and Alternative Medicine
History of Complementary and Alternative Medicine
Complementary and Alternative Health Care Modalities
Laws Affecting Cultural Practices and Health
Summary
Review
Activity
Case Study
References

Chapter 5 Religion, Rituals, and Health
Religion in the United States
Religion and Health Behaviors
Religion and Health Outcomes
Religion and Well-Being
Rituals
Summary
Review
Activity
Case Study
References

Chapter 6 Communication and Health Promotion in
Diverse Societies
Health Communication
Delivering Your Health Message
Printed Materials
Public Health Programs
Evaluating Your Multicultural Health Program
Summary
Review
Activity
Case Study
References

UNIT II Specific Cultural Groups

Chapter 7 Hispanic and Latino American Populations
Introduction
Terminology

History of Hispanics in the United States
General Philosophy About Disease Prevention and
Health Maintenance
Healing Traditions, Healers, and Healing Aids
Behavioral Risk Factors and Common Health Problems
Considerations for Health Promotion and Program
Planning
Tips for Working With the Hispanic Population
Summary
Review
Activity
Case Study
References

Chapter 8 American Indian and Alaskan Native
Populations
Introduction
Terminology
History of American Indians and Alaska Natives in the
United States
American Indian and Alaskan Native Populations in the
United States
American Indian and Alaskan Native General
Philosophy About Disease Prevention and Health
Maintenance
Healing Traditions, Healers, and Healing Aids
Behavior Risk Factors and Prevalent Health Problems
Considerations for Health Promotion and Program
Planning
Tips for Working With American Indian and Alaskan
Native Populations

Summary
Review
Activity
Case Study
References

Chapter 9 African American Populations
Introduction
Terminology
History of African Americans in the United States
African Americans in the United States
General Philosophy About Disease Prevention and
Health Maintenance
Healing Traditions
Behavior Risk Factors and Prevalent Health Problems
Considerations for Health Promotion and Program
Planning
Tips for Working With the African American
Population
Summary
Review
Activity
Case Study
References

Chapter 10 Asian American Populations
Introduction
Terminology
History of Asian Americans in the United States
Asian Americans in the United States

General Philosophy About Disease Prevention and
Health Maintenance
Healing Traditions, Healers, and Healing Aids
Behavioral Risk Factors and Common Health Problems
Considerations for Health Promotion and Program
Planning
Tips for Working With the Asian American Population
Summary
Review
Activities
Case Study
References

Chapter 11 European and Mediterranean American
Populations
Introduction
Terminology
History of European and Mediterranean Americans in
the United States
European and Mediterranean Americans in the United
States
General Philosophy About Disease Prevention and
Health Maintenance
History, Healing Practices, and Risk Factors for Three
Subcultures
Behavior Risk Factors and Prevalent Health Problems
for European and Mediterranean Americans
Tips for Working With European and Mediterranean
American Populations
Summary
Review

Activity
Case Studies
References

Chapter 12 Nonethnic Cultures
Introduction
Introduction to the “Culture of People Suffering
Discrimination”
History of Gay Americans in the United States
Introduction to People With Disabilities
Introduction to the Culture of Commerce
Consumers
Farmworkers
Introduction to People Who Are Recent Immigrants or
Refugees
Summary
Review
Activities
Case Study
References

UNIT III Looking Ahead

Chapter 13 Closing the Gap: Strategies for Eliminating
Health Disparities
Strategies for Reducing or Eliminating Health
Disparities
Summary
Review
Activities

Case Study
References

Glossary

Index

Dedication

To Gary and Samantha, for creating countless hours of laughter—lr

To Sarah—dg

Preface

Your mind is like a parachute . . . it functions only when open.
~ Author unknown

Health care professionals work in a diverse society that presents both
opportunities and challenges, so being culturally competent is essential to
their role. Although knowing about every culture is not possible, having
an understanding of various cultures can improve effectiveness.
Multicultural Health provides an introduction and overview to some of the
major cultural variations related to health.

Throughout this text, those engaged in health care can acquire
knowledge necessary to improve their effectiveness when working with
diverse groups, regardless of the predominant culture of the community
in which they live or work. The content of this book is useful when
working in the field on both individual and community levels. It serves as
a guide to the concepts and theories related to cultural issues in health
and as a primer on health issues and practices specific to certain cultures
and ethnic groups.

New to This Edition

NEW! A Student Activity is added to each chapter to challenge
student comprehension.

NEW! Two new Feature Boxes appear in each chapter—What Do
You Think? and Did You Know?—to engage readers and enhance
critical thinking.

NEW! Chapter 3, Worldview and Health Decisions, provides

information about the ways that worldview and communication affect
health, the provision of health services, health care decisions, and
communication.

Expanded! Reiki has been added to Chapter 4, Complementary and
Alternative Medicine. Chiropractic care, homeopathy, hypnosis, and
hydro-therapy, although important treatment modalities, were
removed to keep the chapter focused on culturally based CAM
modalities.

Expanded! In Chapter 5, Religion, Rituals, and Health, a section was
added about the clinical implications of the relationships among
religion, spirituality, and health.

Expanded! In Chapter 6, Communication and Health Promotion in
Diverse Societies, tips for communicating with people with limited
English proficiency have been added.

Expanded! Chapters 7 through 12 have new sections on worldview,
pregnancy, mental health, and death and dying as they relate to the
cultural group discussed in each chapter.

Expanded! Chapter 12, Nonethnic Cultures, has been expanded to
include people with disabilities, immigrants and refugees, and the
culture of commerce.

Expanded! In Chapter 13, Closing the Gap: Strategies for
Eliminating Health Disparities, information about the Health and
Humans Services Action Plan to reduce racial and ethnic health
disparities and the National Stakeholder Strategy for Achieving
Health Equality have been added.

Revised! Laws and ethics material is now integrated throughout
where appropriate.

Revised! The model programs have been removed from Chapters 7
through 12 and an activity has been added for learners to conduct
research and identify a model program themselves.

About This Book

Multicultural Health is divided into three units.

UNIT I, The Foundations, includes Chapters 1 through 6 and focuses
on the context of culture, cultural beliefs regarding health and illness,
health disparities, models for cross-cultural health and communication,
and approaches to culturally appropriate health promotion programs and
evaluation.

Chapter 1, Introduction to Multicultural Health, discusses the
reasons for becoming knowledgeable about the cultural impact of
health practices. It defines terminology and key concepts that set the
foundation for the remainder of the text. The chapter addresses
diversity in the United States and the racial makeup of the country,
health disparities and their causes, and issues related to medical care in
the context of culture.

Chapter 2, Theories and Models Related to Multicultural Health,
addresses theories regarding the occurrence of illness and its
treatment. Terms and theoretical models related to cultural
competence are provided. Individual and organizational cultural
competence assessments are included.

Chapter 3, Worldview and Health Decisions, explores the concept of
worldview on illness and treatment and cultural influences that affect
health. Differences in worldview and how that affects perceptions
about health, health behaviors, and interactions with health care
providers are described. Verbal and nonverbal communication
considerations are explained. The chapter closes with discussions
about how worldview and communication influence specific areas of
health, such as the use of birth control.

Chapter 4, Complementary and Alternative Medicine, provides an
introduction to complementary and alternative medicine and health
practices. It explores the major non-Western medicine modalities of

care, including Ayurvedic medicine, traditional Chinese medicine,
herbal medicine, and holistic and naturopathic medicine. The history,
theories, and beliefs regarding the source of illness and treatment
modalities are described.

Chapter 5, Religion, Rituals, and Health, explores the role of religion
and spiritual beliefs in health and health behavior. The similarities and
differences between religion and rituals are described. The chapter
integrates examples of religious beliefs in the United States and their
impact on health decisions and behaviors.

Chapter 6, Communication and Health Promotion in Diverse
Societies, includes information about culturally sensitive
communication strategies used in public health. Considerations to
making health care campaigns using various communication channels,
such as social media, appropriate for diverse audiences are explained.
A section on health literacy is included.

UNIT II, Specific Cultural Groups, includes Chapters 7 through 12
and addresses the history of specific cultural groups in the United States,
beliefs regarding the causes of health and illness, healing traditions and
practices, common health problems, and health promotion and program
planning for the various cultural groups. These points are applied to
specific cultural groups as follows:

Chapter 7, Hispanic and Latino American Populations

Chapter 8, American Indian and Alaskan Native Populations

Chapter 9, African American Populations

Chapter 10, Asian American Populations

Chapter 11, European and Mediterranean American Populations

Chapter 12, Nonethnic Cultures

UNIT III, Looking Ahead, outlines priority areas in health disparities
and strategies to eliminate health disparities.

Chapter 13, Closing the Gap: Strategies for Eliminating Health
Disparities, explores the implications of the growth of diversity in the
United States in relation to future disease prevention and treatment. It
further addresses diversity in the health care workforce and its impact
on care, as well as the need for ongoing education in cultural
competence for health care practitioners.

Features and Benefits

Each chapter includes a “Did You Know?” and “What Do You
Think?” section to stimulate critical thinking and classroom discussions.
Also included are chapter review questions, related activities, and a case
study. Key concepts are listed and their definitions are provided in the
glossary.

We hope the information contained in Multicultural Health will
introduce you to the rich and fascinating cultural landscape in the United
States and the diverse health practices and beliefs of various cultural
groups. This book is not intended to be an end point; rather, it is a
starting point in the journey to becoming culturally competent in health
care.

For the Instructor

Instructor resources, including Power-Point presentations, Instructor’s
Manual, and test bank questions, are available. Contact your sales
representative or visit go.jblearning.com/Ritter2e for access.

Acknowledgments

We would like to express gratitude to the many dedicated people whose
contributions made this book possible. We extend a special thanks to
those who provided us with permission to reprint their work. We also are
grateful to the Jones & Bartlett Learning team who assisted with the
editing, design, and marketing of the book. We would like to particularly
acknowledge Sara J. Peterson and Cathy Esperti at Jones & Bartlett
Learning for their efforts. Cherilyn Aranzamendez and Jessica Ross, we
appreciate your efforts to locate research on the topic of multicultural
health. We are also indebted to the reviewers for their thoughtful and
valuable suggestions:

First Edition
Patricia Coleman Burns, PhD, University of Michigan
Maureen J. Dunn, RN, Pennsylvania State University, Shenango Campus
Mary Hysell Lynd, PhD, Wright State University
Sharon B. McLaughlin, MS, ATC, CSCS, Mesa Community College
Melba I. Ovalle, MD, Nova Southeastern University

Second Edition
William C. Andress, DrPH, MCHES, La Sierra University
Debra L. Fetherman, PhD, CHES, ACSMHFS, University of Scranton
Carmel D. Joseph, MPH, Nova Southeastern University
Kirsten Lupinski, PhD, Albany State University
Hendrika Maltby, PhD, RN, University of Vermont
Cindy K. Manjounes, MSHA, EdD, Linden-wood University–Belleville
Mary P. Martinasek, PhD, University of Tampa

To our family, friends, and colleagues, we want to express our gratitude
because you provided continued encouragement, support, and
recognition throughout the process.

About the Authors

Lois A. Ritter earned a doctorate in education and master’s degrees in
health science, health care administration, and cultural and social
anthropology. She has taught at the university level for approximately 20
years and has led national and regional research studies on a broad range
of health topics.

Donald H. Graham is an attorney and holds a master’s degree in urban
affairs. He has developed and managed client-centered and culturally
appropriate health and human service programs for more than 30 years.

UNIT I

The Foundations

CHAPTER 1 Introduction to Multicultural Health

CHAPTER 2 Theories and Models Related to Multicultural Health

CHAPTER 3 Worldview and Health Decisions

CHAPTER 4 Complementary and Alternative Medicine

CHAPTER 5 Religion, Rituals, and Health

CHAPTER 6 Communication and Health Promotion in Diverse
Societies

Courtesy of David Bartholomew

CHAPTER 1

Introduction to Multicultural Health

We have become not a melting pot but a beautiful mosaic.
—Jimmy Carter

One day our descendants will think it incredible that we paid so much attention

to things like the amount of melanin in our skin or the shape of our eyes or our
gender instead of the unique identities of each of us as complex human beings.

—Author unknown

Key Concepts

Multicultural health
Cultural competence
Culture
Dominant culture
Race
Racism
Discrimination
Ethnicity
Cultural ethnocentricity
Cultural relativism
Cultural adaptation
Acculturation
Minority
Assimilation
Heritage consistency
Health disparity
Healthy People 2020
Hill-Burton Act
Ethics
Morality
Autonomy
Respect
Veracity

Fidelity
Beneficence
Nonmaleficence
Justice

© Click Bestsellers/Shutterstock, Inc. and © Ms.Moloko/Shutterstock, Inc.

Learning Objectives

After reading this chapter, you should be able to:

1. Explain why cultural considerations are important in health care.

2. Describe the processes of acculturation and assimilation.

3. Define race, culture, ethnicity, ethnocentricity, and cultural
relativism.

4. Explain what cultural adaptation is and why it is important in health
care.

5. Explain what health disparities are and their related causes.

6. List the five elements of the determinants of health and describe
how they relate to health disparities.

7. Explain key legislation related to health and minority rights.

Why do we need to study multicultural health? Why is culture important
if we all have the same basic biological makeup? Isn’t health all about
science? Shouldn’t people from different cultural backgrounds just adapt
to the way we provide health care in the United States if they are in this
country?

For decades, the role that culture plays in health was virtually ignored,
but the links have now become more apparent. As a result, the focus on
the need to educate health care professionals about the important role

that culture plays in health has escalated. Health is influenced by factors
such as genetics, the environment, and socioeconomic status, as well as by
other cultural and social forces. Culture affects people’s perception of
health and illness, how they pursue and adhere to treatment, their health
behaviors, beliefs about why people become ill, how symptoms and
concerns about the problem are expressed, what is considered to be a
health problem, and ways to maintain and restore health. Recognizing
cultural similarities and differences is an essential component for
delivering effective health care services. To provide quality care, health
care professionals need to provide services within a cultural context,
which is the focus of multicultural health.

Multicultural health is the phrase used to reflect the need to provide
health care services in a sensitive, knowledgeable, and nonjudgmental
manner with respect for people’s health beliefs and practices when they
are different from our own. It entails challenging our own assumptions,
asking the right questions, and working with the patient and the
community in a manner that respects the patient’s lifestyle and approach
to maintaining health and treating illness. Multicultural health integrates
different approaches to care and incorporates the culture and belief
system of the health care recipient while providing care within the legal,
ethical, and medically sound practices of the practitioner’s medical
system.

Knowing the health practices and cultures of all groups is not possible,
but becoming familiar with various groups’ general health beliefs and
preferences can be very beneficial and improve the effectiveness of health
care services. In this text, generalizations about cultural groups are
provided, but it is important to realize that many subcultures exist within
those cultures, and people vary in the degree to which they identify with
the beliefs and practices of their culture of origin. Awareness of general
differences can help health care professionals provide services within a
cultural context, but it is important to distinguish between stereotyping
(the mistaken assumption that everyone in a given culture is alike) and
generalizations (awareness of cultural norms) (Juckett, 2005).
Generalizations can serve as a starting point but do not preclude factoring

in individual characteristics such as education, nationality, faith, and level
of cultural adaptation. Stereotypes and assumptions can be problematic
and can lead to errors and ineffective care. Remember, every person is
unique, but understanding the generalizations can be beneficial because it
moves people in the direction of becoming culturally competent.

Cultural competence refers to an individual’s or an agency’s ability to
work effectively with people from diverse backgrounds. Culture refers to a
group’s integrated patterns of behavior, and competency is the capacity to
function effectively. Cultural competence occurs on a continuum, and
this text is geared toward helping you progress along the cultural
competence continuum.

Specific terms related to multicultural health, such as race and
acculturation, need to be clarified, and this chapter begins by defining
some of these terms. Following that is a discussion of the demographic
landscape of the U.S. population and how it is changing, types and
degrees of cultural adaptation, and health disparities and their causes.
The chapter concludes with an analysis of the legislation related to health
care that is designed to protect minorities.

Key Concepts and Terms

Some of the terminology related to multicultural health can be confusing
because the differences can be subtle. This section clarifies the meaning
of terms such as culture, race, ethnicity, ethnocentricity, and cultural
relativism.

Culture
There are countless definitions of culture. The short explanation is that
culture is everything that makes us who we are. E. B. Tylor (1924/1871),
who is considered to be the founder of cultural anthropology, provided
the classical definition of culture. Tylor stated in 1871, “Culture, or
civilization, taken in its broad, ethnographic sense, is that complex whole

which includes knowledge, belief, art, morals, law, custom, and any other
capabilities and habits acquired by man as a member of society” (p. 1).
Tylor’s definition is still widely cited today. A modern definition of
culture is the “integrated patterns of human behavior that include the
language, thoughts, communications, actions, customs, beliefs, values,
and institutions of racial, ethnic, religious, or social groups” (Office of
Minority Health, 2013).

Culture is learned, changes over time, and is passed on from
generation to generation. It is a very complex system, and many
subcultures exist within each culture. For example, universities,
businesses, neighborhoods, age groups, homosexuals, athletic teams, and
musicians are subcultures of the dominant American culture. Dominant
culture refers to the primary or predominant culture of a region and does
not indicate superiority. People simultaneously belong to numerous
subcultures because we can be students, fathers or mothers, and bowling
enthusiasts at the same time.

Race and Ethnicity
Race refers to a person’s physical characteristics and genetic or biological
makeup, but race is not a scientific construct. Race is a social construct
that was developed to categorize people, and it was based on the notion
that some “races” are superior to others. Many professionals in the fields
of biology, sociology, and anthropology have determined that race is a
social construct and not a biological one because not one characteristic,
trait, or gene distinguishes all the members of one so-called race from all
the members of another so-called race. “There is more genetic variation
within races than between them, and racial categories do not capture
biological distinctiveness” (Williams, Lavizzo-Mourey, & Warren, 1994).

Why is race important if it does not really exist? Race is important
because society makes it important. Race shapes social, cultural, political,
ideological, and legal functions in society. Race is an institutionalized
concept that has had devastating consequences. Race has been the basis
for deaths from wars and murders and suffering caused by discrimination,

violence, torture, and hate crimes. The ideology of race has been the root
of suffering and death for centuries even though it has little scientific
merit.

The 2010 U.S. Census questions related to ethnicity and race can be
found in Figure 1.1 and Figure 1.2. Box 1.1 explains how these terms
were defined in the 2010 census. The U.S. government declared that
Hispanics and Latinos are an ethnicity and not a race.

FIGURE 1.1
U.S. Census origin question, 2010.
Source: Population Reference Bureau (2013).

FIGURE 1.2
U.S. Census race question, 2010.
Source: Population Reference Bureau (2013).

It is important to note that there is great variation within each of the
racial and ethnic categories. For example, American Indians are grouped
together even though there are variations between the tribes. It is
essential to be aware of the differences that occur within these groups and
not to stereotype people. Stereotyping people by their race and ethnicity
is racism. Racism is the belief that some races are superior to others by
nature. Discrimination occurs when people act on that belief and treat
people differently as a result. Discrimination can occur because of beliefs
related to factors such as race, sexual orientation, dialect, religion, or
gender.

Ethnicity is the socially defined characteristic of a group of people
who share common cultural factors such as race, history, national origin,
religious belief, or language. So how is ethnicity different from race?
Race is primarily based on physical characteristics, whereas ethnicity is
based on social and cultural identities. For example, consider these terms
in relation to a person born in Korea to Korean parents but adopted by a
French family in France as an infant. Ethnically, the person may feel
French: she or he eats French food, speaks French, celebrates French
holidays, and learns French history and culture. This person knows
nothing about Korean history and culture, but in the United States she or
he would likely be treated racially as Asian. Let’s …

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