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

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 for access.




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.




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




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.