How is ethnicity different from culture? One can belong to a culture without having ancestral roots to that culture. For example, a person can belong to the hip-hop culture, but he or she is not born into the culture. With ethnicity, the culture is a part of the ethnic background, so culture
is embedded within the ethnic group. Ethnic groups have shared beliefs, values, norms, and practices that are learned and shared. These patterned behaviors are passed down from one generation to another and are thus preserved.
Cultural Ethnocentricity and Cultural Relativism Cultural ethnocentricity refers to a person’s belief that his or her culture is superior to another one. This can cause problems in the health care field. If a professional believes that his or her way is the better way to prevent or treat a health problem, the health care worker may disrespect or ignore the patient’s cultural beliefs and values. The health care professional may not take into consideration that the listener may have different views than the provider. This can lead to ineffective communication and treatment and leave the listener feeling unimportant, frustrated, disrespected, or confused about how to prevent or treat the health issue, and he or she might view the professional as uneducated, uncooperative, unapproachable, or closed-minded.
To be effective, one needs to see and appreciate the value of different cultures; this is referred to as cultural relativism. The phrase developed in the field of anthropology to refute the idea of cultural ethnocentricity. It posits that all cultures are of equal value and need to be studied from a neutral point of view. It rejects value judgments on cultures and holds the belief that no culture is superior to any other. Cultural relativism takes an objective view of cultures and incorporates the idea that a society’s moral code defines whether something is right (or wrong) for members of that society.
What Do You Think?
Cultural imposition occurs when one cultural group, usually the majority group, forces their culture view on another culture or subculture. Can you provide examples of cultural imposition? Do you think it is ethical? Why or why not?
Diversity Within the United States
A great strength of the United States is the diversity of the people. Historically, waves of immigrants have come to the United States to live in the land of opportunity and pursue a better quality of life. Immigrants brought their traditions, languages, and cultures with them, creating a country that developed a very diverse landscape. Of course, some peoples, such as Native Americans, were already on the land, and others, such as African Americans, were forced to come to the United States. An unfortunate outcome was that despite its great advantages, this diversity contributed to racial and cultural clashes as well as to imbalances in equality and opportunities that continue today. These positive and adverse consequences of diversity must be considered in our health care approaches, particularly because the demographics are continuing to change and the inequalities persist. The delivery of health care to individuals, families, and communities must meet the needs of the wide variety of people who reside in and visit the United States.
The percentage of the U.S. population characterized as white is decreasing (see Table 1.1). This is an important consideration for health care providers because ethnic minorities experience poorer health status, which is usually due to economic disparities.
TABLE 1.1 Population Data Related to Origin and Race, 2010
1 In Census 2000, an error in data processing resulted in an overstatement of the Two or More Races population by about 1 million people (about 15 percent) nationally, which almost entirely affected race combinations involving Some Other Race. Therefore, data users should assess observed changes in the Two or More Races population and race combinations involving Some Other Race between Census 2000 and the 2010 Census with caution. Changes in specific race combinations not involving Some Other Race, such as White and Black or African American or White and Asian, generally should be more comparable.
Source: U.S. Census Bureau (2011, March). Sources: U.S. Census Bureau, Census 2000 Redistricting Data (Public Law 94-171) Summary File, Tables PL1 and PL2; and 2010 Census Redistricting Data (Public Law 94-171) Summary File, Tables P1 and P2.
Source: U.S. Census Bureau (2011).
With this changing landscape in the United States, professionals are encouraged to consider the degree of cultural adaptation that the person has experienced. Cultural adaptation refers to the degree to which a person or community has adapted to the dominant culture or retained their traditional practices. Generally, a first-generation individual will identify more with his or her culture of origin than a third-generation person. Therefore, when working with the first-generation person, the health care professional needs to be more sensitive to issues such as
language barriers, distrust, lack of understanding of the American medical system, and the person’s ties to his or her traditional beliefs.
Acculturation relates to the degree of adaptation that has taken place; a process in which members of one cultural group adopt the beliefs and behaviors of another group. Essentially, members of the minority cultural group take up many of the dominant culture’s traits. Because of the great variety of peoples who have immigrated to the United States, the country is often said to be a melting pot. However, given the tendencies of cultural groups to locate together and maintain some familiar practices in a foreign land, the country also has been described as more like a salad bowl. Both of these analogies reflect the process of cultural interaction.
Except for the indigenous population, everyone in the United States is or is descended from immigrants and refugees. For instance, the Pilgrims of Plymouth Rock were refugees from religious persecution. Each group of people who traveled to America built on the strengths of their own culture while adapting to a new social and economic environment through acculturation. Acculturation can include adopting customs from one culture to another or direct change of customs as one culture dominates the other. Each of the cultures discussed in the text has adapted as new populations arrive, territory is acquired or conquered, or popular or useful practices and beliefs are invented and spread throughout the overall population. Some interactions between cultures generate discriminatory responses, individual stress, and family conflict, whereas others create an appreciation for variation as customs or practices are welcomed into other cultures. Whether melting or mixing, the interrelationship of cultures in the United States in constantly changing. The process continues as new people arrive in the country.
People can experience different levels of acculturation as illustrated in Berry and colleagues’ acculturation framework (see Figure 1.3). The acculturation framework identifies four levels of integration:
1. An assimilated individual demonstrates high-dominant and low- ethnic society immersion. This entails moving away from one’s
ethnic society and immersing fully in the dominant society (Stephenson, 2000). As a result, the minority group disappears through the loss of particular identifying physical or sociocultural characteristics. This usually occurs when people immigrate to a new geographic region and in their desire to be part of the mainstream give up most of their culture traits of origin and take on a new cultural identity defined by the dominant culture. Many people do not fully assimilate, however, and tend to keep some of their original cultural beliefs.
2. An integrated person has high-dominant and high-ethnic immersion. Integration entails immersion in both ethnic and dominant societies (Stephenson, 2000). An example of an integrated person is a Russian American who socializes with the dominant group but chooses to speak Russian at home and marries a person who is Russian.
FIGURE 1.3 Acculturation framework.
3. Separated individuals have low-dominant and high-ethnic immersion. A separated individual withdraws from the dominant society and completely submerges into the ethnic society
(Stephenson, 2000). An example is a person who lives in an ethnic community such as Little Italy or Chinatown.
4. A marginalized individual has low-dominant and low-ethnic immersion and does not identify with any particular culture or belief system.
Marginalized people tend to have the most psychological problems and the highest stress levels. These individuals often lack social support systems and are not accepted by the dominant society or their culture of origin. A person in the separated mode is accepted in his or her ethnic society but may not be accepted by the dominant culture, leaving the person feeling alienated. The integrated and assimilated modes are considered to be the most psychologically healthy adaptation styles, although some individuals benefit more from one than from the other. Western Europeans and individuals whose families have been in the United States for a number of generations (and are not discriminated against) are most likely to adopt an assimilated mode because they have many beliefs and attributes of the dominant society. Individuals who retain value structures from their country of origin and encounter discrimination benefit more from an integrated (bicultural) mode. To be bicultural one must be knowledgeable about both cultures and see the positive attributes of both of them.
The degree to which people identify with their culture of origin is sometimes referred to as heritage consistency. Some indicators that can help professionals assess the level of cultural adaptation are inquiring about how long the person has been in the country, how often the person returns to his or her culture of origin, what holidays the person celebrates, what language the person speaks at home, and how much knowledge the person has of his or her culture of origin.
Are people who have higher levels of cultural adaptation healthier? Despite increasing research on the relationships between acculturation and health, the answer to that question is not clear. Research on the influence of acculturation on health indicates contradictory results because the variables are complex. The answer also is dependent upon
which health habits are incorporated into one’s lifestyle and which are lost. For example, acculturation can have detrimental effects on one’s dietary patterns if a person is from a culture where eating fruits and vegetables is common and the person incorporates the habit of eating at fast-food restaurants, which is common in the United States. On the other hand, if someone moves from a culture where smoking is common to a culture where it is frowned upon, the person may stop smoking and reduce his or her chances of serious illness.
Acculturation from traditional, nonindustrialized cultures to a modern westernized culture generally has been associated with higher rates of disease. An example of this is the rate of cardiovascular disease among Japanese males in the United States. Increasing levels of acculturation also have been associated with higher rates of specific mental disorders and with substance abuse, suggesting that these disorders result from acculturation. Increasing levels of acculturation are correlated with advancing socioeconomic status, and higher socioeconomic status is correlated with lower rates of disease and disorders. However, in some instances higher acculturation is correlated with higher rates of disease and disorders. What constitutes healthy acculturation, as contrasted with unhealthy acculturation, for which health outcomes, for whom, and under what conditions? Scientific answers to these questions may help empower diverse communities by promoting health and wellness in the presence of acculturation (González Castro, 2007).
Health disparities “are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes” (Centers for Disease Control and Prevention, Division of Community Health, 2013, p. 4). Health disparities occur among groups who have persistently experienced historic trauma, social disadvantage, or discrimination. They are widespread in the United States as demonstrated by the fact that
many minority groups in the United States have a higher incidence of chronic diseases, higher mortality, and poorer health outcomes when compared to Whites. Numerous other disparities exist such as the health of rural residents being poorer than urban residents and people with disabilities reporting poorer health when compared to those without disabilities.
Eliminating health disparities is an important goal for our nation and is one of the four overarching goals of Healthy People 2020. These four goals are:
1. “Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
2. Achieve health equity, eliminate disparities, and improve the health of all groups.
3. Create social and physical environments that promote good health for all.
4. Promote quality of life, healthy development, and healthy behaviors across all life stages” (U.S. Department of Health and Human Services [USHHS], 2014).
Some examples of health disparities follow, but numerous other statistics illuminate these differences as well.
African Americans can expect to live 6 to 10 fewer years than whites and face higher rates of illness and mortality (Mead et al., 2008, p. 20).
The prevalence of diabetes among American Indians and Alaska Natives is more than twice that for all adults in the United States (USHHS, 2009).
Hispanic and Vietnamese women are twice as likely as white women to face cervical cancer (USHHS, 2009).
African Americans experience rates of infant mortality that are 2.5 times higher than for whites (Mead et al., 2008, p. 20).
Asian and Pacific Islanders make up less than 5% of the total
population in the United States but account for more than 50% of Americans living with chronic hepatitis B (Centers for Disease Control and Prevention [CDC], 2014).
A nationally representative study of adolescents in grades 7 to 12 found that lesbian, gay, and bisexual youth were more than twice as likely to have attempted suicide as their heterosexual peers (Russell & Joyner, 2001).
Rural residents are more likely to be obese than urban residents, 27.4% versus 23.9% (Rural Health Research & Policies Centers, 2008).
People with disabilities have the highest proportion of current smokers (29%), followed by American Indian/Alaska Natives (23%), blacks (22%), Hispanics (16%), and Asians (9%); (Drum, McClain, Horner-Johnson, & Taitano, 2011).
Did You Know?
… that April is National Minority Health month? The purpose is to raise awareness of health disparities. Public health agencies across the national engage in activities to raise awareness about the health disparities that exist around issues such as alcohol and drug use and infectious diseases.
Causes of Health Disparities
Health disparities exist due to both voluntary and involuntary factors. Voluntary factors related to health behaviors, such as smoking and diet, can be avoided. Factors such as genetics, living and working in unhealthy conditions, limited or no access to health care, and language barriers are often viewed as involuntary factors because they are not within that person’s control.
Most experts agree that the causes of health disparities are multiple and complex; no single factor explains why disparities exist across such a wide range of health measures. Access to health care and the quality of health care are important factors, but they do not explain why some groups experience greater risks for poor health in the first place (Alliance for Health Reform, 2010).