Cultural Diversity: Issues in
Education and Practice
Nataliya Lishchenko
Cultural Diversity and Health Care
• We All Have It!
• Obvious Manifestations:
– Religion
– Ethnicity (Race?)
– National Origin (language)
– Gender
Cultural Diversity and Health Care
• Less Obvious Manifestations:
– Age
– Education
– Educational Status
– Mobility (including handicaps)
Cultural Diversity and Health Care
• What is Culture?
Definition: the sum total of the way of living;
includes values, beliefs, standards, language,
thinking patterns, behavioral norms,
communications styles, etc. Guides decisions
and actions of a group through time.
Cultural Diversity and Health Care
• Expressions of Culture in Health Care
– Health Belief Systems
• Define and categorize health and illness
• Offer explanatory models for illness
• Based upon theories of the relationship between
cause and the nature of illness and treatments
• Defines the specific “scope” of practice for healers
Cultural Diversity and Health Care
• The Culture of Western Medicine
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Meliorism – make it better
Dominance over nature – take control
Activism – do something
Timeliness – sooner than later
Therapeutic aggressiveness – stronger=better
Future orientation – plan, newer=better
Standardization – treat similar the same
Cultural Diversity and Health Care
• “Ours”
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Make it Better
Control Over Nature
Do Something
Intervene Now
Strong Measures
Plan Ahead – Recent is
Best
– Standardize – Treat
Everyone the Same
• “Others”
– Accept With Grace
– Balance/Harmony with
Nature
– Wait and See
– Cautious Deliberation
– Gentle Approach
– Take Life As It Comes –
“Time Honored”
– Individualize – Recognize
Differences
Growing Diversity in America
During the Past 20 years
• 􀂄 White population increased 10%
• 􀂄 African American population increased 30%
• 􀂄 Native American population increased 58 %
• 􀂄 Hispanic population increased 125%
Diversity Demographics for the
year 2000
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Whites: 70%
􀂄 Hispanic: 13%
􀂄 African Am: 12%
􀂄 Asian: 4%
􀂄 N Am: 1%
Projected Demographics for
2030
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White: 60%
􀂄 Hispanic: 19%
􀂄 Black: 13%
􀂄 Asian/PI: 7%
􀂄 N Am/Ak N: 1%
In California
Population of 38 Million
• 1/3 of the population is of Hispanic origin
• Over 10% Asian
• Over 4% more than one race
• Nearly 17% identify as “Other race”
In California
• 1 in 4 are foreign born, 37% of these
entered the US after 1990
• Nearly 40% of the population over the
age of 5 speaks a language other than
English at home.
• Over 25% of the population is under the
age of 18
Diversity related facts:
• The population is becoming increasingly diverse
• 􀂄 underrepresented groups make up approximately
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30% of the population
􀂄 Health care workforce has not kept up with the
changing demographics
􀂄 Physicians from underrepresented groups make up
only about 7% of the current workforce
􀂄 Nurses only 3%
􀂄 Pharmacy only 3%
Ethnic Health Disparities
African Americans
• 􀂄 Highest death rate from colon and
rectal cancer of any ethnic group in the
U.S.
• 􀂄 African Am women, diagnosed with
breast cancer, have a 71% survival rate
vs. an 86% rate for white women.
Ethnic Health Disparities
Native Americans
• 􀂄 2-3 times more likely to have diabetes
mellitus that the general population
• 􀂄 Higher than average mortality rates
associated with heart disease, TB, suicide,
Pneumonia, Influenza, homicide, and
alcoholism
Reports of Disparities in Health
Care
Disparities in health care do exist
and are associated with higher
mortality among minorities.
Reported Racial and Ethnic
Disparities in Healthcare
Research has shown that clinicians spend less time
with and prescribe more medication for blacks
compared with whites.
Blacks are also more frequently labeled as
psychotic.
(Segal et al., 1996- Psychiatr. Serv.; Flaskerud and Hu,
1992- Am. J.Psychiatry)
Minority children with fractures of unknown origin
had more skeletal studies ordered than white
children with injuries of unknown origin. (Lane et
al., 2002- JAMA)
Reports of Racial and Ethnic
Disparities in Healthcare
Minorities are less likely to be given appropriate
cardiac medications or to undergo bypass
surgery. There is evidence to suggest significant
racial differences in who receives appropriate
diagnostic tests and treatment for cancer.
Minorities are less likely to receive kidney dialysis
or transplants.
Racial differences have been reported in the
provision of analgesics in the emergency room.
(Bach et al. 1999- NEJM; Todd et al., 1993JAMA)
Client (Patient) Needs
Safe, Effective Care Environment
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Acting as a client advocate
Client rights
Confidentiality
Respecting client’s control of personal
environment and property
Establishing priorities
Ethical practice
Legal responsibilities
Organ donation
Communicating the need for referrals to
memebers of the health care team
Client (Patient) Needs
Health Promotion and Maintenance
• Disease prevention
• Family planning and family systems
• Health and wellness
• Lifestyle choices
Client (Patient) Needs
Psychosocial Integrity
• Coping mechanisms
• Religious and spiritual influences on health
• Support systems
• End of life
• Therapeutic interventions
Client (Patient) Needs
Physiological Integrity
• Basic care and comfort practicies
• Nutritional preferences
• Therapeutical procedures
• Practicies or restrictions related to
procedures and treatments
Dietary Preferences
African-Americans
• Fried foods
• Pork, greens, rice
• Some pregnant African-Americans engage in
pica
Asian-Americans
• Soy sauce
• Raw fish
• Rice
Dietary Preferences
European (White) – Origin Americans
• Carbohydrates (potatoes)
• Red meat
Hispanic-Americans
• Beans
• Fried foods
• Spicy foods
• Chili
• Carbonated beverages
Dietary Preferences
American Indians, Eskimos
• Blue cornmeal
• Fish
• Game
• Fruits and berries
• Navajos prefer meat and blue cornmeal
and tend to avoid consumption of milk
Religion and Dietary Practicies
Seven Day Adventist (Church of God)
• Alcohol, coffee, and tea prohibited
• Some groups prohibit meat
Baptist
• Alcohol prohibited
• Discourage consumption of coffee and tea
Buddhism
• Alcohol and drug use discouraged
• Some sects are vegetarian
Religion and Dietary Practicies
Roman Catholics
• Avoid meat on Ash Wednesday and Good
Friday
• Optional fasting during lent season
• During Lent, discourage meat on Friday
• Children and the ill are exempt from
fasting
Religion and Dietary Practicies
Church of Jesus Christ of Latter-Day
Saints (Mormon)
• Alcohol, prohibited
• Limited consumption of meat
• First Sunday of the month is time for
fasting
Religion and Dietary Practicies
Hinduism
• Beaf and veal prohibited
• Many individuals are vegetarians
• Limited consumption of meat
• Fasting occurs on specific days of week
according to which god the person worship
• Children are not allowed to participate in fasting
• Fasting rituals vary from complete abstinence to
consumption of only one meal per day
Religion and Dietary Practicies
Islam
• Pork prohibited
• Any meat product not ritually slaughtered
is prohibited
• Avoidance of Alcohol and Drugs
• During Ramadan (ninth month of
Mohammedan year) fasting occurs during
daytime
Religion and Dietary Practicies
Jehovah’s Witness
• Prohibition of any foods to which blood
has been added
• Can consume animal flesh that has been
drained
Cultural features: AfricanAmericans
Communication
1. Languages include English and Black
English
2. Head nodding does not necessarily mean
agreement
3. Direct eye contact is often viewed as
being rude
4. Nonverbal communication is very
important
5. It is considered to be intrusive to ask
personal
questions of someone on initial contact or
meeting
African-Americans
Time orientation and space
1 Oriented more to the present than
the future
2. Close personal space is important
3. Touching another's hair is
sometimes viewed as offensive
African-Americans
Social roles
1. Large extended-family networks are
important
2. Many single-parent, female-headed
households
3. Religion is usually Protestant (Baptist)
4. Strong church affiliation with community
is
important
5. Social organizations are strong within
communities
African-Americans
Health and illness
1. Harmony with nature
2. No separation of body, mind, and spirit
3. Illness is a disharmonious state that may be
caused by demons or spirits
4. Illness can be prevented by nutritious
meals, rest, and cleanliness
African-Americans
Health risks
1. Sickle cell anemia
2. Hypertension
3. Coronary heart disease
4. Cancer (especially stomach and
esophageal)
5. Lactose intolerance
6. Coccidioidomycosis
African-Americans
Implementation
1. Avoid stereotyping
2. Do not label Black English as an unacceptable
form of language
3. Clarify meaning of client's verbal and nonverbal
behavior
4. Be flexible and avoid rigidity in scheduling care
5. Encourage involvement with family
6. A folk healer or herbalist may be consulted
before an individual seeks medical treatment
Asian Americans
Communication
1. Languages include Chinese, Japanese,
Korean,Vietnamese, English
2. Silence is valued
3. Eye contact is considered rude
4. Criticism or disagreement is not expressed verbally
5. Head nodding does not necessarily mean agreement
6. The word "no" is interpreted as disrespect for others
Asian Americans
Time orientation and space
1. Oriented more to present
2. Social distance is important
3. Usually do not touch others during conversation
4. Touching is unacceptable with members of opposite sex
5. The head is considered to be sacred; therefore
touching someone on the head is disrespectful
Asian Americans
Social Roles
1. Devoted to tradition
2. Large extended-family networks
3. Loyalty to immediate and extended family and
honor are valued
4. Family unit is very structured and hierarchical
5. Man have the power and authority, and women are
expected to be obedient
6. Education is viewed as important
7. Religions include Taoism (Buddhism), Islam,
Christianity
8. Social organizations are strong within the community
Asian Americans
Health and illness
1. Health is a state of physical and spiritual harmony with
nature and a balance between positive and negative
energy forces (yin and yang)
2. A healthy body is viewed as a gift from ancestors
3. Illness is viewed as an imbalance between yin and yang
4. Yin foods are cold, and yang foods are hot; cold foods
are eaten when one has a hot illness, and hot foods are
eaten when one has a cold illness
5. Illness is contributed to prolonged sitting or lying, or to
overexertion
Asian Americans
Health risks
1. Hypertension
2. Cancer (stomach and
liver)
3. Lactose intolerance
4. Thalassemia
5. Coccidioidomycosis
Asian Americans
Implementation
1. Avoid physical closeness and excessive touching; only touch a client's
head when necessary, in-forming the client before doing so
2. Limit eye contact
3. Avoid gesturing with hands
4. Clarify responses to questions
5. Be flexible and avoid rigidity in scheduling care
6. Encourage involvement with family
7. A healer may be consulted before an individual
seeks out traditional treatment
Hispanic-American
Communication
1. Languages include Spanish and Portuguese, with
various dialects
2. Tend to be verbally expressive, yet confidentiality is
important
3. Eye behavior is significant; for example, the "evil
eye" can be given to a child if a person looks at
and admires a child without touching the child
4. Avoiding eye contact indicates respect and
attentiveness
5. Direct confrontation is disrespectful, and the expression
of negative feelings is impolite
6. Dramatic body language, such as gestures or facial
expressions, is used to express emotion or pain
Hispanic-American
Time orientation and space
1. Oriented more to present
2. Comfortable with close proximity to others
3. Very tactile and use embraces and handshakes
4. Value the physical presence of others
5. Politeness and modesty are essential
Hispanic-American
Social roles
1. The nuclear family is the basic unit; also, there are large extendedfamily networks
2. The extended family is highly regarded
3. Needs of the family take precedence over individual family members'
needs
4. Men are the decision makers and breadwinners, and women are the
caretakers and homemakers
5. Religion includes Catholicism
6. Strong church affiliation
7. Social organizations strong within the community
Hispanic-American
Health and illness
1. Health may be a reward from God or a result of
good luck
2. Health results from a state of balance between "hot and cold" forces and "wet and dry"
forces
3. Illness occurs as a result of God's punishment
for sins
4. Folk medicine traditions
Hispanic-American
Health risks
1. Lactose intolerance
2. Diabetes mellitus
3. Parasites
4. Coccidioidomycosis
Hispanic-American
Implementation
1. Communicate with male head of family
2. Protect privacy
3. Offer to call priest or other clergy because of
the significance of religious practices related to
illnesses
4. Always touch a child when examining him or her
5. Be flexible and avoid rigidity in scheduling care
Native Americans
Communication
1. Languages include English, Navajo, and other
tribal languages
2. Silence indicates respect for the speaker
3. Speak in a low tone of voice and expect others
to be attentive
4. Eye contact is avoided because it is a sign of
disrespect
5. Body language is important
Native Americans
Time orientation and space
1. Oriented more to present
2. Personal space is very important
3. Will lightly touch another person's hand during
greetings
4. Massage is used for the newborn infant to
promote bonding between infant and mother
5. Touching a dead body is prohibited in some
tribes
Native Americans
Social roles
1. Very family oriented
2. Basic family unit is the extended family, which often includes people
from several households
3. I some tribes, grandparents are viewed as family leaders
4. Elders are honored
5. Children are taught to respect traditions
6. The father does all the work outside the home, and the mother
assumes responsibility for domestic duties
7. Sacred myths and legends provide spiritual guidance
8. Religion and healing practicies are integrated
9. Community social organizations are important
Native Americans
Health and illness
1. Health is a state of harmony between the
person, the family, and the environment
2. Illness is caused by supernatural forces and
disequilibrium between person and
environment
3. Traditional health and illness beliefs may
continue to be observed; natural and
magicoreligious folk medicine tradition
4. Traditional healer: medicine man or woman
Native Americans
Health risks
1. Alcohol abuse
2. Accidents
3. Heart disease
4. Diabetes mellitus
5. Tuberculosis
6. Arthritis
7. lactose intolerance
8. Gallbladder disease
9. American Eskimos are susceptible to glaucoma
Native Americans
Implementation
1. Clarify communication
2. Understand that the client may be attentive even when
eye contact is absent
3. Be attentive to own use of body language
4. Obtain input from members of extended family
5. Encourage client to personalize space in which health
care is delivered; for example, encourage client to bring
personal items or objects to the hospital
6. In the home, assess for the availability of running water
and modify infection control and hygiene practices as
necessary
PROLONGATION OF LIFE
A. Christian Science religion is unlikely to
use medical means to prolong life
B. Jewish faith generally opposes
prolonging life after irreversible brain
damage
DEATH AND DYING PRACTICES
A. Autopsy may be prohibited, opposed, or discourB.
C.
D.
E.
aged by Eastern Orthodox religions, Muslims, Jehovah's Witnesses, and Orthodox Jews
Organ donation is prohibited by Jehovah's Witnesses and Muslims
Buddhists in America encourage organ donation
and consider it an act of mercy
Cremation is discouraged, opposed, or prohibited
by the Mormon, Eastern Orthodox, Islamic, and
Jewish faiths
Hindus prefer cremation and cast the ashes in a holy
river
Try your knowledge...
A nurse in an ambulatory care clinic is performing
an admission assessment for an African-American
client scheduled for a cataract removal with an
intraocular lens implant. Which of the following
questions would be inappropriate for the nurse to
ask on an initial assessment?
1. "Do you have any difficulty breathing?"
2. "Do you have a close family relationship?"
3. "Do you ever experience chest pain?"
4. "Do you frequently have episodes of headache?"
A nurse is providing discharge instructions to a
Chinese client regarding prescribed dietary modifications. During the teaching session, the client
continuously turns away from the nurse. Which
nursing action is most appropriate?
1. Continue with the instructions, verifying client
understanding
2. Tell the client about the importance of the
instructions for the maintenance of health care
3. Walk around the client so that the nurse
continuously faces the client
4. Give the client a dietary booklet and return later
to continue with the instructions
A nurse is preparing a plan of care for a client whose
religion is Jehovah's Witness. The client has been
told that surgery is necessary. The nurse considers
the client's religious preferences in developing the
plan of care and documents that:
1. Surgery is prohibited in this religious group
2. The administration of blood and blood products
is forbidden
3. Medication administration is not allowed
4. Faith healing is primarily practiced
Cultural Diversity and Health Care
It is because we are different that
each of us is special.