Chapter 5: Cultural Diversity
Unnatural illnesses
are punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems
stereotyping
assigning characteristics to a group of people without considering specific individuality
Reactions to Pain
behaviors exhibited by people in pain are culturally prescribed. Some cultures allow open expression of emotions related to pain, other cultures encourage suppression of such emotions.
ethnocentrism
belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs
Negative sterotyping
racism, ageism, sexism These are mistaken beliefs that certain races, an age group, or one gender is inherently superior to others, leading to discrimination against those considered inferior
ethnicity
sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns
culture
shared system of beliefs, values and behavioral expectations that provide social structure for daily living. sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group
culture conflict
situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values
Traditional healers
speak the patient's language, often are more accessible, and are usually more understanding of the patient's cultural and personal needs.
Racial categories are typically based on:
specific physical characteristics such as skin pigmentation, body stature, facial features, and hair texture. Because of the significant blending of physical characteristics through the centuries, however, race is becoming harder to define using simple classifications, and physical characteristics are not considered a reliable way to determine an individual's race.
cultural imposition
tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group
cultural blindness
the process of ignoring differences in people and proceeding as though the differences do not exist
culture shock
those feelings, usually negative, a person experiences when placed in a different culture
Minority group
usually have some physical or cultural characteristics (race, religious beliefs, or occupation) different from dominant. At risk of losing what made them different and conforming to the dominant group.
Nursing Considerations: White
•Careful assessment of client's use of over-the-counter medications (observe for signs and symptoms of toxic medication levels, especially fat-soluble vitamins) •Nutritional assessments of dietary habits
Characteristics of Culture
•Culture helps shape what is acceptable behavior for people in a specific group. It is shared by, and provides an identity for, members of the same cultural group. •Culture is learned by each new generation through both formal and informal life experiences. Language is the primary means of transmitting culture. •The practices of a particular culture often arise because of the group's social and physical environment. •Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. •Culture influences the way people of a group view themselves, have expectations, and behave in response to certain situations. Because a culture is made up of individuals, there are differences both within cultures and among cultures.
Elements of Cultural Competence
•Developing an awareness of one's own existence, sensations, thoughts, and environment to prevent them from having an undue influence on those from other backgrounds •Demonstrating knowledge and understanding of the client's culture, health-related needs, and culturally specific meanings of health and illness •Accepting and respecting cultural differences in a manner that facilitates the client's and family's abilities to make decisions to meet their needs and beliefs •Not assuming that the health care provider's beliefs and values are the same as the client's •Resisting judgmental attitudes such as "different is not as good" •Being open to and comfortable with cultural encounters •Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices
Poverty Culture Charactersitics
•Feelings of despair, resignation, and fatalism •Day-to-day attitude toward life, with no hope for the future •Unemployment and need for financial or government aid •Unstable family structure, possibly characterized by abusiveness and abandonment •Decline in self-respect and retreat from community involvement
Family: White
•Nuclear family is highly valued. •Elderly family members may live in a long-term care facility when they can no longer care for themselves.
Nursing care for patient in pain
•Recognize that culture is an important component of individuality and that each person holds (and has the right to hold) various beliefs about pain. •Respect patients' right to respond to pain in their own manner. •Never stereotype a patient's perceptions of or responses to pain based on the person's culture.
Folk and Traditional Health Care: White
•Self-diagnosis of illnesses •Use of over-the-counter drugs (especially vitamins and analgesics) •Dieting (especially fad diets) •Extensive use of exercise and exercise facilities
transcultural assessment of communication
•What language does the patient speak during usual activities of daily living? •How well does the patient speak and write in English? •Does the patient need an interpreter? Are family members or friends available? Are there people the patient would not want to serve as an interpreter? •How does the patient prefer to be addressed? •What cultural values and beliefs of the patient may change your techniques of communication and care (such as eye contact, personal space, or social taboos)? •How does the patient's nonverbal behavior affect the responses of members of the health care team? •What are the cultural characteristics of the patient's communications with others?
Values and Beliefs: White
•Youth is valued over age •Cleanliness •Orderliness •Attractiveness •Individualism •Achievement •Punctuality
Tay-Sachs
Eastern Europeans Jewish descent
Folk and Traditional Health Care - Appalachian
"Granny" woman, or folk healer, provides care and may be consulted even if receiving traditional care. Various herbs, such as foxglove and yellow root, are used for common illnesses such as malaise, chest discomfort, heart problems, and upper respiratory infections. Elderly may have had only limited contact with health care providers and may be skeptical of modern health care.
Natural illnesses
"Natural illnesses" are caused by dangerous agents, such as cold air or impurities in the air, water, or food
Values and Beliefs - Hawaiian
Aloha: a deep love, respect, and affection between people and the land Christian God replaced the myriad of Hawaiian gods. Lifestyle more revered than compliance with health care issues Present oriented, less initiative and drive rather than direction and achievement Death seen as part of life and not feared
5 Federal Standard Race Classifications
American Indian Alaskan Native Asian Black or African American Native Hawaiian Other Pacific islands White
Eye Contact
American culture: emphasizes eye contact direct eye contact may be considered impolite or aggressive by many Asians, Native Americans, Indochinese, Arabs, and Appalachians; these groups of people tend to avert their eyes while speaking. Hispanics may look downward in deference to age, gender, social position, economic status, or authority. Muslim-Arab women often indicate modesty by avoiding eye contact with men Hasidic Jewish men may avoid direct eye contact with women
Values and Beliefs - Muslim
Belief that there is no God but Allah and that Muhammad is his messenger. Belief that God created humans and gave them their bodies as gifts to be cared for through general hygiene, diet, and exercise. Belief that Allah will determine when they die; Death is an important part of the traditional Islamic life cycle. By tradition, family members wash the body of the deceased and bury it as soon as possible. Cremation is not allowed under Islamic law, and embalming should be avoided unless it is required by civil law.
Common Health Problems: White
Breast cancer Heart disease Hypertension Diabetes mellitus Obesity
cultural assimilation
process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different
Family - African American:
Close and supportive extended-family relationships Strong kinship ties with non-blood relatives from church or organizational and social groups Family unity, loyalty, and cooperation are important. Usually matriarchal
Risk of Poverty
Female head of households (single-parent) For example, Pacific/Asian, African American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that an individual has no Social Security or Medicare benefits.
Avoid Mandating Change
Do not force patients to participate in care that conflicts with their values. If a patient is forced to accept such care, resulting feelings of guilt and alienation from a religious or cultural group are likely to threaten that patient's well-being.
Folk and Traditional Health Care - Hispanic
Curanderas(os): folk healers who base treatments on humoral pathology—basic functions of the body are controlled by four body fluids or "humors": Blood—hot and wet Yellow bile—hot and dry Black bile—cold and dry Phlegm—cold and wet The secret of good health is to balance hot and cold within the body; therefore, most foods, beverages, herbs, and medications are classified as hot ( caliente) or cold ( fresco, frio) For example, a cold disease will be cured with a hot treatment).
Common Health Problems: Hispanics
Diabetes mellitus Lactose intolerance
Family - Hispanic
Familial role is important. Compadrazgo: special bond between a child's parents and the child's grandparents Family is the primary unit of society.
Family - Hawaiian
Familial role is important. Ohana, or extended families, are jointly involved in childrearing. Hierarchy of family structure—each gender and age have specific duties. Closely knit families in small, isolated communities
Family - Native American
Families are large and extended. Grandparents are official and symbolic leaders and decision makers. A child's namesake may become the equivalent to another parent to the child.
Health Disparities
Health disparities refer to health differences between groups of people they can affect how frequently a disease affects a group how many people get sick how often the disease causes death. Many different populations are affected by disparities, including racial and ethnic minorities; residents of rural areas; women, children, and the elderly; and persons with disabilities.
Common Health Problems: Native American and Alaskan Natives
Heart disease Cirrhosis of the liver Diabetes mellitus Fetal alcohol syndrome
What ethnic group of people deal with problems within the family and consider it inappropriate to tell problems to a stranger.
Hispanic
Common Health Problems; Asians
Hypertension Cancer of the liver Lactose intolerance Thalassemia
Common Health Problems: African Americans
Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids
Family Support
In many cultural and ethnic groups, people have large, extended families and consider the needs of any family member to be equal to or greater than their own. They may be unwilling to share private information about family members with those outside the family (including health care providers). Other cultural groups have great respect for the elders in the family and would never consider institutional care for them. Including the family in planning care for any patient is a major component in nursing care to meet individualized needs, especially if those needs can be met only through consideration of all members of the family.
Values and Beliefs - Appalachian
Independence and self-determination Isolation is accepted as a way of life. Person oriented May be fatalistic about losses and death Belief in a divine existence rather than attending a particular church
Family - Appalachian
Intense interpersonal relations Family is cohesive, and several generations often live close to each other. Elderly are respected as providers. Tend to live in rural, isolated areas
Nursing Considerations - Hispanic
It may be difficult to convince an asymptomatic patient that he or she is ill. Special diet considerations are necessary if the patient believes in the hot/cold theory of treating illnesses. Diet counseling may be necessary at times, because the usual diet of many members is high in starch.
Poverty as a barrier to health care
It prevents many people from consistently meeting their basic human needs. The lack of affordable or adequate housing is a problem experienced frequently by poor people. When low-income housing is available, it sometimes lacks such necessities as running water, heat, and electricity. To stretch their available money and to pool resources, many poor people live in crowded conditions, with several families living together in one household.
Folk and Traditional Health Care - Hawaiian
Kahuna La'au Lapa'au is the ancient Hawaiian medical practitioner. View patient's illness as part of the whole. Relationships among the physical, psychological, and spiritual Emphasis on preventive medicine Treatment uses more than 300 medicinal plants and minerals
Who Assimilates quickest and learn a new language?
Language acquisition is thus tied to necessity and assimilation rather than to degree of difficulty. Children usually assimilate more rapidly and learn the language of the dominant culture quickly if they leave home each day to go to school and make new friends in the dominant culture. Wage earners also tend to learn a new language more quickly through the work setting. Women or older adults in the family who do not work outside the home and for people who live in proximity to others who speak their primary language do not assimilate quickly and have difficulty speaking English. Assimilation is likewise slower for people who stay at home, especially if they live in communities of their ethnic and cultural background
Socioeconomic Factors
Low income is a major problem in the United States and is often described as having created a culture of poverty lowest income was found in African Americans, Native Americans, and Alaska Natives
Nursing Considerations - African American:
Many African American families may still use various folk healing practices and home remedies for treating particular illnesses. Special care may be necessary for the hair and skin. Special consideration should be given to the sometimes extensive and frequently informal support networks of patients (e.g., religious and community group members who offer assistance in a time of need).
Nursing Considerations - Hawaiian
Many Hawaiians may still use folk healing practices and home remedies. Special consideration given to the extensive family network during hospitalization Acceptance from health care practitioners of current health practices and lifestyle
Gender Roles
Many cultures: male dominated White/African American : may be female dominated
Folk and Traditional Health Care - Native American
Medicine men (shaman) are heavily used. Heavy use of herbs and psychological treatments, ceremonies, fasting, meditation, heat, and massages
Many Hispanic immigrants to the United States learn to speak English, and many Americans learn to cook and enjoy traditional Hispanic foods. We all gain from the many cultures with which we live. Although we seldom think about it, the clothes we wear, the foods we eat, the music we enjoy, many of the words we use, and the leisure activities we practice
Mutual Cultural assimilation
Values and Beliefs - African American:
Present oriented Members of the African American clergy are highly respected Frequently highly religious
Values and Beliefs - Native American
Present oriented. Taught to live in the present and not to be concerned about the future. This time consciousness emphasizes finishing current business before doing something else. High respect for age Great value is placed on working together and sharing resources. Failure to achieve a personal goal frequently is believed to be the result of competition. High respect is given to a person who gives to others. The accumulation of money and goods often is frowned on. Some Native Americans practice the Peyotist religion, in which the consumption of peyote, an intoxicating drug derived from mescal cacti, is part of the service. Peyote is legal if used for this purpose. It is classified as a hallucinogenic drug.
Folk and Traditional Health Care - Muslim
Preventive health care strategies in Muslim experience include personal hygiene, dietary measures such as the restriction in eating specific ingredients (such as pork and its byproducts, and drinking alcohol), and the avoidance of addictive habits such as smoking tobacco or over-consumption of food. Some Muslims may perceive a sudden death or illness as a sign of punishment or a test from God.
In times of high stress or anxiety, what ethnic group may demonstrate a hyperkinetic seizure-like activity known asataques. This behavior is a culturally accepted reaction.
Puerto Ricans
Values and Beliefs - Hispanic
Respect is given according to age (older) and sex (male). Roman Catholic Church may be very influential. God gives health and allows illness for a reason; therefore, many perceive illness as a punishment from God that can be cured through atonement and forgiveness.
Family - Asian:
Welfare of the family is valued above the person. Extended families are common. A person's lineage (ancestors) is respected. Sharing among family members is expected.
Nursing Considerations - Muslim
Respect the modesty needs of both men and women: special clothing or draping may be necessary, assign health care providers of the same sex, avoid touching patients of the opposite sex, and limit eye contact. Make accommodations for prayer needs. Maintain bodily purity by observing their cleansing and ablution rituals. Offer a halal diet free of alcohol and pork or pork products; make sure medications are alcohol- and pork-free. During Ramadan, Muslims must fast from sunrise to sunset. Fasting includes abstaining from all substances, including pharmaceuticals and IV drips. However, illness is an exception.
Seek Cultural Assistance
Seek assistance from a respected family member, member of the clergy, or traditional healer, as appropriate, so that the patient is more likely to accept health care services. Acknowledging the role of the person's traditional healer can be an important way of building trust. Folk medicine practitioners can work closely with professional health practitioners in the interest of the patient and family. Such efforts promote mutual understanding, respect, and cooperation.
Nursing Considerations - Asian
Some members of Asian cultures may be upset by the drawing of blood for laboratory tests. They consider blood to be the body's life force, and some do not believe that it can be regenerated. Some members believe that it is best to die with the body intact, so they may refuse surgery except in dire circumstances. Members of many Asian cultures seldom complain about what is bothering them. Therefore, the nurse must carefully assess the patient for pain or discomfort by observing for nonverbal signs of discomfort, such as facial grimacing or wincing and holding of the painful area. Some Asians consider it polite to give a person the responses the person is expecting. Therefore, the client may transmit misinformation to the questioner in an effort to be respectful. Some members may change physicians in an attempt to be cured of an illness, but to avoid insulting or embarrassing a physician, they will not inform him or her that they are going to another practitioner. This can result in confusion, inaccuracies, and overmedication. Some Asians may refuse diagnostic studies because they believe that a skilled and competent physician can diagnose an illness solely through a physical examination. Some members may have a difficult time understanding the importance of a medication regimen because many folk treatments involve the ingestion of just one dose of herbal mixtures. Dietary counseling may be necessary if the patient is on a salt-restricted diet because many Asian foods have a high salt content related to the use of soy sauce.
Values and Beliefs - Asian:
Strong sense of self-respect and self-control High respect for age Respect for authority Respect for hard work Praise of self or others is considered poor manners Strong emphasis on harmony and the avoidance of conflict
"Think Cultural Health"
The Office of Minority Health created "Think Cultural Health," an online service whose goal is to advance health equity at every point of contact through the development and promotion of culturally and linguistically appropriate services.
Family - Muslim
The family forms the basic building block of Muslim society. The man is considered the head of the family. Marriage forms the sole basis for sexual relations and parenthood. Islamic law generally discourages the use of contraception, extolling the virtues of large families, but there seems to be a trend toward smaller families.
Nursing Considerations - Native American
The family is expected to be part of the nursing care plan. Note taking often is taboo. It is considered an insult to the speaker because the listener is not paying full attention to the conversation. Good memory skills often are required by the nurse. Indirect eye contact is acceptable and sometimes preferred. It often is considered rude or impolite to indicate that you are not clearly hearing what they are saying. A low tone of voice often is considered respectful. A Native American patient may expect the caregiver to deduce the problem through instinct instead of asking many questions and history taking. If this is the case, it may help to use declarative sentences rather than direct questioning.
Folk and Traditional Health Care - Asian:
Theoretical basis is in Taoism, which seeks a balance in all things. Good health is achieved through the proper balance of yin (feminine, negative, dark, cold) and yang (masculine, positive, light, warm). An imbalance in energy is caused by an improper diet or strong emotions. Diseases and foods are classified as hot or cold, and a proper balance between them will promote wellness (e.g., treat a cold disease with hot foods). Many Asian health care systems use herbs, diet, and the application of hot or cold therapy. Also, many Asians believe that there are points on the body that are located on the meridians or energy pathways. If the energy flow is out of balance, treatment of the pathways may be necessary to restore the energy equilibrium. Acumassage—Technique of manipulating points along the energy pathways Acupressure—Technique for compressing the energy pathway points Acupuncture—Technique by which fine needles are inserted into the body at energy pathway points
culture of poverty is passed from generation to generation
This appears to be especially true in such groups as migrant farm workers, families living on public assistance, and people who live in isolated areas of Appalachia
Personal Space
This area, individualized to each person and to different cultures and ethnic groups, is the area into which others should not intrude during personal interactions. If others do not consider a person's personal space, that person may become uncomfortable or even angry.
Food & Nutrition
This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions.
What ethnic group of people often consider mental illness a stigma and seeking psychiatric help a disgrace to the family
Traditional Chinese
Nursing Considerations - Appalachian
Treat each person with regard for personal dignity. Allow family members to remain with patient as support system. Accept the person's current health practices and lifestyle. Allow patients to make decisions about care.
Folk and Traditional Health Care - African American:
Varies extensively and may include spiritualists, herb doctors, root doctors, conjurers, skilled elder family members, voodoo, faith healing
When people immigrate and encounter a new dominant culture as they work, go to school, and learn the dominant language, they often move closer to the dominant culture. The process and rate of assimilation are individualized.
acculturation or cultural assimulation
This may result in psychological discomfort or disturbances, as the patterns of behavior a person found acceptable and effective in one's own culture may not be adequate or even acceptable in the new one. The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings eventually can lead to frustration, anxiety, and loss of self-esteem.
culture shock
National standards issued by the Office of Minority Health 2001
developed to ensure that all people entering the health care system be provided equitable and effective treatment in a culturally and linguistically appropriate manner
cultural diversity
diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location
race
division of human beings based on distinct physical characteristics
personal space
external environment surrounding a person that is regarded as being part of that person
subculture
group of people with different interests or goals than the primary culture
Dominant group
has the most ability to control the values and sanctions of the society. Largest group in the society
Other barriers to health care
isolation language or communication difficulties seasonal occupations migration patterns depersonalization institutional prejudice
Mental Health
norms: research/observations of white middle class people Different ethnic groups have their own norms and acceptable patterns of behaviors
Arabic and African origin
people of Arabic and African origin commonly sit and stand close to one another when talking
Asian and European descent
people of Asian and European descent are more comfortable with some distance between themselves and others.
Research on crowded living
prevents many people from consistently meeting their basic human needs. Lack of transportation The lack of affordable or adequate housing is a problem experienced frequently by poor people. When low-income housing is available, it sometimes lacks such necessities as running water, heat, and electricity. To stretch their available money and to pool resources, many poor people live in crowded conditions, with several families living together in one household.
