Cultural Diversity in Health and Illness


There is something that transcends all of this I am I . . . You are you Yet. I and you Do connect Somehow, sometime.

To understand the “cultural” needs Samenesses and differences of people Needs an open being See—Hear—Feel With no judgment or interpretation Reach out Maybe with that physical touch Or eyes, or aura You exhibit your openness and willingness to Listen and learn And, you tell and share In so doing—you share humanness It is acknowledged and shared Something happens— Mutual understanding

—Rachel E. Spector

Cultural Diversity in Health and Illness


Rachel E. Spector, PhD, RN, CTN-A, FAAN Needham, MA 02494

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ISBN-13: 978-0-13-284006-4 ISBN-10: 0-13-284006-5

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Library of Congress Cataloging-in-Publication Data Spector, Rachel E. Cultural diversity in health and illness/Rachel E. Spector.—8th ed. p. cm. Includes bibliographical references and index. ISBN-13: 978-0-13-284006-4 ISBN-10: 0-13-284006-5 1. Transcultural medical care—United States. 2. Health attitudes—United States. 3. Transcultural nursing—United States. I. Title. RA418.5.T73S64 2013 610—dc23 2012012708

10 9 8 7 6 5 4 3 2 1

I would like to dedicate this text to

My husband, Manny; Sam, Hilary, Julia, and Emma; Becky, Perry, Naomi, Rose, and Miriam; the memory of my parents, Joseph J. and Freda F. Needleman, and my in-laws, Sam and Margaret Spector; and the memory of my beloved mentor, Irving Kenneth Zola.

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Chapter 1 Building Cultural and Linguistic Competence 3 National Standards for Culturally and Linguistically

Appropriate Services in Health Care 8 Cultural Competence 11 Linguistic Competence 11 Institutional Mandates 12 CULTURALCARE 13

Chapter 2 Cultural Heritage and History 19 Heritage Consistency 20 Acculturation Themes 29 Ethnocultural Life Trajectories 32 Commingling Variables 34 Cultural Conflict 36 Cultural Phenomena Affecting Health 37

Chapter 3 Diversity 43 Census 2010 45 Immigration 48 Poverty 54

Chapter 4 Health and Illness 62 Health 63 Illness 74


Chapter 5 HEALTH Traditions 89 HEALTH and ILLNESS 91 HEALTH Traditions Model 92 HEALTH Protection 95 Health/HEALTH Care Choices 102


viii ■ Contents

Folk Medicine 104 Health/HEALTH Care Philosophies 108

Chapter 6 HEALING Traditions 120 HEALING 121 Ancient Forms of HEALING 123 Religion and HEALING 124 HEALING and Today’s Beliefs 136 Ancient Rituals Related to the Life Cycle 138

Chapter 7 Familial HEALTH Traditions 158 Familial Health/HEALTH Traditions 160 Consciousness Raising 171

Chapter 8 Health and Illness in Modern Health Care 178 The Health Care Provider’s Culture 179 Health Care Costs 182 Trends in Development of the Health Care System 187 Common Problems in Health Care Delivery 191 Pathways to Health Services 195 Barriers to Health Care 197 Medicine as an Institution of Social Control 199


Chapter 9 HEALTH and ILLNESS in the American Indian and Alaska Native Population 210 Background 211 Traditional Definitions of HEALTH and ILLNESS 213 Traditional Methods of HEALING 215 Current Health Care Problems 222 The Indian Health Service 228

Chapter 10 HEALTH and ILLNESS in the Asian Populations 238 Background 239 Traditional Definitions of HEALTH and ILLNESS 241 Traditional Methods of HEALTH Maintenance

and Protection 246 Traditional Methods of HEALTH Restoration 247 Current Health Problems 257

Chapter 11 HEALTH and ILLNESS in the Black Population 265 Background 266 Traditional Definitions of HEALTH and ILLNESS 270 Traditional Methods of HEALTH Maintenance

and Protection 271

Contents ■ ix

Traditional Methods of HEALTH Restoration 272 Current Health Problems 279

Chapter 12 HEALTH and ILLNESS in the Hispanic Populations 291 Background 292 Mexicans 294 Puerto Ricans 308

Chapter 13 HEALTH and ILLNESS in the White Populations 323 Background 324 German Americans 326 Italian Americans 330 Polish Americans 334 Health Status of the White Population 339


Appendix A Selected Key Terms Related to Cultural Diversity in Health and Illness 354

Appendix B Calendar: Cultural and Religious Holidays That Change Dates 364

Appendix C Suggested Course Outline 367

Appendix D Suggested Course Activity—Urban Hiking 373

Appendix E Heritage Assessment Tool 376

Appendix F Quick Guide for CULTURALCARE 379

Appendix G Data Resources 381



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Every book, every volume you see here, has a soul. The soul of the person who wrote it and of those who read it and lived and dreamed with it.

—Carlos Ruiz Zafon, The Shadow of the Wind, 2001

In 1977—more than 35 years ago—I prepared the first edition of Cultural Diversity in Health and Illness. Now, as I begin the eighth edition of this book— the sixth revision—I realize that this is an opportunity to reflect on an endeavor that has filled a good deal of my life for the past 30 years. I believe this book has a soul and it, in turn, has become an integral part of my soul. I have lived—through practice, teaching, and research—this material since 1974 and have developed many ways of presenting this content. In addition, I have tracked for 40 years:

1. the United States Census; 2. immigration—numbers and policies; 3. poverty—figures and policies; 4. health care—costs and policies; 5. morbidity and mortality rates; 6. nursing and other health care manpower issues; and 7. the emergence and growth of the concepts of health disparities and

cultural and linguistic competence.

My metaphors are HEALTH, defined as “the balance of the person, both within one’s being—physical, mental, and spiritual—and in the outside world— natural, communal, and metaphysical”; ILLNESS, “the imbalance of the person, both within one’s being—physical, mental, and spiritual—and in the outside world—natural, communal, and metaphysical”; and HEALING, “the restoration of balance, both within one’s being—physical, mental, and spiritual—and in the outside world—natural, communal, and metaphysical.” I have learned over these years that within many traditional heritages (defined as “old,” not con- temporary or modern) people tend to define HEALTH, ILLNESS, and HEALING in this manner. Imagine a kaleidoscope—the tube can represent HEALTH. The ob- jects reflected within the kaleidoscope reflect the traditional tools used to care for a given person’s HEALTH. If you love kaleidoscopes, you know what I am describing and that the patterns that emerge are infinite.

xii ■ Preface

In addition, I have had the unique opportunity to travel to countless places in the United States and abroad. I make it a practice to visit the tra- ditional markets, pharmacies, and shrines and dialogue with the people who work in or patronize the settings, and I have gathered invaluable knowledge and unique items and images. My tourist dollars are invested in amulets and remedies and my collection is large. Digital photography has changed my eyes; I may be a “digital immigrant,” rather than a “digital native,” but the camera has proven to be my most treasured companion. I have been able to use the im- ages of sacred objects and sacred places to create HEALTH Traditions Imagery. The opening images for each chapter and countless images within the chapters are the results of these explorations. Given that there are times when we do not completely understand a concept or an image, several images are slightly blurred or dark to represent this wonderment.

The first edition of this book was the outcome of a promesa—a promise— I once made. The promise was made to a group of Asian, Black, and Hispanic students I taught in a medical sociology course in 1973. In this course, the students wound up being the teachers, and they taught me to see the world of health care delivery through the eyes of the health care consumer rather than through my own well-intentioned eyes. What I came to see I did not al- ways like. I did not realize how much I did not know; I believed I knew a lot. I promised the students that I would take that which they taught me regarding HEALTH and teach it to students and colleagues. I have held on to the promesa, and my experiences over the years have been incredible. I have met people and traveled. At all times I have held on to the idea and goal of attempting to help nurses and other health care providers be aware of and sensitive to the HEALTH, ILLNESS, and HEALING beliefs and needs of their patients.

I know that looking inside closed doors carries with it a risk. I know that people prefer to think that our society is a melting pot and that the traditional beliefs and practices have vanished with the expected acculturation and assimi- lation into mainstream North American modern life. Many people, however, have continued to carry on the traditional customs and culture from their na- tive lands and heritage, and HEALTH, ILLNESS, and HEALING beliefs are deeply entwined within the cultural and social beliefs that people have. To understand HEALTH and ILLNESS beliefs and practices, it is necessary to see each person in his or her unique sociocultural world. The theoretical knowledge that has evolved for the development of this text is cumulative and much of the “old” material is relevant today as many HEALTH, ILLNESS, and HEALING beliefs do not change. However, many beliefs and practices do go underground.

The purpose of each edition has been to increase awareness of the dimen- sions and complexities involved in caring for people from diverse cultural back- grounds. I wished to share my personal experiences and thoughts concerning the introduction of cultural concepts into the education of health care profes- sionals. The books represented my answers to the questions:

■ “How does one effectively expose a student to cultural diversity?” ■ “How does one examine health care issues and perceptions from a

broad social viewpoint?”

Preface ■ xiii

As I have done in the classroom over the years, I attempt to bring you, the reader, into direct contact with the interaction between providers of care within the North American health care system and the consumers of health care. The staggering issues of health care delivery are explored and contrasted with the choices that people may make in attempting to deal with health care issues.

When I began this journey in nursing, there were limited resources avail- able to answer my questions and to support me in my passion for knowledge. The situation has dramatically changed and today there is nearly more informa- tion than one can absorb! Not only is this information being sought by nurses, all stakeholders in the health care industry are struggling with this concept. The de- mographics of America, and the world, have changed and perhaps this challenge of building bridges between cultural groups can be seen as a way to open op- portunities to do this in many disciplines. Indeed, the content is readily available:

■ Countless books and articles have been published in nursing, medicine, public health, and the popular media over the past 40 years that con- tain invaluable information relevant to CULTURALCOMPETENCY.

■ Innumerable workshops and meetings have been available where the content is presented and discussed.

■ “Self-study” programs on the Internet have been developed that pro- vide continuing education credits to nurses, physicians, and other providers.

However, the process of becoming CULTURALLYCOMPETENT is not generally provided for. Issues persist, such as:

■ Demographic disparity exists in the profile of health care providers and in health status.

■ Patient needs, such as modesty, space, and gender-specific care, are not universally met.

■ Religious-specific needs are not met in terms of meal planning, proce- dural planning, conference planning, and so forth.

■ Communication and language barriers exist.

As this knowledge is built, you are on the way to CULTURALCOMPETENCY. As it matures and grows, you become an advocate of CULTURALCARE, as it will be described in Chapter 1.

■ Overview Unit I focuses on the background knowledge one must recognize as the foun- dation for developing CULTURALCOMPETENCY.

■ Chapter 1 presents an overview of the significant content related to the on-going development of the concepts of cultural and linguistic com- petency as it is described by several different organizations.

■ Chapter 2 explores the concept of cultural heritage and history and the roles they play in one’s perception of health and illness. This exploration

xiv ■ Preface

is first outlined in general terms: What is culture? How is it transmit- ted? What is ethnicity? What is religion? How do they affect a person’s health? What major sociocultural events occurred during the life trajec- tory of a person that may influence his or her personal health beliefs and practices?

■ Chapter 3 presents a discussion of the diversity—demographic, im- migration, and poverty—that impacts on the delivery of and access to health care. The backgrounds of each of the U.S. Census Bureau’s cat- egories of the population, an overview of immigration, and an overview of issues relevant to poverty are presented.

■ Chapter 4 reviews the provider’s knowledge of his or her own percep- tions, needs, and understanding of health and illness.

Unit II explores the domains of HEALTH, blends them with one’s personal heritage, and contrasts them with the Allopathic Philosophy.

■ Chapter 5 introduces the concept of HEALTH and develops the con- cept in broad and general terms. The HEALTH Traditions Model is pre- sented, as are natural methods of HEALTH maintenance and protection.

■ Chapter 6 explores the concept of HEALTH restoration or HEALING and the role that faith plays in the context of HEALING, or magico-religious, traditions. This is an increasingly important issue, which is evolving to a point where the health care provider must have some understanding of this phenomenon.

■ Chapter 7 discusses family heritage and explores personal and familial HEALTH traditions. It includes an array of familial health/HEALTH be- liefs and practices shared by people from many different heritages.

■ Chapter 8 focuses on the health care provider culture and the allopathic health care delivery system.

Once the study of each of these components has been completed, Unit III (Chapters 9 to 13) moves on to explore selected population groups in more de- tail, to portray a panorama of traditional HEALTH and ILLNESS beliefs and prac- tices, and to present relevant health care issues.

Chapter 14 is devoted to an overall analysis of the book’s contents and how best to apply this knowledge in health care delivery, health planning, and health education, for both the patient and the health care professional.

Each chapter in the text opens with images relevant to the chapter’s topic. They may be viewed in the CULTURALCARE Museum on the accompanying web page.

These pages cannot do full justice to the richness of any one culture or any one health/HEALTH belief system. By presenting some of the beliefs and practices and suggesting background reading, however, the book can begin to inform and sensitize the reader to the needs of a given group of people. It can also serve as a model for developing cultural knowledge of populations that are not included in this text.

There is so much to be learned. Countless books and articles have now appeared that address these problems and issues. It is not easy to alter attitudes

Preface ■ xv

and beliefs or stereotypes and prejudices, to change a person’s philosophy. Some social psychologists state that it is almost impossible to lose all of one’s prejudices, yet alterations can be made. I believe the health care provider must develop the ability to deliver CULTURALCARE and knowledge regarding per- sonal fundamental values regarding health/HEALTH and illness/ILLNESS. With acceptance of one’s own values come the framework and courage to accept the existence of differing values. This process of realization and acceptance can enable the health care provider to be instrumental in meeting the needs of the consumer in a collaborative, safe, and professional manner.

This book is written primarily for the student in basic allied health profes- sional programs, nursing, medical, social work, and other health care provider disciplines. I believe it will be helpful also for providers in all areas of practice, especially community health, long-term oncology, chronic care settings, and geri- atric and hospice centers. I am attempting to write in a direct manner and to use language that is understandable by all. The material is sensitive, yet I believe that it is presented in a sensitive manner. At no point is my intent to create a vehicle for stereotyping. I know that one person will read this book and nod, “Yes, this is how I see it,” and someone else of the same background will say, “No, this is not correct.” This is the way it is meant to be. It is incomplete by intent. It is written in the spirit of open inquiry, so that an issue may be raised and so that clarifica- tion of any given point will be sought from the patient as health care is provided. The deeper I travel into this world of cultural diversity, the more I wonder at the variety. It is wonderfully exciting. By gaining insight into the traditional attitudes that people have toward health and health care, I found my own nursing practice was enhanced, and I was better able to understand the needs of patients and their families. It is thrilling to be able to meet, to know, and to provide care to people from all over the world and every walk of life. It is the excitement of nursing. As we go forward in time, I hope that these words will help you, the reader, develop CULTURALCARE skills and help you provide the best care to all.

You don’t need a masterpiece to get the idea. —Pablo Picasso

■ Features ■ Research on Culture and Health. As evidence-based practice grows

in importance, its application is expected in all aspects of health care. This special feature spotlights how current research informs and im- pacts cultural awareness and competence.

■ Unit and Chapter Objectives. Each unit and chapter opens with ob- jectives to direct the reader when studying.

■ Unit Exercises and Activities. The beginning of each unit provides ex- ercises and activities related to the topic. Questions stimulate reflective

xvi ■ Preface

consideration of the reader’s own family and cultural history as well as to develop an awareness of one’s own biases.

■ Figures, Tables, and Boxes. Throughout the book are photographs, illustrations, tables, and boxes that exemplify and expand on informa- tion referenced in the chapter.

■ Health Traditions Imagery. These symbolic images are used to link the chapters. The images were selected to awaken you to the richness of a given heritage and the practices inherent within both modern and tra- ditional cultures, as well as the beliefs surrounding health and HEALTH. (HEALTH, when written this way, is defined as the balance of the person, both within one’s being—physical, mental, spiritual—and in the outside world—natural, familial and communal, metaphysical.)

■ Keeping Up. Selected resources that present information that is fre- quently published in a timely manner to keep you abreast of data, on such topics as poverty, income, immigration, and so forth, as the facts and figures change. This is a new feature for this edition.

■ Supplemental Resources

■ CulturalCare Guide. Previously available as a separate booklet, the contents of this helpful guide are now available for downloading on the Companion Website. The guide includes the Heritage Assess- ment Tool, Cultural Phenomena Affecting Health Care, CulturalCare Etiquette, and other assessment tools and guides.

■ Companion Website. The Companion Website includes a wealth of supplemental material to accompany each chapter. In addition to the complete contents of the CulturalCare Guide, the site presents chapter-related review questions, case studies, exercises, and MediaLinks to provide additional information. Panorama of Health and Illness videos accompany many chapters, and a glossary of terms appears for each chapter. Also included is a collection of the author’s photographs and culturally significant images in the CULTURAL- CARE Museum.

■ Instructor’s Resource Center. Available to instructors adopting the book are PowerPoint Lecture Slides and a complete testbank available for downloading from the Instructor’s Resource Center, which can be accessed through the online catalog.

■ Online Course Management. Built to accompany Cultural Diversity in Health and Illness are online course management systems available for Blackboard, WebCT, Moodle, Angel, and other platforms. For more information, contact your Pearson Education sales representative.
About the Author

Dr. Rachel E. Spector has been a student of culturally diverse HEALTH and ILLNESS beliefs and practices for 40 years and has researched and taught courses on culture and HEALTH care for the same time span. Dr. Spector has had the opportunity to work in many different communities, including the American Indian and Hispanic communities in Boston, Massachusetts. Her studies have taken her to many places: most of the United States, Canada, and Mexico; several European countries, including Denmark, England, Greece, Finland, Iceland, Italy, France, Russia, Spain, and Switzerland; Israel and Pakistan; and Australia and New Zealand. She was fortunate enough to collect traditional amulets and remedies from many of these diverse communities, visit shrines, and meet practitioners of traditional HEALTH care in several places. She was in- strumental in the creation and presentation of the exhibit “Immigrant HEALTH Traditions” at the Ellis Island Immigration Museum, May 1994 through January 1995. She has exhibited HEALTH-related objects in several other set- tings. Recently, she served as a Colaboradora Honorifica (Honorary Collabora- tor) in the University of Alicante in Alicante, Spain, and Tamaulipas, Mexico. In 2006, she was a Lady Davis Fellow in the Henrietta Zold-Hadassah Hebrew University School of Nursing in Jerusalem, Israel. This text was translated into Spanish by Maria Munoz and published in Madrid by Prentice Hall as Las Cul- turas de la SALUD in 2003 and into Chinese in 2010. She is a Fellow in the American Academy of Nursing and a Scholar in Transcultural Nursing Society. The Massachusetts Association of Registered Nurses, the state organization of the American Nurses’ Association, honored her as a “Living Legend” in 2007. In 2008 she received the Honorary Human Rights Award from the American Nurses Association. This award recognized her contributions and accomplish- ments that have been of national significance to human rights and have influ- enced health care and nursing practice.



I have had a 35-year adventure of studying the forces of culture, ethnicity, and religion and their profound influence on HEALTH, ILLNESS, and HEALING beliefs and practices. Many, many people have contributed generously to the knowledge I have acquired over this time as I have tried to serve as a voice for traditional people and the HEALTH, ILLNESS, and HEALING beliefs and prac- tices derived from their given heritage. It has been a continuous struggle to in- sure that this information be included not only in nursing education but in the educational content of all helping professions—including medicine, the allied health professions, and social work.

I particularly wish to thank the following people for their guidance, professional support, and encouragement over the 32 years that this book, now in its eighth edition, has been an integral part of my life. They are peo- ple from many walks of life and have touched me in many ways. The people from Appleton-Century-Crofts, which became Appleton & Lang, then became Prentice Hall, and now Pearson. They include Kim Mortimer, Patrick Walsh, and countless people involved in the production of the text. My first encounter with publishing was with Leslie Boyer, an acquisition editor from Appleton- Century-Crofts, who simply said “write a book” in 1976. The experience of preparing this eighth edition has been a formidable one. Most of the new con- tent has been gathered via the World Wide Web. However, the most exciting aspect of this project has been working with people in India throughout the copyediting phase. I was living in Honolulu, Hawaii; the Senior Project Man- ager, Saraswathi Muralidhar, was in India. We were thousands of miles apart, there was a fifteen and one half-hour difference in time; yet, we have completed this challenge in a most timely manner. Yes, the World Wide Web is an amaz- ing asset. In 1976, when the first edition of this book was conceived, I never dreamt that this is where it would be in 2012. In addition, for this edition I have worked closely with Yagnesh Jani, the development editor in the United States. Without their help, this book would not be here today.

The many people who helped with advice and guidance to resources over the years include Elsi Basque, Billye Brown, Louise Buchanan, Julian Castillo, Leonel J. Castillo, Jenny Chan, Dr. P. K. Chan, Joe Colorado, Miriam Cook, Elizabeth Cucchiaro, Norine Dresser, Marjory Gordon, Orlando Isaza, Henry and Pandora Law, S. Dale McLemore, Anita Noble, Carl Rutberg, Sister Mary Nicholas Vincelli, David Warner, and the late Hawk Littlejohn, Father Richard McCabe, and Irving K. Zola.

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