Cultural Competence

• Legal Resident—All persons who were granted lawful permanent residence

• Naturalization—The conferring, by any means, of citizenship upon a person after birth

• Non-immigrant—An alien who seeks temporary entry to the United States for a specific purpose

• Parolee—An alien, appearing to be inadmissible to the inspecting officer, allowed into the United States for urgent humanitarian reasons or when that alien’s entry is determined to be for significant public benefit

• Permanent Resident Alien—An alien admitted to the United States as a lawful permanent resident

• Refugee—Any person who is outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution

• Unauthorized Residents—All foreign-born non-citizens who are not legal residents

• EFFECTIVE CARE results in positive outcomes and satisfaction for the patient.

• RESPECTFUL CARE takes into consideration the values, preferences, and expressed needs of the patient.

• CULTURAL AND LINGUISTIC COMPETENCE is a set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations (Fig. 2-1).

Under the provisions of Title VI of the Civil Rights Act of 1964, when people with limited English proficiency (LEP) seek health care in health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them. There are many forms of illegal discrimination based on race or national origin that frequently limit the opportunities of people to gain equal access to health care services. It is said that “language barriers have a deleterious effect on health care, patients are less likely to have a usual source of health care, and have an increased risk of nonadherence to medication regimens.”6

The United States is home to millions of people from different national origins. English is the predominant language of the United States. However, 12% of the people living in the United States from 2005 to 2007 were foreign born. Among people at least 5 years old living in the United States from 2005 to 2007, 20% spoke a language other than English at home. Of those speaking a language other than English at home, 62% spoke Spanish and 38% spoke some other language; 44% reported that they did not speak English “very well.” The most common non-English languages spoken by people older than 5 years at home are Spanish, Chinese, French, German, and Tagalog (2.6%). Vietnamese, Italian, Korean, and Russian and Polish are next among the top 10 languages.²¹

People who are limited in their ability to speak, read, write, and understand the English language encounter countless language barriers that can result in limiting their access to critical public health, hospital, and other medical and social services to which they are legally entitled. Many health and social service programs provide information about their services in English only. When LEP persons seek health care at hospitals or medical clinics, they are frequently faced with receptionists, nurses, and physicians who speak English only. The language barrier faced by LEP persons in need of medical care or social services severely limits the ability to gain access to these services and to participate in these programs. In addition, the language barrier often results in the denial of medical care or social services, delays in the receipt of such care and services, or the provision of care and services on the basis of inaccurate or incomplete information. Services denied, delayed, or provided under such circumstances could have serious consequences for a LEP person as well as for a provider of medical care. Some states (e.g., California, Massachusetts, New York) recognize the seriousness of the problem and require providers to offer language assistance to patients in health care settings.

Chapter 3 describes in more detail how to communicate with people who do not understand English, how to interact with interpreters, and what services are available when no interpreter is available. It is vital that interpreters be present who not only serve to verbally translate the conversation but who also can describe to you the cultural aspects and meanings of the person’s situation.

Health Disparities

A health disparity is the unusual and disproportionate frequency of a given health problem (e.g., diabetes, hypertension, certain cancers) within a population when compared with other populations. Disparities occur in a broader social and economic context. The factors that contribute to this phenomenon are multilevel and complex and include the health care system, health care providers, health care managers, and patients/families/communities. It is expected that, over time, this major problem in the delivery of health care in the United States will be overcome with the increasing knowledge and research necessary for the provision of culturally competent health care.⁸

Cultural Competence and CULTURAL CARE

One response to the government mandates for cultural competency is the development of CULTURAL CARE, a concept that describes professional health care that is culturally sensitive, appropriate, and competent. There is a discrete body of knowledge relevant to this, and much of the content is introduced in this chapter.

CULTURAL CARE is critical to meeting the complex nursing care needs of a given person, family, and community. It is the provision of health care across cultural boundaries and takes into account the context in which the patient lives as well as the situations in which the patient’s health problems arise.²⁰ Each chapter in this text will include information necessary for delivery of CULTURAL CARE.

More and more institutions are mandating that those who practice must be culturally competent; there are countless ways by which this can be achieved. However, it is NOT a one-lesson program but, rather, a lifetime journey of study and learning. Given the changes in the demographic profile of the United States and the enormous impact that immigration is having in this situation, it becomes imperative that a body of knowledge must be developed to meet this challenge. There are several discrete areas in which you must have knowledge:

Culture

There is no single definition of culture, and too often, definitions tend to omit salient aspects of culture or are too general to have any real meaning. One example of a definition of culture is that it is the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Culture is a complex whole in which each part is related to every other part. It is learned, and the capacity to learn culture is genetic, but the subject matter is not genetic and must be learned by each person in his or her family and social community. Culture also depends on an underlying social matrix, and included in this social matrix are knowledge, belief, art, law, morals, and customs. Culture is also a web of communication, and much of culture is transmitted nonverbally.²⁰

In addition, culture has four basic characteristics in that it is (1) learned from birth through the processes of language acquisition and socialization, (2) shared by all members of the same cultural group, (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources, and (4) dynamic and ever changing.

Culture is a universal phenomenon without which no person exists. Yet the culture that develops in any given society is always specific and distinctive, encompassing all the knowledge, beliefs, customs, and skills acquired by members of that society. Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups.

Ethnicity

Cultural background is a fundamental component of your ethnic background. Ethnicity pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, or symbols, and food preferences.

The term ethnic has aroused strongly negative feelings and often is rejected by the general population. In a nation as large as the United States and comprising as many different peoples as it does—with the American Indians being the only true native population—we find ourselves still reluctant to speak of ethnicity and ethnic differences. This stance stems from the fact that most foreign groups that came to this land often shed the ways of the “old country” and quickly attempt to assimilate themselves into the mainstream, or the so-called melting pot.¹⁵ There are at least 106 ethnic groups and more than 500 American Indian nations in the United States. People from every nation on earth are now residing in this country²⁰ (Fig. 2-2).

Religion

The third major component of a person’s heritage is religion. Religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe. A system of beliefs, practices, and ethical values is a major reason for the development of ethnicity.¹ Religion may be seen as a shared experience of spirituality or as the values, beliefs, and practices that people are either born into or may adopt to meet their personal spiritual needs through communal actions such as religious affiliation; attendance and participation in a religious institution, prayer, or meditation; and religious practices.

On the other hand, spirituality may be seen as focusing more on the self and includes belief systems other than religion.¹⁸ The practice of religion is revealed in numerous cults, sects, denominations, and churches. Ethnicity and religion are clearly related, and religion quite often is the determinant of ethnic group. Religion gives a person a frame of reference and a perspective with which to organize information. Religious teachings vis-á-vis health help present a meaningful philosophy and system of practices within a system of social controls having specific values, norms, and ethics. These are related to health in that adherence to a religious code is conducive to spiritual harmony and health. Illness is sometimes seen as the punishment for the violation of religious codes and morals.

Religion plays a most significant role in the ways people practice their health care. Too often, this aspect of the person is ignored, and in many settings, the question “What is your religious preference?” is not asked. This may be to protect against discrimination based on religion. Yet, religion is seen as the domain of life beyond the body and mind.¹² The following are examples of how religion influences the health practices of countless people:

There are countless health-related behaviors promoted by nearly all religions. The following list presents selected examples. Not every religion speaks to each point: meditating, exercising and maintaining physical fitness, getting enough sleep, being vaccinated, being willing to have the body examined, undertaking a pilgrimage for HEALTH reasons, telling the truth about how you feel, maintaining family viability, hoping for recovery, coping with stress, undergoing genetic screening and counseling, being able to live with a handicap, and caring for children.12

As an integral component of the person’s culture, religious beliefs may influence the person’s explanation of the cause(s) of illness, perception of its severity, and choice of healer(s). In times of crisis, such as serious illness and impending death, religion may be a source of consolation for the person and for his or her family. Religious dogma and spiritual leaders may exert considerable influence on the person’s decision making concerning acceptable medical and surgical treatment, choice of healer(s), and other aspects of the illness.

Spirituality and Religion

Religious concerns evolve from and respond to the mysteries of life and death, good and evil, and pain and suffering. In health care settings, you frequently encounter people who find themselves searching for a spiritual meaning to help explain their illnesses or disabilities. Some health care providers find spiritual assessment difficult because of the abstract and personal nature of the topic, whereas others feel quite comfortable discussing spiritual matters. Comfort with your own spiritual beliefs is the foundation for effective assessment of spiritual needs in others.

An important distinction needs to be made between spirituality and religion. Spirituality is borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life.¹⁸ Although the religions of the world offer various interpretations to many of life’s mysteries, most people seek a personal understanding and interpretation at some time in their lives. Ultimately, this personal search becomes a pursuit to discover a supreme being (called by names such as Allah, God, Yahweh, and Jehovah) or some unifying truth that will render meaning, purpose, and integrity to existence.

Religion, on the other hand, refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. An extensive new survey by the Pew Forum on Religion and Public Life details statistics on religion in America.¹⁶ The study found that religious affiliation in the United States is both very diverse and extremely fluid. The number of people who say they are unaffiliated with any particular faith is now 16.1%. Those reporting religious affiliation with a Christian church number 78.4%. The Christian denominations include Roman Catholic (23.9%); Protestant (51.3%), which includes Mainline Protestant (18.1%), Evangelical Churches (26.3%), and Historical Black Churches (6.9%); Mormon or Church of Jesus Christ of Latter-Day Saints (1.3%); Jehovah’s Witness (0.7%); and others. Those belonging to non-Christian and other religions total 4.7% of the U.S. population; of these, the largest group is Jewish (1.7%), followed by Buddhist (0.7%), Muslim (0.6%), and Hindu (0.4%).

The Landscape Survey also found that among the foreign-born adult population, Catholics outnumbered Protestants by nearly a two-to-one margin (46% Catholic vs. 24% Protestant) and that immigrants are also disproportionately represented among several world religions in the United States, including Islam, Hinduism, and Buddhism.¹⁶ Religious identification among people from different racial and ethnic groups is important because religion and culture are interconnected and play a critical role in HEALTH beliefs and practices.

There are many examples of how spirituality and religion are apparent in daily life and frequently play a role in one’s HEALTH. Shrines are an essential component of this. There are countless shrines, both secular and from a religious tradition, where people visit to remember and/or to pray for favors or healing. Fig. 2-3, A is an image of the Vietnam Memorial Wall in Washington, DC, an example of a secular/spiritual shrine where people go to remember loved ones who died in the Vietnam War. Fig. 2-3, B is a statue of Saint Peregrine, the patron saint of people with cancer. This statue is in the chapel in the Mission San Juan Capistrano in California. Fig. 2-3, C is the Thai Spirit House, in Los Angeles, California. The shrine is on a public street and visited by believers; offerings such as flowers and food are frequently left at the base. Fig. 2-3, D is an example of a sacred Buddhist shrine that can be found in a store or in a home.

Just as the trends in immigration have influenced our newest citizens, there has been a growing interest in the religious preferences of the oldest group, the American Indians. The religious profile of American Indians is similar to that of non-Hispanic whites: 20% identified themselves as Baptist, 17% as Catholic, and 17% indicated no religious preference. Only 3% indicated their primary religious identification as a tribal Indian religion, perhaps a reflection of the growing number of native people who reside in non-reservation urban centers.^1a

Socialization

Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Education—be it elementary school, high school, college, or professional school—is a form of socialization. For many people who have been socialized within the boundaries of a “traditional culture” or a non-modern culture (usually associated with the East or with developing nations), modern “American,” or Western, first-world culture becomes a second cultural identity. Those who immigrate here (legally or illegally) from non-Western or non-modern countries may find socialization into the American culture, whether in schools or in society, to be an extremely difficult and painful process. As time passes, many people experience biculturalism, which is a dual pattern of identification and often of divided loyalty.¹¹ In addition, many people who have been socialized in cultures in which traditional health care resources are used may prefer to use this type of care even when residing in a modern cultural setting with modern health care resources available.

It is not possible to isolate the aspects of culture, religion, ethnicity, and socialization that shape a person’s worldview. Each is part of the other, and all are united within the person. When we write of religion, we cannot eliminate culture or ethnicity but descriptions and comparisons can be made.

There are several other terms related to socialization:

1. Childhood development occurred in the country of origin or in an immigrant neighborhood in the United States of like ethnic and religious group: Where were you born? Where did you grow up?
Both you and the person were raised in a specific ethnic neighborhood, such as an Italian, Black, Hispanic, or Jewish one, in a given part of a city and were exposed only to the culture, language, foods, and customs of that particular group.

2. Extended family members encouraged participation in traditional religious and cultural activities: Did your parents encourage you to participate in religious or ethnic activities? What kind of school did you go to? Did you go to a special religious school after regular school hours?
Parents and members of the extended family and ethnoreligious community encouraged the person to know his or her ethnocultural heritage and sent the person to religious (parochial) school, and most social activities were church related.

3. The person engages in frequent visits to the country of origin or returns to the “old neighborhood” in the United States: Have you visited the nation(s) or neighborhoods where your family originated?
The desire to return to the old country or to the old neighborhood is expressed by many people; however, many people, for various reasons, cannot return to the “old country or neighborhood.” The people who came here to escape religious persecution or whose families were killed during World War II, during the Holocaust, in the killing fields of Cambodia, or other recent massacres may not want to return to European or other homelands. Other reasons why people may not return to their native countries include political conditions in the homeland or lack of relatives or friends in that land.

4. The person’s family home is within the ethnic community of which he or she is a member: Who are the people living in the neighborhood where you now live?
As an adult, the person has elected to live with his or her family in the ethnic neighborhood or community wherein the people are from a similar heritage.

5. The person participates in ethnic cultural events, such as religious festivals or national holidays, sometimes with singing, dancing, and costumes: Do you participate in ethnic celebrations from your heritage?
The person is active in social and cultural groups and participates in festivities of his or her family. One example is the August festival of Saint Anthony that is celebrated by people of Italian descent in the Northeast.

6. The person was raised in an extended family setting: Who lived in your home? Were they related to you?
When the person was growing up, there may have been grandparents living in the same household or aunts and uncles living in the same house or close by. The person’s social frame of reference was the family and the extended family.

7. The person maintains regular contact with the extended family: Do you maintain ties to family?
The person maintains close ties, either with visits or telephone contact, with family members of the same generation, surviving members of the older generation, and members of the younger generation. This includes aunts, uncles, and cousins.

8. The person’s name has not been Americanized: Was your family name changed when the family came to the United States? Was the name changed to facilitate assimilation?
Many people’s surnames were changed, either by immigration officials when they entered the country or by personal choice to make their names more “American” as an attempt to assimilate to the dominant culture more fully.

9. The person was educated in a parochial (nonpublic) school with a religious or ethnic philosophy similar to the family’s background: What school did you go to? Was it public or private?
The person’s education plays an enormous role in socialization, and the major purpose of education is to socialize a given person into the dominant culture. Children learn English and the customs and norms of American life in the schools. In the parochial or private schools, they not only learn English but also are socialized in the culture and norms of the particular religious or ethnic group that is sponsoring the school.

10. The person engages in social activities primarily with others of the same religious or ethnic background: Who are your friends, and how often do you spend time with them?
For example, the major portion of the person’s personal time is spent with family and friends from his or her ethnocultural or religious community.

11. The person has knowledge of the culture and language of origin: Do you speak or read the language of your parents or grandparents?
For example, the person has been socialized in the traditional ways of the family and expresses this as a central theme of life.

12. The person expresses pride in his or her heritage: Do you identify as an ethnic American or as an American?
For example, the person may identify himself or herself as ethnic American and be supportive of ethnic activities to a great extent.

1. Do you mostly participate in social activities with members of your family?

2. Do you mostly have friends from a similar cultural background as you?

3. Do you mostly eat the foods of your family’s tradition?

4. Do you mostly participate in the religious traditions of your family?

Biomedical

The first, called the biomedical or scientific theory of illness causation, is based on the assumption that all events in life have a cause and effect, that the human body functions more or less mechanically (i.e., the functioning of the human body is analogous to the functioning of an automobile), that all life can be reduced or divided into smaller parts (e.g., the reduction of the human person into body, mind, and spirit), and that all of reality can be observed and measured (e.g., intelligence tests and psychometric measures of behavior). Among the biomedical explanations for disease is the germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. Most educational programs for physicians, nurses, and other health care providers embrace the biomedical or scientific theories that explain the causes of both physical and psychological illnesses.

Naturalistic

The second way in which people explain the cause of illness is from the naturalistic or holistic perspective, found most frequently among American Indians, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. The people may believe that the forces of nature must be kept in natural balance or harmony.

Some Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. Rooted in the ancient Chinese philosophy of Tao, the yin/yang theory states that all organisms and objects in the universe consist of yin and yang energy forces. The seat of the energy forces is within the autonomic nervous system where balance between the opposing forces is maintained during health. Yin energy represents the female and negative forces, such as emptiness, darkness, and cold, whereas yang forces are male and positive, emitting warmth and fullness. Foods are classified as hot and cold in this theory and are transformed into yin and yang energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The yin/yang theory is the basis for Eastern or Chinese medicine and is commonly embraced by many Asian Americans.

The naturalistic perspective posits that the laws of nature create imbalances, chaos, and disease. People embracing the naturalistic view use metaphors such as the healing power of nature, and they call the earth “Mother.” From the perspective of the Chinese, for example, illness is not seen as an intruding agent but as a part of life’s rhythmic course and as an outward sign of disharmony within.

Many Hispanic, Arab, Black, and Asian groups embrace the hot/cold theory of health and illness, an explanatory model with origins in the ancient Greek humoral theory. The four humors of the body—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.

Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not on their physical characteristics. Illnesses believed to be caused by cold entering the body include earache, chest cramps, paralysis, gastrointestinal discomfort, rheumatism, and tuberculosis. Among those illnesses believed to be caused by overheating are abscessed teeth, sore throats, rashes, and kidney disorders.

According to the hot/cold theory, the person is whole, not just a particular ailment. Those who embrace the hot/cold theory maintain that health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. Paradoxically, the language used to describe this artificial dissection of the body into parts is itself a reflection of the biomedical/scientific perspective, not a naturalistic or holistic one.

Magicoreligious

The third major way in which people explain the causation of ILLNESS is from a magicoreligious perspective. The basic premise is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil. Examples of magical causes of illness include belief in voodoo or witchcraft among some African Americans and others from circum-Caribbean countries. Faith healing is based on religious beliefs and is most prevalent among certain Christian religions, including Christian Scientists, whereas various healing rituals may be found in many other religions such as Roman Catholicism and Mormonism.

Of course, it is possible to have a combination of worldviews, and many people are likely to offer more than one explanation for the cause of their illness, the means of protecting themselves from such an illness, and the means to recovery. As a profession, nursing largely embraces the scientific/biomedical worldview, but some other aspects are gaining popularity, including techniques for management of chronic pain, such as acupuncture, herbal therapies, hypnosis, therapeutic touch, and biofeedback.

Amulets are objects, such as charms, that may be worn on a string or chain around the neck, wrist, or waist to protect the wearer from the “evil eye” or the “evil spirits” that could be transmitted from one person to another or that could have supernatural origins. They may also be hung in the home, car, or workplace. Natural folk medicine uses remedies from the natural environment—herbs, plants, minerals, and animal substances—to treat illnesses. Amulets and remedies have come to the United States from every corner of the world, the East and the West. They may be purchased in pharmacies, markets, and natural food stores. Fig. 2-5 illustrates the interior of a botanica, a store in which a person can purchase amulets and remedies used by people from many Latino heritages. Others may be objects or substances used externally. Fig. 2-6 presents samples of traditional amulets.

Healing and Culture

When self-treatment is unsuccessful, the person might turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. All cultures have their own preferred lay or popular healers, recognized symptoms of ill health, acceptable sick role behavior, and treatments. In addition to seeking help from you as a biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Hispanic or American Indian origins, may believe that the cure is incomplete unless healing of body, mind, and spirit are all carried out. The division of the person into parts is itself a Western concept. For example, a Hispanic person with a respiratory infection may take the antibiotics prescribed by a physician or nurse practitioner and herbal teas recommended by a curandero and may say prayers for healing suggested by a Catholic priest. Many people from different faith traditions practice prayer or visit healing shrines, as discussed earlier in this chapter. There are countless shrines in the United States and the rest of the world where people make pilgrimages for this purpose, including Chimayo in New Mexico, Fatima in Portugal, and Lourdes in France.

The variety of healing beliefs and practices used by the many ethnocultural populations found in this country far exceeds the limitations of this chapter. It is important, however, that you be aware of the existence of traditional practices and recognize that, in addition to folk practices, many other complementary healing practices exist. Although it is dangerous to assume that all indigenous approaches to healing are innocuous, the majority of practices are quite harmless, regardless of whether they are effective cures. Fig. 2-7 presents samples of traditional remedies used for recovery.

Table 2-2 lists questions to ask and sample answers for this phase of assessment.

Some people may have a condition that is culturally defined, known as a culture-bound syndrome. Some of these conditions have no equivalent from a biomedical/scientific perspective, whereas others, such as anorexia nervosa and bulimia, are examples of the cultural aspects of illness among members of a dominant cultural population in North America. Table 2-4 summarizes selected examples from among the more than 150 culture-bound syndromes that have been documented by medical anthropologists, mental health providers, or community spokespeople.

After a symptom is identified, the first effort at treatment is often self-care. In the United States, an estimated 38% of adults use some form of complementary therapy to treat an illness. Furthermore, U.S. adults spent $33.9 billion out-of-pocket on visits to complementary and alternative medicine practitioners and the purchase of related products.13a The availability of over-the-counter medications, the relatively high literacy level of Americans, the growing availability of herbal remedies, and the influence of the Internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Home treatments are attractive for their accessibility, especially compared with the inconvenience associated with traveling to a physician, nurse practitioner, or pharmacist, particularly for people from rural or sparsely populated areas. Furthermore, home treatment may mobilize the person’s social support network and provide the sick person with a caring environment in which to convalesce. You should be aware, however, that not all home remedies are inexpensive. For example, urban Black populations in the Southeast sometimes use medicinal potions that cost much more than the equivalent treatment with a biomedical intervention.

A wide variety of alternative, complementary, or traditional interventions are gaining the recognition of health care professionals in the biomedical/scientific health care system. Acupuncture, acupressure, therapeutic touch, massage, therapeutic use of music, biofeedback, relaxation techniques, meditation, hypnosis, distraction, imagery, iridology, reflexology, herbal remedies, and others are interventions that people may use either alone or in combination with other treatments. Many pharmacies and grocery stores routinely carry herbal treatments for a wide variety of common illnesses. The efficacy of complementary and alternative interventions for specific health problems has been studied extensively (see National Center for Complementary and Alternative Medicine at www.nccam.nih.gov). The frequency of use of traditional remedies, such as herbs purchased in botanicas and Chinese herbal drugs, is unknown at this time. However, personal observations in these settings indicate great popularity within the traditional members of the ethnocultural community. Fig. 2-7 illustrates examples of the remedies.

Culture and Disease Prevalence

For the past generation, the United States and Canada have enjoyed improvement in the health status of the population. Despite this fact, there continues to be disparities in deaths and illnesses experienced by racial and ethnic emerging majority populations, and it is well known that diseases are not distributed equally among all segments of the population. Abnormal biocultural variations may be genetic or acquired. Information about disease prevalence for various racial and ethnic groups is useful because you are able to focus your assessment according to the increased statistical probability that a particular condition may occur. For example, if you are examining an African-American child with gastrointestinal symptoms, you may focus more on the possibility of lactose intolerance or sickle-cell anemia while considering cystic fibrosis, known primarily among white children, a much less likely source of the problem. Poverty also plays a role in the disparities. Thus, in your assessment, you will want to be certain that you have gathered the appropriate data needed to support or to refute your suspicions. Information regarding several health disparities is included in the CULTURE AND GENETICS section of chapters in this text.