Multicultural Health

Multicultural Health

Second Edition

Lois A. Ritter, EdD, MS, MA, MS-HCA, PMP Consultant, Health and Education

Donald H. Graham, JD, MA Attorney and Consultant, Human Services

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Dedication Preface

Acknowledgments About the Authors

UNIT I The Foundations

Chapter 1 Introduction to Multicultural Health Key Concepts and Terms Diversity Within the United States Cultural Adaptation Health Disparities Causes of Health Disparities Legal Protections for Ethnic Minorities Personal Health Decisions Ethical Considerations Summary Review Activity Case Study References

Chapter 2 Theories and Models Related to Multicultural Health Theories of Health and Illness Pathways to Care Cultural Competence Promoting Cultural Competence Summary Review Activity

Case Study References

Chapter 3 Worldview and Health Decisions Worldview Worldview and Medical Decisions Worldview and Response to Illness Summary Review Activity Case Study References

Chapter 4 Complementary and Alternative Medicine History of Complementary and Alternative Medicine Complementary and Alternative Health Care Modalities Laws Affecting Cultural Practices and Health Summary Review Activity Case Study References

Chapter 5 Religion, Rituals, and Health Religion in the United States Religion and Health Behaviors Religion and Health Outcomes Religion and Well-Being Rituals Summary Review Activity Case Study References

Chapter 6 Communication and Health Promotion in Diverse Societies Health Communication Delivering Your Health Message

Printed Materials Public Health Programs Evaluating Your Multicultural Health Program Summary Review Activity Case Study References

UNIT II Specific Cultural Groups

Chapter 7 Hispanic and Latino American Populations Introduction Terminology History of Hispanics in the United States Hispanics in the United States General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavioral Risk Factors and Common Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the Hispanic Population Summary Review Activity Case Study References

Chapter 8 American Indian and Alaskan Native Populations Introduction Terminology History of American Indians and Alaska Natives in the United States American Indian and Alaskan Native Populations in the United States American Indian and Alaskan Native General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavior Risk Factors and Prevalent Health Problems Considerations for Health Promotion and Program Planning Tips for Working With American Indian and Alaskan Native Populations

Summary Review Activity Case Study References

Chapter 9 African American Populations Introduction Terminology History of African Americans in the United States African Americans in the United States General Philosophy About Disease Prevention and Health Maintenance Healing Traditions Behavior Risk Factors and Prevalent Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the African American Population Summary Review Activity Case Study References

Chapter 10 Asian American Populations Introduction Terminology History of Asian Americans in the United States Asian Americans in the United States General Philosophy About Disease Prevention and Health Maintenance Healing Traditions, Healers, and Healing Aids Behavioral Risk Factors and Common Health Problems Considerations for Health Promotion and Program Planning Tips for Working With the Asian American Population Summary Review Activities Case Study References

Chapter 11 European and Mediterranean American Populations Introduction Terminology History of European and Mediterranean Americans in the United States European and Mediterranean Americans in the United States General Philosophy About Disease Prevention and Health Maintenance History, Healing Practices, and Risk Factors for Three Subcultures Behavior Risk Factors and Prevalent Health Problems for European and Mediterranean Americans Tips for Working With European and Mediterranean American Populations Summary Review Activity Case Studies References

Chapter 12 Nonethnic Cultures Introduction Introduction to the “ Culture of People Suffering Discrimination” History of Gay Americans in the United States Introduction to People With Disabilities Introduction to the Culture of Commerce Consumers Farmworkers Introduction to People Who Are Recent Immigrants or Refugees Summary Review Activities Case Study References

UNIT III Looking Ahead

Chapter 13 Closing the Gap: Strategies for Eliminating Health Disparities

Strategies for Reducing or Eliminating Health Disparities Summary

Review Activities Case Study References




To Gary and Samantha, for creating countless hours of laughter—lr

To Sarah—dg


Your mind is like a parachute . . . it functions only when open. ~ Author unknown

Health care professionals work in a diverse society that presents both opportunities and challenges, so being culturally competent is essential to their role. Although knowing about every culture is not possible, having an understanding of various cultures can improve effectiveness. Multicultural Health provides an introduction and overview to some of the major cultural variations related to health.

Throughout this text, those engaged in health care can acquire knowledge necessary to improve their effectiveness when working with diverse groups, regardless of the predominant culture of the community in which they live or work. The content of this book is useful when working in the field on both individual and community levels. It serves as a guide to the concepts and theories related to cultural issues in health and as a primer on health issues and practices specific to certain cultures and ethnic groups.

New to This Edition NEW! A Student Activity is added to each chapter to challenge student comprehension.

NEW! Two new Feature Boxes appear in each chapter—What Do You Think? and Did You Know?—to engage readers and enhance critical thinking.

NEW! Chapter 3, Worldview and Health Decisions, provides information about the ways that worldview and communication affect health, the provision of health services, health care decisions, and communication.

Expanded! Reiki has been added to Chapter 4, Complementary and Alternative Medicine. Chiropractic care, homeopathy, hypnosis, and hydro-therapy, although important treatment modalities, were removed to keep the chapter focused on culturally based CAM modalities.

Expanded! In Chapter 5, Religion, Rituals, and Health, a section was added about the clinical implications of the relationships among religion, spirituality, and health.

Expanded! In Chapter 6, Communication and Health Promotion in Diverse Societies, tips for communicating with people with limited English proficiency have been added.

Expanded! Chapters 7 through 12 have new sections on worldview, pregnancy, mental health, and death and dying as they relate to the cultural group discussed in each chapter.

Expanded! Chapter 12, Nonethnic Cultures, has been expanded to include people with

disabilities, immigrants and refugees, and the culture of commerce.

Expanded! In Chapter 13, Closing the Gap: Strategies for Eliminating Health Disparities, information about the Health and Humans Services Action Plan to reduce racial and ethnic health disparities and the National Stakeholder Strategy for Achieving Health Equality have been added.

Revised! Laws and ethics material is now integrated throughout where appropriate.

Revised! The model programs have been removed from Chapters 7 through 12 and an activity has been added for learners to conduct research and identify a model program themselves.

About This Book Multicultural Health is divided into three units.

UNIT I, The Foundations, includes Chapters 1 through 6 and focuses on the context of culture, cultural beliefs regarding health and illness, health disparities, models for cross-cultural health and communication, and approaches to culturally appropriate health promotion programs and evaluation.

Chapter 1, Introduction to Multicultural Health, discusses the reasons for becoming knowledgeable about the cultural impact of health practices. It defines terminology and key concepts that set the foundation for the remainder of the text. The chapter addresses diversity in the United States and the racial makeup of the country, health disparities and their causes, and issues related to medical care in the context of culture.

Chapter 2, Theories and Models Related to Multicultural Health, addresses theories regarding the occurrence of illness and its treatment. Terms and theoretical models related to cultural competence are provided. Individual and organizational cultural competence assessments are included.

Chapter 3, Worldview and Health Decisions, explores the concept of worldview on illness and treatment and cultural influences that affect health. Differences in worldview and how that affects perceptions about health, health behaviors, and interactions with health care providers are described. Verbal and nonverbal communication considerations are explained. The chapter closes with discussions about how worldview and communication influence specific areas of health, such as the use of birth control.

Chapter 4, Complementary and Alternative Medicine, provides an introduction to complementary and alternative medicine and health practices. It explores the major non-Western medicine modalities of care, including Ayurvedic medicine, traditional Chinese medicine, herbal medicine, and holistic and naturopathic medicine. The history, theories, and beliefs regarding the source of illness and treatment modalities are described.

Chapter 5, Religion, Rituals, and Health, explores the role of religion and spiritual beliefs in health and health behavior. The similarities and differences between religion and rituals are described. The chapter integrates examples of religious beliefs in the United States and their impact on health decisions and behaviors.

Chapter 6, Communication and Health Promotion in Diverse Societies, includes information about culturally sensitive communication strategies used in public health. Considerations to making health care campaigns using various communication channels, such as social media, appropriate for diverse audiences are explained. A section on health literacy is included.

UNIT II, Specific Cultural Groups, includes Chapters 7 through 12 and addresses the history of specific cultural groups in the United States, beliefs regarding the causes of health and illness, healing traditions and practices, common health problems, and health promotion and program planning for the various cultural groups. These points are applied to specific cultural groups as follows:

Chapter 7, Hispanic and Latino American Populations

Chapter 8, American Indian and Alaskan Native Populations

Chapter 9, African American Populations

Chapter 10, Asian American Populations

Chapter 11, European and Mediterranean American Populations

Chapter 12, Nonethnic Cultures

UNIT III, Looking Ahead, outlines priority areas in health disparities and strategies to eliminate health disparities.

Chapter 13, Closing the Gap: Strategies for Eliminating Health Disparities, explores the implications of the growth of diversity in the United States in relation to future disease prevention and treatment. It further addresses diversity in the health care workforce and its impact on care, as well as the need for ongoing education in cultural competence for health care practitioners.

Features and Benefits Each chapter includes a “Did You Know?” and “What Do You Think?” section to stimulate critical thinking and classroom discussions. Also included are chapter review questions, related activities, and a case study. Key concepts are listed and their definitions are provided in the glossary.

We hope the information contained in Multicultural Health will introduce you to the rich and fascinating cultural landscape in the United States and the diverse health practices and beliefs of various cultural groups. This book is not intended to be an end point; rather, it is a starting point in the journey to becoming culturally competent in health care.

For the Instructor Instructor resources, including Power-Point presentations, Instructor’s Manual, and test bank questions, are available. Contact your sales representative or visit for



We would like to express gratitude to the many dedicated people whose contributions made this book possible. We extend a special thanks to those who provided us with permission to reprint their work. We also are grateful to the Jones & Bartlett Learning team who assisted with the editing, design, and marketing of the book. We would like to particularly acknowledge Sara J. Peterson and Cathy Esperti at Jones & Bartlett Learning for their efforts. Cherilyn Aranzamendez and Jessica Ross, we appreciate your efforts to locate research on the topic of multicultural health. We are also indebted to the reviewers for their thoughtful and valuable suggestions:

First Edition Patricia Coleman Burns, PhD, University of Michigan Maureen J. Dunn, RN, Pennsylvania State University, Shenango Campus Mary Hysell Lynd, PhD, Wright State University Sharon B. McLaughlin, MS, ATC, CSCS, Mesa Community College Melba I. Ovalle, MD, Nova Southeastern University

Second Edition William C. Andress, DrPH, MCHES, La Sierra University Debra L. Fetherman, PhD, CHES, ACSMHFS, University of Scranton Carmel D. Joseph, MPH, Nova Southeastern University Kirsten Lupinski, PhD, Albany State University Hendrika Maltby, PhD, RN, University of Vermont Cindy K. Manjounes, MSHA, EdD, Linden-wood University–Belleville Mary P. Martinasek, PhD, University of Tampa

To our family, friends, and colleagues, we want to express our gratitude because you provided continued encouragement, support, and recognition throughout the process.

About the Authors

Lois A. Ritter earned a doctorate in education and master’s degrees in health science, health care administration, and cultural and social anthropology. She has taught at the university level for approximately 20 years and has led national and regional research studies on a broad range of health topics.

Donald H. Graham is an attorney and holds a master’s degree in urban affairs. He has developed and managed client-centered and culturally appropriate health and human service programs for more than 30 years.


The Foundations

CHAPTER 1 Introduction to Multicultural Health

CHAPTER 2 Theories and Models Related to Multicultural Health

CHAPTER 3 Worldview and Health Decisions

CHAPTER 4 Complementary and Alternative Medicine

CHAPTER 5 Religion, Rituals, and Health

CHAPTER 6 Communication and Health Promotion in Diverse Societies

Courtesy of David Bartholomew


Introduction to Multicultural Health

We have become not a melting pot but a beautiful mosaic. —Jimmy Carter

One day our descendants will think it incredible that we paid so much attention to things like the amount of melanin in our skin or the shape of our eyes or our gender instead of the unique identities of each of us as complex human beings.

—Author unknown

Key Concepts

Multicultural health Cultural competence Culture Dominant culture Race Racism Discrimination Ethnicity Cultural ethnocentricity Cultural relativism Cultural adaptation Acculturation Minority Assimilation Heritage consistency Health disparity Healthy People 2020 Hill-Burton Act Ethics Morality Autonomy Respect Veracity Fidelity Beneficence Nonmaleficence Justice

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Learning Objectives

After reading this chapter, you should be able to:

1. Explain why cultural considerations are important in health care.

2. Describe the processes of acculturation and assimilation.

3. Define race, culture, ethnicity, ethnocentricity, and cultural relativism.

4. Explain what cultural adaptation is and why it is important in health care.

5. Explain what health disparities are and their related causes.

6. List the five elements of the determinants of health and describe how they relate to health disparities.

7. Explain key legislation related to health and minority rights.

Why do we need to study multicultural health? Why is culture important if we all have the same basic biological makeup? Isn’t health all about science? Shouldn’t people from different cultural backgrounds just adapt to the way we provide health care in the United States if they are in this country?

For decades, the role that culture plays in health was virtually ignored, but the links have now become more apparent. As a result, the focus on the need to educate health care professionals about the important role that culture plays in health has escalated. Health is influenced by factors such as genetics, the environment, and socioeconomic status, as well as by other cultural and social forces. Culture affects people’s perception of health and illness, how they pursue and adhere to treatment, their health behaviors, beliefs about why people become ill, how symptoms and concerns about the problem are expressed, what is considered to be a health problem, and ways to maintain and restore health. Recognizing cultural similarities and differences is an essential component for delivering effective health care services. To provide quality care, health care professionals need to provide services within a cultural context, which is the focus of multicultural health.

Multicultural health is the phrase used to reflect the need to provide health care services in a sensitive, knowledgeable, and nonjudgmental manner with respect for people’s health beliefs and practices when they are different from our own. It entails challenging our own assumptions, asking the right questions, and working with the patient and the community in a manner that respects the patient’s lifestyle and approach to maintaining health and treating illness. Multicultural health integrates different approaches to care and incorporates the culture and belief system of the health care recipient while providing care within the legal, ethical, and medically sound practices of the practitioner’s medical system.

Knowing the health practices and cultures of all groups is not possible, but becoming familiar with various groups’ general health beliefs and preferences can be very beneficial and improve the effectiveness of health care services. In this text, generalizations about cultural groups are provided,

but it is important to realize that many subcultures exist within those cultures, and people vary in the degree to which they identify with the beliefs and practices of their culture of origin. Awareness of general differences can help health care professionals provide services within a cultural context, but it is important to distinguish between stereotyping (the mistaken assumption that everyone in a given culture is alike) and generalizations (awareness of cultural norms) (Juckett, 2005). Generalizations can serve as a starting point but do not preclude factoring in individual characteristics such as education, nationality, faith, and level of cultural adaptation. Stereotypes and assumptions can be problematic and can lead to errors and ineffective care. Remember, every person is unique, but understanding the generalizations can be beneficial because it moves people in the direction of becoming culturally competent.

Cultural competence refers to an individual’s or an agency’s ability to work effectively with people from diverse backgrounds. Culture refers to a group’s integrated patterns of behavior, and competency is the capacity to function effectively. Cultural competence occurs on a continuum, and this text is geared toward helping you progress along the cultural competence continuum.

Specific terms related to multicultural health, such as race and acculturation, need to be clarified, and this chapter begins by defining some of these terms. Following that is a discussion of the demographic landscape of the U.S. population and how it is changing, types and degrees of cultural adaptation, and health disparities and their causes. The chapter concludes with an analysis of the legislation related to health care that is designed to protect minorities.

Key Concepts and Terms Some of the terminology related to multicultural health can be confusing because the differences can be subtle. This section clarifies the meaning of terms such as culture, race, ethnicity, ethnocentricity, and cultural relativism.

Culture There are countless definitions of culture. The short explanation is that culture is everything that makes us who we are. E. B. Tylor (1924/1871), who is considered to be the founder of cultural anthropology, provided the classical definition of culture. Tylor stated in 1871, “ Culture, or civilization, taken in its broad, ethnographic sense, is that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society” (p. 1). Tylor’s definition is still widely cited today. A modern definition of culture is the “ integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Office of Minority Health, 2013).

Culture is learned, changes over time, and is passed on from generation to generation. It is a very complex system, and many subcultures exist within each culture. For example, universities, businesses, neighborhoods, age groups, homosexuals, athletic teams, and musicians are subcultures of the dominant American culture. Dominant culture refers to the primary or predominant culture of a region and does not indicate superiority. People simultaneously belong to numerous subcultures because we can be students, fathers or mothers, and bowling enthusiasts at the same time.

Race and Ethnicity Race refers to a person’s physical characteristics and genetic or biological makeup, but race is not a scientific construct. Race is a social construct that was developed to categorize people, and it was based on the notion that some “ races” are superior to others. Many professionals in the fields of biology, sociology, and anthropology have determined that race is a social construct and not a biological one because not one characteristic, trait, or gene distinguishes all the members of one so- called race from all the members of another so-called race. “ There is more genetic variation within races than between them, and racial categories do not capture biological distinctiveness” (Williams, Lavizzo-Mourey, & Warren, 1994).

Why is race important if it does not really exist? Race is important because society makes it important. Race shapes social, cultural, political, ideological, and legal functions in society. Race is an institutionalized concept that has had devastating consequences. Race has been the basis for deaths from wars and murders and suffering caused by discrimination, violence, torture, and hate crimes. The ideology of race has been the root of suffering and death for centuries even though it has little scientific merit.

The 2010 U.S. Census questions related to ethnicity and race can be found in Figure 1.1 and Figure 1.2. Box 1.1 explains how these terms were defined in the 2010 census. The U.S. government declared that Hispanics and Latinos are an ethnicity and not a race.

FIGURE 1.1 U.S. Census origin question, 2010. Source: Population Reference Bureau (2013).

FIGURE 1.2 U.S. Census race question, 2010. Source: Population Reference Bureau (2013).

It is important to note that there is great variation within each of the racial and ethnic categories. For example, American Indians are grouped together even though there are variations between the tribes. It is essential to be aware of the differences that occur within these groups and not to stereotype people. Stereotyping people by their race and ethnicity is racism. Racism is the belief that some races are superior to others by nature. Discrimination occurs when people act on that belief and treat people differently as a result. Discrimination can occur because of beliefs related to factors such as race, sexual orientation, dialect, religion, or gender.

Ethnicity is the socially defined characteristic of a group of people who share common cultural factors such as race, history, national origin, religious belief, or language. So how is ethnicity different from race? Race is primarily based on physical characteristics, whereas ethnicity is based on social and cultural identities. For example, consider these terms in relation to a person born in Korea to Korean parents but adopted by a French family in France as an infant. Ethnically, the person may feel French: she or he eats French food, speaks French, celebrates French holidays, and

learns French history and culture. This person knows nothing about Korean history and culture, but in the United States she or he would likely be treated racially as Asian. Let’s consider another example. The physical characteristics of Caucasians (a race) are typically light skin and eyes, narrow noses, thin lips, and straight or wavy hair. A person whose appearance matches these characteristics is said to be a Caucasian. However, there are many ethnicities within the Caucasian race such as Dutch, Irish, Greek, German, French, and so on. What differentiates these Caucasian ethnic groups from one another is their country of origin, language, cultural heritage and traditions, beliefs, and rituals.

BOX 1.1 Definition of Race Categories Used in the 2010 Census

“ White” refers to a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicated their race(s) as “ White” or reported entries such as Irish, German, Italian, Lebanese, Arab, Moroccan, or Caucasian.

“ Black or African American” refers to a person having origins in any of the black racial groups of Africa. It includes people who indicated their race(s) as “ Black, African Am., or Negro” or reported entries such as African American, Kenyan, Nigerian, or Haitian.

“ American Indian or Alaska Native” refers to a person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. This category includes people who indicated their race(s) as “ American Indian or Alaska Native” or reported their enrolled or principal tribe, such as Navajo, Blackfeet, Inupiat, Yup’ik, or Central American Indian groups or South American Indian groups.

“ Asian” refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. It includes people who indicated their race(s) as “ Asian” or reported entries such as “ Asian Indian,” “ Chinese,” “ Filipino,” “ Korean,” “ Japanese,” “ Vietnamese,” and “ Other Asian” or provided other detailed Asian responses.

“ Native Hawaiian or Other Pacific Islander” refers to a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicated their race(s) as “ Pacific Islander” or reported entries such as “ Native Hawaiian,” “ Guamanian or Chamorro,” “ Samoan,” and “ Other Pacific Islander” or provided other detailed Pacific Islander responses.

“ Some Other Race” includes all other responses not included in the White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander race categories described above. Respondents reporting entries such as multiracial, mixed, interracial, or a Hispanic or Latino group (for example, Mexican, Puerto Rican, Cuban, or Spanish) in response to the race question are included in this category. Source: Humes, Jones, & Ramirez (2011).

How is ethnicity different from culture? One can belong to a culture without having ancestral roots to that culture. For example, a person can belong to the hip-hop culture, but he or she is not

born into the culture. With ethnicity, the culture is a part of the ethnic background, so culture is embedded within the ethnic group. Ethnic groups have shared beliefs, values, norms, and practices that are learned and shared. These patterned behaviors are passed down from one generation to another and are thus preserved.

Cultural Ethnocentricity and Cultural Relativism Cultural ethnocentricity refers to a person’s belief that his or her culture is superior to another one. This can cause problems in the health care field. If a professional believes that his or her way is the better way to prevent or treat a health problem, the health care worker may disrespect or ignore the patient’s cultural beliefs and values. The health care professional may not take into consideration that the listener may have different views than the provider. This can lead to ineffective communication and treatment and leave the listener feeling unimportant, frustrated, disrespected, or confused about how to prevent or treat the health issue, and he or she might view the professional as uneducated, uncooperative, unapproachable, or closed-minded.

To be effective, one needs to see and appreciate the value of different cultures; this is referred to as cultural relativism. The phrase developed in the field of anthropology to refute the idea of cultural ethnocentricity. It posits that all cultures are of equal value and need to be studied from a neutral point of view. It rejects value judgments on cultures and holds the belief that no culture is superior to any other. Cultural relativism takes an objective view of cultures and incorporates the idea that a society’s moral code defines whether something is right (or wrong) for members of that society.

What Do You Think?

Cultural imposition occurs when one cultural group, usually the majority group, forces their culture view on another culture or subculture. Can you provide examples of cultural imposition? Do you think it is ethical? Why or why not?

Diversity Within the United States A great strength of the United States is the diversity of the people. Historically, waves of immigrants have come to the United States to live in the land of opportunity and pursue a better quality of life. Immigrants brought their traditions, languages, and cultures with them, creating a country that developed a very diverse landscape. Of course, some peoples, such as Native Americans, were already on the land, and others, such as African Americans, were forced to come to the United States. An unfortunate outcome was that despite its great advantages, this diversity contributed to racial and cultural clashes as well as to imbalances in equality and opportunities that continue today. These positive and adverse consequences of diversity must be considered in our health care approaches, particularly because the demographics are continuing to change and the inequalities persist. The delivery of health care to individuals, families, and communities must meet the needs of the wide variety of people who reside in and visit the United States.

The percentage of the U.S. population characterized as white is decreasing (see Table 1.1). This is an important consideration for health care providers because ethnic minorities experience poorer health status, which is usually due to economic disparities.

TABLE 1.1 Population Data Related to Origin and Race, 2010

1 In Census 2000, an error in data processing resulted in an overstatement of the Two or More Races population by about 1 million people (about 15 percent) nationally, which almost entirely affected race combinations involving Some Other Race. Therefore, data users should assess observed changes in the Two or More Races population and race combinations involving Some Other Race between Census 2000 and the 2010 Census with caution. Changes in specific race combinations not involving Some Other Race, such as White and Black or African American or White and Asian, generally should be more comparable.

Source: U.S. Census Bureau (2011, March). Sources: U.S. Census Bureau, Census 2000 Redistricting Data (Public Law 94- 171) Summary File, Tables PL1 and PL2; and 2010 Census Redistricting Data (Public Law 94-171) Summary File, Tables P1 and P2.

Source: U.S. Census Bureau (2011).

Cultural Adaptation With this changing landscape in the United States, professionals are encouraged to consider the degree of cultural adaptation that the person has experienced. Cultural adaptation refers to the degree to which a person or community has adapted to the dominant culture or retained their traditional practices. Generally, a first-generation individual will identify more with his or her culture

of origin than a third-generation person. Therefore, when working with the first-generation person, the health care professional needs to be more sensitive to issues such as language barriers, distrust, lack of understanding of the American medical system, and the person’s ties to his or her traditional beliefs.

Acculturation relates to the degree of adaptation that has taken place; a process in which members of one cultural group adopt the beliefs and behaviors of another group. Essentially, members of the minority cultural group take up many of the dominant culture’s traits. Because of the great variety of peoples who have immigrated to the United States, the country is often said to be a melting pot. However, given the tendencies of cultural groups to locate together and maintain some familiar practices in a foreign land, the country also has been described as more like a salad bowl. Both of these analogies reflect the process of cultural interaction.

Except for the indigenous population, everyone in the United States is or is descended from immigrants and refugees. For instance, the Pilgrims of Plymouth Rock were refugees from religious persecution. Each group of people who traveled to America built on the strengths of their own culture while adapting to a new social and economic environment through acculturation. Acculturation can include adopting customs from one culture to another or direct change of customs as one culture dominates the other. Each of the cultures discussed in the text has adapted as new populations arrive, territory is acquired or conquered, or popular or useful practices and beliefs are invented and spread throughout the overall population. Some interactions between cultures generate discriminatory responses, individual stress, and family conflict, whereas others create an appreciation for variation as customs or practices are welcomed into other cultures. Whether melting or mixing, the interrelationship of cultures in the United States in constantly changing. The process continues as new people arrive in the country.

People can experience different levels of acculturation as illustrated in Berry and colleagues’ acculturation framework (see Figure 1.3). The acculturation framework identifies four levels of integration:

1. An assimilated individual demonstrates high-dominant and low-ethnic society immersion. This entails moving away from one’s ethnic society and immersing fully in the dominant society (Stephenson, 2000). As a result, the minority group disappears through the loss of particular identifying physical or sociocultural characteristics. This usually occurs when people immigrate to a new geographic region and in their desire to be part of the mainstream give up most of their culture traits of origin and take on a new cultural identity defined by the dominant culture. Many people do not fully assimilate, however, and tend to keep some of their original cultural beliefs.

2. An integrated person has high-dominant and high-ethnic immersion. Integration entails immersion in both ethnic and dominant societies (Stephenson, 2000). An example of an integrated person is a Russian American who socializes with the dominant group but chooses to speak Russian at home and marries a person who is Russian.

FIGURE 1.3 Acculturation framework.

3. Separated individuals have low-dominant and high-ethnic immersion. A separated individual withdraws from the dominant society and completely submerges into the ethnic society (Stephenson, 2000). An example is a person who lives in an ethnic community such as Little Italy or Chinatown.

4. A marginalized individual has low-dominant and low-ethnic immersion and does not identify with any particular culture or belief system.

Marginalized people tend to have the most psychological problems and the highest stress levels. These individuals often lack social support systems and are not accepted by the dominant society or their culture of origin. A person in the separated mode is accepted in his or her ethnic society but may not be accepted by the dominant culture, leaving the person feeling alienated. The integrated and assimilated modes are considered to be the most psychologically healthy adaptation styles, although some individuals benefit more from one than from the other. Western Europeans and individuals whose families have been in the United States for a number of generations (and are not discriminated against) are most likely to adopt an assimilated mode because they have many beliefs and attributes of the dominant society. Individuals who retain value structures from their country of origin and encounter discrimination benefit more from an integrated (bicultural) mode. To be bicultural one must be knowledgeable about both cultures and see the positive attributes of both of them.

The degree to which people identify with their culture of origin is sometimes referred to as heritage consistency. Some indicators that can help professionals assess the level of cultural

adaptation are inquiring about how long the person has been in the country, how often the person returns to his or her culture of origin, what holidays the person celebrates, what language the person speaks at home, and how much knowledge the person has of his or her culture of origin.

Are people who have higher levels of cultural adaptation healthier? Despite increasing research on the relationships between acculturation and health, the answer to that question is not clear. Research on the influence of acculturation on health indicates contradictory results because the variables are complex. The answer also is dependent upon which health habits are incorporated into one’s lifestyle and which are lost. For example, acculturation can have detrimental effects on one’s dietary patterns if a person is from a culture where eating fruits and vegetables is common and the person incorporates the habit of eating at fast-food restaurants, which is common in the United States. On the other hand, if someone moves from a culture where smoking is common to a culture where it is frowned upon, the person may stop smoking and reduce his or her chances of serious illness.

Acculturation from traditional, nonindustrialized cultures to a modern westernized culture generally has been associated with higher rates of disease. An example of this is the rate of cardiovascular disease among Japanese males in the United States. Increasing levels of acculturation also have been associated with higher rates of specific mental disorders and with substance abuse, suggesting that these disorders result from acculturation. Increasing levels of acculturation are correlated with advancing socioeconomic status, and higher socioeconomic status is correlated with lower rates of disease and disorders. However, in some instances higher acculturation is correlated with higher rates of disease and disorders. What constitutes healthy acculturation, as contrasted with unhealthy acculturation, for which health outcomes, for whom, and under what conditions? Scientific answers to these questions may help empower diverse communities by promoting health and wellness in the presence of acculturation (González Castro, 2007).

Health Disparities Health disparities “ are differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes” (Centers for Disease Control and Prevention, Division of Community Health, 2013, p. 4). Health disparities occur among groups who have persistently experienced historic trauma, social disadvantage, or discrimination. They are widespread in the United States as demonstrated by the fact that many minority groups in the United States have a higher incidence of chronic diseases, higher mortality, and poorer health outcomes when compared to Whites. Numerous other disparities exist such as the health of rural residents being poorer than urban residents and people with disabilities reporting poorer health when compared to those without disabilities.

Eliminating health disparities is an important goal for our nation and is one of the four overarching goals of Healthy People 2020. These four goals are:

1. “ Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

2. Achieve health equity, eliminate disparities, and improve the health of all groups.

3. Create social and physical environments that promote good health for all.

4. Promote quality of life, healthy development, and healthy behaviors across all life stages” (U.S. Department of Health and Human Services [USHHS], 2014).

Some examples of health disparities follow, but numerous other statistics illuminate these differences as well.

African Americans can expect to live 6 to 10 fewer years than whites and face higher rates of illness and mortality (Mead et al., 2008, p. 20).

The prevalence of diabetes among American Indians and Alaska Natives is more than twice that for all adults in the United States (USHHS, 2009).

Hispanic and Vietnamese women are twice as likely as white women to face cervical cancer (USHHS, 2009).

African Americans experience rates of infant mortality that are 2.5 times higher than for whites (Mead et al., 2008, p. 20).

Asian and Pacific Islanders make up less than 5% of the total population in the United States but account for more than 50% of Americans living with chronic hepatitis B (Centers for Disease Control and Prevention [CDC], 2014).

A nationally representative study of adolescents in grades 7 to 12 found that lesbian, gay, and bisexual youth were more than twice as likely to have attempted suicide as their heterosexual peers (Russell & Joyner, 2001).

Rural residents are more likely to be obese than urban residents, 27.4% versus 23.9% (Rural Health Research & Policies Centers, 2008).

People with disabilities have the highest proportion of current smokers (29%), followed by American Indian/Alaska Natives (23%), blacks (22%), Hispanics (16%), and Asians (9%); (Drum, McClain, Horner-Johnson, & Taitano, 2011).

Did You Know?

… that April is National Minority Health month? The purpose is to raise awareness of health disparities. Public health agencies across the national engage in activities to raise awareness about the health disparities that exist around issues such as alcohol and drug use and infectious diseases.

Causes of Health Disparities Health disparities exist due to both voluntary and involuntary factors. Voluntary factors related to health behaviors, such as smoking and diet, can be avoided. Factors such as genetics, living and working in unhealthy conditions, limited or no access to health care, and language barriers are often viewed as involuntary factors because they are not within that person’s control.

Most experts agree that the causes of health disparities are multiple and complex; no single factor

explains why disparities exist across such a wide range of health measures. Access to health care and the quality of health care are important factors, but they do not explain why some groups experience greater risks for poor health in the first place (Alliance for Health Reform, 2010).

Socioeconomic status (SES) is one of the most important predictors of health. Socioeconomic status is typically measured by educational attainment, income, wealth, occupation, or a combination of these factors. In general, the higher one’s SES, the better one’s health (Alliance for Health Reform, 2010). Socioeconomic status is thought to affect health in many ways, such as by increasing access to health-enhancing resources, access to health care, and living in healthier neighborhoods.

SES is related to health disparities, and racial and ethnic minorities are disproportionately found in lower socioeconomic levels. An important exception is the “ Hispanic Epidemiologic Paradox.” This refers to the fact that new Hispanic immigrants are found to have generally better health than U.S.-born individuals of the same SES (Alliance for Health Reform, 2010).

Another way to frame the causes of health disparities is via the factors affecting health that were identified in the 1974 Lalonde report, “ A New Perspective on the Health of Canadians.” This report probably was the first acknowledgment by a major industrialized country that health is determined by more than biological factors. The report led to the development of the “ health field” concept, which identified four health fields that were interdependently responsible for individual health:

1. Environment. All matters related to health external to the human body and over which the individual has little or no control. Includes the physical and social environment.

2. Human biology. All aspects of health, physical and mental, developed within the human body as a result of organic makeup.

3. Lifestyle. The aggregation of personal decisions over which the individual has control. Self- imposed risks created by unhealthy lifestyle choices can be said to contribute to, or cause, illness or death.

4. Health care organization. The quantity, quality, arrangement, nature, and relationships of people and resources in the provision of health care.

These four domains were later refined to include five intersecting domains:

1. environmental exposures,

2. genetics,

3. behavior (lifestyle) choices,

4. social circumstances, and

5. medical care (Institute of Medicine [IOM], 2001).

All five domains are integrated and affected by one another. For example, people who have more education usually have higher incomes (social circumstances), are more likely to live in neighborhoods with fewer environmental health risks (environmental exposures), and have money to purchase healthier foods (lifestyle). Let’s look at each of these domains in more detail.

Environmental Exposures

Environmental conditions are believed to play an important role in producing and maintaining health disparities. The environment influences our health in many ways, including through exposures to physical, chemical, and biological risk factors and through related changes in our behavior in response to those factors. In general, whites and minorities do not have the same exposure to environmental health threats because they live in different neighborhoods. Residential segregation still exists.

Residential segregation between white and black populations continues to be very high in U.S. metropolitan areas. Residential segregation of Hispanics/Latinos is not yet as high as that of African Americans, but it has been increasing over the past few decades; black segregation has modestly decreased (Iceland, Weinberg, & Steinmetz, 2002).

Growing evidence suggests that segregation is a key determinant of racial inequalities for a broad range of societal outcomes, including health disparities (Acevedo-Garcia, Osypuk, McArdle, & Williams, 2008). Segregation affects health outcomes in a multitude of ways. It limits the socioeconomic advancement of minorities through educational quality and employment, and lowers the returns of home ownership due to lower school quality, fewer job opportunities, and lower property values in disadvantaged neighborhoods. Segregation also leads to segregation in health care settings, which in turn is associated with disparities in the quality of treatment (Acevedo-Garcia et al., 2008).

FIGURE 1.4 Racial and ethnic neighborhood disparities. Source: Acevedo-Garcia et al. (2008).

Minorities tend to live in poorer areas (see Figure 1.4), and these disadvantaged neighborhoods are exposed to greater health hazards, including tobacco and alcohol advertisements, toxic waste incinerators, and air pollution. Tiny particles of air pollution contain more hazardous ingredients in non-white and low-income communities than in affluent white ones (Katz, 2012). The greater the concentration of Hispanics, Asians, African Americans, or poor residents in an area, the more likely it is that potentially dangerous compounds such as vanadium, nitrates, and zinc are in the mix of fine particles they breathe. In a study conducted in 2012, the group with the highest exposure to the largest number of these ingredients was Latinos, while whites generally had the lowest exposure. Economic stress within a community may exacerbate tensions between social groups, magnify workplace stressors, induce maladaptive coping behaviors such as smoking and alcohol use, and

translate into individual stress, all of which makes individuals more vulnerable to illness (e.g., depression, high blood pressure). Factors associated with living in poor neighborhoods—crime, noise, traffic, litter, crowding, and physical deterioration—also can cause stress.

Some health issues related to where one lives include the following (Cooper, 2014):

Two to three times as many fast food outlets are located in segregated black neighborhoods than in white neighborhoods of comparable socioeconomic status, contributing to higher black consumption of fatty, salty meals and in turn widening racial disparities in obesity and diabetes.

Black neighborhoods contain two to three times fewer supermarkets than comparable white neighborhoods, creating the kind of “ food deserts” that make it difficult for residents who depend on public transportation to purchase the fresh fruits and vegetables that make for a healthy diet.

Fewer African-Americans have ready access to places to work off excess weight that can gradually cause death. A study limited to New York, Maryland and North Carolina found that black neighborhoods were three times more likely to lack recreational facilities where residents could exercise and relieve stress.

Because of “ the deliberate placement of polluting factories and toxic waste dumps in minority neighborhoods,” exposure to air pollutants and toxins is five to twenty times higher than in white neighborhoods with the same income levels.

Regardless of their socioeconomic status, African-Americans who live in segregated communities receive unequal medical care because hospitals serving them have less technology, such as imaging equipment, and fewer specialists, like those in heart surgery and cancer.

Genetics Genetics have been linked to many diseases, including diabetes, cancer, sickle-cell anemia, obesity, cystic fibrosis, hemophilia, Tay-Sachs disease, schizophrenia, and Down syndrome. Currently, about 4,000 genetic disorders are known. Some genetic disorders are a result of a single mutated gene, and other disorders are complex, multifactorial or polygenic mutations. (Multifactorial means that the disease or disorder is likely to be associated with the effects of multiple genes in combination with lifestyle and environmental factors.) Examples of multifactorial disorders are cancer, heart disease, and diabetes. Although numerous studies have linked genetics to health, social and cultural factors play a role as well. For example, smoking may trigger a genetic predisposition to lung cancer, but that gene may not have been expressed if the person did not smoke.

There are concerns about relating genetics and health disparities because race is not truly biologically determined, so the relationship between genetics and race is not clear cut. There are more genetic differences within races than among them, and racial categories do not capture biological distinctiveness. Another problem with linking genetics to race is that many people have a mixed gene pool due to interracial marriages and partnerships. Also, it is difficult at times to determine which diseases are related to genetics and which are related to other factors, such as lifestyle and the environment.

Sometimes disease is caused by a combination of factors. For example, African Americans have been shown to have higher rates of hypertension than whites, but is that difference due to genetics? African Americans tend to consume less potassium than whites and have stress related to

discrimination, which could be the cause of their higher rates of hypertension. Health disparities also can be related to the level of exposure to environmental hazards, such as toxins and carcinogens, that some racial groups are exposed to more than others. Therefore, it is difficult to link health disparities to genetics alone because a variety of factors may be involved. Genetics does play a role in health however, and some clear links have been made, such as people with lighter skin tones being more prone to skin cancer.

Lifestyle Behavior patterns are factors that the individual has more control over. Many of the diseases of the 21st century are caused by personally modifiable factors, such as smoking, poor diet, and physical inactivity. So how does lifestyle relate to ethnicity? Studies reveal that differences in health behaviors exist among racial and ethnic groups. For example, the national Youth Risk Behavior Survey (YRBS) monitors priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States. The national YRBS is conducted every 2 years during the spring semester and provides data representative of 9th through 12th grade students in public and private schools throughout the United States. Data shows racial and ethnic differences in behaviors such as alcohol consumption, use of sunscreen, physical activity levels, substance use, and being injured in a fight.

Social Circumstances Social circumstances include factors such as SES, education level, stress, discrimination, marriage and partnerships, and family roles. SES is made up of a combination of variables including occupation, education, income, wealth, place of residence, and poverty. These variables do not have a direct effect on health, but they do have an indirect effect. For example, low SES does not cause disease, but poor nutrition, limited access to health care, and substandard housing certainly do, and these are just a few of the many indirect effects. Discrimination does not cause poor health directly either, but it can lead to depression and high blood pressure.

One variable of social circumstances, poverty, can be measured in many ways. One approach is to measure the number of people who are recipients of federal aid programs, such as food stamps, public housing, and Head Start. Another method is through labor statistics, but the most common way is through the federal government’s measure of poverty based on income. The federal government’s definition of poverty is based on a threshold defined by income, and it is updated annually. So how is poverty related to ethnicity?

FIGURE 1.5 Poverty rates by race. Source: Data from U.S. Census Bureau (2011).

Poverty is higher among certain racial and ethnic groups (see Figure 1.5) and is a contributing factor to health disparities because poverty affects many factors, including where people live and their access to health care. What may not be surprising is that low SES groups more often act in ways that harm their health than do high SES groups. It is perplexing that some of these unhealthy behaviors are adopted despite the monetary and health costs. For example, smoking cigarettes and alcohol consumption require that the person spend money on these items. Pampel, Krueger, and Denney (2010) noted some important facts related to socioeconomic factors in health behaviors. One example is access to health aids. Adopting many healthy behaviors does not require money, but having more money to pay for tobacco cessation aids, joining fitness clubs and weight loss programs, and buying more expensive fruits, vegetables, and lean meats can help people achieve

better health.

Medical Care The shortfalls for minorities in the health care system in the United States can be categorized into three general areas: (1) lack of access to care, (2) lower quality of care, and (3) limited providers with the same ethnic background.

Lack of Access to Medical Care Research has shown that without access to timely and effective preventive care, people may be at risk for potentially avoidable conditions, such as asthma, diabetes, and immunizable conditions (National Center for Health Statistics, 2006). Access to health care is also important for prompt treatment and follow-up to illness and injury.

Access to health care is a problem for many Americans due to lack of health care insurance. According to the National Health Interview Survey (NHIS), in 2012, 45.5 million persons of all ages (14.7%) were uninsured at the time of interview (Cohen & Martinez, 2013). Access to health care is particularly problematic for minorities because they have higher rates of being uninsured than whites. Based on data from the 2012 NHIS, Hispanics were more likely than non-Hispanic whites, non-Hispanic blacks, and non-Hispanic Asians to be uninsured at the time of interview, to have been uninsured for at least part of the past 12 months, and to have been uninsured for more than a year. More than one quarter of Hispanics were uninsured at the time of interview, and one third had been uninsured for at least part of the past year (Cohen & Martinez, 2013).

The Patient Protection and Affordable Care Act (ACA), passed in 2010, was designed to increase the quality and affordability of health insurance, hence lowering the rate of uninsured. The ACA went into effect on January 1, 2014, but it is too soon to know whether it will achieve this goal.

Lower Quality of Care Despite improvements, differences persist in health care quality among racial and ethnic minority groups. People in low-income families also experience poorer quality care. Disparities in quality of care are common. For example,

Blacks and American Indians and Alaska Natives received worse care than whites for about 40% of measures.

Asians received worse care than whites for about 20% of measures.

Hispanics received worse care than non-Hispanic whites for about 60% of core measures.

Poor people received worse care than high-income people for about 80% of core measures. (Agency for Healthcare Research and Quality, 2011a)

Disparities in access are also common, especially among Hispanics and poor people:

Blacks had worse access to care than whites for one third of core measures.

Asians and American Indians and Alaska Natives had worse access to care than whites for 1 of 5 core measures.

Hispanics had worse access to care than non-Hispanic whites for 5 of 6 core measures.

Poor people had worse access to care than high-income people for all 6 core measures. (Agency for Healthcare Research and Quality, 2011a.)

Examples of core measures include adults 40 and over with diabetes who received their exams, adults over age 50 who received a colonoscopy, and children ages 19 to 35 months who received their vaccines.

Limited Providers With the Same Ethnic Background Ethnic minorities are poorly represented among physicians and other health care professionals. For almost all of the following list of health care occupations, Euro-Mediterraneans and Asians are overrepresented while blacks and Hispanics are underrepresented: physicians and surgeons, registered nurses, licensed practical and licensed vocational nurses, dentists, dental hygienists, dental assistants, pharmacists, occupational therapists, physical therapists, and speech-language pathologists (Agency for Healthcare Research and Quality, 2011b). Two exceptions were noted. Blacks are overrepresented among licensed practical and licensed vocational nurses, and Hispanics are overrepresented among dental assistants. Of the health care occupations tracked, these two require the least amount of education and have the lowest median annual wages (Agency for Healthcare Research and Quality, 2011b). More specifically, although African Americans, Hispanics, and Native Americans make up over a quarter of the nation’s population, in 2007 African Americans accounted for only 3.5%, Hispanics 5%, and Native Americans/Native Alaskans 0.2% of physicians (American College of Physicians, 2010). Similar workforce disparities are found among some Asian subgroups, such as Samoans and Cambodians (American College of Physicians, 2010).

As a result, minority patients are frequently treated by professionals from a different racial or ethnic background. Many programs, funding agencies, and research studies suggest that more diversity is needed among health care professionals to improve quality of care and reduce health disparities. But is there evidence that racial concordance (patients being treated by people in the same ethnic group) accomplishes these goals?

A comprehensive review of research published between 1980 and 2008 was conducted by Meghani et al. (2009). Twenty-seven studies having at least one research question examining the effect of patient–provider race-concordance on minority patients’ health outcomes and pertained to minorities in the United States were included in this review. Of the 27 studies, patient–provider race-concordance was associated with positive health outcomes for minorities in only 9 studies (33%); 8 studies (30%) found no association of race-concordance with the outcomes studied; and 10 studies (37%) presented mixed findings. The authors concluded that having a provider of same race did not improve “ receipt of services” for minorities.

Legal Protections for Ethnic Minorities Many laws have been passed to help reduce discrimination, including in the health care arena. The Civil Rights Act of 1964 was passed by Congress and signed into law by President Lyndon Baines Johnson. Title VI of the Civil Rights Act prohibits federally funded programs or activities from

discriminating on the basis of race, color, or national origin. Federal agencies are responsible for enforcement of this law. In areas involving discrimination in health care, the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS), is responsible for enforcement. Title VI of the act is the operative section that informs non-discrimination in health care. It has three key elements:

1. It established a national priority against discrimination in the use of federal funds.

2. It authorized federal agencies to establish standards of nondiscrimination.

3. It provided for enforcement by withholding funds or by any other means authorized by law.

Since the Civil Rights Act of 1964 was passed, numerous other statutes and regulations have been created to address discrimination against ethnic minorities in health care, including the Hill- Burton Act. The Hill-Burton Act has been amended a number of times since its inception. The amendment entitled “ Community Service Assurance under Title IV of the U.S. Public Health Service Act” requires facilities to provide services to persons living within the service area without discrimination based on race, national origin, color, creed, or any other reason not related to the person’s need for services. The subsequent HHS regulations set forth the requirements with which a Hill-Burton facility must comply (USHHS, Office for Civil Rights, 2006):

A person residing in the Hill-Burton facility’s service area has the right to medical treatment at the facility without regard to race, color, national origin, or creed.

A Hill-Burton facility must post notices informing the public of its community service obligations in English and Spanish. If 10% or more of the households in the service area usually speak a language other than English or Spanish, the facility must translate the notice into that language and post it as well.

A Hill-Burton facility may not deny emergency services to any person residing in the facility’s service area on the grounds that the person is unable to pay for those services.

A Hill-Burton facility may not adopt patient admission policies that have the effect of excluding persons on grounds of race, color, national origin, creed, or any other ground unrelated to the patient’s need for the service or the availability of the needed service.

Title VI and HHS services regulations require recipients of federal financial assistance from HHS to take reasonable steps to provide meaningful access to limited English proficiency (LEP) persons. Federal financial assistance includes grants, training, use of equipment, donations of surplus property, and other assistance. Recipients of HHS assistance may include hospitals, nursing homes, home health agencies, managed care organizations, universities, and other entities with health or social service research programs. It also may include state Medicaid agencies; state, county, and local welfare agencies; programs for families, youth, and children; Head Start programs; public and private contractors, subcontractors, and vendors; and physicians and other providers who receive federal financial assistance from HHS (USHHS, Office for Civil Rights, n.d.).

Recipients are required to take reasonable steps to ensure meaningful access to their programs and activities by LEP persons. The obligation to provide meaningful access is fact dependent and starts with an individualized assessment that balances four factors: (1) the number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee; (2) the frequency

with which LEP individuals come into contact with the program; (3) the nature and importance of the program, activity, or service provided by the recipient to its beneficiaries; and (4) the resources available to the grantee/recipient and the costs of interpretation/translation services. There is no “ one size fits all” solution for Title VI compliance with respect to LEP persons, and what constitutes “ reasonable steps” for large providers may not be reasonable where small providers are concerned (USHHS, Office for Civil Rights, n.d.).

If, after completing the four-factor analysis, a recipient determines that it should provide language assistance services, a recipient may develop an implementation plan to address the identified needs of the LEP populations it serves. Recipients have considerable flexibility in developing this plan. The guidance provides five steps that may be helpful in designing such a plan: (1) identifying LEP individuals who need language assistance; (2) language assistance measures (such as how staff can obtain services or respond to LEP callers); (3) training staff; (4) providing notice to LEP persons (such as posting signs); and (5) monitoring and updating the LEP plan (USHHS, Office for Civil Rights, n.d.).

Culturally and Linguistically Appropriate Services (CLAS) In compliance with Title VI and the LEP regulations, the HHS Office of Minority Health (OMH) has developed “ National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS).” In promulgating these standards, OMH provided its rationale for preparing the standards and recommendations for their use. The CLAS standards are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of these standards is expected to help advance better health and health care in the United States. The CLAS standards are listed in Table 1.2.

It is worth noting that both federal and state governments have begun addressing the need for cultural competence through various standards and legislation. States are requiring cultural competence education in medical and nursing schools, and legislation in many states includes requiring cultural competence training for health care providers to receive licen-sure or relicensure. Figure 1.6 highlights the states that are proposing to implement cultural competence training.

TABLE 1.2 National CLAS Standards

Source: USHHS, Office of Minority Health (n.d.).

FIGURE 1.6 Map of states with cultural competence legislation.

Personal Health Decisions Perhaps the area where law and cultural health issues intersect the most is in the area of personal health care decisions. How an individual approaches health care decisions is informed by his or her

personal experiences as well as family, religious, and cultural influences. Different cultures approach how to undergo treatment, when to treat, and when to stop treatment differently. Even more important, who will make such decisions for a patient may differ from culture to culture.

Therefore, it is important to understand the legal construct that affects health care decisions. The laws of all the states reflect an individual’s constitutional right to privacy and to make personal decisions free from outside influence. Consequently, the right to make health care decisions is personal to the patient involved, and no one else has the right to interfere. In cultures where family input is sought for such decisions, or a surrogate decision maker is used, this legal principle could create decision-making conflicts. A competent individual can appoint someone else to make decisions for him or her, thus removing the conflict.

The more problematic situation is when the patient is unable to make his or her wishes known because of the patient’s medical condition. In that situation, it is important to have documents prepared in advance that name who will make decisions for the person and what decisions are to be made that are consistent with the person’s cultural beliefs. Health care powers of attorney are documents that appoint who will make decisions for the person if he or she is unable to decide. A living will documents what decisions and desires a person has about his or her care and end-of-life decisions, and it can, and should, include instructions respecting the person’s cultural beliefs. Many states have combined these two documents into one advance health care document that covers all the various decisions. Whatever format is utilized in a particular state, the importance of having these documents remains.

Ethical Considerations Ethics point to standards or codes of behavior expected by the group to which the individual belongs. Ethics are different from morals in that morality refers to personal character and what the individual believes is right or wrong conduct. For example, a nurse’s moral code may consider murder to be wrong, but the nurse has an ethical obligation to provide services for a murderer if the murderer is a patient in the medical facility.

The legal system is a set of rules and regulations that are binding on the members of a society and that set out what behavior is acceptable. They are subject to review and change as the society changes. The relationship between law and ethics significantly affects health care decisions and cultural influences. The ethical principles with the most impact on cultural issues in health care are autonomy, nonmaleficence, beneficence, and justice.

Autonomy is the ethical principle that embodies the right of self-determination. It is the right to choose what happens to one’s self and decision making. It is embodied in the concept of informed consent in health care, which is the right to be informed about recommended treatment prior to consent. Autonomy requires that certain conditions exist, including understanding; an absence of controlling influences, which is traditionally understood as liberty; and agency, which is the ability to act intentionally (Beauchamp & Childress, 2001).

For this ethical principle to be achieved, the health care provider must respect and guard the patient’s right to self-determination. This includes informing patients in a manner that considers both cultural and language barriers to understanding. The CLAS standards are an attempt to respect

the ethical concept of autonomy. Respect takes into account individuals’ rights to make determinations about their health and to live or die with the consequences. Respect for others does not allow cultural, gender, religious, or racial differences to interfere with that individual right. Respect is evident when the cultural heritage and practices of patients are considered in treatment even when the provider does not share that value.

In respect for autonomy, not only the right to choose is respected, but a right not to choose should be respected as well. Valuing a patient’s right to defer decision making to another person, or not to be informed about the extent of his or her condition, is as essential to the principle of autonomy as ensuring that a patient who desires autonomy is fully informed about his or her treatment options.

Associated with respecting patient autonomy are two principles that should be followed by the caregiver: veracity and fidelity. Veracity involves being truthful and providing necessary information in an honest way. Fidelity entails keeping one’s promises or commitments. It requires not promising what one cannot do or control. Both of these principles are necessary for patients to be truly informed about their care so they can make autonomous decisions.

Beneficence is the principle that requires doing good or removing harm. It is often intertwined with nonmaleficence, but it is a distinct ethical construct. Beneficence is at work when balancing the risk, benefit, harm, and effectiveness of treatment. When harm is found, positive actions are required to remove or limit it. This ethical principle was at work when segregated hospitals were outlawed by the Civil Rights Act.

Nonmaleficence is the principle that states that one should do no harm. Although simple in concept, it is often difficult in practice. In health care, actions can often cause harm, and very few treatment modalities are completely without risk of harm. Thus the practitioner must weigh the risks and benefits of any treatment.

However, it is the unknown harm that should be addressed in the cultural context. Practitioners should be aware that patients from cultures other than their own may perceive situations as harmful that are not readily apparent to them. For example, physical examination of a female by a male practitioner is considered to be unacceptable in some cultures and can lead to serious consequences for the female patient. Making arrangements for a female examiner would evidence the ethical concept of nonmaleficence.

Justice is the ethical principle that holds that people should be treated equally and fairly. Justice requires that people not be treated differently because of their culture or ethnic background. Justice is also at issue when the allocation and distribution of limited health resources are discussed. Ensuring that health resources are available to all without regard to race or ethnicity is the theory of distributive justice. It is this ethical principle that is breached when care is denied or withheld on racial or ethnic grounds.

The fair opportunity rule of justice states that no one should receive social benefits based on undeserved advantages or be denied benefits on the basis of disadvantages (Beauchamp & Childress, 2001). Although this may seem fairly straightforward, it becomes difficult to manage when applied to the variances of social inequalities. The rule states that discrimination is not ethically justifiable on the basis of social status or ethnicity.


One of the great attributes of the United States is its diverse landscape. Immigrants (voluntary and forced) who have come to the United States and natives of this country have experienced different levels of cultural adaptation to blend into the dominant society. Some have retained their strong cultural ties to create a society of rich and diverse cultures filled with various beliefs, traditions, languages, and societal norms. Understanding and respecting this diverse landscape is a goal for the nation, specifically for the health care industry. Health care providers need to be knowledgeable about and sensitive to cultural differences to provide effective care and education. Laws have been established to address inequalities.

This chapter provides an understanding of the foundations of multicultural health and the key terms and concepts associated with it, such as culture, race, assimilation, and cultural relativism. You should now have a general appreciation of how culture affects health, the breadth and depth of health disparities and their related causes, as well as the legal protections provided to people in the United States.

Review 1. What is the focus of multicultural health, and why is it important?

2. Is race a biological or a social construct? Why is race important?

3. What is the difference between ethnicity and culture? What is the difference between race and ethnicity?

4. Explain cultural ethnocentricity and cultural relativism.

5. Explain the differences between the concepts of acculturation, assimilation, and bicultural.

6. Does the level of acculturation have a positive or negative effect on health? Explain.

7. Explain what health disparities are and their causes.

8. Describe the key intentions of the Civil Rights Act and the Hill-Burton Act.

9. Explain the ethical principles related to health care decision making and how they influence health care services.


Conduct research to identify a legal case related to health and culture. Write a paper explaining the situation, the court’s decision and the reason behind the decision, and your reaction to the outcome.

Case Study The book titled The Spirit Catches You and You Fall Down, by Anne Fadiman, tells the story of Lia Lee, a Hmong child with epilepsy, who lived in Merced, California. When 3-month-old Lia Lee arrived at the county hospital emergency room in Merced, a chain of events was set in motion from

which Lia, her parents, and her doctors would never recover. Lia’s parents, Foua and Nao Kao, were part of a large Hmong community in Merced, refugees from the “ Quiet War” in Laos. Her parents and doctors both wanted the best for Lia, but their ideas about the causes of her illness and its treatment were very different.

The Hmong see illness and healing as spiritual matters that are linked to virtually everything in the universe, but the U.S. medical community marks a division between body and soul and concerns itself almost exclusively with the former. Lia’s doctors attributed her seizures to the misfiring of her cerebral neurons; her parents called her illness “ qaug dab peg”—the spirit catches you and you fall down—and ascribed it to the wandering of her soul. The doctors prescribed anticonvulsants; her parents preferred animal sacrifices. The Spirit Catches You and You Fall Down moves from hospital corridors to healing ceremonies, and from the hill country of Laos to the living rooms of Merced, uncovering in its path the complex sources and implications of two dramatically clashing worldviews.

Lia’s doctors prescribed a complex regimen of medication designed to control her seizures. However, her parents believed that the epilepsy was a result of Lia “ losing her soul” and did not give her the medication as indicated because of the complexity of the drug therapy and the adverse side effects. Instead, they did everything logical in terms of their Hmong beliefs to help her. They took her to a clan leader and shaman, sacrificed animals, and bought expensive amulets to guide her soul’s return. Lia’s doctors believed that her parents were endangering her life by not giving her the medication, so they called child protective services, and Lia was placed in foster care. Lia was a victim of a misunderstanding between these two cultures that were both intent on saving her. The results were disastrous: a close family was separated, and Hmong community faith in Western doctors was shaken.

Lia was surrounded by people who wanted the best for her and her health. Unfortunately, the involved parties disagreed on the best treatment because they understood her epilepsy differently. The separate cultures of Lia’s caretakers had different concepts of health and illness.

This example illustrates how culture and health influence each other and at times clash. To help ensure good care for diverse patients, health care providers must address cultural issues and respect the cultural values of each patient.

There are several issues to consider about this case:

How can health care providers prepare for situations like Lia’s?

Should child protective services have been contacted?

Were Lia’s parents irresponsible?

How did the parents’ belief system affect Lia’s health care?

Were the parents’ decisions morally and legally wrong?

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Theories and Models Related to Multicultural Health

An understanding of the determinants of the different distribution of health problems among racial or ethnic groups is a prerequisite to the development and direction of effective programs and services to address them.

—Williams, Lavizzo-Mourey, & Warren (1994)

Key Concepts

Personalistic belief system Naturalistic theories of disease

Humoral system Ayurvedic system Vitalistic system Biomedical (allopathic) medicine Germ theory Holistic medicine

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Learning Objectives

After reading this chapter, you should be able to:

1. Explain three overarching theories of the causes of illness and provide examples of each.

2. Explain the differences between the biomedical and holistic systems of care.

3. Explain two models of cultural competence.

“ Being cold will give you a cold,” “ cracking your knuckles will give you arthritis,” and “ feed a fever, starve a cold” are three of many commonly held beliefs by the dominant culture in the United States about how illness can occur and be cured. People from different cultures hold their own beliefs about the causes and cures of illness, and these beliefs influence their behavior and where and when they decide to seek care. Many others factors also affect our health care experience, such as how we communicate about health, whether we believe we have control over our own health, and how health care decisions are made. These factors can be so deeply ingrained that they are almost invisible. Because of this invisibility, health care professionals can overlook these key differences and forget that not all people who reside within the United States have the same beliefs about health and illness. Therefore, it is essential to bring these issues to light, which is the purpose of this chapter.

This chapter begins with a discussion of theories about how illness occurs and then presents models of care for when illness does occur. The chapter ends with a focus on cultural competence and ways to improve cultural competence.

Theories of Health and Illness Theories about health and illness address the beliefs people hold about how to maintain health and the causes of illness. These ideas, beliefs, and attitudes are socially constructed and are deeply ingrained in people’s cultural experience, and they can have a profound effect on medical care. Where people seek care and when are rooted in their cultural belief system (Carteret, 2011). Their beliefs influence prevention efforts, delay or prevent medical care, and complicate the care given (Carteret, 2011).

Ideas about health maintenance vary among cultures and include ideologies such as consuming a well-balanced diet, wearing amulets, rewards for good behavior, and prayer. Illness causation ideologies include breach of taboo, soul loss, exposure to germs, upset in the hot–cold balance of the body, or a weakening of the body’s immune system. Treatment methods range from medications and surgeries to witchcraft and returning the soul to the ill person. In the Western world, the human body is thought of as a machine; when the machine breaks, illness occurs. Eastern philosophies generally view health as a state of balance between the physical and social environments as well as the supernatural environment (Carteret, 2011).

Theories of health and illness serve to create a context of meaning within which the patient can make sense of his or her bodily experience. They assist the patient in framing the illness in a meaningful and logical manner. A meaningful context for illness usually reflects core cultural values and helps the patient bring order to the chaotic world of serious illness and regain some sense of control in a frightening situation. Theories of illness shape how people receive and respond to prevention programs, treatment, and health education messages.

Theories of illness are often divided into three broad categories: personalistic, naturalistic, and biomedical (allopathic). In a personalistic system, illness is believed to be caused by the intentional intervention of an agent who may be a supernatural being (a deity or ancestral spirits) or a human being with special powers (a witch or sorcerer). The sick person’s illness is considered to be a direct result of the harmful influence of these agents and is often linked to the ill person’s behavior. In naturalistic causation, illness is explained in terms of a disturbed natural equilibrium. When the body is in balance with the natural environment, a state of health is achieved. When the balance no longer exists, then illness occurs. In the biomedical theory, illness is identified and cured using scientific evidence. The cause of illness is physiological in nature.

Many people’s beliefs systems are a combination of these three theories. The theories are used by people to understand and respond to the illness. Through communication, patients and providers can work together and combine the theories to try to achieve a positive outcome for the patient.

Personalistic Theories In the personalistic belief system, illness is believed to be caused by the person’s misbehavior. The behavior could be related to violations of social or religious norms. As a result of moral or spiritual failings, the person may have punishment invoked in the form of illness by a supernatural being or a human with special powers. The supernatural being may be a dead ancestor or a deity (Carteret, 2011). A dead ancestor may retaliate for not carrying out proper rituals of respect for the dead ancestor. The deity may retaliate for breaching a religious taboo. Bad luck or karma also may cause illness.

Illness also can be caused by people who have the power to make others ill, such as witches, practitioners of voodoo, and sorcerers. These malevolent human beings manipulate secret rituals and charms to cause illness in their enemies.

Recovery from the illness involves healers using supernatural means to understand what is wrong with their patients and to return them to health. These supernatural means usually involves rituals or symbolisms used by healers, such as shaman, who are trained in the healing methods. Native Americans and people from Latin America and Asia often hold the personalistic belief system

(Carteret, 2011). Preventing personalistic illness includes avoiding situations that can provoke jealousy or envy, wearing certain amulets, adhering to social norms and moral behaviors, adhering to food taboos and restrictions, and performing certain rituals. Several personalistic beliefs and practices are reviewed in later chapters.

Did You Know?

Osteopathic medicine is a form of medical care based on the philosophy that all body systems are interrelated and dependent upon one another for good health. In 1874, Dr. Andrew Taylor Still, who recognized the importance of treating illness within the context of the whole body, developed the philosophy of osteopathic medicine. In 1892, Dr. Still opened the first school of osteopathic medicine in Kirksville, Missouri. Physicians licensed as Doctors of Osteopathic Medicine (DOs) must pass a national or state medical board examination to obtain a license to practice medicine (American College of Osteopathic Medicine, 2014).

Osteopathic physicians utilize the same tools available through modern medicine including prescription medicine and surgery. In addition, DOs use osteopathic manipulative medicine (OMM) into their regimen of patient care when appropriate. “ OMM is a set of manual medicine techniques that may be used to diagnose illness and injury, relieve pain, restore range of motion, and enhance the body’s capacity to heal” (American College of Osteopathic Medicine, 2014).

Naturalistic Theories Naturalistic theories of disease tend to view health as a state of harmony between the person and his or her environment; when this balance is upset, illness will result. The naturalistic explanation assumes that illness is due to impersonal, mechanistic causes in nature that potentially can be understood and cured by returning the patient to a balanced state. Humoral, Ayurvedic, and vitalistic are three of the widely practiced approaches to curing naturalitically caused illness or to explain what causes illness. Preventing naturalistic illness includes methods such as proper hygiene, a balanced diet, and meditation. These types of illness are treated by practitioners such as physicians, nurses, acupuncturists, and chiropractors. Methods include dietary changes, massage, medication, exercise, and physical adjustments.

Humoral Humoral pathology was developed and became the basis of both ancient Greek and Roman medicine. It is part of the mainstream medical system in Latin America and Asia.

The humoral system is an ancient belief system based on the idea that our bodies have four important fluids, or humors: blood, phlegm, black bile, and yellow bile. These four fluids are related to seasons, internal organs, physical qualities (hot–cold; wet–dry), and human temperaments (see Table 2.1). Each humor is thought to have its own “ complexion.” For example, blood is hot and wet, and yellow bile is hot and dry. Different kinds of illnesses, medicines, foods, and most natural objects also have specific complexions.

Curing an illness involves discovering the complexion imbalance and rectifying it. A hot injury

or illness must be treated with a cold remedy and vice versa (O’Neil, 2005). In the 19th century there was a radical transition from the humoral theory to the germ theory of disease, which involved new concepts, rules, and classifications, as well as the abandonment of old ones.

TABLE 2.1 Humor and Related Organ and Complexion

Ayurvedic Ayurvedic is an ancient naturalistic approach to health that is used in India and other parts of the world. The term “ ayurveda” is taken from the Sanskrit words ayus, meaning life or life span, and veda, meaning knowledge. In the Ayurvedic system, illness is caused by an energy imbalance. The belief system has a long history and embraces the ideology that disease is a result of an imbalance in vital energies, which distinguish living and nonliving matter. In ayurvedic medicine the vital force is called the prana.

Ayurveda suggests that three primary principles govern every human body. These principles, called doshas, are derived from the five elements: earth, air, water, fire, and space. Doshas regulate all actions of the body. Most people have a predominant dosha, and each dosha type has typical attributes or characteristics. The Ayurveda system of medicine uses a genetically determined concept, prakriti, to categorize the population into several subgroups based on phenotypic characters such as appearance, temperament, and habits. This system is useful in predicting an individual’s susceptibility to a particular disease, prognosis for that illness and selection of therapy, and variations in platelet aggregation (Bhalerao, Deshpande, & Thatte, 2012).

When the doshas are balanced, we experience good health, vitality, ease, strength, flexibility, and emotional well-being. When the doshas fall out of balance, we experience energy loss, discomfort, pain, mental or emotional instability, and, ultimately, disease. Ayurvedic ways to restore balance include breathing exercises, rubbing the skin with herbalized oil, meditation, yoga, mantras,

massage, and herbs. These modalities are energetic ways to balance the chakras. The system links the body’s chakras, or energy centers associated with organs of the body, with

primal forces, such as prana (breath of life), agni (spirit of light or fire), and soma (manifestation of harmony). Each and every cell has a chakra, but like the doshas, one or more often can be found to be more dominant than some of the others. When the life force withdraws, the physical body dies; if the life force becomes blocked or compromised, illness or disease is the likely result. Two ways in which the life force enters the body are through breath and through the chakra system.

Breath sustains all life, and when we breathe we take in life-force energy and move the energy to the entire body via the respiratory and circulatory system. The chakra system is another way in which that energy force enters the body. Chakra means “ wheels of life,” and these invisible “ wheels” pull in this vital life force. Our physical bodies contain seven major chakras between the base of the spine and the top of the head as well as many minor chakras (see Figure 2.1). Each chakra is associated with a major gland or organ and plays an important role in our emotional well- being. As we become older or ill, these chakras may slow down or become blocked, reducing the amount of life force taken into the body, which compromises health and vitality. Our life force also may become depleted due to prolonged stress, poor health habits, or unexpressed emotions (Gilberti, 2004).

Vitalistic In China a system similar to Ayurveda was developed. The vitalistic system can be defined as the concept that bodily functions are due to a vital principle or “ life force” that is distinct from physical forces explainable by the laws of chemistry and physics and is not detectable by scientific instrumentation. The system is built on the belief that an imbalance in vital energies causes disease.

FIGURE 2.1 Chakra system.

The imbalance is related to the polar opposites yin (female, dark, cold) and yang (male, light, hot) in which one combines the interaction of body fluids and energy channels, or meridians. This vitalistic belief system is widespread in China, South Asia, and Southeast Asia. In the Chinese system, the vital force is called the chi; in the ayurvedic system it is the prana. When vital forces within the body flow in a harmonious pattern, a positive state of health is maintained. Illness results when this smooth flow of energy is disrupted, and therapeutic measures are aimed at restoring a normal flow of energy in the body. In China the ancient art of acupuncture is based on this understanding of the body. Acupuncture needles help restore a proper flow of energy within the body.

Biomedical Theory

Biomedical medicine (also known as allopathic medicine) is based on the mechanical view, or machine view, of the body; when the machine breaks illness occurs. Spirituality is generally kept separate from health and healing matters. Spirituality is usually viewed as a nonscientific approach to health and healing. Mental health problems are generally viewed as disorders of the mind, and physicians tend to treat these disorders by affecting brain physiology with pharmaceuticals or with counseling or behavior modification.

Allopathic medicine is the type of medicine most familiar to westerners today. Allopathy is a biologically based approach to healing. For instance, if a patient has high blood pressure, an allopathic physician might give him or her a drug that lowers blood pressure. A core assumption of the value system of allopathic medicine is that diagnosis and treatment should be based on scientific data. The system is built on a molecular understanding of the mechanisms underlying disease, and this lays the foundation for all medical application, diagnosis, and treatment (Carteret, 2011).

Allopathic medicine quickly rose to dominance in the West, in part due to successful scientific progress in developing specific drugs that treat disease. The discovery of antibiotics also triggered rapid growth of the pharmaceutical industry. Pharmacy evolved as an enabling discipline to allopathic medicine, helping it to achieve and maintain its dominance through many successful treatments and cures.

The germ theory of disease is a core component of contemporary allopathic medicine. Germ theory proposes that microorganisms are the cause of many diseases. Although highly controversial when first introduced, it is now a cornerstone of modern medicine and has led to innovations and concepts such as antibiotics and hygienic practices.

Typical causes of illness, according to the allopathic belief, are (O’Neil, 2005):

Organic breakdown or deterioration (e.g., tooth decay, heart failure, senility)

Obstruction (e.g., kidney stones, arterial blockage due to plaque buildup)

Injury (e.g., broken bones, bullet wounds)

Imbalance (e.g., too much or too little of specific hormones and salts in the blood)

Malnutrition (e.g., too much or too little food, not enough proteins, vitamins, or minerals)

Parasites (e.g., bacteria, viruses, amoebas, worms)

What Do You Think?

What are your personal beliefs about how health is maintained and illness occurs? Do you hold any beliefs such as that a glass of milk will help you fall asleep? Where does that belief come from? Is it valid? How do your beliefs affect your behavior?

Pathways to Care The theory of illness with which a person identifies has an impact on where he or she seeks care.

Within the United States there are two general systems of care to choose from: the allopathic (biomedical) approach and the holistic approach. The allopathic approach is often viewed as being scientific and focuses more on the physical components of illness than on the social aspects. Holistic medicine is viewed by some as being unscientific, and it is based on a psychosocial model of health care. A comparison of these two approaches can be found in Table 2.2. People select one health care delivery system over the other for a variety of reasons, and this decision-making process includes considerations such as culture, access to care, health beliefs, and affordability, but many people use both systems.

TABLE 2.2 Two Health Paradigms

Source: © Lonny J. Brown is the author of Enlightenment in Our Time (, Meditation— Beginners’ Questions & Answers (, and Self-Actuated Healing ( www.Lonny

Allopathic Medicine In the Western world, the theoretical construct about the cause of illness is biomedicine. In biomedicine, the body is viewed as a machine, and a core assumption of biomedicine is that scientific data should be the basis of diagnosis and treatment. The approach is built on the ideology that illness occurs when the human biological system goes out of balance and that microorganisms are the cause of many diseases.

Care in the biomedical system is provided by a variety of types of professionals with diverse expertise and levels of training. Allopathic physicians include doctors of medicine (MDs) and doctors of osteopathic medicine (DOs). Numerous allied health professionals, such as nurses, respiratory therapists, physical therapists, physician assistants, health educators, and radiologists, also practice allopathic medicine.

Holistic Medicine The holistic approach (also called alternative medicine or complementary medicine) has a long history and has been rapidly gaining popularity worldwide. Holistic medicine is an approach to maintaining and resuming health that takes the body, mind, and spiritual being into consideration. Holistic medicine uses a variety of therapies, such as massage, prayer, herbal remedies, and reiki. More detail about these therapies is provided in Chapter 4.

Holistic providers have vast differences in their levels of training. These differences include length of training, certification and licensing requirements, and required experience. For example, people who study ayurvedic medicine in India often have four or more years of training, and in the United States it is often much less. Because of this broad range of training and educational requirements, it is essential to inquire about education and experience when seeking a provider. Providers include professionals such as homeopaths, naturopaths, acupuncturists, and hypnotherapists.

Cultural Competence Cultural competence occurs when an individual or organization has the ability to function effectively within the cultural context of beliefs, behaviors, and needs of the patients or community it serves. Campinha-Bacote (2009) defined cultural competence as “ the process in which the healthcare professional continually strives to achieve the ability and availability to effectively work within the cultural context of a client.” Cultural competence requires a set of skills and knowledge that all health care professionals and organizations should strive to acquire. The ability to be culturally competent is on a continuum, with cultural destructiveness on one end of the continuum and cultural proficiency at the other end, as illustrated in Figure 2.2.

FIGURE 2.2 Cultural competence continuum. Source: Adapted from University of Michigan Health Sy stem, Program for Multicultural Health.

Being culturally competent does not mean that people need to know everything about every culture because that is not possible. What it does mean is that people are respectful and sensitive to cultural differences and can work with clients’ cultural beliefs and practices. To be culturally competent, one needs to understand his or her own worldviews and those of the person or community in which he or she serves while avoiding stereotyping, judgment, and misapplication of scientific knowledge. Becoming culturally competent is a process that health care professionals should continue to strive to achieve. Models have been developed to assist individuals and organizations in achieving this goal.

Cultural Competence Models Models are tools that assist with understanding the causes of behaviors, predicting behaviors, and evaluating interventions. Cultural competence models help the learner understand the different components of cultural competence, guide their interactions with people of different cultural groups, and help them identify areas in which they may need to increase their education.

The Process of Cultural Competence in the Delivery of Health Care Services Josepha Campinha-Bacote (2009) developed a model of cultural competence that is based on five constructs:

1. Cultural awareness. The process of conducting a self-examination of one’s own biases toward other cultures and the in-depth exploration of one’s cultural and professional background.

2. Cultural knowledge. The process in which the health care professional seeks and obtains a sound information base regarding the worldviews of different cultural and ethnic groups as well as biological variations, diseases and health conditions, and variations in drug metabolism found among ethnic groups (biocultural ecology).

3. Cultural skill. The ability to conduct a cultural assessment to collect relevant cultural data regarding the client’s presenting problem as well as accurately conducting a culturally based physical assessment.

4. Cultural encounter. The process that encourages the health care professional to directly engage in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds to modify existing beliefs about a cultural group and to prevent possible stereotyping.

5. Cultural desire. The motivation of the health care professional to “ want to” rather than to “ have to” engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and to seek cultural encounters.

The Purnell Model for Cultural Competence The Purnell model for cultural competence started as an organizing framework in 1991 when Dr. Larry Purnell discovered the need for both students and staff to have a framework for learning about their cultures and the cultures of their patients and families. The purposes of the model are to provide a framework for health care providers to learn concepts and characteristics of culture and to define circumstances that affect a person’s cultural worldview in the context of historic perspectives (Purnell, 2005).

The model (illustrated in Figure 2.3) is a circle in which an outlying rim represents global society, a second rim represents community, a third rim represents family, and an inner rim represents the person. Table 2.3 lists the four rings with their related definitions. The interior of the circle is divided into 12 pie-shaped wedges that depict cultural domains and their concepts. The dark center of the circle represents unknown phenomena. Along the bottom of the model is a jagged line that represents the nonlinear concept of cultural consciousness. The 12 cultural domains

(constructs) provide the organizing framework of the model. Health care providers can use this same process to understand their own cultural beliefs, attitudes, values, practices, and behaviors.

FIGURE 2.3 The Purnell model for cultural competence. Source: Reprinted with permission from Dr. Larry Purnell, University of Delaware.

TABLE 2.3 The Rings of the Purnell Model for Cultural Competence

Source: Reprinted with permission from Dr. Larry Purnell, University of Delaware.

Promoting Cultural Competence Promoting cultural competence within organizations is increasingly becoming a higher priority in the health care industry. The rationale for this includes the existence of health disparities, existing differences in access to care and quality of care among minorities, concerns about providing quality of care and legal actions, and credentialing. Ways to promote and assess your own level of cultural competence and that of your organization are the focus of this section.

Implementing cultural competence programs is a nonlinear, multilevel, complex process. The paths to progression are varied. Areas for promoting cultural competence are related to policies, human resource development, and services. Two tools are used to assess cultural competence: one at an individual level and the other at an organizational level. These types of assessments are a good place to start, and they will help you identify areas in need of improvement.

Individual Assessment of Cultural Competence As a member of the organization, the knowledge you have of yourself and others is important and is reflected in the ways you communicate and interact. The individual assessment instrument in Table 2.4 was developed to assist you in reflecting on and examining your journey toward cultural competence.

The following statements are about you and your cultural beliefs and values as they relate to the organization. Please check the one answer that best describes your response to each of the statements.

Organizational Assessment of Cultural Competence Table 2.5 offers a means of assessing an organization’s cultural competence. Some suggestions for achieving a culturally competent organization include the following:

Maximize diversity among the workforce.

Involve community representatives in the organization’s planning and quality improvement


TABLE 2.4 Individual Cultural Assessment

Source: Reprinted with permission from the Committee of the Association of University Centers on Disabilities (AUCD) Multicultural Council.

TABLE 2.5 Organizational Cultural Assessment

Source: Reprinted with permission from the Committee of the Association of University Centers on Disabilities (AUCD) Multicultural Council.

Establish a cultural competence board to help guide the implementation of culturally sensitive prevention and treatment efforts.

Provide ongoing training to staff members.

Develop health materials for the target population written at the appropriate literacy level, in a variety of languages, and with culturally appropriate images—this includes materials such as educational brochures, consent forms, signage, postprocedural directions, and advance directives.

Make onsite interpretation services available when possible, and be sure that all appropriate staff members are educated about how to use telephone interpretation services.

Assess customer satisfaction and clinical outcomes regularly.

Consider the health disparities that exist in your community when planning outreach efforts.

When an individual, organization, or system has implemented change to progress toward cultural competence, the change process should be measured. This is important because it can indicate the progress that has been made and identify areas that are in need of improvement. The measurement process itself can be a catalyst for change.


We have all heard an abundance of stories about how illness can occur and how it can be cured. Some of these belief systems are ancient and are believed to be true, regardless of whether or not controversial evidence exists. These beliefs influence who we ask for medical advice and when. This is part of our worldview, which is our perception of how the world works. Health care professionals need to take these issues into consideration, and that is a step toward the progression of cultural competence.

Several concepts that one needs to consider when working with people from different cultures have been identified in this chapter. These concepts include different beliefs about how illness occurs, which affects how, where, and when people seek medical care. Health care professionals should assess the person’s worldview and tailor their approach and communication to successfully prevent and treat illness. Because of these differences, health care professionals need to become culturally competent. The concept of cultural competence and what that means has been discussed, and two tools to assess the level of cultural competence among individuals and organizations are included to assist with assessing cultural competence at both the individual and organizational levels.


1. Explain three overarching theories about the causes of illness.

2. Explain the two overarching systems of care in the United States and their differences.

3. Explain the components of the process of cultural competence in the delivery of health care services model.

4. Explain the components of the Purnell model for cultural competence.

5. List ways to improve cultural competence within an organization.


Write a research paper on three types of holistic healers (e.g., shamans, medicine men, accupuncturists). Include information about their training, approaches to healing, and evidence-based patient outcomes.

Case Study

Public health workers are offering free measles vaccinations to children. The worker is speaking with the parents of a child and explaining why the vaccination is important. The parents express concerns that the vaccine will interfere with God’s plan, and they refuse to have the child vaccinated.

Consider these related questions:

What are the parents’ beliefs about how health is maintained?

How do the theories of health and illness discussed in this chapter apply to this case study?

Using the Purnell model for cultural competence, what approach, if any, should the public health workers take to help protect the child by assisting the parents with understanding the need for the


References American College of Osteopathic Medicine. (2014). The history of osteopathic medicine. Retrieved from Bhalerao, S., Deshpande, T., & Thatte, U. (2012). Prakriti (Ay urvedic concept of constitution) and variations in platelet

aggregation. BMC Complementary & Alternative Medicine, 12, 248. Campinha-Bacote, J. (2009). The process of cultural competence in the delivery of healthcare services. Retrieved from Carteret, M. (2011). Culturally-based beliefs about illness causation. Retrieved from -based-beliefs-about-illness-causation/ Gilberti, T. C. (2004). Reiki: The re-emergence of an ancient healing art in modern times. Home Health Care

Management Practice, 16(6), 480–486. O’Neil, D. (2005). Explanations of illness. Retrieved from Purnell, L. (2005, Summer). The Purnell model for cultural competence. Journal of Multicultural Nursing & Health, 11:

(2), 7–15. Williams, D. R., Lavizzo-Mourey, R., & Warren, R. C. (1994). The concept of race and health status in America. Public

Health Reports, January –February, 109(1), 26–41.


Worldview and Health Decisions

After all, when you come right down to it, how many people speak the same language even when they speak the same language?

—Russell Hoban

Key Concepts

Worldview Temporal relationships Proxemics Individualism Collectivism Fate versus free will Euthanasia Karma Ahimsa Advance directive Living will Durable power of attorney Biomedical worldview Mind–body integration

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Learning Objectives

After reading this chapter, you should be able to:

1. Explain what worldview means and how it is related to culture.

2. Describe at least three components of worldview that affect health.

3. Explain how worldview influences beginning- and end-of-life medical decisions.

4. Describe how worldview is related to how health is perceived and how problems are expressed.

A person’s worldview is closely linked to his or her cultural and religious background, and it has profound implications for health care. Worldview influences lifestyle, and it is imperative that health care professionals understand its impact on health care decisions, involve patients in decisions and actions, and accommodate patients’ beliefs to provide congruent care.

This chapter begins with a discussion of worldview, particularly in terms of time, personal space, individual autonomy, free will, and fate, and explains how these major components relate to health care. Then we move into more specific ways that worldview affects medical decisions and how people perceive and respond to illness.

Worldview A worldview is a set of cultural assumptions and beliefs that express how people see, interpret, and explain their experience (Tilbert, 2010). It helps us make sense of our lives. Worldview includes our relationships with nature, our social relationships, our ethical reasoning, and cosmology (study of the universe and humanity’s place) (Purnell, 2013). It even affects our view of aesthetics. For example, most of us know that sun exposure contributes to skin cancer, but some cultures view tans as healthy whereas others see very white skin as beautiful (e.g., the Japanese culture), which is why skin lightening is done.

Culture fits within the larger structure of worldviews. Worldviews are the beliefs and assumptions by which an individual can make sense of experiences, and these are what culture is built upon. Cultural groups have varied views of the world, and when they clash, people may find the behavior of others offensive or confusing. Some of the prominent variances in worldviews include health beliefs, orientation toward time, use of space, social and family organization, and communication.

Because worldviews contain and shape cultures (shared starting points and values), working effectively across cultures requires some understanding of the soil from which cultures grow—the seedbed called worldviews.

Worldviews can be resources for understanding and analyzing conflicts when fundamental differences divide groups of people. By looking at the stories, rituals, myths, and metaphors used by a group, we can learn efficiently and deeply about group members’ identities (who they see themselves to be) and meanings (what matters to them and how they make meaning). When we do this with each side to a conflict, places of connection and divergence may become clearer, leading to a better understanding of the conflict in context. (LeBaron, 2003)

Worldview encourages a broader understanding of and elaborates on the implicit content of culture. For example, a health care professional may know that a patient or a family holds many unfamiliar beliefs, but by understanding worldviews the health care professional can appreciate the mind-set that those beliefs create (Tilbert, 2010).

A person’s worldview is closely linked with his or her cultural and religious background and has profound health care implications. For example, people with chronic diseases who believe in fatalism (predetermined fate) may not adhere to treatment because they believe that medical intervention cannot affect their outcomes. Worldview is an equally important concept for educating health professionals about their own beliefs and assumptions that may influence the care they deliver. Health care providers play a mediating role in whether or not populations experience health disparities. A weakness of the medical profession is that not all of its members appreciate and accept that it has a professional culture (and subcultures) that consists of its own beliefs and assumptions just as do the cultures of the patients (Tilbert, 2010). Some of the major components of worldview

that affect health care professionals are discussed in the following sections.

Temporal Relationships Temporal relationships refers to people’s worldview in terms of time. These perceptions of time vary among cultures. In the West, time tends to be seen as quantitative elements of past, present, and future and is measured in units that reflect the march of progress. It is logical, sequential, and present focused, moving with incremental certainty toward a future. In the East, time feels like it has unlimited continuity, and it does not have a defined boundary. Birth and death are not such absolute ends because the universe continues, and humans, though changing form, continue as part of it.

Some cultures are present oriented, and others focus on the past or future. Time perspective affects our health behaviors and expectations of health care behavior. In general, people in the West understand that healthy behaviors in the present will affect our health in the future, and future- oriented people are willing to make sacrifices now for future benefits. Present-focused people are not willing to make sacrifices for the future and engage in behaviors to satisfy their immediate desire regardless of the long-term consequences. Future-oriented individuals place value on getting screenings and preventive measures for future payoffs. Present-oriented cultures, including American Indians and African Americans, may see living in the moment as the priority and are less willing to forgo immediate pleasures for future benefits. Cultures that are past oriented tend to value elders and honor traditions. For example, the Asian culture is generally past oriented, and they value and perform traditional healing practices, such as acupuncture and herbal remedies.

Another component of time related to health care is expectations related to punctuality. Some cultures are very punctual, and people in these groups (for example, people with a Polish culture) will arrive for appointments on time. Others are less rigid and will arrive around the time of the appointment. Some clinics who serve cultures who have less rigidity around time have stopped making appointments and changed to seeing patients on a first-come, first-served basis.

Space (Proxemics) Another variable across cultures is perception of space, or proxemics, which includes interpersonal distance and boundaries. North Americans tend to prefer a large amount of space, and Europeans tend to stand more closely together when talking and are accustomed to smaller personal spaces (LeBaron, 2003).

Violating these boundaries can lead to conflict, stress, anxiety, miscommunication, or discomfort. If someone is accustomed to standing or sitting very close when he or she is talking with another, that person may see the other’s attempt to create more space as evidence of coldness, condescension, or a lack of interest. Those who are accustomed to more personal space may view attempts to get closer as pushy, disrespectful, or aggressive (LeBaron, 2003).

Also related to space is the degree of comfort we feel when furniture or other objects are moved. A German executive working in the United States became so upset with visitors to his office moving the guest chair to suit themselves that he had it bolted to the floor (LeBaron, 2003). Contrast this with United States and Canadian mediators and conflict-resolution trainers, whose first step in preparing for a meeting is frequently a complete rearrangement of the furniture (LeBaron, 2003).

Social Organization and Family Relationships Social organization refers to patterns of social interactions. Examples include how people interact and communicate, the kinship system, marriage residency patterns, division of labor, who has access to specific goods and knowledge, social hierarchy, religion, and economic systems. Four components of social organization that have an immense impact in health care are explored here: individualism versus collectivism, fate versus free will, communication, and family relationships.

TABLE 3.1 Individualism Versus Collectivism

Individualism Versus Collectivism Individualism and collectivism are contrasting perspectives and values (see Table 3.1). In individualism each person is seen as a social unit, and each person has primary responsibility for him- or herself. In the United States the overarching culture values of individualism, autonomy, and independence are rewarded and respected. Other individualistic cultures include Germany, Canada, and Sweden (Purnell, 2013). If someone is successful, it is primarily because of these personal qualities.

In collectivism, people are socialized to view themselves as part of a larger group, such as a family, a community, or a tribe. The group is the social unit, and dependence and connections within the group are valued. An individual’s identity is determined by his or her relationship and position within the group. People make decisions based on what is good for the group rather than on what is good for themselves. Saving face is valued as is showing respect for others. The needs and goals of the individual are subordinate to those of the larger group and should be sacrificed when the collective good so requires. Collectivists believe that achievement is a product of society. Examples of collectivist cultures include the Amish, Chinese, Mexicans, and Vietnamese (Purnell,

2013). Why are these two opposing views important in health care? People from individualistic cultures

make their health care decisions independently whereas individuals in collectivist cultures involve their families in the decision-making process. Health care professionals need to be aware of these differences in worldview. In collectivist cultures, illness is considered to be a family event rather than an individual occurrence. Knowledge transmission, personal responsibility, shame and guilt, help- seeking behaviors, competitiveness, and communication are affected by this aspect of worldview (Purnell, 2013). In individualistic cultures, direct questioning, sharing personal issues, and asking personal questions are typical. In a collectivist culture, disagreeing or saying “ no” to a health care professional is considered rude; therefore, when a health care professional asks if the patient understands, the patient may answer “ yes” even though understanding has really not occurred. In addition, disabilities, mental health issues, and other health problems that are stigmatized may be kept hidden to save face, and treatment may be delayed and care provided in the home (Purnell, 2013).

In the United States, legal documents such as advance directives and durable powers of attorney are strategies to prolong autonomy in situations in which patients can no longer represent themselves (Searight & Gafford, 2005). Other cultures de-emphasize autonomy, perceiving it as isolating rather than empowering. Their belief is that communities and families, not individuals alone, are affected by life-threatening illnesses and that they should be involved in making medical decisions (Searight & Gafford, 2005).

Fate Versus Free Will “ Fate and free will” refer to the degree to which people believe they are the masters of their own lives (free will) or believe they are subject to events outside their control (fate). Basically, fate and free will refer to the beliefs people hold about their ability to change and maneuver the course of their lives and relationships. This concept also is called locus of control. People who believe that they have control over their health have an internal locus of control (free will belief), and people who believe that it is outside of their control (fate belief) have an external locus of control. In some ethnic groups, factors outside medical intervention, such as a divine plan and personal coping skills, may be more important for health and survival than medical intervention and health behaviors.

Health care professionals need to consider this aspect of social organization. For example, when health outreach workers in India attempted to provide children with free polio vaccinations, they found that many parents refused the immunization because they believed Allah would take care of their children’s health. Providing preventive care and treatment can be challenging when people believe that fate will determine their health and that their health behaviors will not change what the master plan is for them.

Communication Communication is an interactive process that involves sending and receiving information, emotions, thoughts, and ideas through verbal and nonverbal means. It is the basis of human interaction. Effective communication enables health care professionals to accurately exchange information, establish relationships, and understand the person’s needs and concerns. Effective communication is

important in all facets of life, but in health care it can be the deciding factor between life and death. Intercultural communication is sensitive to exchanging information across cultural boundaries in

a way that preserves mutual respect and minimizes miscommunication and conflict. If communication is hindered, patients who utilize traditional remedies may be reluctant to inform their biomedical providers about them, leading to potentially dangerous interactions between medications prescribed by the two types of providers.

In addition to better health outcomes, effective communication can lead to higher patient satisfaction, continued care, and better adherence to treatment recommendations while reducing conflict and errors, lost opportunities for encouraging health behavior changes, misinterpretations of treatment plans, damaged relationships (including a loss of trust) between provider and patient or community member, and legal actions. All of these reasons illustrate why culturally competent communication is a vital component of health care.

Verbal Communication As indicated in the quotation of Hoban at the beginning of this chapter, even people who speak the same language do not necessarily communicate even when using the same words. For example, in some age groups the word “ fox” means attractive, but someone from a different generation may think of the animal. People in the United States whose first language is English have a difficult time communicating, so imagine how difficult it must be to communicate with people when English is not their first language. The limitations of language to convey experience—even between people who speak the same language—are extremely obvious when we cannot explain something as important as the intensity of pain we feel or the unrelenting worry and frustration pain sometimes causes. To further complicate communications, not all cultures describe health problems in the same way, and words from their language may not be easily translated to English and vice versa. For example, words used to describe pain typically include “ sharp,” “ throbbing,” “ stabbing,” or “ aching.” But in many tribal cultures, stories or symbols are essential in relating one’s worldview, so very different words are used to describe pain. Clinicians might be baffled by patients explaining their pain using natural symbols like lightning, trees with deep spreading roots, spider webs, or the tones of drums and flutes (Carteret, 2011a).

In addition to the risks of everyday language breeding possibilities for miscommunication, health care has a language of its own with specialized terminology that can increase the chances of communication mishaps. Health care providers should avoid jargon and select words that people will understand without making them feel like you are talking down to them. Ask the receiver to summarize what you said to check for understanding, and look for nonverbal cues that indicate when miscommunication has occurred. A few cultural communication differences are described in the following paragraphs.

In some cultures, asking questions of health care providers is not an acceptable behavior. Patients from these cultures may be less likely to ask even clarifying questions and, subsequently, may not understand their condition or be able to follow their treatment plan, potentially resulting in a lower quality of care or even medical error.

In some cultures doctors do not want to inform the patient about his or her health problem. This nondisclosure may be because of the belief that the discussion about illness may eliminate or reduce the patient’s hope or induce depression or anxiety. Others believe that discussing the illness may

make the person worse or that it is disrespectful. This issue also is a concern with regard to consent forms. The patient may believe that discussing the possible death or side effects of a medical procedure or medication may make it self-fulfilling and actually happen.

Some cultures dictate that doctors protect patients from the emotional and physical harm caused by directly addressing death and end-of-life care. Many Asian and American Indian cultures value beneficence (physician’s obligation to promote patient welfare) by encouraging the patient’s hope, even in the face of terminal illness (Searight & Gafford, 2005). Emotional reaction to news of serious illness may be considered to be directly harmful to health. It is thought that a patient who is already in pain should not have to struggle with depression or stress as well. This negative emotional impact on health appears to be one of the primary reasons Chinese patients are less likely to sign do not resuscitate (DNR) orders (Searight & Gafford, 2005). This concern, together with Asian values of admiration for the elderly, may be especially pronounced in senior patients who, because of their frailty, are perceived to be more vulnerable to being upset by bad news. In addition, the special status of the elderly in Asian cultures includes a value that they should not be burdened unnecessarily when they are ill.

Direct disclosure of bad health news may eliminate patient hope. Bosnian respondents indicated that they expected physicians to maintain patients’ optimism by not revealing terminal diagnoses (Searight & Gafford, 2005). Filipino patients may not want to discuss end-of-life care because these exchanges demonstrate a lack of respect for the belief that individual fate is determined by God (Searight & Gafford, 2005). American Indian, Filipino, and Bosnian cultures emphasize that words should be carefully chosen because when they are spoken they may become a reality (Searight & Gafford, 2005). Carrese and Rhodes (1995) noted that Navajo informants place a particularly high value on thinking and speaking in a “ positive way.” About one half of their Navajo informants would not even discuss advance directives or anticipated therapeutic support status with patients because these discussions were considered to be potentially injurious.

Nonverbal Communication Communication is more than just words, and much information is conveyed nonverbally. Our system of nonverbal communication includes gestures, posture, silence, spatial relations, emotional expression, touch, and physical appearance (LeBaron, 2003). Our sense of what nonverbal behavior is appropriate is derived from our culture. Differences in nonverbal communication may lead to misunderstandings, misinterpretations about the person’s character, damaged relationships, conflict, or escalate an existing conflict. For example, people in some cultures attach great superstition to particular numbers, and smiling does not suggest feeling good in all cultures. In some Asian cultures, people tend to smile when they are embarrassed or angry (Carteret, 2011b).

Differences in nonverbal communication can be seen in the following ways:

Voice tone and volume

Pace of speech

Tolerance of silence

Physical distance between speakers


Eye contact


Direct versus indirect approaches

Ways of greeting people

Amount and location of touch

Nonverbal communication can be received in three general ways: (1) the nonverbal message may exist in both cultures but not have the same meaning, (2) the nonverbal message exists in the sender’s culture but not in the receiver’s culture, or (3) the nonverbal message exists in both cultures and has the same meaning. Here are some examples of nonverbal communications that have different meanings in various parts of the world:

In Asian cultures smiling is used to show pleasure, and it also is used to cover emotional pain or embarrassment. When a patient is asked if he or she understands the treatment plan, if the person does not understand he or she may smile to cover embarrassment.

The “ ring” or “ okay” gesture has different meaning in different countries. In the United States and other English-speaking countries, the ring or okay gesture means “ everything is okay.” In Japan it can mean money; in some Mediterranean countries it is used to infer that a man is homosexual; in Indonesia it means zero.

In the United States, getting someone to come toward you by motioning with your index finger is common or acceptable; however, in the Philippines, Korea, and parts of Latin America, as well as other countries, the same gesture is considered to be rude.

In some cultures, direct eye contact is an indication of honestly, listening, and respect. People from some other cultures consider direct eye contact to be rude and feel as though they are being disrespected or challenged; therefore, they may avoid direct eye contact.

Touch has variations of meanings among cultures as well. For some, casual touching is seen as a sexual overture and should be avoided. People of the same sex (especially men) or opposite sex do not generally touch one another. In other cultures, especially among collectivist ones, same genders can touch without having a sexual connotation. Health care providers should ask permission before touching someone (Purnell, 2013).

Family Relationships Family relationships include issues such as who makes the decisions in the home, family goals and priorities, child-rearing practices, family and community social status, marriage decisions, divorce acceptance, the roles of the elderly and extended family, and acceptance of alternative lifestyles. These factors influence related issues such as health behaviors and decisions, living situations, and age to marry. Family structure is an important consideration because the quality of social support from family, a practice highly driven by culture, has been shown to have significant consequences for health.

What Do You Think?

Reflect on your own worldview and how it differ from others. What are the philosophical reasons for how your worldview differs from others? How do these beliefs affect relationships and possibly lead to conflict? Consider the following questions:

How comfortable are you with being touched?

What is your perspective of time?

What does it mean to you when people are late?

How do you make health care decisions?

How do you view illness?

Worldview and Medical Decisions Medical decisions such as abortion, the use of birth control, permission to allow blood transfusion, utilization of chemotherapy, advance directives, and euthanasia are difficult and life altering. In this section the focus is on two areas of medical decisions: beginning-of-life and end-of-life decisions.

Beginning-of-Life Decisions The beginning-of-life decisions include choices related to pregnancy, abortion, birth control use, fertility practices, birthing, and the postpartum period. Some of these decisions have deep ties to religious beliefs.

Birth Control Decisions surrounding the use of birth control center around the view about the purpose of sexual intercourse. Is it for procreation or other reasons? The use of birth control is prohibited by some religions for reasons such as that men are not permitted to waste “ their seed” or that it is a violation of the design built into the human race by God. Other religions permit the use of hormonal birth control methods such as pills, patches, injections, and implants, but they do not allow the use of birth control methods that block or destroy sperm, such as condoms and vasectomies. Condom use may be permitted to protect one from sexually transmitted infections, and birth control may be allowed when a woman needs a rest between pregnancies, when pregnancy poses a risk to the mother or baby, or when the man cannot financially support another child.

Abortion A central issue surrounding abortion is related to the core question about when life begins. Does it begin when the egg is fertilized, when the soul enters the fetus, when consciousness occurs, when the embryo becomes embedded in the uterine wall, when the fetus moves, or when the birth occurs? The answer to this question depends on who you ask, and the answer one gives will shape his or her views on the morality of abortion. Some religions prohibit abortion because it is viewed as

murder, because it brings bad karma, or because it is an act of violence regardless of when or why the abortion takes place.

Many religions approve of abortion under certain circumstances, such as when

the health of the mother is at risk if the pregnancy is continued,

the child may be born with a disability that will cause suffering, or

in cases of rape or incest.

End-of-Life Decisions In “ The Parable of the Mustard Seed,” the Buddha teaches a lesson that is valid for all cultures: human beings receive no exemption from mortality. Deep in the throes of grief after the death of her son, a woman seeks wisdom from the Buddha, who says that he does indeed have an answer to her queries. Before giving it, however, he insists that she must first collect a mustard seed from every house that has not been touched by death. She canvasses her entire community but fails to collect a single seed. Returning to the Buddha, she understands that, like all other living beings, we are destined to die.

Death is inevitable, but how people respond to death has cultural ties. In some cultures it is appropriate to cry, sob, and wail loudly, whereas mourning in other cultures requires controlling grief and being stoic in public. Variations in burial practices also are culturally determined.

Although death is inevitable, modern life-extending technologies have changed the process. Organ transplantation, respirators, antibiotics, surgical procedures, and feeding tubes enable life to be prolonged. Other technologies, such as lethal injections, may hasten death. Using these technologies is a complex choice. In some situations, prolonging life in these ways may be contradictory to another fundamental human value—going against God’s will. Human beings struggle with not overstepping these boundaries or playing God with life and death. Individual wishes may be subsumed by the will of other family members or the dictates of their religion.

Decisions surrounding continuing treatment, discontinuing treatment, or hastening death are difficult and agonizing. As individuals and their families face these controversial questions and as many states consider revising their laws about end-of-life choices, religious traditions and values can offer guidance and insight, if not solutions, for some.

In the remainder of this section the more controversial and general decisions are addressed, but there are many other end-of-life decisions to consider, such as burial versus cremation, timing of the burial, length of the mourning process, appropriate dress and behavior before and during the service and after the burial, and permission to conduct an autopsy.

Organ Transplants Organ transplantation is the removal of tissues of the human body from a person who has recently died or from a living donor for the purpose of transplanting or grafting them into other persons. Cultural and religious views regarding organ transplantation are changing. Some religions that previously prohibited organ donation are now altering their views and seeing it as an act of compassion, but others continue to prohibit organ donation. Religions that prohibit organ transplants do so because of their beliefs regarding life after death and resurrection. Some religions

will consent to an organ donation if they are certain that it is for the health and welfare of the transplant recipient, but if the outcome is questionable, then the donation is not encouraged.

Euthanasia Euthanasia is a Greek term that means “ good death.” Also called mercy killing, it is the act or practice of ending the life of an individual who is suffering from a terminal illness or an incurable condition by lethal injection or the suspension of extraordinary medical treatment. The person who is suffering from the painful and incurable disease or incapacitating physical disorder is painlessly put to death. Because there is no specific provision for it in most legal systems, it is usually regarded as a crime: suicide (if performed by the patient) or murder (if performed by another person, which includes physician-assisted suicide).

Murder and suicide are against the belief systems of most religions, so in those systems it would be considered morally wrong. In some religions, such as Hinduism, suicide is acceptable if it is done by fasting because it is nonviolent. Other reasons for religious opposition are the concern for patients who may be in vulnerable positions because of their illness or their lack of social and economic resources. There is fear that patients who cannot afford expensive treatment, for example, will be pressured to accept euthanasia. There also is great concern about the moral nature of the doctor’s professional self.

Karma and rebirth are other considerations for not supporting euthanasia. Karma is the total effect of a person’s actions and conduct during the successive phases of the person’s existence, which is regarded as determining the person’s destiny. Karma extends beyond one’s present life to all past and future lives as well. In Hinduism and Buddhism, human beings are believed to be captured in endless cycles of rebirth and reincarnation. In both traditions, all living creatures (humans, animals, and plants) represent manifestations of the laws of karmic rebirth. To honor these laws, one must show great respect for the preservation of life and the noninjury of conscious beings. Acts that are destructive of life are morally condemned by the principle of ahimsa, which is the conceptual equivalent of the Western principle of the sanctity of life. Religions may permit physicians to hasten death in the very few jurisdictions that allow it through legal injection but not by withholding care.

On the other side of the issue, most religions also consider acts of compassion and concern about the dignity of the dying person to be part of humanity. Concern for the welfare of others as one is dying is seen as a sign of spiritual enlightenment. A person can decide to forgo treatment to avoid imposing a heavy burden of caregiving on family or friends. He or she may also stop treatment to relieve loved ones of the emotional or economic distress of prolonged dying.

These two different perspectives lead to the dilemma of whether euthanasia is an act of compassion or murder. Different cultures and religions answer the question differently, and debate exists within religions. This personal and difficult decision obviously needs to be made on an individual basis, but health care professionals should be aware of the conflicting perspectives and the rationale behind them.

Advance Directives and End-of-Life Care Advance directives are legal documents that enable a person to convey his or her decisions about end-of-life care ahead of time. Advance directives include the living will and durable power of

attorney, and they provide a way for patients to communicate their wishes to their family, friends, and health care professionals and to avoid confusion later in the event that the person becomes unable to communicate.

A living will is a set of instructions that documents a person’s wishes about medical care intended to sustain life. People can accept or refuse medical care, and many types of life-sustaining care should be taken into consideration when drafting a living will:

The use of life-sustaining equipment, such as dialysis and breathing machines

Resuscitation if breathing or heart beat stops

Artificial hydration and nutrition (tube feeding)

Withholding food and fluids

Organ or tissue donation

Comfort care

A durable power of attorney for health care is a document that names your health care representative who can speak for you when you cannot. This is someone you trust to make health care decisions if you are unable to do so. Survey data suggest that about 26% of the U.S. population has an advance directive, with significantly lower rates among nonwhite races (Rao, Anderson, Lin, & Laux, 2014). For example, one study revealed significant differences among racial and ethnic groups in the rate of completion of advance directives, with about twice as many whites as African Americans completing advance directives (Morhaim & Pollack, 2013). This difference is likely attributable to several factors, including cultural differences in family-centered decision making, distrust of the health care system, and poor communication between health care professionals and patients. Collectivist groups, such as Hispanics, may be reluctant to formally appoint a specific family member to be in charge because of concerns about isolating this person or offending other relatives. Instead, a consensual decision-making approach seems to be more acceptable in this population. Among Asian Americans, aggressive treatment for elderly family members is likely to be frowned upon because family members should have love and respect for their parents and ancestors and because of their high respect for the elderly.

Did You Know?

The ability to take medical histories and diagnose current symptoms may be adversely affected by the patient’s comfort with modesty. Cultural values surrounding modesty are more than one’s comfort level with covering the intimate body parts. By definition, modesty is about respect. A provider who takes cultural modesty into consideration shows respect and caring in the highest degree. Modesty in many cultures often means showing good manners via verbal communication, dress, or behavior.

“ In societies that place a high value on modesty, it is important for both sexes, but particularly emphasized for women. A woman’s sexual purity and chastity honors her entire family. American women may view this as more discriminatory than protective. It is important not to assume that women in high-modesty cultures are forced to accept the restrictions placed on them by men. In fact, for many women in these cultures modesty is an attribute to be admired

and attained. Women often impose modesty on themselves and other women as a way of keeping boundaries of privacy and respect” (Carteret, 2011b).

Worldview and Response to Illness Worldview has an impact on how people perceive and respond to illness. The dominant values and standards regarding pain and illness affect the behaviors of the individual. When people with a biomedical worldview of the mind and body being separate was shared by providers and most patients, this shared belief often contributed to substantial patient stress and alienation. In contrast, in a study conducted in Puerto Rico, providers and patients often shared a view of mind–body integration in illness and valued treatments that addressed chronic pain as a biopsychosocial experience. In this setting, shared views and values contributed to more supportive patient–provider relationships, and patients thus experienced less treatment-related stress (Bates, Rankin-Hill, & Sanchez-Ayendez, 1997).

The level of stigma plays a role in how people respond to illness as well. Mental health issues, tuberculosis, HIV, and other illnesses create a sense of embarrassment and shame in some cultures. As a result, people may not seek care or delay seeking care. If the person is diagnosed with a stigmatized illness, it can affect how the family responds. For example, the person may be “ hidden” from the public, the family may be embarrassed by the ill family member and distance themselves from the patient, or the patient may be shunned. In some cultures chronic illness and disability are viewed as forms of punishment, and the patient is viewed as being evil.

How people express and communicate about the illness has cultural roots. Most people experience pain sensations similarly, yet studies show there are important differences in the way people express their pain and expect others to respond to their discomfort. Stoic and emotive are two categories in which patients’ culturally based responses to pain are often divided. Stoic patients are less expressive of their pain, tend to “ grin and bear it,” and socially withdraw. Emotive patients are more likely to verbalize their expressions of pain, prefer to have people around, and expect others to react to their pain to validate their discomfort. A broad generalization is that expressive patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, and stoic patients often come from Northern European and Asian backgrounds. There are also culturally based attitudes about using pain medication. For example, a Filipino or an East Indian patient might not take pain medications due to being fearful of harmful effects, including addiction (Carteret, 2011a).

The family structure and child-rearing practices also influence the expression and communication of illness and pain. Stoicism in European American culture has a long history. For many generations, children, especially boys, would be reprimanded for crying like babies but applauded for keeping a stiff upper lip. In general, people made as little fuss as possible over injuries and illness. Children socialized in this manner will grow up to be “ easy patients” who behave in ways consistent with the values of the Western medical system. In other cultures a child’s crying immediately elicits the greatest sympathy, concern, and aid. In such cultures, children’s health is fretted over constantly—even a sneeze can be seen as illness. This predisposes children to become more anxious about their health in general, and as adults, they may need greater reassurance from

caregivers even when their symptoms are minor. In general, when people are ill, they revert to childhood behavior. If complaining brought them attention as children, they will likely complain out of habit as adults—even if the desired results are not provided by their caregivers (Carteret, 2011a).

Patients from Asian cultures are often stoic in the face of pain because self-restraint is a strong cultural value. Complaining is viewed as having poor social skills. In traditional Asian cultures, preserving harmony in interactions with others is very important, so an individual should never draw personal attention, especially in negative ways. Though an individual may feel sadness or pain, it is not customary to make this obvious. This translates to communications with doctors and nurses, who have high status in Asian cultures. People of high status should not be bothered with complaints and should not be questioned (Carteret, 2011a).


Worldview is our perception of how the world works. It includes issues such as moral and ethical reasoning, social relationships, and communication. Health care professionals need to take a person’s worldview into consideration because it affects behaviors, perceptions, communication, and decisions. Some decisions are made daily, such as whether to take a medication or not, but major health decisions, such as beginning-and end-of-life decisions, are also subject to patients’ worldview.

Review 1. What does worldview mean? Provide examples of why it is important to consider worldview

in health care.

2. Provide examples of differences in verbal and nonverbal communication methods among different cultures.

3. Explain some beginning- and end-of-life decisions related to worldview and culture.


Select a culture of your choice. Write a paper explaining some key components of their worldview and explain how these views relate to health.

Case Study A physician receives the pathology report from a recent endoscopy of her patient, a 78-year-old Japanese man. The report reveals adenocarcinoma of the stomach. The physician intends to disclose the diagnosis to the patient. However, as the provider approaches the patient’s room, the patient’s daughter stops her. The daughter demands to know the diagnosis and states that, if indeed it is cancer, her father should not be told. The daughter insists that she and her mother will decide what is best for her father. She argues that in her father’s culture, family members make the decisions for the patient.

Consider these related questions:

Is it the physician’s duty to disclose the truth to her patient?

How can the physician–patient relationship be preserved while taking into consideration the wishes of family members?

What role should culture play in how a case is handled? Source: Rosen, et al. (2004).

References Bates, M. S., Rankin-Hill, L., & Sanchez-Ay endez, M. (1997). The effects of the cultural context of health care on

treatment of and response to chronic pain and illness. Social Science & Medicine, 45(9), 1433–1447. Carrese, J. A., & Rhodes, L. A. (1995). Western bioethics on the Navajo reservation. Benefit or harm? Journal of the

American Medical Association, 274, 826–829. Carteret, M. (2011a). Cultural aspects of pain management. Retrieved from Carteret, M. (2011b). Modesty in health care: A cross-cultural perspective. Retrieved from -in-health-care-a-cross-cultural-perspective/ LeBaron, M. (2003, August). Cultural and world-view frames. Retrieved from /cultural-frames Morhaim, D. K., & Pollack, K. M. (2013). Rate of Americans who have completed advance directives. American Journal

of Public Health, 103(6), e8–e10. Purnell, L. D. (2013). Transcultural health care. Philadelphia, PA: F. A. Davis Company. Rao, J. K., Anderson, L. A., Lin, F-C., & Laux, J. P. (2014). Completion of advanced directives among U.S. consumers.

American Journal of Prevention Medicine, 46(1), 65–70. Retrieved from 3797(13)00521-7/pdf

Rosen, J., Spatz, E. S., Gaaserud, A. M. J., Abramovitch, H., Weinreb, B., Wenger, N. S., & Margolis, C. Z. (2004). A new approach to developing cross cultural communication skills. Medical Teacher, 26(2), 126–132.

Searight, H. R., & Gafford, J. (2005). Cultural diversity at the end of life: Issues and guidelines for family physicians. American Family Physician, 71(3), 515–622. Retrieved from

Tilbert, J. C. (2010). The role of worldviews in health disparities education. Journal of General Internal Medicine, 25(Suppl. 2), 178–181. Retrieved from


Complementary and Alternative Medicine

Everyone has a doctor in him or her; we just have to help it in its work. The natural healing force within each one of us is the greatest force in getting well. Our food should be our medicine. Our medicine should be our food.


© Click Bestsellers/Shutterstock, Inc. and © Ms.Moloko/Shutterstock, Inc.

Key Concepts Complementary medicine Alternative medicine Doshas Prakriti Yoga Qi Five elements Yin and yang Meridians Acupuncture Qigong Tai chi Naturopathy Hydrotherapy Reiki Meditation Mindfulness meditation Transcendental meditation

Learning Objectives After reading this chapter, you should be able to:

1. Identify the difference between complementary and alternative medicine (CAM) practices.

2. Understand the various types of CAM practices.

3. Discuss the potential benefits and risks of CAM practices.

4. Appreciate the cultural influences on CAM practices.

It is not entirely clear when humans began to develop modalities to deal with pain, injury, and disease. However, we know that these practices have been in existence for ages. The various practices to treat disease and injury have been passed down through the centuries from person to person and family member to family member. The practices have been influenced by observation and experimentation, as well as religious, social, and cultural practices. Over time, the various forms of these practices have taken on the unique characteristics of the people and cultures that utilize them.

These practices have been termed “ folk medicine” by the mainstream science-based medical professions. With the advent of the scientific approach to medicine, it might be assumed that the various traditional folk medicine practices would die out. However, that has not been the case. As new cultures immigrated to the United States, so did their traditional healing practices. Increased interest in these traditional practices has spurred research into their efficacy and recharacterized them as complementary and alternative medical practices.

Complementary medicine refers to using a non-mainstream approach together with conventional medicine. Alternative medicine refers to using a non-mainstream approach in place of conventional medicine. Complementary and alternative medicine (CAM) is a broad range of modalities outside the traditional Western medicine approach to care (see Box 4.1). Folk medicine, or the use of traditional remedies, is considered to be a form of complementary and alternative medicine. Folk remedies include, but are not limited to long-existing practices, such as Chinese medicine, acupuncture, and naturopathy, to name a few. The history and utilization of CAM, along with culturally based CAM modalities and related laws, are the focus of this chapter.

BOX 4.1 CAM Systems of Health Care

I. Alternative health care systems Ayurvedic medicine Chiropractic Homeopathic medicine American Indian medicine (e.g., sweat lodge, medicine wheel) Naturopathic medicine Traditional Chinese medicine (e.g., acupuncture, Chinese herbal medicine)

II. Mind–body interventions Meditation Hypnosis Guided imagery Dance therapy Music therapy

Art therapy Prayer and mental healing

III. Biological-based therapies Herbal therapies Special diets (e.g., macrobiotics, extremely low fat or high carbohydrate diets) Orthomolecular medicine (e.g., megavitamin therapy) Individual biological therapies (e.g., shark cartilage, bee pollen)

IV. Therapeutic massage, body work, and somatic movement therapies Massage Feldenkrais Alexander method

V. Energy therapies Qigong Reiki Therapeutic touch

VI. Bioelectromagnetics Magnet therapy

Source: White House Commission on Complementary and Alternative Medicine Policy (2002).

History of Complementary and Alternative Medicine

CAM predates the history of the United States. Prior to the latter part of the 19th century, medical care was provided by lay healers, naturopaths, homeopaths, midwives, and botanical healers as well as formally trained doctors. Nineteenth-century advances in science, such as germ theory, antisepsis, and anesthesia, spurred the trend to scientific medical education. Nonconventional treatments were marginalized in the first half of the 20th century after Abraham Flexner’s 1910 report on the need for standardization in medical education. Interest in whole foods and dietary supplements in the 1950s began a resurgence of interest in alternative medical practices. The traditional health practices of immigrant cultures exposed Americans to alternatives, and the counterculture movements of the 1960s renewed the interest in natural healing practices. In the 1970s, the holistic health approach began incorporating Eastern medical traditions with conventional Western medical practices (White House Commission, 2002).

This resurgent public interest in modalities, characterized as folk medicine, has encouraged medical practitioners to investigate their efficacy and impact on conventional medical practices. It has been noted that many folk medicine traditions have common features. Hufford (1988, 1997)

noted that folk traditions tend to view the cause of disease as an imbalance or lack of harmony; they are based on personal responsibility and connections between health and the person’s environment; they tend to be complex practices that involve a holistic approach to disease; and they often include an energy that provides harmony and balance. Being aware of cultural differences in beliefs regarding disease and treatment is imperative to a modern medical practitioner because patients who engage in CAM practices may also seek help from Western medicine.

Use of Complementary and Alternative Medicine The 2007 National Health Interview Survey (NHIS) gathered data from 23,393 interviews with U.S. adults and 9,417 interviews for U.S. children aged 0 to 17. The 2007 CAM section included questions on 36 types of CAM therapies commonly used in the United States: 10 types of provider- based therapies, such as acupuncture and chiropractic, and 26 other therapies that do not require a provider, such as herbal supplements and meditation. In 2007, approximately 38% of U.S. adults and approximately 12% of children used some form of CAM (Barnes, Bloom, & Nahin, 2008). In that same year, U.S. adults spent $33.9 billion out-of-pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials (Nahin, Barnes, Stussman, & Bloom, 2009). Figure 4.1 through Figure 4.5 provide additional information on CAM usage.

FIGURE 4.1 CAM use by race/ethnicity among adults, 2007. Source: Barnes, Bloom, & Nahin (2008).

FIGURE 4.2 CAM use by age, 2007. Source: Barnes, Bloom, & Nahin (2008).

FIGURE 4.3 Diseases/conditions for which CAM is most frequently used among adults, 2007. Source: Barnes, Bloom, & Nahin (2008).

FIGURE 4.4 Ten most common CAM therapies among adults, 2007. Source: Barnes, Bloom, & Nahin (2008).

The White House Commission on Complementary and Alternative Medicine Policy was convened to evaluate CAM utilization in the United States and to make recommendations regarding future governmental action. It noted that the use of CAM is prevalent in the U.S. patient population, which indicates a patient interest in exploring therapeutic options for chronic conditions that are not offered by conventional medicine. The commission produced 25 recommendations for further action by the government and private enterprises that focus on the coordination of research, education and training of health practitioners, CAM information and development and dissemination, access and delivery, coverage and reimbursement, and coordination of federal efforts.

FIGURE 4.5 Ten most common therapies among children, 2007. Source: Barnes, Bloom, & Nahin (2008).

Reviewing the White House commission’s recommendations, the National Center for Complementary and Alternative Medicine ([NCCAM] 2011) released its third strategic plan, which specifically addressed racial and ethnic health disparities in the utilization of CAM practices. The plan presents a series of goals and objectives to guide NCCAM in determining priorities for future research in complementary and alternative medicine. The five strategic objectives are as follows:

Strategic Objective 1. Advance research on mind and body interventions, practices, and disciplines Strategic Objective 2. Advance research on CAM natural products Strategic Objective 3. Increase understanding of “ real-world” patterns and outcomes of CAM use and

its integration into health care and health promotion Strategic Objective 4. Improve the capacity of the field to carry out rigorous research Strategic Objective 5. Develop and disseminate objective, evidence-based information on CAM


Complementary and Alternative Health Care Modalities

The White House Commission on Complementary and Alternative Medicine Policy noted that the major CAM systems have common characteristics that include focusing on individual treatment, a holistic approach to care, promotion of self-care and self-healing, and addressing spiritual influences on health. The commission then created a classification model for CAM systems that listed the various practices by their major domains (Table 4.1) and policy recommendations (Table 4.2). The major modalities of complementary and alternative medicine that are culturally related are included in this chapter.

TABLE 4.1 Domains of CAM

Source: White House Commission on Complementary and Alternative Medicine Policy (2002).

Ayurvedic Medicine Ayurveda, a Sanskrit word meaning science of life, was originally described in the ancient Hindu texts called Vedas. This ancient practice is based on the theory that the five great elements—ether, air, fire, water, and earth—are the basis for all living systems. The five elements are in constant interaction and are constantly changing. The elements combine in pairs to form doshas, the three vital energies that regulate everything in nature (see Table 4.3).

At the time of conception, the doshas combine in a unique way for each individual. This combination is known as prakriti. A person’s physiology, personality, intellect, and weaknesses are governed by two dominant doshas. If the doshas become imbalanced, the flow of prana (life energy)

and agni (digestion) become upset. It is these imbalances that result in illness.

TABLE 4.2 White House Commission on Complementary and Alternative Medicine Policy Recommendations and Actions

Source: White House Commission on Complementary and Alternative Medicine Policy (2002).

TABLE 4.3 The Doshas

Ayurvedic practitioners seek to balance the doshas through methods such as herbal remedies, yoga, meditation, and massage. For example, Panchakarma is a purification process used to remove impurities and restore balance to the doshas. Panchakarma is a set of therapeutic procedures that is intended to improve health and expand the life span. The specific treatments vary and may include using a special diet, emetics, herbal enemas, massage, herbs, and nose cleaning.

Yoga Yoga is an ancient system of exercises and breathing techniques designed to encourage physical and spiritual well-being. It incorporates a number of guidelines for well-being, including good nutrition and hygiene. The physical practice of yoga consists of going through asanas (physical postures) to improve the physical body and calm the nerves. Pranayamas are breathing techniques and meditations designed to improve spiritual well-being.

Some yoga practitioners teach that centers of energy, known as chakras, are connected to the nerves and spinal cord. It is believed that certain asanas and meditations can positively influence the chakras, improving physical and mental health. The exercise and relaxation techniques utilized in yoga are practiced by many people every day.

Traditional Chinese Medicine Traditional Chinese medicine (TCM) is the term used for a group of ancient healing practices that date back some 2,000 years to 200 BCE. The concepts utilized have been adapted by the Koreans, Japanese, and Vietnamese into their own versions of treatment. The system includes, among other treatments, herbalism, acupuncture, qigong, and tai chi.

TCM is based on diagnosis from the pattern of symptoms rather than on endeavoring to identify a specific illness. It is believed that the cause of disease must be cured, not just its symptoms. TCM considers a person’s body, mind, spirit, and emotions as part of one complete whole rather than individual parts that are to be treated separately. TCM is based on a number of interrelated theories: the theory of Qi, the theory of the five elements, the theory of yin and yang, and the meridian theory.

The Theory of Qi Qi, pronounced “ chee,” is the vital life force that animates all things. Qi flows through the 12

meridians that run through the body. Physical, emotional, and mental harmony rely on the flow of qi. Qi has two parts, energy or power, and conscious intelligence. These parts are found in organ systems and allow them to perform their physical and energetic functions. Qi also can be described by how it functions. Qi creates all movement, protects the body, provides for harmonious transformation, such as water being turned into urine, keeps the organs and body parts in proper position, and warms the body. This theory holds that qi:

Is spiritual in origin

Makes up and moves through all living things

Is available in infinite quantities, is positive in nature, and is important to all aspects of health

Is present both inside the body and on its surface

Flows throughout the body in specific channels

Has its flow disturbed by negative thoughts or feelings

Qi deficiency can result in problems, such as what Western medicine calls chronic fatigue syndrome or a fever. Qi stagnation, where the energy cannot flow correctly, can result in what Western medicine calls pain.

The Five Elements Theory The five elements are based on the perception of the relationships between all things. These patterns are grouped and named for the five elements: (1) wood, (2) fire, (3) earth, (4) metal, and (5) water. This theory states that the five organ systems are each tied to a particular element and to a broader group of phenomena that are associated with their elements, including the seasons, colors, emotions, and foods (see Table 4.4). This theory illustrates the interrelatedness of all things.

TABLE 4.4 The Characteristics of the Five Elements

The Yin and Yang Theory The yin and yang theory holds that everything is made up of two polar energies. Neither can exist without the other, and they never separate. It is the principle of interconnectedness and interdependence. Yin and yang describe how things function in relation to one another and the important principle of harmony where things blend together into a whole.

Yin is female and is associated with the moon and night, late afternoon, cold, rest, responsiveness, passivity, darkness, interiority, downwardness, inwardness, and decrease. Yang is male and is associated with the sun and daytime, early morning, heat, stimulation, movement, activity, excitement, vigor, light, exteriority, upwardness, outwardness, and increase (see Figure 4.6).

The Meridian Theory Meridians are channels through which qi, blood, and information flow to all parts of the body (Figure 4.7). There are 12 meridians in the body; 6 are yin and 6 are yang. Although each meridian is attributed to, and named for, an organ or body function, the network of meridians connects the meridians to one another and all parts of the body, and they connect the body to the universe. When qi flows easily, the body is balanced and healthy. The meridians work to regulate the energy functions of the body and keep it balanced and in harmony.

TCM encompasses many different treatment modalities. Some of the treatment options utilized include acupuncture, herbal therapies, and qigong.

Acupuncture Acupuncture is one of the most researched and accepted complementary practices in the United States today. It is experiencing greater acceptance by traditional medical practitioners, and research of its efficacy in treating various conditions has been undertaken, although it has proven to be a difficult subject to study.

Acupuncture involves stimulating specific points along the meridians to achieve a therapeutic purpose. The usual practice involves inserting a needle into one of the acu-points along a meridian associated with that organ or function. Besides puncturing the skin, practitioners also use other methods, including pressure, heat, friction, or electrical stimulation of the needle.

FIGURE 4.6 The symbol of yin and yang is a circle with two equal and opposite halves.

FIGURE 4.7 Meridians.

The TCM theory is that acupuncture works by bringing healing energy, qi, to the affected part of the body through the meridians. The stimulation of the appropriate meridian can assist in bringing the affected organ into balance.

Chinese Herbal Therapies Another significant aspect of traditional Chinese medicine is the use of herbal remedies. Although it is not as prevalent in the United States as acupuncture, the use of herbal remedies is widespread in China and other Asian countries as well as among immigrants from Asian countries. Like acupuncture, herbal remedies are used to bring balance back to the body. Herbs are classified according to the five elements and their yin and yang properties to determine how they will be used. Herbs are combined according to their properties to treat a particular disharmony. They are usually administered as teas, pills, powders, or creams. Safety and efficacy issues related to herbal remedies are discussed in the “ Herbal Remedies” section of this chapter.

Qigong The term qigong translates to “ energy work.” It is a part of TCM that involves movement, breathing, and meditation, and it is intended to improve the flow of qi throughout the body. Qigong is an ancient technique that is practiced by millions of people every day. It involves a number of basic postures that are involved in daily practice, and a master can tailor the techniques to address specific problems.

The ancient noncombative martial art, tai chi, is a form of qigong. The purpose of tai chi is to improve the flow of qi through the body to encourage balance and harmony.

Naturopathy Naturopathy, also known as naturopathic medicine, is a holistic system of medicine based on the healing power of nature. Naturopathy originated in Germany during the late 19th century. The system is built on the ancient belief in the healing power of nature and that natural organisms have the ability to heal themselves and maintain health. Such systems include hydrotherapy (water therapy), which was popular in Germany, and nature cure, developed in Austria, based on the use of food, air, light, water, and herbs to treat illness (University of Maryland, 2011). In 1902 naturopathy was introduced to the United States by Benjamin Lust, a German immigrant. Mr. Lust founded the American School of Naturopathy. The school emphasized the use of natural cures, proper bowel habits, and good hygiene as the tools for health. This was the first time that principles of a healthy diet, such as increasing fiber intake and reducing saturated fats, became popular (University of Maryland, 2011).

Naturopathic doctors (NDs) or naturopathic medical doctors (NMDs) work to identify the cause of disease through an understanding of the body, mind, and spirit of the person. Naturopathic doctors use a variety of therapies and techniques including nutrition, behavior change, herbal medicine, homeopathy, and acupuncture. Naturopathy has two major focus areas: (1) supporting the body’s own healing abilities, and (2) empowering people to make lifestyle changes necessary to achieve the best possible health. Naturopathic doctors emphasize prevention and patient education; they treat both acute and chronic conditions (University of Maryland, 2011).

Naturopaths believe that the body strives to maintain a state of equilibrium, known as homeostasis, and unhealthy environments, diets, physical or emotional stress, and lack of sleep or fresh air can disrupt that balance (see Table 4.5). When homeostasis is upset, naturopaths utilize any number of treatments to return the body to balance. All treatments are designed to enhance the body’s ability to heal itself. Modalities include diet, yoga, manipulation, massage, hydrotherapy, and natural herbs. Naturopathic practitioners take a holistic approach to treatment and focus on the cause of a disruption of homeostasis rather than treating only symptoms.

Herbal Remedies Plants used for medicinal purposes are classified as medicinal herbs. Herbs have been used to treat diseases for centuries. Many conventional medications were originally developed from herbs. Naturopaths as well as other types of practitioners use herbs to restore homeostasis through treating the cause of diseases.

Herbal preparations use either whole plants or parts of plants. Many herbalists believe in synergy, the idea that whole plants are more effective than their individual parts. Herbal remedies are prepared in pill or liquid form for ingestion or as tinctures, creams, or ointments for external use.

In the United States, herbal products are sold as dietary supplements. They are not regulated by the U.S. Food and Drug Administration (FDA) as foods. This means that they do not have to meet the same standards as drugs and over-the-counter medications for proof of safety, effectiveness, and what the FDA calls Good Manufacturing Practices (see Table 4.6).

TABLE 4.5 The Six Key Principles of Naturopathy

Source: National Center for Complementary and Alternative Medicine (2007).

When considering using herbal remedies, it is important to consult a professional who is informed about the use of these remedies. Because a product is labeled “ natural” does not mean it is safe or does not have harmful effects. Further, the product may not be recommended for a person’s specific situation, such as pregnancy. It should be remembered that these remedies can act in the same way as many prescription or over-the-counter drugs and can cause side effects or interfere with the actions of other medications. As with any medication, herbal remedies are not without hazards, and their use must be properly monitored.

TABLE 4.6 About Dietary Supplements

Source: National Center for Complementary and Alternative Medicine (2009).

Did You Know?

Ephedra is a plant native to Central Asia and Mongolia. Ephedrine, the main ingredient in ephedra, is a compound that can powerfully stimulate the nervous system and heart. Ephedra has been used for more than 5,000 years in China and India to treat conditions such as colds, fever, flu, headaches, asthma, wheezing, and nasal congestion. More recently, ephedra was used as an ingredient in dietary supplements for weight loss, increased energy, and enhanced athletic performance.

In 2004, the FDA banned the U.S. sale of dietary supplements containing ephedra. The FDA found that these supplements had an unreasonable risk of injury or illness. This includes the risk of anxiety, cardiovascular complications, headache, seizures, and death (National Center for Complementary and Alternative Medicine, 2013a).

Reiki Reiki, pronounced “ ray-kee,” is a complementary health approach in which practitioners place their hands lightly on or just above a person, with the goal of facilitating the person’s own healing response (see Figure 4.8). More high-quality research in this field is needed to determine its effectiveness. Despite the lack of evidence, more than 1.2 million adults—0.5% of the U.S. general adult population—used an energy healing therapy, such as Reiki, in 2006, according to the 2007 National Health Interview Survey. Reiki appears to be generally safe, and no serious side effects have been reported. There are many different forms of Reiki, and no special background is needed to receive training (National Center for Complementary and Alternative Medicine, 2013b). Training programs and certification are available from Reiki organizations; however, these organizations are not regulated by any government agency.

FIGURE 4.8 Reiki being performed by a practitioner. © Dragon Images/Shutterstock

The basis for modern-day Reiki practice may have started in Tibet more than 2,500 years ago. Reiki was rediscovered in the early 1900s by a Japanese man named Mikao Usui. During a lengthy period of travel and research, Usui found ancient texts that described Reiki and its power to heal by using the energy that flows through all living things. From his studies and meditations, he developed what came to be known as the Usui system of Reiki. Other systems of Reiki have been developed as well. The word Reiki comes from Japanese terms that translate as “ universal life energy” (American Cancer Society, 2012).

Reiki is not used to diagnose or treat specific illnesses. Reiki is used to promote relaxation, decrease stress and anxiety, and increase a person’s general sense of well-being. Therapy is delivered through the Reiki practitioner’s hands, with the goal of raising the amount of universal life energy in and around the client. “ Reiki practitioners intend to strengthen the flow of energy, which they say will decrease pain, ease muscle tension, speed healing, improve sleep, and generally enhance the body’s ability to heal itself” (American Cancer Society, 2012).

A Reiki session is usually about an hour. The practitioner places his or her hands in 12 to 15 positions on or above parts of the patient’s clothed body. Each hand position is sustained for 2 to 5

minutes. The hands are intended to be a conduit for universal life energy, balancing energy within and around the body. Some practitioners believe that the best results occur when patients have three Reiki sessions within a relatively short time, take a break, and then repeat the process. There are three levels of Reiki practice. A Reiki I practitioner can offer hands-on sessions; a Reiki II practitioner can offer hands-on or distant Reiki; and a Reiki master can offer hands-on Reiki, distant Reiki, and Reiki instruction (American Cancer Society, 2012).

What Do You Think?

Many of the CAM modalities do not have scientific evidence that they work yet they are frequently used. Should a hospital offer these services if there is no scientific merit for their use? Is a hospital that does not offer CAM culturally insensitive? Does a hospital that does offer CAM give users the impression that the hospital believes in these practices and encourages their use?

Meditation Meditation refers to a group of mental techniques intended to provide relaxation and mental harmony, quiet one’s mind, and increase awareness. It has been a practice in many cultures for thousands of years. Meditative practices are found in Christian, Jewish, Buddhist, Hindu, and Islamic religious traditions. Although meditation found its origins in religious practices, it is currently utilized for nonreligious purposes, such as improved emotional and physical health. Meditation is utilized to decrease stress and anxiety, decrease pain, improve mood, and positively affect heart disease and the symptoms of physical illness. Scientific research indicates that meditation decreases oxygen consumption, decreases heart and respiratory rates, and influences brain wave and hormone activity (Freeman, 2004).

Various techniques are used by different groups and religions. All techniques have some common factors, namely, use of a quiet location, assuming a comfortable position, focusing one’s attention by concentrating on one’s breath or a mantra (word or sound), and having an open attitude by not allowing distractions to disrupt focus. There are two common types of meditation practices: mindfulness meditation and transcendental meditation.

Mindfulness meditation originated in the Buddhist traditions. It is the concept of increasing awareness and acceptance of the present. During meditation one observes thoughts and images in a nonjudgmental manner with the goal of learning to experience thoughts and feelings with greater balance and acceptance. This technique has been used to treat posttraumatic stress disorder, drug abuse, chronic pain, and to increase cognitive function in the elderly.

Transcendental meditation found its origins in the Indian Vedic tradition. This practice is designed to allow the practitioner to experience ever-finer levels of thought until the source of thought is experienced. A mantra (a sound uttered repeatedly) is used to focus the mind, and the choice of mantra is vital to success. Transcendental meditation enables the mind to reach a quiet state and strives to create a state of relaxed alertness. Transcendental meditation has been found to stimulate what is termed the “ relaxation response,” which is responsible for decreased blood pressure, muscular relaxation, decreased heart and respiratory rate, and a decrease in lactate levels, which are associated with anxiety. Research shows that a number of relaxation meditation techniques

include four parts: a mental focus, passive attitude, decreased muscle tone, and a quiet environment (Freeman, 2004). One relaxation technique is described in Table 4.7.

Studies have shown that transcendental meditation has a positive effect on blood pressure, cardiovascular disease, and overall health. Mindfulness meditation is useful in the treatment of chronic pain and certain psychological disorders. The only situation in which meditation is considered to be unsafe is for people with serious mental disorders such as psychosis and schizophrenia. Otherwise, meditation has been determined to be a safe practice for almost everyone.

TABLE 4.7 Relaxation Technique

Laws Affecting Cultural Practices and Health Many cultures have traditions and practices that involve health and healing. The members of the cultural group are familiar with the healing practices and find them normative. However, those practices often conflict with state and federal laws intended to protect the welfare of the community.

Unlicensed Practices Every state licenses those who engage in the provision of health care services. Physicians, nurses, pharmacists, dentists, and so on must meet certain state-mandated requirements for education and testing before receiving a license to practice their profession. Again, the state’s concern is protecting its citizens from unsafe practitioners. Those who attempt to practice the healing arts without obtaining the requisite license and complying with the licensing laws are prosecuted for the unlicensed practice of the particular profession. Penalties for unlawful practice can be stiff and include both prison time and monetary penalties.

Practitioners of various cultural healing traditions must be aware of and cautious regarding these

types of laws. An example of a common area where these laws come in conflict with cultural practices is midwifery. Many cultures have customs regarding childbirth. Those who assist the mother in the delivery must be aware of the state’s laws regarding that practice. For many years the practice of midwifery was banned by the great majority of states on the premise propounded by the medical associations that modern medical care during childbirth was safer for the mother and infant. Although those ideas have changed, and many states now sanction the practice of midwifery, the midwife must comply with licensing laws or risk sanctions for the unlawful practice of medicine or nursing. Therefore, traditional practitioners must be informed about both the legal requirements and the liabilities that exist in their practice.

Another area of cultural practice that attracts scrutiny is the use of herbs and other natural products in the treatment of illness or disease. We are all familiar with herbal dietary supplements that are available in practically every store in the country. In ethnic areas of many cities in the United States, shops offer various products common to ethnic or cultural tradition. On the surface it appears that no difference exists between those herb shops and the over-the-counter dietary supplements at the local drug store. However, herbal treatments are often treated differently from dietary supplements.

Ethnic healers and herbalists risk running afoul of licensing laws in the manner in which they apply their healing practices. If the healer is merely making available various herbs or natural products to the public, then they are no different from over-the-counter preparations at the local drug store. However, when the healer begins to evaluate and diagnose symptoms and prescribe treatment, healers are considered to be invading the domain of medical practitioners and become subject to sanctions for unlicensed practice.

For example, Lee Wah was a healer in the ancient Chinese traditions. A patient came to Lee’s herb shop, described her ailment to him, and he prescribed certain herbs for the problem. He then chose the herbs and prepared them for her use. Lee was convicted of the unlicensed practice of medicine and was imprisoned (People v. Lee Wah, 1886).

Mexican Americans are very familiar with curanderas, traditional Mexican healers. Curanderas have treated illness in rural areas of Mexico for hundreds of years. It is not unexpected, then, that they should continue those practices in Mexican communities in the United States. However, the licensing laws apply to their practices as well. When a curandera visited an ill person in his home and prescribed a mixture of rhubarb, soda, glycerin, and spirits of peppermint for the patient’s ailment, he was found to be in violation of the licensing laws (People v. Machado, 1929).

Many states now have licensing or registration requirements for herbal practitioners, and anyone engaging in those activities should consult local and state regulations to determine the rules with which they must comply.

Ethnic Remedies The remedies utilized by traditional healers are often prepared by the healer or herbalist or are brought to the United States from the native country. These remedies are subject to government oversight and regulation to ensure safety. The FDA is responsible for ensuring the safety of all foods, drugs, and medical devices marketed and distributed in the United States. How the FDA views a particular remedy, and therefore the amount of regulation applicable to it, depends on how that remedy is classified.

Pharmaceutical products are subject to stringent regulation and testing both before and after approval by the FDA for placement on the market. These drugs are researched for mass production and distribution. No traditional ethnic remedy has ever been taken through the rigorous process for FDA approval.

Because traditional folk remedies contain ingredients such as vitamins, minerals, herbs, or other botanicals and substances such as enzymes and glandular and organ tissues, they are more likely to be viewed as dietary supplements and subject to less stringent regulation. The Dietary Supplement Health and Education Act of 1994 (DSHEA) established the FDA’s current authority to regulate dietary supplements. A dietary supplement is a product taken by mouth that contains a “ dietary ingredient” intended to supplement the diet. Those ingredients often are the very things that were previously noted as the components of ethnic remedies.

According to the DSHEA, a producer is responsible for determining that the dietary supplements it manufactures or distributes are safe and that any representations or claims made about them are substantiated by adequate evidence to show that they are not false or misleading. Dietary supplements do not need approval from the FDA before they are marketed (Center for Food Safety and Applied Nutrition, 2001). After a dietary supplement is on the market, the FDA has the responsibility of monitoring its safety and, if found to be unsafe, to take action to remove it from the market. Further, a product may not be sold as a dietary supplement and promoted as a treatment, prevention, or cure for a specific disease or condition. Such an action would be considered the distribution of an illegal drug (Center for Food Safety and Applied Nutrition, 2001). Although most ethnic healers would not consider their practices to include marketing a dietary supplement, nonetheless a traditional healer who provides any type of remedy is technically subject to these regulations and could be held responsible for their violation.

On a more local level, the state and county health departments are responsible for ensuring the health of the local community. It is not unusual for local health departments to investigate traditional healing practitioners for the unauthorized practice of medicine or the provision of remedies as treatments rather than as dietary supplements. For example, health investigators in Houston, Texas, investigated the lead poisoning of siblings where the children had been given a traditional Mexican remedy for stomach ailments that was found to be 90% lead (Rhor, 2008). Serious consequences for the health and welfare of an unwary population such as this demand government involvement to protect the general welfare.


This chapter includes descriptions of complementary and alternative health care modalities that are associated with a number of cultures. Many are ancient practices that continue to exist despite the emergence of modern Western medicine. Although research on the efficacy of many of these practices is scarce, the prevalence of use indicates a need for further investigation of the risks and benefits of these practices. People using this modalities and preparing ethnic remedies need to be aware of the laws in the United States to avoid violating them.


1. Describe the advantages and disadvantages of three of the CAM modalities discussed in this chapter.

2. Discuss how meditation could be used in Western health care practice.

3. Describe the relationship between ethnic cultures and CAM in the United States.

4. Describe how the laws in the United States affect CAM practitioners.


Select a CAM method that interests you. Conduct research on the topic and interview a practitioner in the field. Write a paper explaining what you learned from the research and the interview. Include a list of the questions that you asked the practitioner and his or her responses in the appendix of the paper.

Case Study

Some cultural practices used to treat illness produce marks on the body that can mimic abuse. Coining and cupping are two such examples. Coining is a form of dermabrasion commonly used in Southeast Asian cultures to rid the body of “ bad winds” by bringing bad blood to the surface (Harris, 2010). The process of coining involves applying ointment to the skin and using a coin or spoon to firmly rub the skin until purple-colored spots and patches appear on the skin. The result is a distinct, symmetrical pattern of bruises typically on the back, shoulders, chest, temples, and forehead that resolve without residual effects (see Figure 4.9). Cupping is another cultural practice used to treat illness. Cupping has been practiced by Russian, Asian, and Mexican cultures (Harris, 2010). A heated cup is applied to the skin, which creates suction on the skin, causing bruises that have been mistaken for abuse (see Figure 4.10). Both of these practices leaves burns or bruises on the child’s skin, but they are cultural norms.

FIGURE 4.9 Coining. © Ty ler Olson/Shutterstock

FIGURE 4.10 Cupping. © Alfred Wekelo/Shutterstock

Consider these related questions:

Are coining and cupping child abuse? Why or why not?

When do cultural practices cross over to being abuse?

References American Cancer Society. (2012, March 8). Reiki. Retrieved from sicaltouch/reiki Barnes, P. M., Bloom, B., & Nahin, R. (2008, December 10). Complementary and alternative medicine use among adults

and children: United States, 2007. (CDC National Health Statistics Report #12.) Washington, DC: U.S. Department of Health and Human Services.

Center for Food Safety and Applied Nutrition. (2001, January 3). About the Center for Food Safety and Applied Nutrition. Retrieved from

Freeman, L. (2004). Complementary and alternative medicine: A research-based approach (2nd ed.). St. Louis, MO: Mosby.

Harris, T. S. (2010). Bruises in children: Normal or child abuse? Journal of Pediatric Health Care, 24(4), 216–221. Hufford, D. J. (1988). Contemporary folk medicine. In N. Gevitz (Ed.), Other healers: Unorthodox medicine in the United

States. Baltimore, MD: Johns Hopkins University Press. Hufford, D. J. (1997). Folk medicine and health culture in contemporary society. Primary Care, 24, 723–741. Nahin, R. L., Barnes, P. M., Stussman, B. J., & Bloom, B. (2009). Costs of complementary and alternative medicine (CAM)

and frequency of visits to CAM practitioners: United States, 2007. (National Health Statistics Reports, No. 18.) Hyattsville, MD: National Center for Health Statistics.

National Center for Complementary and Alternative Medicine. (2007). Backgrounder: An introduction to naturopathy. Retrieved from

National Center for Complementary and Alternative Medicine. (2009). Using dietary supplements wisely. Retrieved from

National Center for Complementary and Alternative Medicine. (2011). Exploring the science of complementary and alternative medicine: NCCAM third strategic plan: 2011–2015. Retrieved from

National Center for Complementary and Alternative Medicine. (2013a, June), Ephedra. Retrieved from

National Center for Complementary and Alternative Medicine. (2013b, April). Reiki: An introduction. Retrieved from

People v. Lee Wah, 71 C. 80 (1886). People v. Machado, 99 CA 702 (1929). Rhor, M. (2008, January 23). Folk medicines pose poison risk. San Francisco Chronicle, p. A8. University of Mary land. (2011). Naturopathy. Retrieved from White House Commission on Complementary and Alternative Medicine Policy. (2002). Chapter 10: Recommendations

and actions. Retrieved from


Religion, Rituals, and Health

Nothing is so conducive to good health as the regularity of life without haste and without worry which the rational practice of religion brings in its train.

—James J. Walsh To prevent disease or to cure it, the power of truth, of divine Spirit, must break down the dream

of the material senses. —Mary Baker Eddy

Key Concepts

Spirituality Religion Rituals Shrines Animal sacrifice

© Click Bestsellers/Shutterstock, Inc. and © Ms.Moloko/Shutterstock, Inc.

Learning Objectives

After reading this chapter, you should be able to:

1. Describe the role religion plays in people’s lives.

2. Explain how religion influences health behaviors and the rationale behind these choices.

3. Describe ways that religion can have positive and negative effects on physical and mental health.

4. Describe religious differences in birthing and death rituals.

5. Explain the difference between spirituality and religion.

Have you ever prayed for a loved one or yourself when ill? If so, you fall within the majority of Americans. In 2007, almost 50% of adults said they had prayed about their health during the previous 12 months, up from 43% in 2002 and 14% in 1999 (Wachholtz & Sambamoorthi, 2011). Thirty-six percent of Americans surveyed reported that they had experienced or witnessed a divine healing of an illness or injury (Pew Forum on Religion & Public Life, 2008).

Spirituality, religion, and health have been related in all population groups since the beginning of recorded history (Koenig, 2012). In earlier times, physicians were often clergy, and for hundreds of years religious organizations were responsible for licensing physicians (Koenig, 2012). Belief in the ability of the supernatural to heal surfaced in shamanism thousands of years ago. Recorded history describing spiritual healing includes Egyptian belief in the healing power of a particular holy site

and Greek and Roman temples built to the healing gods. These types of practices are still known today. Shamanic traditions continue today in Africa, Central and South America, and among some American Indian tribes, and Christians continue to make pilgrimages to holy sites that are believed to heal, such as the Sanctuary of Our Lady of Lourdes in France.

Spirituality is often described as a belief in a higher power, something beyond the human experience. For many people, spirituality is a means of living with, confronting, or otherwise addressing universally mysterious events and occurrences. These events include birth, death, health, personal challenges, and tragedies. Scientific research has determined that spiritual practices positively influence health and increase longevity. However, there is disagreement as to the mechanism of these benefits.

Closely related but distinctive is religion, which is the acceptance of the specific beliefs and practices of an organized religion. Religion is generally an organized approach to practicing a form of spiritual belief in and respect for a supernatural power or powers, which is regarded as a creator or a governing framework of the universe and is supported by personal or institutionalized systems grounded in belief and worship.

Although many people find spirituality in the form of religious practice, religion and spirituality are conceptually different. A person may be spiritual without being religious, or may be both. Research has shown that both spirituality and religious beliefs have positive effects on health.

Those who practice Eastern religions seek to refine the life force within themselves, and they attempt to find meaning and purpose in life through these efforts. Practitioners of Western Christianity may focus more on faith and belief in external guidance and salvation from a supreme being, a god, or gods.

Although much human conduct is related to spiritualism that goes beyond practicing formal

religious teachings, these two concepts flow universally throughout all cultures. However, most of the research has focused on health and religion, as opposed to health and spirituality, primarily because religion is associated with behaviors that can be quantified (e.g., how often one prays or attends a place of worship), it can be categorized by type of religion, and there is more agreement about its meaning. Religion has a significant role in the United States and in the health. It has an impact on social lives and health behaviors and, hence, on physical and mental well-being.

Religion and rituals overlap, but not all rituals are related to religion. Rituals such as baptism and the burning of ghost money when a person dies (a tradition in China) are related to religious practices, but other rituals are not tied to religion, such as drinking tea at 3 o’clock in the afternoon every day. The chapter begins with a discussion of religion and then moves into rituals, but the separation is not definitive. We discuss how religion in America influences health. Then we focus on rituals related to health. Because these topics have such a vast scope, only a few religious practices within the United States are discussed.

Religion in the United States Spirtualism was part of the indigenous populations when the Europeans first arrived in what would become the United States. The conquering Spanish brought their Catholic priests not only for their own guidance but also to impose Christian beliefs on the natives. To a large extent the United States was established by people of strong religious beliefs, including Protestants from Europe seeking a place to practice their beliefs free from religious conflict with other European religions including Catholicism. In part because of the successful establishment of religious colonies, the United States has become “ The Land of the Free,” drawing immigrants from all over the world. The result is that almost every religion is represented and practiced somewhere in the United States.

In the 2011 Gallup poll, about 91% of the U.S. population reported a belief in God or a universal spirit (Newport, 2011). In 2008, 65% of Americans had reported that religion is an important part of their daily lives (Newport, 2009).

Religion and race/ethnicity are linked, but it is important not to assume a person’s religion is based on his or her ethnicity (see Table 5.1). It also is not safe to assume that a person strictly adheres to the practices of a religion. Adherence to religious practices exists on a continuum, with some strictly adhering to all of the guidelines and others having looser ties.

TABLE 5.1 Religious Groups in the United States by Denomination, 2015

Data from Muslims from “Muslim Americans: Middle Class and Mostly Mainstream,” Pew Research Center, 2007. For more information, please see the detailed tables in the Full Reports section.

Source: Pew Research Center (2015). Comparisons. Retrieved from

Religion and Health Behaviors Lifestyle represents the single most prominent influence on our health today. As a result, the United States is seeing the need for more emphasis on prevention and behavior modification. People with religious ties of any kind have been shown to engage in healthier behavioral patterns, and these positive lifestyle choices lead to improved health and longer lives. Why do people with stronger religious ties have better health? The answer includes several possible factors, such as proscribed behaviors, closer social relationships, and improved coping mechanisms.

Health behaviors encouraged or proscribed by particular religions are one possible explanation for

how religion can positively affect health. Some religions prohibit tobacco, alcohol, caffeine, certain sexual practices, and premarital sex, and some encourage vegetarianism. Social relationships are another potential explanatory factor for the connection between religion and improved health indicators. Social ties can provide both support and a sense of connectedness. Many churches and temples offer workshops, health fairs, and craft fairs, which provide social interactions. Social relationships also are tied to coping mechanisms because they provide support in multiple forms during times of stress. For example, financial support may be provided to people who have incurred a tragedy, such as a disability, loss of job, or a house fire. Religious organizations also conduct fundraisers for families who have experienced a death or personal tragedy in the family. Churches and temples assist elders by providing transportation or taking food to the homebound. Friendships and a sense of purpose also are methods of support.

Dietary Practices Dietary practices have a long history of being incorporated into religions around the world. Some religions prohibit followers from consuming certain foods and drinks all of the time or on certain holy days; require or encourage specific dietary and food preparation practices and/or fasting (going without food and/or drink for a specified time); or prohibit eating certain foods at the same meal, such as dairy and meat products. Other religions require certain methods of food preparation and have special rules about the use of pans, plates, utensils, and how the food is to be cooked. Foods and drinks also may be a part of religious celebrations or rituals.

The restriction of certain foods and beverages may have a positive impact on the health of those engaged in such practices. For example, restricting consumption of animal products, such as beef and pork or all animal products, may reduce the risk of health problems. Many religions, such as Hinduism and Buddhism, practice or promote vegetarianism, and these diets have been shown to have several health effects, such as the reduction of heart disease, cancer, obesity, and stroke. Some religions help prevent obesity through beliefs that gluttony is a sin, only take what you need, and the need for self-discipline. Table 5.2 presents a list of religions, their related dietary practices and restrictions, and the rationale behind them.

Religions may incorporate some element of fasting in their practices. In many religions, the general purpose for fasting is to become closer to God, show respect for the body (temple) that is a gift from God, understand and appreciate the suffering that the poor experience, acquire the discipline required to resist temptation, atone for sinful acts, and/or cleanse evil from within the body (Advameg Inc., 2008). Fasting may be recommended for specific times of the day; for a specified number of hours; on designated days of the week, month, or year; or on holy days.

TABLE 5.2 Religions and Their Related Food and Substance Practices and Restrictions and Related Rationales

Source: Adapted from Advameg Inc. (2008).

During times of fasting, most but not all religions permit the consumption of water. Water restriction can lead to a risk of dehydration. Some fasters may not take their medication during the fast, which may put their health at risk. Prolonged fasting and/or restrictions from water and/or medications may pose health risks for some followers. Because of these health risks, certain groups are often excused from fasting. These groups include people with chronic diseases, frail elderly, pregnant and lactating women, people who engage in strenuous labor, young children, and people suffering from malnutrition.

Did You Know?

Most Hindus prefer to die at home. If that cannot occur, then certain rituals are to be performed at the hospital. Examples include assisting the patient with facing east and lighting a lamp near the patient’s head. Often family and friends will be present, singing hymns or chanting mantras from sacred scriptures.

Holy ash or sandalwood paste is applied on the forehead after the patient dies. Members of the family may want the body to face south as that symbolizes facing the god of death. A few drops of holy water are trickled into the mouth, and the incense near the head of the deceased remains burning.

Use of Stimulants and Depressants In addition to foods, some religions prohibit or restrict the use of stimulants. A stimulant is a product (including medications), food, or drink that stimulates the nervous system and alters the recipient’s physiology. Stimulants include substances that contain caffeine, including some teas, coffee, chocolate, and energy drinks. Caffeine is prohibited or restricted by many religions because of its addictive properties. A depressant slows down the nervous system. Alcohol is an example. Many religions also restrict spices and certain condiments, such as pepper, pickles, or foods with preservatives because they are believed to be harmful by nature and favor the natural taste and effect of foods (Advameg Inc., 2008).

Some religions prohibit the use of stimulants and depressants, but others use them during ceremonies. For example, Roman Catholics, Eastern Orthodox Christians, and certain Protestant denominations use wine as a sacramental product to represent the blood of Christ in communion services (Advameg Inc., 2008). Rastafarians introduced marijuana into their religious rites because they consider it to be the “ weed of wisdom,” and they believe it contains healing ingredients (Advameg Inc., 2008). American Indians use tobacco and the hallucinogenic peyote as part of their spiritual ceremonies.

Cigarette Smoking The influence of religion and spirituality is most evident in its “ effects” on cigarette smoking. At least 137 studies have examined relationship between religion and spirituality and smoking, and of those, 123 (90%) reported statistically significant inverse relationships (including three at a trend level), and no studies found either a significant or even a trend association in the other direction. Of

the 83 methodologically most rigorous studies, 75 (90%) reported inverse relationships with religion and spirituality involvement. Not surprisingly, the physical health consequences of not smoking are enormous. Decreased cigarette smoking will mean a reduction in chronic lung disease, lung cancer, all cancers (30% being related to smoking), coronary artery disease, hypertension, stroke, and other cardiovascular diseases (Koenig, 2012).

Exercise Level of exercise and physical activity also appears linked to religion and spirituality. Koenig (2012) located 37 studies that examined this relationship. Of those, 25 (68%) reported significant positive relationships between religion and spiritual involvement and greater exercise or physical activity, whereas 6 (16%) found significant inverse relationships. Of 21 studies with the highest quality ratings, 16 (76%) reported positive associations and 2 (10%) found negative associations (Koenig, 2012).

Religion and Health Outcomes As a result of religion’s effects on health behaviors, it is not surprising that religion has been shown to have positive effects on both physical and mental health. Over the last several decades, a notable body of empirical evidence has emerged that examines the relationship between religion or religious practices and a host of outcomes. Most of the outcomes have been positive, but it is important to note that religion does not always have favorable effects on health.

Religion has sometimes been used to justify hatred, aggression, and prejudice (Lee & Newberg, 2005). Religion can be judgmental, alienating, and exclusive. Religious conflict is perhaps the greatest controllable threat to health and well-being in the modern era. Though raised as a Christian, during World War II, Adolph Hitler intentionally murdered 6 million Jews. Jews and Muslims repeatedly attack one another, keeping the Middle East in a constant state of tension over the last 50 years. Islamic extremists have declared war on Christian believers and used explosives on subways in Spain, crashed jetliners into high rises in New York, and used modern media to display multiple and serial beheadings while ostensibly practicing their religion. Threats of nuclear proliferation and potential use of “ dirty” nuclear weapons have been driven by religious conflict.

Religion also may have a negative impact on health through the failure to conform to community norms. Open criticism by other congregation members or clergy can increase stress in social relationships. Feelings of religious guilt and the failure to meet religious expectations or cope with religious fears can contribute to illness. In some cases, parents’ reliance on religion instead of traditional medical care has led to children’s deaths. Also, people may not participate in healthy behaviors because they believe that their health is in God’s hands, so their behaviors will not change God’s plan. This is referred to as a fatalistic attitude.

In terms of positive effects, an abundance of research supports religion’s constructive effect on health outcomes. Koenig (2012) found that religion and spirituality were related to lower levels of depression and anxiety and an improved ability to cope with adversity. Studies of health behavior have found that higher levels of religious involvement are inversely related to alcohol and drug use, smoking, sexual activity, depressive symptoms, and suicide risk (Koenig, 2012; Williams &

Sternthal, 2007). These studies also found that spirituality and religion are positively related to immune system function. A review of 35 studies of the relationship between religion and health- related physiological processes found that both Judeo–Christian and Eastern religious practices were associated with reduced blood pressure and improved immune function; moreover, Zen, yoga, and meditation practices correlated with lower levels of stress hormones and cholesterol and better overall health outcomes in clinical patient populations (Williams & Sternthal, 2007).

In an important publication, Duke University researcher Harold Koenig and colleagues Michael McCullough and David Larson (2000) systematically reviewed much of the research on religion and health. This lengthy and detailed review of hundreds of studies focuses on scholarship from refereed journals. In sum, the review demonstrates that the majority of published research is consistent with the notion that religious practices or religious involvement are associated with beneficial outcomes in mental and physical health (Johnson, Tompkins, & Webb, 2008). These outcome categories include hypertension, mortality, depression, alcohol use or abuse, drug use or abuse, and suicide. Reviews of additional social science research also confirm that religious commitment and involvement in religious practices are significantly linked to reductions not only in delinquency among youth and adolescent populations but also in criminality among adult populations. Part of the following information is a summary of the findings from an extensive literature review conducted by Johnson, Tompkins, and Webb (2008). This information is reprinted with permission from the Baylor Institute for Studies of Religion.

Hypertension As of 2012, nearly 1 in 3 adults (about 67 million) had high blood pressure, also known as hypertension (Centers for Disease Control and Prevention, 2012b). Though there is strong evidence that pharmacologic treatment can lower blood pressure, there remains concern about the adverse side effects of such treatments. For this reason, social epidemiologists are interested in the effects of socioenvironmental determinants of blood pressure. Among the factors shown to correlate with hypertension is religion. Epidemiological studies have found that individuals who report higher levels of religious activities tend to have lower blood pressure. Johnson, Tompkins, and Webb’s (2008) review of the research indicates that 76% of the studies found that religious activities or involvement tend to be linked with reduced levels of hypertension (see Table 5.3).

TABLE 5.3 Results of Religion and Health Outcomes Studies

The data represent the percentage of published studies that were reviewed.

Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Bay lor Institute for Studies of Religion.

Koenig (2012) found that at least 63 studies have examined the relationship between religion and spirituality and blood pressure, of which 36 (57%) reported significantly lower blood pressure in those who are more religious or spiritual and 7 (11%) reported significantly higher blood pressure.

Mortality A substantial body of research reveals an association between intensity of participation in religious activities and greater longevity. Studies reviewed for the report done by Johnson, Tompkins, and Webb (2008) examined the association between degree of religious involvement and survival (see Table 5.3). Involvement in a religious community is consistently related to lower mortality and longer life spans. Johnson, Tompkins, and Webb’s (2008) review of this literature revealed that 75% of these published studies conclude that higher levels of religious involvement have a sizable and consistent relationship with greater longevity (see Figure 5.1). This association was found to be independent of the effect of variables such as age, sex, race, education, and health. In a separate analysis, McCullough and colleagues conducted a meta-analytic review that incorporated data from more than 125,000 people and similarly concluded that religious involvement had a significant and substantial association with increased length of life (as cited in Johnson et al., 2008). In fact, longitudinal research in a variety of different cohorts also has documented that frequent religious attendance is associated with a significant reduction in the risk of dying during study follow-up periods ranging from 5 to 28 years.

Cancer At least 29 studies have examined relationships between religion/spirituality and either the onset or the outcome of cancer (including cancer mortality). Of those, 16 (55%) found that those who are more religious or spiritual had a lower risk of developing cancer or a better prognosis, although 2 (7%) studies reported a significantly worse prognosis. Of the 20 methodologically most rigorous studies, 12 (60%) found an association between religion or spirituality and lower risk or better outcomes, and none reported worse risk or outcomes. The results from some of these studies can be partially explained by better health behaviors (less cigarette smoking, alcohol abuse, etc.), but not

all. Effects not explained by better health behaviors could be explained by lower stress levels and higher social support in those who are more religious or spiritual. Although cancer is not thought to be as sensitive as cardiovascular disorders to psychosocial stressors, psychosocial influences on cancer incidence and outcome are present (Koenig, 2012).

FIGURE 5.1 Research examining the relationship between religion and health outcomes (total of 498 studies reviewed). Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Bay lor Institute for Studies of Religion.

Mental Health Religion can be helpful or problematic when it comes to mental health. Generally, religion is helpful in providing explanations and practices that can support individuals in understanding and dealing with distress. However, religion also can be a contributor to distress and the onset of mental illness when individuals are confronted with distress that seems to demonstrate the failure of religious beliefs (Pargament, 2013). Religion has been used to justify unhealthy and lethal behavior, for example, when a woman says God told her to kill her three children. Bad judgment and mental illness are no excuse to blame religion, but unhealthy acts do occur in the name of religion.

Depression Approximately 1 in 10 adults in the United States reports depression (Centers for Disease Control and Prevention, 2012a). Over 100 studies that examined the religion–depression relationship were reviewed by Johnson, Tompkins, and Webb (2008), and they found that religious involvement tends to be associated with less depression in 68% of the articles (see Figure 5.1). People who are frequently involved in religious activities and who highly value their religious faith are at reduced risk for depression. Religious involvement seems to play an important role in helping people cope with the effects of stressful life circumstances. Prospective cohort studies and quasi-experimental and experimental research all suggest that religious or spiritual activities may lead to a reduction in depressive symptoms. These findings have been replicated across a number of large, well-designed studies and are consistent with much of the cross-sectional and prospective cohort research that has found less depression among more religious people (see Table 5.3).

Suicide Suicide was the 10th leading cause of death for all ages in 2010 (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2010). A substantial body of literature documents that religious involvement (e.g., measured by frequency of religious attendance, frequency of prayer, and degree of religious salience) is associated with less suicide, suicidal behavior, and suicidal ideation, as well as less tolerant attitudes toward suicide across a variety of samples from many nations. This consistent inverse association is found in studies using both group and individual-level data. In total, 87% of the studies reviewed on suicide found these beneficial outcomes (see Figure 5.1). However, with increasing use of suicide bombers as agents of religious practice, such as the U.S. World Trade Center attacks and individuals boarding U.S. – bound airplanes with explosive material in shoes, this area may need further review. Constructive peaceful religious practice has apparently proven to mediate isolated suicide behavior. But what is the prognosis for religion that encourages suicide?

Promiscuous Sexual Behaviors Out-of-wedlock pregnancy is associated with poverty, higher infant mortality rates, increased risk of contracting sexually transmitted diseases, and other issues. Studies in the Johnson, Tompkins, and Webb (2008) review generally show that those who are religious are less likely to engage in premarital sex or extramarital affairs or to have multiple sexual partners (see Table 5.3). In fact,

approximately 97% of the studies that were reviewed reported significant correlations between increased religious involvement and lower likelihood of promiscuous sexual behaviors (see Figure 5.1). None of the studies found that increased religious participation or commitment was linked to increases in promiscuous behavior.

Drug and Alcohol Use In 2011, an estimated 22.5 million Americans aged 12 or older—or 8.7% of the population—had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month (National Institute on Drug Abuse, 2014). Both chronic alcohol consumption and abuse of drugs are associated with increased risks of morbidity and mortality. Johnson, Tompkins, and Webb (2008) reviewed over 150 studies that examined the relationship between religiosity and drug use (n = 54) or alcohol use (n = 97) and abuse. The vast majority of these studies demonstrate that participation in religious activities is associated with less of a tendency to use or abuse drugs (87%) or alcohol (94%). These findings are consistent regardless of the population under study (children, adolescents, or adults) or whether the research was conducted prospectively or retrospectively (see Table 5.3). The greater a person’s religious involvement, the less likely he or she will be to initiate alcohol or drug use or have problems with these substances if they are used (see Table 5.3). Only four of the studies that were reviewed reported a positive correlation between religious involvement and increased alcohol or drug use. Interestingly, these four tended to be some of the weaker studies with regard to methodological design and statistical analyses.

Delinquency There is growing evidence that religious commitment and involvement helps protect youth from delinquent behavior and deviant activities. Recent evidence suggests that such effects persist even if there is not a strong prevailing social control against delinquent behavior in the surrounding community. There is mounting evidence that religious involvement may lower the risks of a broad range of delinquent behaviors, including both minor and serious forms of criminal behavior. There is also evidence that religious involvement has a cumulative effect throughout adolescence and thus may significantly lessen the risk of later adult criminality. There is growing evidence that religion can be used as a tool to help prevent high-risk urban youths from engaging in delinquent behavior. Religious involvement may help adolescents learn prosocial behavior that emphasizes concern for other people’s welfare. Such prosocial skills may give adolescents a greater sense of empathy toward others, which makes them less likely to commit acts that harm others. Similarly, when individuals become involved in deviant behavior, it is possible that participation in specific kinds of religious activities can help steer them back to a course of less deviant behavior and, more important, away from potential career criminal paths.

Research on adult samples is less common but tends to represent the same general pattern—that religion reduces criminal activity by adults. An important study by T. David Evans and colleagues found that religion, indicated by religious activities, reduced the likelihood of adult criminality as measured by a broad range of criminal acts (as cited in Johnson et al., 2008). The relationship persisted even after secular controls were added to the model. Further, the finding did not depend on

social or religious contexts. A small but growing body of literature focuses on the links between religion and family violence. Several recent studies found that regular religious attendance is inversely related to abuse among both men and women. As can be seen in Figure 5.1, 78% of these studies report reductions in delinquency and criminal acts to be associated with higher levels of religious activity and involvements.

In sum, Johnson, Tompkins, and Webb’s (2008) review of the research on religious practices and health outcomes indicates that, in general, higher levels of religious involvement are associated with reduced hypertension, longer survival, less depression, lower level of drug and alcohol use and abuse, a reduction in promiscuous sexual behaviors, reduced likelihood of suicide, lower rates of delinquency among youth, and reduced criminal activity among adults. As can be seen in Figure 5.1, this substantial body of empirical evidence demonstrates a very clear picture: People who are most involved in religious activities tend to fare better with respect to important and yet diverse outcome factors. Thus, aided by appropriate documentation, religiosity is now beginning to be acknowledged as a key protective factor, reducing the deleterious effects of a number of harmful outcomes.

Religion and Well-Being Well-being has been referred to as the positive side of mental health. Symptoms for well-being include happiness, joy, satisfaction, fulfillment, pleasure, contentment, and other indicators of a life that is full and complete (Johnson et al., 2008). Many studies have examined the relationship between religion and the promotion of beneficial outcomes (see Table 5.4). Many of these studies tend to be cross-sectional in design, but a significant number are important prospective cohort studies. As reported in Figure 5.2, Johnson, Tompkins, and Webb (2008) found that the vast majority of these studies, some 81% of the 99 studies reviewed, reported some positive association between religious involvement and greater happiness, life satisfaction, morale, positive affect, or some other measure of well-being. Koenig (2012) found that out of the 256 studies he reviewed, 79% of them found only a positive relationship between religion and spirituality and well-being and three studies showed a significant inverse relationship. The vast number of studies on religion and well-being have included younger and older populations as well as African Americans and Caucasians from various denominational affiliations. Only one study found a negative correlation between religiosity and well-being, and this study was conducted in a small, nonrandom sample of college students.

TABLE 5.4 Results of Religion and Well-Being Outcomes Studies

The data represent the percentage of published studies that were reviewed.

Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Bay lor Institute for Studies of Religion.

FIGURE 5.2 Research examining the relationship between religion and well-being outcomes (total of 171 studies reviewed). Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Bay lor Institute for Studies of Religion.

Hope, Purpose, and Meaning in Life Many religious traditions and beliefs have long promoted positive thinking and an optimistic outlook on life. Not surprisingly, researchers have examined the role religion may or may not play in instilling hope and meaning or a sense of purpose in life for adherents. Researchers have found, on the whole, a positive relationship between measures of religiosity and hope in varied clinical and nonclinical settings. In total, 25 of the 30 studies reviewed (83%) document that increases in religious involvement or commitment are associated with having hope or a sense of purpose or meaning in life (see Figure 5.2). Similarly, studies show that increasing religiousness also is associated with optimism as well as larger support networks, more social contacts, and greater satisfaction with support. In fact, 19 out of the 23 studies reviewed by Johnson, Tompkins, and Webb (2008) conclude that increases in religious involvement and commitment are associated with increased social support.

Koenig (2012) reviewed 40 studies on the relationship between hope and religion and spirituality. Seventy-three percent (n = 29) reported significant positive relationships with hope; none of these reported the inverse. Koenig (2012) identified six studies with the highest quality, and of those six, half found a positive relationship.

Self-Esteem Most people would agree that contemporary American culture places too much significance on physical appearance and the idea that one’s esteem is bolstered by his or her looks. Conversely, a common theme of various religious teachings is that physical appearance, for example, should not be the basis of self-esteem. Religion provides a basis for self-esteem that is not dependent upon individual accomplishments, relationships with others (e.g., who you know), or talent. In other words, a person’s self-esteem is rooted in the individual’s religious faith as well as the faith community as a whole. Of the studies Johnson, Tompkins, and Webb (2008) reviewed, 65% conclude that religious commitment and activities are related to increases in self-esteem (see Figure 5.2).

Educational Attainment The literature on the role of religious practices or religiosity on educational attainment represents a relatively recent development in the research literature. In the last decade or so, a number of researchers have sought to determine whether religion hampers or enhances educational attainment. Even though the development of a body of evidence is just beginning to emerge, some 84% of the studies reviewed concluded that religiosity or religious activities are positively correlated with improved educational attainment (see Figure 5.2). Educational attainment is relevant to health because those with a higher education tend to have higher socioeconomic status, and hence, better health status.

To summarize, a review of the research on religious practices and various measures of well-being reveals that, in general, higher levels of religious involvement are associated with increased levels of well-being, hope, purpose, meaning in life, and educational attainment. As can be seen in Figure 5.2, this substantial body of evidence shows quite clearly that those who are most involved in

religious activities tend to be better off, which is one of the critical indicators of well-being. Just as the studies reviewed earlier (see Table 5.3 and Figure 5.1) document that religious commitment is a protective factor that buffers individuals from various harmful outcomes (e.g., hypertension, depression, suicide, and delinquency), there is mounting empirical evidence to suggest that religious commitment is also a source for promoting or enhancing beneficial outcomes (e.g., well-being, purpose, or meaning in life). This review of a large number of diverse studies leaves one with the observation that, in general, the effect of religion on physical and mental health outcomes is remarkably positive. These findings have led some religious health care practitioners to conclude that further collaboration between religious organizations and health services may be desirable (see Box 5.1).

BOX 5.1 Clinical Implications of the Relationship Between Religion, Spirituality, and Health

There are many practical reasons for addressing spiritual issues in clinical practice. Here are eight important reasons for doing so, and there are others as well.

First, many patients are religious or spiritual and have spiritual needs related to medical or psychiatric illness. Studies of medical and psychiatric patients and those with terminal illnesses report that the vast majority have such needs, and most of those needs currently go unmet. Unmet spiritual needs, especially if they involve spiritual struggles, can adversely affect health and may increase mortality independent of mental, physical, or social health.

Second, religion and spirituality influence the patient’s ability to cope with illness. In some areas of the country, 90% of hospitalized patients use religion to enable them to cope with their illnesses and over 40% indicate it is their primary coping behavior. Poor coping has adverse effects on medical outcomes, both in terms of lengthening hospital stay and increasing mortality.

Third, religious and spiritual beliefs affect patients’ medical decisions, may conflict with medical treatments, and can influence compliance with those treatments. Studies have shown that religious and spiritual beliefs influence medical decisions among those with serious medical illness, and especially among those with advanced cancer or HIV/AIDs.

Fourth, physicians’ own religious or spiritual beliefs often influence medical decisions they make and affect the type of care they offer to patients, including decisions about use of pain medications, abortion, vaccinations, and contraception. Physician views about such matters and how they influence the physician’s decisions, however, are usually not discussed with a patient.

Fifth, as noted earlier, religion and spirituality are associated with both mental and physical health and likely affect medical outcomes. If so, then health professionals need to know about such influences, just as they need to know if a person smokes cigarettes or uses alcohol or drugs. Those who provide health care to the patient need to be aware of all of the factors that influence health and health care.

Sixth, religion and spirituality influence the kind of support and care that patients receive once they return home. A supportive faith community may ensure that patients receive medical follow- up (by providing rides to doctors’ offices) and comply with their medications. It is important to know whether this is the case or whether the patient will return to an apartment to live alone

with little social interaction or support. Seventh, research shows that failure to address patients’ spiritual needs increases health care

costs, especially toward the end of life. This is a time when patients and families may demand medical care (often very expensive medical care) even when continued treatment is futile. For example, patients or families may be praying for a miracle. “ Giving up” by withdrawing life support or agreeing to hospice care may be viewed as a lack of faith or lack of belief in the healing power of God. If health professionals do not take a spiritual history so that patients and their families feel comfortable discussing such issues openly, these situations may go on indefinitely and consume huge amounts of medical resources.

Finally, standards set by the Joint Commission and Medicare require that providers of health care show respect for patients’ cultural and personal values, beliefs, and preferences (including religious or spiritual beliefs). If health professionals are unaware of those beliefs, they cannot show respect for them and adjust care accordingly. Source: Koenig (2012).

What Do You Think?

Health care professionals should take a patient’s religion and spirituality into consideration, but to what extent should a health care professional’s beliefs be taken into consideration? If a pharmacist has religious beliefs against abortion, should he or she be required to fill prescriptions for the emergency contraceptive? If a pharmacist works in Oregon, where doctors are, by law, permitted to write life-ending prescriptions for dying patients, should a pharmacist who believes that such a practice is murder be required to fill that prescription? Should a faith-based hospital be able to prohibit providing an abortion? Would your answer be different if it was the only hospital in a large rural region so women wanting an abortion would have to travel for 5 hours to reach a clinic? Should the rural hospital be able to prohibit providing an abortion if the life of the mother is threatened?

Rituals A ritual is a set of actions that usually is structured and has a symbolic value or meaning. The performance of rituals is usually tied to religion or traditions, and their forms, purposes, and functions vary. These include compliance with religious obligations or ideals, satisfaction of spiritual or emotional needs of the practitioners, to ward off evil, to ensure the favor of a divine being, to maintain or restore health, as a demonstration of respect or submission, stating one’s affiliation, obtaining so