Health, Salud, 健康: Individualizing Behavioral Needs in a Multicultural World

Abstract

Diversity within the United States continues to increase, making it imperative that health care providers understand the impact of cultural background on health behaviors and perceptions. These practices promote trusting patient–provider relationships, improve outcomes, and increase patient satisfaction. In this article, we discuss the 3 largest ethnic or racial minority groups in the United States, Hispanics, African Americans, and Asians, and the intersection of culture and health care through the lens of these distinct communities. We also offer behavioral recommendations to increase awareness and knowledge regarding vast cultural variations within our communities while embracing cultural humility.

“In a society as diverse as the United States, medical workers play a critical role in ensuring health care is culturally sensitive and equitable.”

As the United States becomes progressively more diverse, health care workers are tasked with providing culturally appropriate, high-quality care to an evolving patient population. Projections indicate that by 2050 the 3 largest racial or ethnic minority groups in the United States, Hispanics, African Americans, and Asians, will comprise of more than 50% of the nation’s population. ¹ However, as Bailey et al noted in this issue, health interventions often lack personalization for individual patients. ² It is critical that health care providers are equipped with the tools to deliver tailored care that meets the needs of an increasingly multicultural population. To achieve this, we offer the following brief examination of select shared beliefs and values among individuals in these 3 major United States cultural groups while concurrently emphasizing that profound diversity exists within these broad categorizations.

Hispanic Americans

The Hispanic population is the largest and second fastest-growing ethnic minority in the United States next to Asian Americans. ³ While often discussed as a homogenous group, the term, Hispanic American, encompasses people of Mexican, Cuban, Puerto Rican, South American, Central American, and other Spanish origins.^3-5 Country of origin significantly impacts health care needs and utilization and has resulted in vast variations in education levels, disease complications, and life expectancy.^6-8 This may largely relate to differences in acculturation between differing countries of origin.

Acculturation, the process by which immigrants learn and adopt elements of a new culture, plays a critical role in shaping health behaviors. ⁹ For Hispanic Americans, language is a notable indicator of acculturation and, consequently, health status. ⁹ For example, English proficiency is associated with higher health literacy, increased utilization of preventive care including vaccinations and physician visits, and improved overall health.^4,9,10 In contrast, low levels of acculturation are associated with negative health outcomes including poorer dietary habits and higher rates of smoking and alcohol use. ¹¹ Specifically, obesity rates are higher in Hispanic Americans relative to the amount of time spent in the United States further suggesting a relationship between acculturation and well-being. ¹² Awareness of acculturation in the Hispanic population is a vital component of individualized care in this population.

African Americans

The African American community, while characterized by substantial diversity, shares core beliefs and values that connect individuals to a broader culture, particularly through religion and family values. ¹³ The majority (79%) of African American individuals identify as Christian, frequently turning to their faith to navigate medical challenges.^14-16 Religion often provides social support and serves as a buffer against stress and adversity. ¹⁷ Religion can also influence medical decisions.^16,18 For example, African Americans are less likely to engage in end-of-life planning tools or resources, such as advanced directives, which may be attributed to beliefs that life and death are in God’s hands and prioritization of family-centered decision-making.^19-21

Trust is a critical concern for African American communities. Suboptimal health outcomes in this population can be partly attributed to widespread distrust in the health care system, rooted in personal experiences and historical mistreatment.^13,22 Noonan et al. shed light on the extensive history of oppression and injustice endured by the African American community in the United States, which has contributed to the persistent distrust and disparities in medical experiences and outcomes for this population. ²³ These disparities are further influenced by numerous social determinants of health.^23,24 Continuing to increase initiatives that provide adequate nutrition, reliable transportation, and secure housing will be critical building blocks to improve the health of the African American population. ²⁴

Asian Americans

Asian Americans represent the fastest-growing racial or ethnic group in the United States. ²⁵ While often categorized as a single culture, communities of Asian origin are tremendously diverse with a wide range of backgrounds.^25,26 Six origin groups comprise 85% of all Asian Americans, with Chinese Americans representing the largest group at 24%. ²⁷ A key aspect of Chinese culture that influences health care perspectives includes the use of Traditional Chinese Medicine (TCM). This form of medicine includes acupuncture, herbal medicine, and therapeutic exercise, and it considers health as a balance of the individual’s body, mind, and environment. ²⁶ This contrasts with Western medicine, which defines health as the absence of disease or illness. ²⁸ TCM is widely used among Chinese Americans, often without discussion with or supervision from a medical provider. ²⁸ Many Chinese immigrants use TCM in addition to prescribed Western medicine therapies, which if not sufficiently communicated between patient and provider, may result in adverse interactions. ²⁹ Similarly, investigators have found that in spite of high rates of complementary alternative medicine use within health care providers and patients often do not communicate about or are knowledgeable of their use. ³⁰

Chinese perspectives on health are highly influenced by several philosophies and religious ideologies including Confucianism, Taoism, and Buddhism. ³¹ Confucianism guides social interactions and emphasizes family loyalty, respect for elders, and avoiding self-centeredness. ³² The philosophy also assigns roles within families and social groups and often entrusts decision-making to the elderly, parents, male spouse, men, and teachers.^32,33 Taoism prioritizes harmony with nature and incorporates the concepts of yin, yang, and qi, or “vital energy,” which forms the basis of traditional Chinese medicine. ³¹ Buddhism teaches that performing good deeds and being merciful and humble lead to good health. ³⁴ Understanding these principles can promote communication. For example, Chinese Americans are likely to value subtlety, reservation, and harmony. They may withhold questions or disagreements with health care providers, whom they view as authority figures. ³⁵ This differs from the direct, open style of communication in American culture. ²⁶ Awareness of communication, religious, and medicinal differences of Asian cultures must be recognized when caring for this population.

The Importance of Family

Although the interactions with different cultures and the medical community have various histories and barriers, understanding the family values and ways to optimize them is a consistent factor to be considered across all cultures. For example, for Hispanics, the cultural value of familism, an emphasis strong familial bonds, is a powerful protective factor linked to improved mental health and reduced risky behaviors.^36-38 In contrast, machismo, the promotion of traditional gender roles, hypermasculinity, and aggression, is often associated with cynicism and mistrust which may extend to patient–provider relationships.^39,40 Intervention efforts to improve the health of Hispanic communities, therefore, should consider the utility of incorporating culturally-specific ideologies such as familism. ⁴¹

Familial decision-making is also a key value among African Americans, and strong family connections are associated with increased overall well-being and reduced mortality.^42,43 However, family influence can alternatively perpetuate unhealthy habits. For example, dietary norms are often deeply embedded in cultures. Social pressure to adhere to traditional cuisine along with limited access to nutritious foods, exercise spaces, and medical insurance contribute to a disproportionate impact of obesity on African Americans.^13,44

The role of families in the care of Chinese Americans is also crucial. Specifically, providers should be aware of Chinese Americans’ family values and language diversity. ⁴⁵ Chinese culture emphasizes collectivism and the well-being of the family unit which can impact the exchange of health information among family members. ⁴⁵ For example, informed consent may require involving entire families, not just individual patients. ⁴⁶ In palliative discussions, Chinese patients may avoid discussing death with their families as it is taboo to discuss culturally and there are strong values to reduce family burden. ⁴⁷ Further, language diversity is significant. Chinese immigrants speak in a variety of dialects and accents, and bilingual health professionals may not be able to understand individuals’ regional dialects, leading to miscommunication. ⁴⁸

Behavioral Recommendations

Cultivating cultural humility is an essential behavioral practice. Many have been trained under a cultural competency model. ⁴⁹ Cultural humility deviates from the concept that training in cultural differences has a demonstrable mastery or finite body of knowledge to master as suggested by cultural competency. Specifically, this discipline champions commitment to curiosity, self-reflection, and continuous learning from individuals of various backgrounds. ⁵⁰ Increasing knowledge around health beliefs and practices remains critical, as we have attempted to do briefly in this manuscript; however, we urge individuals to not fall into the trap of having a static notion of competence and instead have flexibility and humility to assess the differences in cultural dimensions in the experiences of each patient. ⁵¹

The practice of cultural humility may be fostered in a variety of avenues. For example, the practice of self-reflection, taking the time to have intentional thought about your actions and motives, lends itself to self-awareness. Additionally, training that occurs in community-based settings may also help health care providers to engage in this process. Other activities may include participating in cultural events, learning specific population characteristics, and better understanding potential resource disparities. Ultimately, the practice of cultural humility lends itself to participating in shared decision-making when delivering patient care (e.g., engaging with individuals as multifaceted persons with unique backgrounds that may impact their health) which is associated with improved adherence and outcomes. We recommend that health care providers value the contributions of patients and their families as experts in their own lives and collaborate to implement thoughtful treatment plans aligned with individualized preferences.

Conclusions

In a society as diverse as the United States, medical workers play a critical role in ensuring health care is culturally sensitive and equitable. Each cultural population has distinct backgrounds and values that influence their health care choices, utilization, and outcomes, with substantial diversity even within these groups. Consequently, there cannot be a one-size-fits-all approach to health care. Providers should strive to foster cultural humility and employ shared decision-making in order to provide patient-centered care. Respecting cultural diversity is not only ethically imperative but also a means to improve the overall health and well-being of all patients in an increasingly multicultural world.