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Diversity Issues in the Delivery of Healthcare

Luna, Isela PhD, RN, CLNC

Articles: CE

What does it mean to be culturally competent and proficient? What criteria are used to describe a culturally competent healthcare delivery system and how can an individual or an organization grow in competency? What is the delivery of competent care related to me personally?

This article addresses these questions with the assumption that knowing one’s viewpoints on how culture change offers a sample of the glasses through which we view others. Culture and culture change are defined, and four models that explain the process of culture change are discussed in detail. These models represent different world views held to explain the phenomena of acculturation. The article concludes with a summary of the recommended National Standards for cultural and linguistic appropriate healthcare services developed by the Office of Minority Health.

The concepts described can serve as universal tools for individuals and/or organizations interested in cultural competency.

Isela Luna, PhD, RN, CLNC, is a Manager, Carondelet Community Trust, Carondelet Health Network, Tucson, Ariz.

Address correspondence to: Isela Luna, PhD, RN, CLNC, Carondelet Community Trust, Carondelet Health Network, 120 N. Tucson Boulevard, Tucson, AZ 85716-4740 (e-mail:

The acts of terrorism in recent years have taught the world multiple lessons. One lesson that surfaced time and time again is the concept that “United We Stand.” In times of tragedy, it seems that our humanity longs to connect to each other’s souls. What does this have to do with diversity in the delivery of healthcare?

It has been said that our individual lives are only a microcosm of the macrocosm. The recent terrorist attacks on the United States and in the Middle East and Afghanistan is the macrocosm, the very mirror of the conflicts in our individual local lives. At the core of the terrorists acts are diverse and often opposing cultural viewpoints as is the case between Israel and the Palestine. Terrorists groups have diverse definitions of what it means to be a “martyr.” The macrocosm is reflected in the microcosm and vise versa. Accepting the rule of others may not pose a problem until you bump up against them and feel your own behavior is impacted, or your lifestyle threatened. Like the microcosm described, the individual delivery of healthcare is diverse and complicated. Delivering cultural competent care to diverse populations requires knowledge, skill, and acceptance of our diverse humanity.

It would be impossible to provide, in one article, a prescription to being culturally competent in the delivery of healthcare. However, various tools and information can be applied in the delivery of healthcare to diverse groups. This article will concentrate on several of the issues that, from experts in the field and through my own professional experience, have proven to be useful in delivering healthcare to diverse populations. This article will address several topics including: defining culture, factors that influence culture, and models that can assist us in explaining culture change. I will conclude by summarizing the recommended National Standards for culturally and linguistic appropriate healthcare services by the Office of Minority Health.

We consider culture in the delivery of healthcare because it helps us to understand the values, attitudes, and behaviors of others. Holding stereotypes and biases often leads to an undermining of our efforts as teachers and learners in the delivery of care. For example, in most Hispanic cultures including Mexican and Mexican Americans as well as Cuban Americans, there is a common belief that a fat child is a healthy child. This belief has often resulted in prolonged bottle-feeding and its devastating effects on dental health, as well as having obese infants to the point that they cannot perform the developmental growth functions of sitting and standing. 1 Anticipatory guidance from healthcare practitioners may assist in preventing these detrimental effects. Valuing diversity in healthcare enhances the delivery and effectiveness of care, both physically and symbolically.

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Definitions of Culture

Many definitions of culture have surfaced over the years since early anthropologists began to distinguish between population groups of varied heritages. A commonly used definition by Leininger defines culture as the values, beliefs, norms and practices of a particular group that are learned and shared and that guide thinking, decisions, and actions in a patterned way. 2 Leininger defines cultural values as a desirable or preferred way of acting or knowing something that, over time, is reinforced and sustained by the culture and ultimately governs one’s actions or decisions. 3 With migration and the ever-growing global society, cultural groups change and evolve as they react (or not react) to their environment. An example of this found is the Mexican American group. Although few other ethnic minority groups have been as persistent in maintaining their language, cultural beliefs, and traditions as have Mexican-Americans, there is evidence that some traits do not vary much over time. 4 The basic traits of Catholicism, dietary preferences, the extended family, and a tendency to live close persist over several generations. 5

Although it can be said with great certainty that all social, economic, and environmental factors influence culture, several factors are more important than others in influencing culture and culture change. These factors include and are not limited to age, gender, country of origin, socio-economic status, education, individual experiences, and length of residency in the United States.

Several conceptual models can assist health professionals in explaining the phenomena of culture change. Culture change or acculturation (to which it is most often referred) is the process that occurs in individuals and groups as a result of having close and continuous contacts with other cultural groups. 6 Have you ever wondered why some cultural groups seem to adopt the Anglo-American culture faster than others? What has been your explanation for how that culture change occurs? How have your assumptions of that culture change affected the way in which you delivered care to an individual of a certain cultural group. Let us explore a very personal example. Before immigrating to the United States I lived in Mexico, and there is a belief in Mexico, at least in the town in which I was raised, that the United States is overflowing with money, that it “grows out of trees” and the government is anxious to give it away. I remember my adolescent friends and I talking and wondering if I would find money on the streets. From that belief, grew the conclusion that the most important item to Americans is money. It took many years for me to begin to understand that my friends and I were not completely right, and I began to explore a different picture than the one that had been painted for me.

Acculturation is but an elaborate way of saying rules exist in every civilization. When you enter into an existing group, be mindful of the codes that have been developed over time. Not only is this respectful behavior, it is smart. The dominant culture will be more accommodating if it perceives its culture is valued and partly adopted. For example, consider a new job you might have started. Chances are that you were more successful if you accommodated to existing norms. Reflect upon issues that perhaps conflicted with your views. The process of acculturation is very similar, except that the norms and behaviors that are not mainstream are usually imbedded in people for generations. As a result, they become more difficult to change or adapt.

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Models of Acculturation

The first conceptual model is the single continuum model.7–10 In this model it is assumed that there is unidirectional continuum of change from ethnic minority culture to Anglo culture (see Figure 1). Another assumption in this model is that traditional culture traits are dropped and replaced with Anglo traits. Spindler used this model in explaining the behavior of the Menomini Indians. 8



A second model of acculturation is the two-culture matrix, in which two cultures are treated independently. It proposes two dimensions of change: 1) maintenance or loss of traditional culture, and 2) gain of new culture traits (see Figure 2). Thus, the addition of Anglo traits requires no concomitant loss of traditional behaviors and values. Individuals who do not fully accept either culture are marginal.



Stonequist first developed the concept of the “Marginal Man.”11 According to Stonequist, the victims of this disorder, which is caused by the incompatible demands of multicultural situations, suffer from feelings of “double consciousness or duality of personality” (p. 338). They are described as being emotionally unstable, living in limbo, and experiencing severe inner conflicts and “alternation currents of attraction and repulsions of love and hatred” (p. 338).

A third model of acculturation, (see Figure 3) the multidimensional model, recognized that the acceptance of new cultural traits and the loss of traditional cultural traits varies from trait to trait. 12 Each aspect of culture change must be measured independently. The assumption in the second model that a bicultural individual is highly adept in both cultures is not held in this model. Instead, the concept of selective acculturation is used to demonstrate how individuals at different levels of an acculturation adopt certain new traits while retaining certain traditional cultural traits. This model has been used by a variety of authors and it considers new social and cultural patterns that result from the culture contact. Watson 13 termed the process criolization.



It is important to distinguish between acculturation and another theory of ethnicity, assimilation. Some researchers view the two processes as linked, and others use the terms interchangeably. While acculturation refers to the acceptance of cultural patterns and traits, assimilation refers to the social, economic, and political integration of an immigrant or minority into the mainstream society. 14 Acculturation does not require assimilation. However, assimilation requires not only acculturation but also the approximation of one culture in direction of another wherein both cultures have full and free economic, political, and social access.

The assimilation model grew out of the 1920s when the United States experienced massive immigration from Europe. It was assumed that if the nation were to remain undivided, the different ethnic groups would have to become part of the mainstream society. Gordon points out that except for the White Protestants from Northern and Western Europe, true assimilation has never occurred in the United States. 15 Even those groups that have been in the United States for many generations tend to experience only limited assimilation. Mexican Americans are one such group. The lack of assimilation of ethnic groups has been tried to explain through the concept of internal colonialism. This concept describes the exploitation of a group culturally different from the dominant group, and has been applied to ethnic groups such as African Americans and “Chicanos” as termed by Acuna 16 and Barrera. 17 The general application of the model to different groups has been criticized because it does not consider socioeconomic mobility.

The pluralism model is the fourth model and it was first used by Furnivall 18 before being revised by Smith. 19 The pluralism model endorses a peaceful coexistence between members of two different ethnic groups. There is little real interaction between the groups. It supports the maintenance of separate cultural and social ethnic systems. The coexistence between two groups endorsed in the pluralism model seems to best represent the current state of US ethnic relations, and at this time the coexistence between some groups is not peaceful. The general application of the model to different groups has been criticized because it does not consider socioeconomic mobility. Consider the four models discussed: the single continuum model; the culture matrix model, the multidimensional model; and the pluralism model. Which model do you use when caring for people of different ethnic cultures? The assumptions imbedded in each model will determine not only how you care for someone, but your attitudes, behaviors, and expectations of the people for whom you are caring. For example, there is a wide expectation that when people immigrate to the United States they “should” be linguistically adept in the English language, and those who do not learn it are often judged as disinterested, disloyal, and perhaps not caring much about being “American.” My experience on the field varies. There are, of course, people who will fit this stereotype. However, in general, the reasons why people from other ethnic groups do not learn English are very much based not only on their level of acculturation and the length of time they have lived in the United States, but on socioeconomic issues that may or may not be within the realm of their control. Therefore, a deeper exploration of our own personal assumptions and an examination of the other person’s situation can lead a nurse to further understanding and a more appropriate and useful approach when teaching health education.

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Cultural Competence

A common understanding of what it means to be culturally competent or proficient is essential in assuring quality of care. Today, if a provider asserts itself as culturally competent (which many increasingly do), it may be impossible for the consumer to know how, if at all, that relates to specific services. Standards offer a guidepost for may different purposes and audiences. They set forth what should be done by service providers and how it should be done, and provide a basis for evaluation, comparison, and quality assurance by policy makers, consumers, and researchers.

Cultural competence is usually subdivided into linguistic competence and cultural competence, although true cultural competence recognizes language and culture as inseparable. Many cultural competence training approaches often fall into one of two categories: programs that focus on specific population groups and/or health conditions and programs that address overall organizational cultural competence. Over the years, efforts to reduce the disparities in health status between Caucasian and other groups have led to millions of dollars spent on targeted interventions for particular ethnic groups or communities. Health People 2010 has identified two overarching goals that acknowledge the health disparities in minority populations:20 1) to increase the quality and years of healthy life; and 2) to eliminate health disparities among different segments of the population.

Eliminating health disparities has become a difficult venture. In general, linguistically appropriate services constitute a more targeted, measurable intervention. Although expensive and difficult, tracking language needs of individual patients, whether the need was met, is straightforward and the efficiency of interpreters is easy compared to determining the actual culturally competence of an activity. Cultural competence depends more on the philosophy and ethics of the institution and the specific practices of the individual health practitioners. Many models exist and a multitude of organizations are presently at task on this issue. However, a practical starting place is the individual practitioner. Cultural competence, like the process of acculturation, occurs in a continuum, originally developed by Terry Cross and colleagues. 21 The continuum has been shown as a progression upward from negative practices to positive approaches within an individual or organization. The continuum begins on one end at cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, cultural competence, and cultural proficiency. A cultural-proficient individual or organization develops new and innovative approaches to manage and deliver services based on cultural needs. Cultural incapacity includes practices by agencies, which enforce racist policies such as discriminatory hiring practices, and the maintenance of stereotypes in the delivery of service and treatment of their staff. Most organizations or individuals I encounter are in the process of precompetence, where they have begun the process of acquiring competency. These individuals or agencies may explore culture as an integral component in the development of their organization and practices, and there is a true commitment.

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Standards of Care

In 2000, the US Department of Health and Human Services Office of Minority Health produced a series of 14 recommendations to be used as national standards to assure cultural competence in healthcare. 22 For purposes of this article, I have categorized the 14 recommendations into three categories including the development of organizational competence, staff competence, and competent delivery of care. Following is a summary of those categories.

  1. Develop strategies and procedures to address cross-cultural ethical and legal conflicts in the delivery of healthcare.
  2. Plan for an annual assessment documenting the organization’s progress in implementing cultural proficient practices at all levels.
  1. Promote and support a culturally diverse work environment.
  2. Develop and implement strategies to recruit retain and promote qualified diverse and culturally competent administrative, clinical, and support staff.
  3. Require and arrange ongoing education.
  1. Ensure that interpreters can demonstrate bilingual proficiency.
  2. Ensure that client’s primary spoken language is self-identified and make information available.
  3. Provide educational material and other material in the predominant language groups in service areas.
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This article has discussed four conceptual models that have been used over time to understand the process of culture change. These models represent the assumptions that are imbedded in healthcare professionals and that determine the type of care those professionals will provide to minority groups. As a tool, they can be helpful in exploring our own individual views of culture and how culture changes occur. In addition, understanding of this process serves as an educational tool to steer us to the continuum of cultural proficiency. The recommendations described by the National Office of Minority Health are standards that every health practitioner and individual organization must emulate if we are to decrease the disparities in the health of minority populations. Over the next 10 years, those who choose to live in the United States are being asked to expand their definitions of culture so that we can truly stand united as Americans.

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