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Figure 1: Percent of Foreign Born U.S. Population

There are 192 member states in the United Nations. Each one is represented in the United States of America Census, ² making America the most diverse nation on earth. It also is growing rapidly as a result of our nation's birthrate rising faster than the mortality rate and life expectancy increasing by 30 years in the 20^th century. When these two factors combine with immigration and mixed ethnicity marriages, a faster growth of minority ethnicities is created. Minority ethnicity is defined by the U.S. Census Bureau as a group that has different cultural traditions from the majority of the population. Majority is defined as greater than 50 percent of the population.

Consequently, the U.S. Census Bureau has changed its data collection methods to more accurately reflect the diversity of the United States. In 1977, the Office of Management and Budget (OMB) issued Statistical Policy Directive Number 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting." In this new government policy, only four races were options. A review of the directive by an interagency committee in the mid-1990s resulted in recommendations for change, the most notable of which was the ability for respondents to select one or more race on surveys.

For example, a respondent can simultaneously select "White" and "Asian" for a respondent with biracial parents. Tiger Woods even lightheartedly comments that he is "Cablinasian" when asked about his ethnicity, which represents his mix of Caucasian, Black, Indian, and Asian heritage. In October 1997, the OMB announced a directive governing these revised standards for federal data on race and ethnicity: By January 2003, they would be utilized in all governmental agencies.³

When the Immigration and Naturalization Act was passed in 1965, people from all over the world could come to America and become citizens for the first time since 1924. Figure 1 shows how the trend of foreign born U.S. citizens was affected by legislation. There was a distinct drop in foreign born population after the Johnson Reed Act expanded a strict set of existent quotas on immigration by origin. This drop was followed by a recovery increase after the Immigration and Naturalization Act.

With our nation's immigrants come different cultures. Although the cultures have always been present, they were not readily visible. Expression of uniqueness was not the norm in American culture until recent decades. Over the years, as the minority populations have grown, their cultures have made their way out of private gatherings and into mainstream America. The national paradigm is rapidly shifting from a "melting pot" to a "mixed salad." Rather than the dissolution of immigrant cultures into our society, unique cultures now stand out as individual parts.⁵

Today, the fastest growing groups in the U.S. are Hispanics and Asians. Each is nearly as large as U.S. black population. Racial minorities comprise 28 percent of the population and are expected to increase to 40 percent by the year 2030. Figure 2 displays the growth of the minority population in the U.S. by the four main regions from 1950 to 2000. In 1900, 1 in 8 Americans was Caucasian. Today, less than 1 in 4 Americans is Caucasian. In California, Caucasians became the minority in 1999. By 2050, Caucasians are predicted to no longer be the majority in the United States.³

For instance, some cultures find it disrespectful to make direct eye contact while others see it as a sign of respect. Some cultures have limited personal space boundaries while others find an invasion of personal space offensive. Verbalizations are equally important. Many cultures take great pride in their origins and can be easily offended if a

wrong assumption is made about their heritage. Just because someone speaks Spanish does not mean they are from Spain. While it is not feasible to learn about all of the different cultures represented in America, it is realistic to anticipate these differences and adjust our practices accordingly. The sooner we learn to deal with different cultures, and sometimes different languages or dialects, the sooner we will be able to deliver improved outcomes to our patients.

However, cultural competency goes beyond patient interaction. The Hill-Burton Act and Title VI of the Civil Rights Act have been consistently interpreted by the Office of Civil Rights to fully include healthcare. Public and private healthcare organizations that receive federal funds of any kind, including Medicare and Medicaid, are required to meet the following standards:

1. Ensure that patients/consumers receive from all staff members effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
2. Implement strategies to recruit, retain and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.
3. Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.⁶ 

Even if your practice is private and receives no federal funds, following standard 3 is advisable as a minimum. Maintaining an awareness of different cultures among your staff will increase your readiness to address cultural issues in the clinic and reduce your liability in an ever-litigious society. In a rapidly and constantly changing nation, it is paramount that we continue to develop our understandings and skills to better serve our communities. Respecting the different cultural norms is a form of professionalism that includes a willingness to consider customs and values of individuals when developing intervention strategies. To succeed in this patient-centered approach, providers must enhance the communication skills necessary to collaborate with patients to optimize outcomes that work within their patients' world.

References

1. Department of Health and Human Services Office of Disease Prevention and Health Promotion Website. Accessed November 25, 2008 at www.healthypeople.gov.

2. United Nations Website. Accessed March 31, 2008 at www.un.org/News/Press/docs/2006/org1469.doc.htm.

3. Hobbs, F and Stoops, N. (2002). U.S. Census Bureau, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century, U.S. Government Printing Office, Washington, DC.

4. Day, J. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050. U.S. Bureau of the Census, Current Population Reports, P25-1130, U.S. Government Printing Office. Washington, DC, 1996.

5. Eck, D. (2001). A New Religious America. San Francisco. Harper Collins.

6. U.S. Department of Health and Human Services Office of Minority Health Web site. Accessed November 25, 2008 at www.omhrc.gov.

D. Scott McIlwain, AuD, is a faculty member of the U.S. Army's Academy of Health Sciences at Fort Sam Houston, TX, and is an instructor of epidemiology and biostatistics. Contact him at 210-693-9469, scott@hearwell.org.

Melinda Hill, AuD, is a primary investigator at the U.S. Army Aeromedical Research Laboratory Department of Acoustics at Fort Rucker, AL. Contact her at 334-255-6823, melinda.hill@amedd.army.mil.