Culturally Competent Care For African Americans

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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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 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 access.




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

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

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?




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; Hea

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