Cultural Humility in Healthcare ________________________________________________________________
prominent dimensions of diversity an individual may have as well as determine where that individual falls within the soci- etal hierarchy. Dimensions of diversity also serve to privilege and empower some members of society while oppressing and marginalizing other members of society (Sue & Sue, 2021). Intersectionality is a concept that is used to describe how these various dimensions come together to privilege or oppress indi- viduals and groups of individuals. Intersectionality is defined as multiple, intersecting identities and ascribed social positions (e.g., race, gender, sexual identity, class) along with associated power dynamics, as people are at the same time members of many different social groups and have unique experiences with privilege and disadvantage because of those intersections (Kuran et al., 2020). Each individual has a multitude of diverse identities; some are visible and some are not readily identifiable. Each of the identities intersects with the other identities. The multiple intersections can serve to provide for further oppression and marginalization or further power and privilege, and/or they could mitigate one another, providing some facets of privilege and others of oppression. For example, an African American college professor who is a heterosexual woman with a doctoral degree is often oppressed and marginalized because of her race and gender; however, as a highly educated academic who is not gay, she experiences power and privilege, particularly in the academic classroom setting as the course professor. Another example is a female student who has experienced poverty on and off throughout her life cycle and identifies as biracial and gay; she may experience multiple identities that compound her oppression and marginalization (i.e., female, poor, gay, biracial). The concept of intersectionality provides a useful framework for healthcare professionals, as it helps them to understand the complexity of patients’ diverse identities. Further, it provides a structure for understanding the multitude of factors that may cause a patient to be oppressed and/or privileged within the context of American society. In this same manner, it is important to recognize that culture is best described as fluid and subjective, as will be discussed in greater detail with respect to providing patient care with cultural humility. RACE, ETHNICITY, AND IMMIGRATION The United States (U.S.) is a nation of immigrants. The racial, ethnic, and immigrant diversity within American society is often cited as one of its greatest strengths. However, it has also been a challenge for America and for Americans in terms of fully accepting and embracing the broad array of immigrant groups that have become American. Historically, every new immigrant group has experienced various degrees of prejudicial and discriminatory treatment and exclusion from mainstream society. However, the experience of many European (e.g., Irish, Italian, German) immigrants was one of initial discrimina- tion followed by swift acculturation and assimilation, likely aided by the physical appearance and language similarities to those of earlier settlers. Asian and Latina/o immigrants have experienced prejudicial treatment, possibly because of readily
identifiable physical and language differences. Historical evi- dence of mistreatment is well documented, with perhaps one of the most egregious examples being the internment of Japanese Americans during World War II (Nagata and Patel, 2021). Although Americans often think of the journey of voluntary immigration of the many ethnic groups come to America to build a “better” life, the legacy of the forced immigration of African American slaves is often overlooked. African Ameri- cans endured 250 years of enslavement followed by 60 years of a status of “separate but equal” as well as continuing racist practices in education, housing, health, and criminal justice system. The systemic and continuous oppression of African Americans is a direct legacy of this forced immigration and has resulted in enduring educational, health, and wealth disparities (Craemer et al., 2020). “New” immigrants from Afghanistan, Haiti, and other war- torn or environmentally impacted countries are experiencing prejudicial treatment in society and healthcare. The economic and social burden of caring for these immigrants, in addition to the typical flow of immigrant populations, has aroused discriminatory attitudes in society and even in healthcare pro- fessionals that may already be stressed by COVID patient care. Healthcare professionals’ understanding of the differential treatment of current and past immigrant groups based upon ethnic, racial, religious, and linguistic background is para- mount to their understanding of their patients. The way in which individuals and groups are treated from a sociopolitical (macro) level and from a daily individual interactional level (micro) necessarily affects their views and understanding of the world in which they live. From a person in environment perspective, individuals act upon the environment and the environment acts and reacts to the individual. Thus, while individuals help shape the environment around them, the environment also shapes the individual (Hutchison, 2021). A demographic breakdown of the diversity in the US is pro- vided in Tables 1 and 2. This breakdown may help healthcare professionals better conceptualize the potential diversity of experiences among their patients. DEMOGRAPHICS The U.S. has more immigrants than any other country in the world. Currently, more than 47.8 million people in 2023 living in the U.S. were born in another country. This figure represents an increase of 1.6 million from the previous year. Nearly every country in the world is represented among U.S. immigrants (Pew Research Center, 2024a). In 2023, there were a record 47.8 million immigrants living in the US. This figure represents 14.3% of the nation’s popu- lation. Since 1965, the number of immigrants living in the US has more than quadrupled. Since 1970, the number of immigrants has nearly tripled (Pew Research Center, 2024b). Table 1 provides a breakdown of the US foreign-born popula- tion by national origin.
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