The population of the United States is becoming increasingly diverse. In recent years, the populations within the federally defined minority groups have grown faster than the population as a whole. In 1970, minority groups accounted for 16% of the population. By 1999, this share increased to 30%. Assuming that current trends continue, the U.S. Census Bureau (2009) projects that, by 2025, more than half of all children will be minorities and that, by 2050 minorities will account for 54% of the total population. For the first time in U.S. history, minorities will make up a majority of the total population.

Furthermore, the numbers of certain minority groups, such as Hispanics, are growing considerably faster than those of whites and other groups. If current demographic trends continue, the United States will have the following population composition by the year 2050: white, 44%; Hispanic, 30%; black, 15%; Asian, 9%; and American Indians and Alaska Natives, 2% (U.S. Census Bureau, 2009).

Although the nursing profession has representatives from diverse groups, minorities are generally underrepresented. Currently about 81.8% of registered nurses (RNs) in the United States are white/non-Hispanic. Estimates for each minority group are as follows: black, 4.2%; Hispanic, 1.7%; Asian and Pacific Islander, 3.1%; and Native American and Alaska Native, 0.3% (Health Resources and Services Administration [HRSA], 2009). Additionally, each minority group is distributed differently around the country. Black nurses are more likely to be found in the South, Hispanics in the West or South (i.e., especially states bordering Mexico), and Asian and Pacific Islanders in the West or Northeast. Native American and Alaska Native nurses are predominantly in states with reservations.

The United States has grown and achieved its success largely through immigration. Since 1991, more than 13 million legal immigrants have come to United States (U.S. Department of Homeland Security, 2006). In 2003, the U.S. population included 33.5 million foreign-born individuals, or 11.7% of the total population. Among those foreign born, 53.3% were born in Latin America, 25% in Asia, 13.7% in Europe, and the remaining 8% in other regions of the world (U.S. Census Bureau, 2004). The number of immigrants and refugees in the United States is projected to continue to increase.

In addition, people from other countries will continue to seek treatment in U.S. hospitals, particularly for cardiovascular, neurological, and cancer care, and U.S. nurses will have the opportunity to travel abroad to work in a variety of health care settings in the international marketplace. In the course of a nursing career, it is possible to encounter foreign visitors, international university faculty members, international high school and university students, family members of foreign diplomats, immigrants, refugees, as well as members of more than 130 different ethnic groups, and Native Americans from more than 557 federally recognized tribes. A serious conceptual problem exists within nursing in that nurses are expected to know, understand, and meet the health needs of these culturally diverse individuals, groups, and communities.

Members of some cultural groups desire culturally relevant health care that incorporates their specific beliefs and practices. An increasing expectation exists among members of certain cultural groups that health care providers will respect their “cultural health rights,” an expectation that frequently conflicts with the unicultural, Western biomedical worldview taught in most U.S. educational programs that prepare nurses and other health care providers.

Given the multicultural composition of the United States and the projected increase in the number of individuals from diverse cultural backgrounds, concern for cultural beliefs and practices of people in community health nursing is becoming increasingly important. Nursing is inherently a transcultural phenomenon, in that the context and process of helping people involves at least two people who often have different cultural orientations or intracultural lifestyles.

Healthy People 2020, the new proposed prevention agenda for the nation, identifies priority areas and objectives. By developing a set of national health targets, which includes eliminating racial and ethnic disparities in health, U.S. health officials, together with state and local officials and members of the private sector, set goals to increase the quality and years of healthy life for all Americans (U.S. Department of Health and Human Services [USDHHS], 2009).

The Healthy People 2020 proposed objectives embrace and focus on ways to close the gaps in health outcomes. Particularly targeted are racial and ethnic disparities in areas including diabetes, acquired immunodeficiency syndrome (AIDS), heart disease, infant mortality rates, cancer screening and management, and immunizations. The objectives bring focus on disparities among racial and ethnic minorities, women, youth, older adults, people of low income and education, and people with disabilities (USDHHS, 2000). The Healthy People 2020 box lists selected objectives from Healthy People 2020 specific to cultural health issues.

The aims of Healthy People 2020 are the promotion of healthy behaviors, promotion of healthy and safe communities, improvement of systems for personal and public health, and prevention and reduction of diseases and disorders. The initiative is a tool for monitoring and tracking health status, health risks, and use of health services.

In 1959, Madeleine Leininger, a nurse-anthropologist, used the term transcultural nursing to define the philosophical and theoretical similarities between nursing and anthropology. In 1968, Leininger proposed her theory-generated model, and, in 1970, she wrote the first book on transcultural nursing, Nursing and Anthropology: Two Worlds to Blend (Leininger, 1970). According to Leininger (1978), transcultural nursing is “a formal area of study and practice focused on a comparative analysis of different cultures and subcultures in the world with respect to cultural care, health and illness beliefs, values, and practices with the goal of using this knowledge to provide culture-specific and culture-universal nursing care to people” (p. 493). Culture specific refers to the “particularistic values, beliefs, and patterning of behavior that tend to be special, ‘local,’ or unique to a designated culture and which do not tend to be shared with members of other cultures” (Leininger, 1991, p. 491), whereas culture universal refers to the “commonalties of values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles and form the bases for formulating theories for developing cross-cultural laws of human behavior” (Leininger, 1991, p. 491).

Although many nurse-scholars have developed theories of nursing, Leininger’s theory of culture care diversity and universality is the only one that gives precedence to understanding the cultural dimensions of human care and caring. Leininger’s theory is concerned with describing, explaining, and projecting nursing similarities and differences focused primarily on human care and caring in human cultures. Leininger used worldview, social structure, language, ethnohistory, environmental context, and the generic or folk and professional systems to provide a comprehensive and holistic view of influences in cultural care and well-being. The following three models of nursing decisions and actions may be useful in providing culturally congruent and competent care (Andrews and Boyle, 2008; Leininger, 1978, 1991, 1995; Leininger and McFarland, 2002):

Among the strengths of Leininger’s theory is its flexibility for use with individuals, families, groups, communities, and institutions in diverse health systems. Leininger’s Sunrise Model (Figure 13-1) depicts the theory of cultural care diversity and universality and provides a visual representation of the key components of the theory and the interrelationships among its components.

In 1871, the English anthropologist Sir Edward Tylor was the first to define the term culture. According to Tylor (1871), culture refers to the complex whole, including knowledge, beliefs, art, morals, law, customs, and any other capabilities and habits acquired by virtue of the fact that one is a member of a particular society. Culture represents a person’s way of perceiving, evaluating, and behaving within his or her world, and it provides the blueprint for determining his or her values, beliefs, and practices. Culture has four basic characteristics:

Poverty is another factor that dramatically influences health and well-being. National poverty data are calculated using the official U.S. Census Bureau definition of poverty, which has remained standard since its initial introduction in the mid-1960s. Under this definition, poverty is determined by comparing pretax cash income with the poverty threshold, which adjusts for family size and composition. Table 13-1 provides an overview of the poverty thresholds according to size of family and number of related children under age 18 years residing in the home. The poverty guidelines are issued each year by the USDHHS. The guidelines are a simplification of the poverty threshold for administrative purposes, such as determining financial eligibility for federal programs (e.g., Head Start, National School Lunch, Medicaid, Aid to Families with Dependent Children) (U.S. Census Bureau, 2007).

According to the U.S. Census Bureau (2008), the poverty rate in 2007 was 12.5%. The distribution of the poor varies considerably on the basis of certain factors such as age, race or ethnicity, and marital status. For example, 24.5% of the black population, 10.2% of the Asian population, and 21.5% of the Hispanic population live in poverty. In addition, children under 6 years of age are particularly vulnerable to poverty, with 20.8% of all U.S. children in this age-group being poor.