Because of our traditions, we’ve kept our balance for many, many years. . . . we have traditions for everything: how to sleep, how to eat . . . how to work . . . how to wear clothes.
Tevye, Fiddler on the Roof
Note: this page and neighboring pages are from teaching materials designed for a lab on GIS and the corresponding lecture/discussion series developed on ‘GIS, population health surveillance, epidemiology and public health’. Since this project is currently being further developed it may at times be locked up for changes or implementation and “brand-related” concerns.
Cultural Metrics — Part 2 . . . is a continuation of the following series:
- Applying Culture to Managed Care Metrics
- Cultural Care and Medicine in General and in the Past
- Redefining Cultural Care
- Integrating Cultural Care to Traditional Allopathic Care Practices
- Life Stages and Cost
- Life Stages and Health (Designing A Plan that Changes with Age)
Ethnicity and religion are two very important ways to categorize the cultural medicine for people. In the health care system, our emphasis on cultural medicine has first focused on language and the ability of the patient and health care provider to communicate. Neither ethnicity nor religion have ever played a direct role in changing how medicine is to be practiced in the medical world. But they do influence the meaning of certain medical activities, such as the meaning of circumcision practiced on a newborn or the purpose for engaging in infibulation on a very young girl. Culture plays a very strong role in how and why we allow each of these procedures to happen. Culture not only makes such practices possible, but also a morally acceptable necessity. Such a view of culture and medicine conflicts greatly with how we interpret and manage the relationship between culture and medicine at the health care administration level.
In past years as a Quality Improvement analyst, one of the service related metrics for the annual review I participated in focused on culture and ethnicity. This was done because it was required for the reaccreditation process and the way we managed this step in the evaluation was to document whatever internal activities existed that meet these basic requirements. This meant that we performed an annual review of the database on staff documenting those who checked a box indicating they could read and/or speak in some foreign language, and then informing us of which languages he or she could speak. It also inferred a possible use of these skills to provide unexpected patients from abroad with sufficient health care practices. The most common foreign languages spoken in the Colorado area were Spanish, Russian and French, with the latter more attached to the health care of African patients than Canadian or French tourists.
We also had to review the walk-in service environments, places where patients might enter this place for the first time with a public health concern such as a suspected STD, a recent sexual encounter with an HIV+ date, a very young newborn to care for, or some distant relative from another country who is older and is possibly carrying some foreign born disease. I did this by walking about the entire facilities, collecting samples of documents we were circulating that were published in other languages. Of course, the bulk of these materials were published by some governmental press or grant sponsored organization devoted to specific ethnic groups, and by far the largest language was presented by these materials was Hispanic. But in the right setting, in particular where certain languages were needed, like in nearby Russian speaking communities, some example of the right languages could be found. Very rarely did we find any polylinguistic documents, and where they existed they usually published by some federal office or npo. They were rarely in any sort of Asian format, or even Russian at times, but certainly meant the needs of the Spanish, traditional Africans (even French African), and Italians. They meant the needs of the Christian populations for the most part, but were rarely found in a form that might satisfy the Hebrew or Islamic populations.
So, in this course of documenting foreign language communication efficiency, I usually gathered:
- a list of all staff members able to speak and provide services to patients whose primarily language was not English
- any materials developed to meet the foreign language requirements. This usually consisted of finding, filing and listing any documents produced which were in some foreign language and shared with patients by workers and offices on the premises.
- a fairly rich collection of educational materials in Spanish, for use by the primary non-English speaking population of patients
For providing an appropriate form of care to foreign language speakers representative of other cultures, the focus was on communications, not form or philosophy of care, or special needs and special forms of care that might arise on occasion due to cultural traditions and practices.
A more modern interpretation of the role and monitoring of culture in the health care system is now needed. This need for a more rounded review of cultural medicine evaluation is implied by several recent and several ongoing changes in the US health care system, especially with regard to local, rural community, small area cultural group settings now developed, the greater openness of non-allopathic care activities that appear to be going on in these communities, and the greater numbers of culturally-related, linked or bound medical diagnoses now appearing in the medical records.
In general, medical conditions linked to culture have for the most part been either a social worker’s, medical anthropologist’s or even psychologist’s or psychiatrist’s issue. But in fact, for some of these diagnoses, the western approach to these cases are simply theoretical in nature, and follow a specific paradigm out there redefining those health concepts believed in by other traditional settings in western terminology. Some of these diagnoses were based on the ICD9 strategy for classifying diseases, and those up to date in their ICD use are already implementing the ICD10 evaluation of the same conditions, but still relying upon a listing that is to date incomplete about cultural disease patterns.
For this reason, a four+ step process of evaluating cultural health was developed. These major four steps define medical diagnoses as either: culturally-specific infectious disease patterns, culturally-related common diseases with culturally related high prevalence rates, culturally-linked conditions that have culture as a link to their physical manifestation and etiology, and culturally-bound, meaning they exist because of traditional cultural beliefs that exist in the living environment.
Culture will not go away and those who believe in the value of their family’s heritage or cultural background will no doubt seek out the best forms of care when this required due to their cultural upbringing. In such a setting, physicians and health care systems which are insensitive to cultural needs and are unable to provide certain care requests.
Redefining Cultural Medicine in the US
There are numerous ways in which culture impacts health and well being. Culture influences our lives by influencing the basic living habits each of us abide by. The food we eat, how we treat others who are sick, how we behave in standard and potentially promiscuous social settings. The ways in which diseases and diagnoses evolve and develop within certain cultural environments require certain unique area-specific cultural traits. These traits relate back to tradition by way of religious philosophies, the presence of individuals on staff familiar with the various communication practices and rituals related to a patient with a strong cultural or ethnic heritage, a strong family support system attached to this heritage, and a specific set of religious and non-religious beliefs systems and certain cultural morees and taboos that had to be adhere to in the health acre setting. In terms of religion and the immediately family-related metaphysical-religious belief systems and practices, many of these needs could be provided by the health acre program. Examples of this include the presence of a Rabbi or an important Muslim cultural and community leader on call.
These features make a health program prepared for meeting the potential multicultural demands of the future. But most of these programs only deal with personal and family needs. The need for a cultural community intervention program has not been met.
To fully understanding the cultural meaning, philosophy and lines of reasoning for specific illnesses, we don’t always expect a translator of foreign language to fully understand everything about a given cultural belief system regarding health and disease. Due to the complexity of populations of people in general, and the number of possible cultural medical beliefs and philosophies that can exist in each community dictating the meaning and purpose for certain diseases, practitioners often lack a full understanding of the history, cause, meaning and culturally-related conclusions drawn about a disease pattern. This is because some diseases have direct cultural meaning, which in turn is related to a very specific cultural philosophy. This philosophy in turn not only impacts the results of the care being given physically as well as emotionally in certain kinds of maladies, it also has impacts on the long term outcomes of these services and the overall quality of care being provided.
During the 1990s, an example of the role of culturally based care was demonstrated by Canadian in-hospital care services provided for patients with an indigenous background engaged in mental health care services. In indigenous cultures, certain illnesses are considered to be important to specific stages in life, and so care provided using the right methods but with the right philosophy and framework in mind resulted in the healthiest outcomes. The Canadian care of mental health patients who appeared to be demonstrating various levels and forms of social detachment behaviors, emotional instability, pseudo-schizophrenic or dissociative states, and even epilepsy and sleep disorders, often allowed cultural input to be provided regarding the purpose of these health events. Each was considered by Indigenous culture to be result of new stages and stresses in life, for which adequate and culturally correct treatment should result in a fairly effective, health-promoting outcome. The underlying psychology attached to the purpose and meaning of the condition served in paving the way to provide the best treatment and longterm outcome.
A lot of what we “know” about other nations’ approach to health care is simply myth.
T.R. Reid, The Healing of America . . .
Integrating Two Forms of Health Care
Within the American health care systems, especially those serving fairly large culturally-defined communities, similar opportunities to provide these services exist, but are rarely engaged in. The most common routes taken for providing culturally-proper, sensitive and adequate care involve the use of important community leaders, religious leaders, and occasionally cultural-trained counselors and psychologists. The mental health health care system allows for some culturally-defined interventions to happen within the health care setting. The somatic or physical care system that focuses on the body itself, often has specific protocols in place that neither allow for much flexibility and change, nor allow for culturally-defined modifications recommended by outside care givers to be practiced. It is not unexpected to see hospital visitors engaged in performing sacred ceremonies around a patient such as a laying of hands by a church prayer group or a blessing by an indigenous or community leader, but certain native practices that require physical activities are usually not allowed within this setting such as a symbolic use of fire or incense, certain highly visible or audible activities.
Administration. The key to cultural medicine practice within the four walls of an allopathic setting are expected to obey common sense safety codes and regulations, and those forms of traditional practice allowed to be engaged in within a clinical or hospital room setting normally have regular clinicians absent from the patient’s room or care setting, or non-participatory. The motions of a practice are allowed. The actual physical changes in place, body and many physical objects are often not allowed. Certain food ways and medication practices for example may not be engaged in, due to innumerable reasons, the chief of which include the unknown on behalf of both sides regarding their interactions with treatment methods already in place and public safety standards. Any procedure that requires significant movement of a bedridden patient for example is not allowed for obvious reasons. The inclusion of an herbal tea mix is generally taboo for most allopathic care facilities.
In spite of these restrictions of culture, for the most part culture and cultural practices can be allowed to play an important role in the in-hospital patient care system. Once the patient leaves the room he or she has resided in within such a place, the ambulatory care services is where the best and most effective interventions can be developed and promoted for certain culturally-related or culturally-specific health care opportunities. This means that for every cultural medicine program that exists, it helps to have a program and method designed for integrating this care for those patient most in need. Like any program designed to manage the care of a group of special needs patients, the conditions most in need of treatment need to be identified, limits to what care can and should be provided have to be defined, protocols have to be developed for those treatments normally engaged in by these groups, an effective communications network has to be developed identifying those individuals with special skills and privileges enabling them to provide such care services, educational materials need to be developed defining the goals, objectives and ways to measure activity and success of these programs and their activities, and the means for engaging in the complete care process need to be defined, from beginning to end, from initial recognition of the need for such a health care intervention, through the intervention process itself, ending with the follow-up to these processes on behalf of the patient, and then on behalf of the crew or people/system engaged in this part of the integrative process of care.
Management. Obviously, the detail of managing such a complex method for culturally managed patient care means that the cultural care portion of this system has to be linked to the traditional systems already in place. It helps to have a database defining the care process itself, as well as background knowledge needed to fully employ such a care program, such as information about other culturally bound, linked or related health care needs and related special intervention and prevention concerns. With a well defined centralized database system, the data required for documenting culturally related needs for special services and activities can be implemented as part of a typical patient database for a health care facility or region. Similar systems have often been developed to serve as standalones most of the time, but when needed provide the data needed for analysis of their efficiency and values. Like these other systems, the cultural medicine database management approach would include the development of standard base data found in the standard system, to which are added modules or templates detailing the unique page requirements for the other cultural components that could be lacking from regular electronic health care data, such as names of facilities design to meet specific culturally-related needs, links to specific data warehouses with descriptions of specific culture related health care diagnoses, processes and observations, and links to a specific patient dataset defining the diagnosis, condition or other reason for need of culturally specific treatments.
Relating this back to the real world of health care, a cultural medicine office, clinic setting, program, non-profit health education service, or special care provider service has to abide by all the same rules as the regular health care systems in general. The distinct value of the cultural care setting is its unique emphasis on the managed care needs and requirements related to cultural medical issues. Examples of these often already exist, in the form of clinics that specialize in ESL patients of Hispanic or Latino/a, Russian and Oriental background.
Philosophical exchange. One of the major questions pertaining to the quality of care provided by these providers involves the unique philosophies used to support their practices. The cultural care path is not designed to support and document or find a replacement or substitute for these unique forms of integrated managed care. A Chinese Herbal Medicine physician for example has to maintain his/her own medical records for the most part, kept and stored independently of the allopathic program in place. Likewise, a culturally sensitive clinic setting design to meet specific needs for culturally bound diseases may promote or forward patients to certain other kinds of healers. These methods of providing unique outside care may be a legal risk, but so long as standard protocols for this process are established, and the clinical services and providers involved monitored and reviewed like any other adjunct health care provider, this method can become more fully integrated into the standard cultural health care module, so long as all of the steps and processes involved are documented enough for sufficient retrospective reviews to be possible.
Therefore, it is logical to assume that one primary role of the cultural medicine program staff is to monitor the care of people engaged in two different avenues of health care, usually involving care for one or more uniquely identified personal, sociocultural, mental and/or physical health need. This process enables adequate surveillance and monitoring to document or diagnose conditions linked to a given cultural setting, and then. like any program, assess quality of services. For example, we already have in place the methods for documenting the infectious diseases that are attached to certain cultural environments and certain foreign country settings. We are also involved in programs designed to pay closer attention to high cultural risk chronic and acute disease problems, like asthma (rural versus urban), diabetes, hypertension, hyperlipidemia. Similar approaches will need to be developed for culturally-linked diseases, which will be more focused on the allopathy approach, and culturally-bound conditions and diseases, the treatments for which may have responsibilities shared amongst the two health care provider systems.
Public Health Surveillance. Culturally linked disease patterns provide us with a very valuable benefit of having this kind of program in place. Culturally-linked disease patterns are infrequent to rare usually, and their diagnosis missed as a result. Therefore, one of the primary benefits of this program is making the medical community more educated and aware of the possibility of culturally linked, combined physical and psychological disease states. This prevents the early misdiagnoses of one culturally-linked cardiac condition for another more common condition. This also allows for earlier intervention practices to be implemented when an individual is considered to be potentially at risk for some unheard of medical condition. The presence of a program itself makes clinicians more aware of what signs and symptoms to remain aware of, and how to properly address certain culturally bound behaviors, conditions or diseases when they arise, such as the numerous pseudo-epilepsy like conditions that exist in given cultural settings, certain pseudo-psychiatric or psychological states, and certain physical states of an unanticipated nature such as infibulation. For some of these types of cases, the need for education and intervention may be identified for specific moral issues linked to specific cultural beliefs, mores, taboos and practices. Even legal interventions can be prevented by properly managing certain culturally bound behaviors involving mental health related activities. For the above reasons and more, there are numerous needs for such a program devoted to cultural medicine to be developed in community settings where culturally-distinct populations make up a substantial percentage of the local population and/or demonstrate a tendency to form fairly stable social settings or communities.
Within the United States health care system, there are numerous diseases for which culture can play an important role in prevention and recovery. Diabetes for example is influenced by culture due to the role of diet and eating habits in certain cultural settings. Epilepsy treatment both in and outside cultural setting is influenced by the belief system about how and why seizures are generated, with western medical philosophy performing better in terms of health risk and quality of life, but cultural medical philosophy deciding whether or not seizure control or even a “cure” can become possible. For mental health linked to family stability, cultural traditions can worsen the interspousal relationship that ensues due to highly stressful economic concerns. For a number of diagnoses linked to birthing, feeding, clothing, caring for, and desires of everyone from newborns to the very old, culturally-defined and culturally-linked examples exist. Cultural medicine, interpreted as such today as part of a standard health care system review, has to include for the first time certain metrics related to scoring all of the different impacts culture has on medicine, not just the cultural communication studies so common to the past. The following detail this important change in overall Quality of Care reviews that have to be developed.
A very simple example illustrating the impact of cultural differences on people’s health involved the elderly population. United States traditions have been broadly criticized for the limited caring provided on older population due to the costs for this care. Older populations receive less respect than older populations in some working class settings, are classified as misfits in others, are considered old timers and not kept up with the times in yet others, and often placed in higher level positions due to age and earlier success, with less of a need to continue on the previously laid path towards success that once existed. This very schizophrenic way of interpreting ageing in the workplace has attached to it a much less rewards-punishment system once an individual is old and retires. Once you retire, your options are significantly less, and you become a potential financial burden in many people’s eyes. Cost now becomes an issue in life, the cost for medicines, the cost for prescription drugs, the cost of having a place to live and remain healthy, and the cost of undergoing whatever forms of visits, preventive health care, and health maintenance operations are needed to keep the heart, kidneys, intestines and brains present and working correctly. Now it is the younger population and the government that is essentially paying for all of this care, relying upon a philosophy that not at all matches the idealistic attitudes traditional cultures once and sometimes still have about their elders. We don’t care for the retired worker like our earlier family members cared for our great great great grandparents a century ago. This is due to the lack of cultural connections within our current medical system.
A major purpose for a cultural medicine setting pertains to Ageing population care. Successful, effective health care during earlier decades of life results in increased survival rates and oncreased numbers of older people in need of care, paid for by future generations. Attached to age is cost, and for the oldest population, multiple chronic diseases means much higher costs. In one study I did on the number of claims filed relative to age for specific disease groups (ICDs, singularly or combined), I found that there is an inverse relationship between age and number of claims filed per one year age increments. In other words, in spite of the continued reduction in numbers of people alive with a particular condition as age progresses, claims increase and attached to each claim is rising cost.
This inverse relationship begins at the peak age in an individual’s health, an age which is defined by the peak age for all people with a medical history similar to the individual under review. Peak age is that age when the greatest number of individuals are alive with similar health diagnoses and conditions, after which, individuals remaining alive begin to reduce in number. There is this relationship between the slope of the decay in the population size and the slope in the increase in claims that can be evaluated and compared for each of these two measures. Typically, the ascent curve of claims signifies the beginning of an exponential relationship taking place in terms of claims. As the patient gets older, and each claim becomes different and more complex in nature, the cost per claim also increases, the disease complexity increases, and the number of visits and other services needed to attend to the increasingly ill patient sky rockets in very short time. This therefore results in a unique set of lines that represent the end results of one exponential increase in numbers (costs) riding atop another (claims). In spite of reducing numbers of remaining survivors, remaining costs for caring for the remaining individual continues to rise, rarely plateauing. In the best of circumstances this suggests that to deal with these increased costs, we need to in the least reduce the temporal and systems generated increases in costs (inflation and cost per service/equipment/materials required), if not plateau or fix these costs on an individual basis in a much more effectively way than in the past.
Life Stages and Cost
By adding cultural medicine program to the program at hand, the question is can this system reduce overall costs for health care?
In the least, this additional system of case management will improve the quality of life for ageing individuals in certain cultural groups. It can also influence overall health, and perhaps level out some of the effects of increasing cost in relationship to increasing age. The longer term impact of this way of managing health care pertains to how we apply it to the earlier age groups. By improving the health of younger people, it is hoped that there would be a long term reduction in older age multiple chronic disease states and related reduced costs for chronic disease care.
The age range immediately prior to the retirement years could be approached via a cultural medical system to avoid severe decreases in health status on down the road. For this approach to care management in a cultural medicine setting, the following age groups are defined:
- geriatrics ageing, 85+ (some systems like to analyze 85+ as well as a unique group of age related health care)
- aging, 75-84
- early retirement 65-74
- 55-64, the Palliative Care group
- 45-54, the Preventive Care group (those with Chronic Diseases may immediately undergo processes defined more by the palliative care group)
- Peak years Adult Age, 35-44
- Adult, 25-34
- Young Adult, 18-24
- Teen age, 13-17
- Pre-teen, 9-12
- Mid-age Child, 6-8
- Young Child, >2-<6
- Infant, 0-2
Each of the above age ranges has specific public health issues to be faced, and specific methods of intervention that can be developed.
Life Stages and Health
The above periods in life can be evaluated at the population level to see how health a given population is. In terms of cultural medicine, this has applications to the focus upon culturally-related public health topics. We can look at specific age groups and score them based on the prevalence of specific risk defining metrics, namely ICDs, and V- and E-codes. For each of the above categories of age ranges, these stages in life are described in a little more detail.
The following ICDs were identified as stress or risk indicators for domestic and sociocultural settings. They are listed in order of age ranges primarily impacted by these conditions.
Pre-teen to Young Adult (9-12, 13-17, 18-24)
In a past study if ICDs related to age, I defined the HEDIS chronic disease measures to age relationships, to demonstrate what age ranges are covered adequately by HEDIS, and which age ranges are lacking in much coverage. The highest risk age range, the ages not heavily reviewed by HEDIS in general, were the Mid-age child to Young Adult years (6-8, 9-12, 13-17, and 18-24). According to the bulk of the claims and ICD diagnostics pyramids, the lowest age range of care for a child is 6 to 8 years.
According to a preliminary review of pre-teen to young adult years (9-12, 13-17, 18-24), risk increases with age for these three groups combined. ICDs demonstrating highest risk and/or significant changes in risk relate to the following:
- mental health and behavioral diagnoses,
- STDs and sexual activity,
- sexual behaviors and misbehaviors,
- abuse in various forms (applied and received, physical, mental, etc., engaged in as teen on teen, teen on child, adult on child, etc.) as defined by V-codes
- criminal and criminal like activity as defined by V-codes
Adult, and Peak Years (25-34, 35-44)
Adult years (25-34) are in theory the healthiest years of life. These are the ages when accidents, outdoor activities, experimental drug use and other unhealthy behaviors begin to set in and have an impact on quality of life, usually in a more acute manner. Certain decisions are made in life during this decade as well, such as the final decision as to whether or not to smoke for your remaining life, what healthy and unhealthy activities to engage in, what dietary programs to adhere to, what family and domestic lifestyle to live, what working class environment, or non-working class lifestyle you opt to lead. There is some stabilization of the mental health behaviors seen in young adult, teen-age and preteen populations, but other more chronic forms of mental health disease begin to set in, such as tendencies for schizophrenia to develop, seizure activities to worsen, bipolarism to begin to impact employability, etc. Long term Career related decisions are made and solidified during this time. For those with genetic or other chronic disease ailments eluded to in earlier years, the reality of the potential long term impacts of these can set in.
The first half of this 20 year period, Adult, 25-34, is followed by Peak Years (35-44). Two things are seen for this period in life. First, individuals are very healthy, very active, very much engaged in careers and work, or very much engaged now in a developing chronic condition in either of two ways: acceptance or denial. Either way, you are away of your physiological condition changing and make decisions as to how to deal with it, like deciding whether or not to engage actively in weight loss activities, undergo dietary changes, begin to adhere faithfully to chronic disease medications for dealing with asthma, epilepsy, MS, etc., whether to be a habitual smoker, drug user, alcoholic beverage consumer, etc. For those who have a serious chronic disease state in their near future, these are the years that help to define which way life is going to go. With epilepsy for example, deciding whether or not to adhere to medications, and reduce seizure activity as much as possible, either results in the development of severe post-secondary convulsion activity related complications, or results in adequate prevention of this type of exacerbation so common, and deadly, to young patients with epilepsy. At the end of the peaks years, one is also close to that peak age that exists for chronic disease populations, after which, members of this particular community of people with multiple illnesses begin to reduce in number due to increasing mortality.
Age of Prevention (45-54)
One is now in the peak years in terms of productivity and quality of life, assuming no chronic diseases have yet emerged. But these are also the years immediately preceding heart disease, hypertension, diabetes type II in the older sense (now children are developing this due to obesity), and various health conditions linked to be either sedentary or not at home and in the workplace. For those with a chronic disease now in place, this serves as a prevention period with the goal of improving later years quality of life. For those without disease, these years require healthy management of life practices and health mental and physical behaviors.
Age of Palliation and Remediation, 55-64
This decade is when a healthy body can remain healthy, at least symptomatically, as well as when old chronic diseases get significantly worse, and new chronic diseases emerge. Conditions like hyperlipidemia and asthma tend to display severe problems during these years. If no prevention was ever engaged in until this point, palliation and remediation are the primary activities engaged in with health care. This is the period when multiple prescription drug use begins to demonstrate it presence, when organ system stress and failure are displayed such as liver failure, and when severe chronic diseases take their toll regarding quality of life.
This is called age of palliation because care switches to improving quality of life and preventing later higher cost procedures, rather than focusing mostly on prevention. This can be the decade when ER visits and related hospitalizations really take a toll on the cost of a person’s individual health care costs. Some cases of serious high cost needs for care develop during these years as well, in particular those related to chronic heart disease, the early risk of stroke, the exacerbation of severe autoimmune disease symptoms ranging from severe MS development to the common rheumatoid arthritis problem.
The cost for palliative health care has been a growing problem for the past 5 to 15 years. The years of highest costs have begun to impact quality of life and quality of care. Chronic disease impacts demonstrate their greatest effects upon longevity during this time, and many times, care is focused almost completely on remediation practices designed to improve quality of life. Serious chronic diseases like diabetes display their effects about this time, in terms of secondary organ and tissue systems like the retina, peripheral nerves, and peripheral vasculature. Rheumatism has its effects upon joint tissue integrity and heart functionality. Hypertension can begin to demonstrate long term impacts on vision, solid organ functions, etc.
In previous reviews of culture and medicine, I came up with several strategies to review culture and public health topics. There are four to seven major ethnic groups, each with unique spatial behavior that can be easily identified using standard census and population health data. These ethnicities are as follows:
- Hispanic/Mexican Latino/a
- African/African American
- Native American
- Asian/Asian American
- Russian/Russian American
- Central (excl. Mexico) and South American
Other smaller groups to consider are
- Australian/New Zealander, etc.
- Pacific Islander
- Mediterranean Europe (vs. Northern European)
Smaller Cultural Groups
Religious vs. Non-religious?
Cultural vs. Non-Cultural?
Social-Urban vs. Utopian Rural-Isolated?