Cultural Competence in Health Education and Health Promotion (Public Health AAHE)

CULTURAL COMPETENCE IN HEALTH EDUCATION AND HEALTH PROMOTION Editors MIGUEL A. PÉREZ RAFFY R. LUQUIS

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CULTURAL COMPETENCE IN HEALTH EDUCATION AND HEALTH PROMOTION

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CULTURAL COMPETENCE IN HEALTH EDUCATION AND HEALTH PROMOTION Editors MIGUEL A. PÉREZ RAFFY R. LUQUIS

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Copyright © 2008 by American Association of Health Education/American Alliance for Health, Physical Education, Recreation, and Dance (AAHE/AAHPERD). All rights reserved. Published by Jossey-Bass A Wiley Imprint 989 Market Street, San Francisco, CA 94103-1741—www.josseybass.com No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass directly call our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at 317-572-3986, or fax 317-572-4002. Jossey-Bass also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Library of Congress Cataloging-in-Publication Data Cultural competence in health education and health promotion / Miguel A. Perez and Raffy R. Luquis, editors. p. cm. Includes bibliographical references and index. ISBN 978-0-7879-8636-0 (pbk.) 1. Transcultural medical care—United States. 2. Minorities—Medical care—United States. 3. Health education—United States. 4. Health promotion—United States. I. Perez, Miguel A., 1969- II. Luquis, Raffy R., 1966[DNLM: 1. Health Education. 2. Cultural Competency. 3. Cultural Diversity. 4. Health Promotion. WA 18 C968 2008] RA418.5.T73C853 2008 362.1089—dc22 2008014871 Printed in the United States of America FIRST EDITION

PB Printing

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CONTENTS Foreword The Editors

xiii xv

The Contributors

xvi

Acknowledgments

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CHAPTER ONE: CHANGING U.S. DEMOGRAPHICS: CHALLENGES AND OPPORTUNITIES FOR HEALTH EDUCATORS Miguel A. Pérez and Raffy R. Luquis Learning Objectives Introduction Demographic Shifts Demographics of Racial and Ethnic Groups Conclusion Points to Remember Case Study Key Terms CHAPTER TWO: DISPARITIES IN HEALTH AMONG RACIAL AND ETHNIC GROUPS: IMPLICATIONS FOR HEALTH EDUCATION Suzanne Kotkin-Jaszi Learning Objectives Introduction Health Disparities by Condition and Treatment Health Disparities by Ethnic Group Health Disparities and Health Education Conclusion

1 1 2 2 13 18 18 18 19

23 23 24 25 30 35 37

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vi

Contents

Points to Remember

38

Case Study

38

Key Terms

39

CHAPTER THREE: CULTURAL COMPETENCE AND HEALTH EDUCATION Emogene Johnson Vaughn Learning Objectives Introduction Defining Cultural Competence Related and Discipline-Specific Cultural Competence Principles Culturally Competent Practices in Diverse Settings Issues, Concerns, and Strategies in Multicultural Training The Counseling Role in Health Education Conclusion Points to Remember Case Study Key Terms CHAPTER FOUR: COMPLEMENTARY AND ALTERNATIVE MEDICINE IN CULTURALLY COMPETENT HEALTH EDUCATION Helda Pinzon-Pérez Learning Objectives Introduction Use of CAM Definitions of Concepts in Nontraditional Healing Modalities of CAM The National Center for Complementary and Alternative Medicine Application to Health Education Conclusion Points to Remember Case Study Key Terms

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Contents

CHAPTER FIVE: A SPIRITUALLY GROUNDED AND CULTURALLY RESPONSIVE APPROACH TO HEALTH EDUCATION Ann L. Swartz and Elizabeth J. Tisdell Learning Objectives Introduction Defining Spirituality Spirituality and Culture in Health Education Spirituality and Health: Rooted in Example Educating for Health and Wholeness in Context Conclusion Points to Remember Case Study Key Terms CHAPTER SIX: HEALTH EDUCATION THEORETICAL MODELS AND MULTICULTURAL POPULATIONS Raffy R. Luquis Learning Objectives Introduction Models for Assessing Cultural Competence Models for Developing Health Education Programs Conclusion Points to Remember Case Study Key Terms CHAPTER SEVEN: DEVELOPING CULTURALLY APPROPRIATE NEEDS ASSESSMENTS AND PLANNING, IMPLEMENTATION, AND EVALUATION FOR HEALTH EDUCATION AND PROMOTION PROGRAMS Nayamin Martinez-Cossio Learning Objectives Introduction Identifying Cultural Factors Affecting Health Education Conducting Needs Assessments in Culturally Diverse Groups

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105 105 106 107 115 120 120 121 121

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Contents

Planning and Implementing Culturally Appropriate Programs

134

Designing Culturally Appropriate Evaluations

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Conclusion

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Points to Remember

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Case Studies

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Key Terms

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CHAPTER EIGHT: COMMUNICATION AND CULTURAL COMPETENCE Matthew Adeyanju Learning Objectives Introduction Communication and Culture Communication and Cultural Competence Historical Perspectives on Communication Across Cultures Communicating Across Cultures About Health and Disease Communication and Personal Health Communication and Community Health Communication and Marketing Techniques Communication Patterns and Language Barriers Conclusion Points to Remember Case Study Key Terms CHAPTER NINE: TOWARD A CULTURALLY COMPETENT HEALTH EDUCATION WORKFORCE Eva I. Doyle Learning Objectives Introduction Cultural Competence and Professional Preparation Programs Cultural Competence and the Work Setting Conclusion Points to Remember

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Contents

Case Study

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Key Terms

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CHAPTER TEN: STRATEGIES, PRACTICES, AND MODELS FOR DELIVERING CULTURALLY COMPETENT HEALTH EDUCATION PROGRAMS Miguel A. Pérez Learning Objectives Introduction Health Indicators Cultural Diversity and Health Education Cultural Diversity and Health Education Professional Programs CLAS Standards Four Areas of Cultural Competence Recommendations for Working with Diverse Groups Conclusion Points to Remember Case Study Key Terms CHAPTER ELEVEN: AGING AND HEALTH EDUCATION: PARTNERS FOR LEARNING Carolina Aguilera, William H. Dailey Jr., and Miguel A. Pérez Learning Objectives Introduction Demographic Characteristics of Older Americans Issues Facing the Older Adult Population Health Literacy Among Older Adults Cultural Competence with Older Adults Healthy Aging and Health Education Conclusion Points to Remember Case Study Key Terms

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Contents

CHAPTER TWELVE: CULTURE AND SEXUAL ORIENTATION Kay Woodiel and Kate Brindle Learning Objectives Introduction The LGBT Culture Health Issues of the LGBT Community Health Issues Common to All LGBT Groups Health Issues of LGBT Youths Health Issues of Lesbian and Bisexual Women Health Issues of Gay and Bisexual Men Health Issues of Transgender Communities Health Issues of LGBT Racially and Ethnically Diverse Communities Increasing Cultural Sensitivity Toward the LGBT Community Conclusion Points to Remember Case Study Key Terms

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CHAPTER THIRTEEN: CULTURAL COMPETENCE AND HEALTH EDUCATION: CHALLENGES AND OPPORTUNITIES FOR THE TWENTY-FIRST CENTURY 231 Raffy R. Luquis and Miguel A. Pérez Learning Objectives 231 Introduction 232 Understanding the Need for Cultural and Linguistic Competence 232 Achieving Cultural Competence 235 Acquiring Linguistic Competence 236 Supporting Cultural and Linguistic Competence in Health Education 237 Strategies to Incorporate Cultural and Linguistic Competence into Health Education 238 Standards for Cultural and Linguistic Competence in Health Education 240 Conclusion 242

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Contents

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Points to Remember

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Key Terms

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Appendix A: A Position Statement of the American Association for Health Education, April 2006

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Appendix B: Web Resources for Understanding Health Disparities

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Appendix C: Known Health Disparities Among Racial and Ethnic Groups

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Appendix D: Web Resources for Working with the Elderly

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Index

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FOREWORD Cultural competency has been one of the essential skill sets for effective health education and promotion in locations where diverse populations exist. The dramatic demographic change that has taken place in the United States during the past two decades, however, means that undreamed of diversity now exists in small cities and towns across the country due to workforce recruitment from other countries, refugee resettlement, and a variety of other factors. It is now essential that all current and future health education specialists have knowledge and skills in cultural competency. For more than fifteen years the American Association for Health Education (AAHE) has been working actively to advance cultural competency among health education and promotion professionals, and during the mid-1990s AAHE promulgated training in cultural competency through a series of AAHE-developed workshops funded by a grant from the U.S. Department of Education and conducted across the nation. Two written texts emerged from that work, and the authors of this book have reinforced a number of the guidelines and principles for cultural competency established at that time. However, the authors of this book have also greatly expanded upon that very early work. Cultural Competence in Health Education and Health Promotion fulfills current and future needs in cultural competency for both professional preparation and implementation by practitioners. The authors of this book present a thorough exploration of up-to-date research about the impact of culture on health disparities, communication, wellness, belief systems, educational strategies, and a plethora of other factors essential to having a complete understanding of cultural competency. As Swartz and Tisdell point out in Chapter Five, delivering health education and promotion programs appropriately within a cultural framework requires taking into account the importance of not only health behaviors but also attitudes toward health and healing and the impact of leadership, religion, and spiritual beliefs within the culture. The officers and staff of the American Association for Health Education (AAHE) wish to extend sincere appreciation to Dr. Miguel A. Pérez and Dr. Raffy R. Luquis for their excellent vision in conceptualizing and developing the content focus and organization of this important new resource for health education and promotion professionals. Their leadership and expertise coalesced to fill a need for the profession as well as for our organization. We also wish to extend our sincere gratitude to all of the authors who contributed their expertise to Cultural Competence in Health Education and Health Promotion: Matthew Adeyanju, Carolina Aguilera, Kate Brindle, William H. Dailey Jr., Eva I. Doyle, Emogene Johnson Vaughn, Suzanne Kotkin-Jaszi, Nayamin Martinez-Cossio, Helda Pinzon-Pérez, Ann L. Swartz, Elizabeth J. Tisdell, and Kay Woodiel.

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Foreword

The Swahili word harambe means a coming together—not just physically but a coming together of spirit, of mind, and on a common ground. This is what these authors have accomplished in support of cultural competency for the American Association for Health Education. We believe harambe is also what the authors wish for all health education and promotion professionals and their clients or students. The officers and staff of AAHE also wish to take this opportunity to recognize Cultural Competence in Health Education and Health Promotion as the launch of the American Association for Health Education/American Alliance for Health, Physical Education, Recreation, and Dance joint publishing venture with Wiley/Jossey-Bass. The anticipated outcome of this joint venture over a period of years is a series of books under our own imprint—AAHE Press. We are delighted to acknowledge the outstanding quality provided by Wiley/Jossey-Bass in health education, health promotion, and public health publications, and we look forward to a partnership that will set the standard for many years. Becky J. Smith Executive Director, AAHE Katherine M. Wilbur President, AAHE March 2008

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THE EDITORS MIGUEL A. PÉREZ is a health educator who specializes in international health and applied research, adolescent health, and cultural competence. In 2001, he received a Fulbright award to teach at the Universidad El Bosque in Bogota, Colombia. In 2005, he was a Fulbright Senior Specialist Scholar in public/global health at the Nelson Mandela Metropolitan University in South Africa. In 2006, he was a Fulbright Senior Specialist Scholar in public/global health at the Universidad del Norte in Barranquilla, Colombia. He received his PhD degree in 1994 and his MS degree in 1993 in health education from the Pennsylvania State University, and his BS degree in research in mental health from California State University, Dominguez Hills. RAFFY R. LUQUIS is a faculty member in the School of Behavioral Sciences and Education at the Pennsylvania State University, Harrisburg. He earned his PhD degree in health science at the University of Arkansas in 1996 and his MS degree in health education in 1991 and BS degree in science in 1988 at Penn State. His primary teaching and research interests are in community health education and health promotion, multicultural health, and sexuality.

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THE CONTRIBUTORS MATTHEW ADEYANJU is a professor and the director of the School of Health Sciences at the Ohio University, Athens, Ohio. Prior to joining Ohio University, Adeyanju was an associate professor and the graduate program coordinator for health education and health promotion at the University of Kansas. Before earning his PhD degree from the University of Illinois in 1985, Adeyanju served the World Health Organization in his native home in Nigeria, where he was also a public health educator. CAROLINA AGUILERA obtained her MPH degree, with an emphasis in health promotion, in 2006 and her BS degree in health science, with an emphasis in community health, in 2001 from California State University, Fresno. Her current research interest is the effects of diabetes among Latino populations throughout the Central Valley region in California. KATE BRINDLE has been at Eastern Michigan University since 2003, where she is program coordinator of the Lesbian, Gay, Bisexual and Transgender Resource Center. She holds an MLS degree in women’s studies from Eastern Michigan University and a BFA degree from New York University. While a graduate student at EMU, she was recognized as a Woman of Excellence and was awarded the Margaret L. Rossiter Outstanding Graduate Paper Award. She is a recipient of the Stonewall Scholarship and has been recognized as an Outstanding Role Model and Mentor by the LGBT Resource Center. She has also been a nominee for the Gerri Collins Medal for Exemplary Service and the Best New Employee Gold Medallion Award. WILLIAM H. DAILEY JR. is a lecturer in gerontology in the Health Science Department at California State University, Fresno, and also teaches periodically at Fresno City College in the Social Sciences Department. He works alongside Merlin, his guide dog of ten years, who is considered an “elder” dog. Dailey earned his MPA degree from California State University, Fresno, and is currently studying for his doctorate at Fielding Graduate University, focusing on educational leadership and change in dealing with disabilities related to aging. His doctoral dissertation will address practitioners’ limitations, perceptions, and interactions as they work collaboratively to meet the needs of an increasing older population. Dailey was a delegate to the White House Conference on Aging held in December of 2005 in Washington, D.C., and he continues to collaborate with the California delegation to advocate for key aging issues. His research interests include the role of grandparents in raising their grandchildren, aging and disability issues facing elders, and also alternative housing and transportation issues.

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The Contributors

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EVA I. DOYLE is an associate professor and the director of health education in the Department of Health, Human Performance, and Recreation at Baylor University. She is a certified health education specialist (CHES) with a PhD degree in health education from the University of Maryland and an MS degree from Baylor University. She specializes in assessing health needs and providing cross-cultural health education in medically underserved communities. She regularly involves students in communitybased health promotion projects in international and local settings. EMOGENE JOHNSON VAUGHN is a professor in the Department of Health, Physical Education and Exercise Science at Norfolk State University, Norfolk, Virginia. Her teaching interests are in the areas of personal health and online instruction. Her other responsibilities have included serving as a wellness coordinator and coordinating the health education service course. Among her ongoing interests is the evaluation of teen pregnancy prevention programs with the Virginia Department of Health. She received her PhD degree from the University of Maryland. SUZANNE KOTKIN-JASZI is an associate professor of health science in the College of Health and Human Services, California State University, Fresno, where she also serves as undergraduate adviser for the health administration option of the health science major and as the adviser for graduate study in the health policy and administration option in the Master of Public Health Program. She is a Health Policy Research Fellow at the Central Valley Health Policy Institute, and she was formerly director of the New Mexico Health Policy Commission, where she conducted research on Medicaid reform, the uninsured, health professional shortages, prescription drug coverage, pain management, and other critical health policy issues. She has taught and written about the financing, delivery, and organization of community health services; health policy; welfare reform and privatization; health law and legislation; and the integration of chronic care management into primary health care settings. She holds a DPH degree from the University of California, Berkeley. NAYAMIN MARTINEZ-COSSIO has been working with Centro Binacional para el Desarrollo Indigena Oaxaqueño (CBDIO), Inc., since 2001 as the coordinator of Proyecto de Salud (Indigenous Health Project), a role that has involved her in partnerships with such health promotion initiatives as the Children’s Health Initiative, the Multicultural Community Alliance, the HIV Surveillance Project, and the Fresno region Binational Health Task Force. Martinez earned her BA degree in international relations from Universidad Iberoamericana in Mexico City, and her MA degree in sociology from Instituto de Investigaciones Dr. José Maria Luis Mora, also in Mexico City. Her undergraduate and graduate theses addressed the sociopolitical dynamics of Mexican migration to the United States. She is currently studying for an MPH degree at California State University, Fresno, gaining skills and knowledge to apply to the development of community projects targeting indigenous migrants in California. She has also designed and implemented two health promotion programs (Comenzando Bien and

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The Contributors

Na Vali Daatun) to provide prenatal education and assistance in accessing health and social services to pregnant, indigenous women. HELDA PINZON-PÉREZ, a native of Colombia, South America, is a faculty member in the Department of Health Science at California State University, Fresno. Her research interests center on multicultural issues in health care, international health, and holistic health. She teaches multiple courses related to cultural competence and is a member of the Multicultural Involvement Committee of the American Association for Health Education. She received her RN degree from the Pontificia Universidad Javeriana in Bogota, Colombia, and her PhD degree from the Pennsylvania State University. ANN L. SWARTZ is an instructor of nursing at the Pennsylvania State University, Harrisburg. She is a family nurse practitioner and psychiatric clinical nurse specialist. She has received an MSN degree with a family nurse practitioner certificate from Widener University, an MSN degree from the Catholic University of America, and a BSN degree from the University of Virginia. She is currently pursuing her EdD degree at the Pennsylvania State University. ELIZABETH J. TISDELL is an associate professor of adult education at the Pennsylvania State University, Harrisburg. She researches and writes about culturally responsive education and spirituality in higher education. She earned her EdD degree at the University of Georgia, MA degree at Fordham University, and BA degree at the University of Maine, Orono. KAY WOODIEL has been at Eastern Michigan University since 1998, where she serves as associate professor of health education. Since 2005, she has served as director of the Department of Diversity and Community Involvement, which includes the Center for Multicultural Affairs; the Lesbian, Gay, Bisexual and Transgender Resource Center (LGBTRC); the VISION (Volunteers in Service to our Neighborhoods) office; and the Women’s Center. She has received two teaching awards at EMU: the LGBTRC has recognized her with its Role Model and Mentor Award and the Women’s Center has recognized her as a Woman of Excellence. She has also received two faculty fellowships at EMU, one in diversity and the other in academic service learning. Woodiel received her PhD degree from the University of Arkansas.

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ACKNOWLEDGMENTS We would like to thank each of the chapter contributors for his or her work in this book, the American Association for Health Education for its continuous support of the content of this book, and especially the staff at Jossey-Bass for their careful review and assistance in the development of this book. Finally, we want to thank our respective families for their support and understanding; without them we would not have been able to spend the many hours on writing and editing that this book required. M. A. P. R. R. L.

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CULTURAL COMPETENCE IN HEALTH EDUCATION AND HEALTH PROMOTION

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CHAPTER

1 CHANGING U.S. DEMOGRAPHICS Challenges and Opportunities for Health Educators MIGUEL A. PÉREZ RAFFY R. LUQUIS

LEARNING OBJECTIVES After completing this chapter, you will be able to ■

Explain the demographic changes and population trends in the United States.

■

Describe characteristics of the major racial and ethnic groups in the United States.

■

Discuss challenges and opportunities for health educators.

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Cultural Competence in Health Education and Health Promotion

INTRODUCTION On January 25, 2000, the U.S. surgeon general released Healthy People 2010, a document designed to provide a road map for improving the health status of all Americans. Healthy People 2010 has two primary goals: increasing the quality of and extending the number of years of healthy life for individuals and eliminating health disparities among Americans (U.S. Department of Health and Human Services, 2000). In order to accomplish the second goal, we need to explore and embrace the shifting demographics of the U.S. population, the policies that have contributed to these changes, and the challenges and opportunities these demographics and policies represent for health educators. The purpose of this chapter is to describe the demographic shifts that are affecting the U.S. population and to explore their impact on preparing a culturally competent health education workforce. These demographic shifts include the overall growth in population and the increase in the proportion of Hispanics, or Latinos, in that population; the increase in the number of foreign-born residents and related changes in immigration policy; the increase in the number of residents who do not speak English at home; the increase in the overall number of elderly and in the number of minority elderly; the increase in the number of women in the workforce; the population trends among lesbian, gay, bisexual, and transgender individuals; and the trends among people with disabilities. This chapter will also provide a brief description of relevant cultural characteristics for each of the major ethnic groups in the United States. These descriptions are essential background for the discussions of the challenges and responsibilities of health educators that follow in the remaining chapters of this book.

DEMOGRAPHIC SHIFTS Population Growth According to the U.S. Census Bureau the U.S. population passed the 300 million mark in 2006. This demographic shift1 is not surprising given the trend of population increases observed between 2000 (282,216,952) and 2007 (301,621,157) (see Table 1.1). Exponential population growth is expected to continue for the next few decades, with an expected population increase from 296,507,061 residents in 2005 to 419,854,000 in 2050. Moreover, the Census Bureau projects that as the population increases, the majority of the population will be concentrated in urban areas, continuing a trend started in the late nineteenth century (see Figure 1.1). Race and Ethnicity A report by the Agency for Healthcare Research and Quality states that members of underrepresented groups are expected to make up more than 40 percent of the U.S. population by 2035 and 47 percent by 2050 (Brach & Fraser, 2000). The shifts in the ethnic and racial distribution and the age distribution of the U.S. population denote an urgent need for health educators to develop programs that are culturally appropriate

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Changing U.S. Demographics

TABLE 1.1.

3

Estimates of U.S. Population, 2000–2007.

July 1, 2007

301,621,157

July 1, 2006

298,754,819

July 1, 2005

295,895,897

July 1, 2004

293,191,511

July 1, 2003

290,447,644

July 1, 2002

287,888,021

July 1, 2001

285,112,030

July 1, 2000

282,194,308

April 1, 2000 (Estimates Base)

281,424,602

April 1, 2000 (Census 2000)

281,421,906

Source: U.S. Census Bureau, 2007f.

(Luquis & Pérez, 2005, 2006; Luquis, Pérez, & Young, 2006; Marín et al., 1995; Pérez, Gonzalez, & Pinzon-Pérez, 2006). The 2000 Census marked a shift in how ethnic and racial data are collected. The Census Bureau introduced a larger pool of options, which allowed individuals, among other things, to select more than one ethnic or racial background. Although controversial, this measure allows the identification of individuals of mixed descent.2 Data from the American Community Survey conducted by the U.S. Census Bureau (2006) show that the U.S. population reached one of its most diverse stages in terms of race and ethnicity in 2005 (see Table 1.2). These data also show the richness in diversity found within the Hispanic population (see Table 1.3), which has become the fastest growing ethnic group in the United States.

Foreign-Born and Immigrant In 2005, the foreign-born population numbered 35,689,467, or 12 percent of the U.S. population. The foreign-born population includes any resident who was not a U.S. citizen at birth. It includes legal permanent residents (immigrants), temporary migrants

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4

Cultural Competence in Health Education and Health Promotion

AK

Population, 2006 WA

ME ND

MT

MN

VT

OR ID

NY

WI

SD WY

OH IL

UT CO

CA

KS

IN

MD WV VA

MO

KY

RI CT

PA

LA

NE

NV 20,000,000 to 36,457,549 10,000,000 to 19,999,999 5,000,000 to 9,999,999 1,500,000 to 4,999,999 515,004 to 1,499,999

NH MA

MI NJ DE DC

NC TN AZ

OK

NM

SC

AR MS

TX

AL

GA

LA FL

PR

HI

Population Density

Population Distribution

DC

DC

12.2 (CA)

9518.7 (DC)

4.0 to 7.9

500.0 to 1,999.9 Average population per square mile

U.S. density 84.7

FIGURE 1.1.

200.0 to 499.9 84.7 to 199.9

Percentage of U.S. population

2.0 to 3.9 1.0 to 1.9

50.0 to 84.6

0.2 to 0.9

1.2 to 49.9

Not included in calculation

U.S. Population by State, Density, and Distribution, 2006.

(such as students), humanitarian migrants (refugees), naturalized U.S. citizens, and persons illegally present in the United States (U.S. Census Bureau, 2006). The impact of the foreign-born population on the diversification of the U.S. population merits a little discussion of U.S. immigration policy, which not only affects the number of foreign-born nationals admitted to the United States but has also at times

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TABLE 1.2.

U.S. Population Estimate by Race and Ethnicity, 2005. Estimate

Percentage

Total population

288,378,137

100

White

192,615,561

66

34,364,572

12

2,046,735

1

12,312,949

4

355,513