Trans Cultural - 10-1-07
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TRANSCULTURAL NURSING
Course Content PREPARED BY
PROF. VALENTINA B. PATACSIL 1
MAPÚA INSTITUTE OF TECHNOLOGY
SCHOOL OF HEALTH SCIENCES VISION Mapúa shall be an international center of excellence in technology education by: • providing instructions that are current in content and state-of-the art in delivery; • • •
b)
c) d) e)
MISSION The mission of Mapúa Institute of Technology is to disseminate, generate, preserve and apply scientific, engineering, architectural and IT knowledge. The Institute shall, using the most effective means, provide its students with professional and advanced scientific foundation in engineering, architectural, information technology and health sciences education through rigorous and up-todate academic programs with ample opportunities for the exercise of creativity and the experience of discovery. It shall implement curricula that, while being steeped in technologies, shall also be rich in the humanities, languages and social sciences that will inculcate ethics. The Institute shall advance and preserve knowledge by undertaking research and reporting on the results of such inquiries. The Institute, singly or in collaboration with others, shall bring to bear the world's vast store of knowledge in health sciences, engineering and other realms on the problems of the industry, and the community in order to make the Philippines and the world a better place
PROGRAM EDUCATIONAL OBJECTIVES 1. To equip the students with a broad foundation on the basic concepts, theories, principles and fundamentals of professional nursing practice 2. To develop the student’s capability to apply these learned concepts, theories, and principles in the practice of professional nursing 3. To inculcate in the students the importance of lifelong learning. 4. To develop in the student an appreciation of human values in the care of individuals, families, population at
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engaging in cutting-edge research; and responding to the big local and global technological challenges of the times
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COURSE SYLLABUS
1. Course Code
: HUN 023
2. Course Title
: ASIAN CIVILIZATION
3. Pre-requisite
: NONE
4. Co-requisite
:
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Credit/ Class Schedule: 3 Units Lec.
Second Year Quarter 3
6. Course Description
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Focuses on health practices of different countries as a basis for the practice of Transcultural Nursing. It examines the transcultural bases of health care based on Giger and Davidhizer’s six cultural organizing phenomena: environmental control, biological variations, social organizayion, communication, space, and time orientation. It also takes into consideration the contemporary challenges in transcultural nursing such as transcultural aspects of pain, cultural disparities in health and health care delivery, cultural diversity in the workforce and transcultural values and ethics. 7.
Program Outcomes and Relationship to Program Educational Objectives
Program Educational Objectives 1 2 3 4
Program Outcomes
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(b) (c) (d)
(e)
A. Utilize the health process in a variety of institutional and community settings to design nursing systems which shall assist clients to attain and maintain an optimum level of self care through: 1. application of principles of goal oriented communication to establish and maintain therapeutic relationship with individuals, families, groups 2. synthesizing knowledge from general education, sciences and nursing courses as basis for health interventions designed to meet the self-care deficits of clients across life span 3. collaboration with health team members to improve the delivery of care to individuals, families, groups and the community 4. utilization of research methods and findings in the provision of nursing care and investigation of client health problems 5.implementation of strategies based on knowledge of teaching-learning principles, leadership-management methodologies and theories in the attainment of goals with clients (individual, family, group, community) B. Demonstrate beginning skills in the application of information technology in the development of skills for nursing practice C.Accept responsibility and accountability for the choice and outcomes of nursing interventions and for their legal and ethical implications
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8. Course Objectives and Relationship to Program Outcomes:
Course Objectives The students should be able to: 1. Examine the interrelationships of socio-cultural, public health and medical events that have produced the crisis in today’s modern health care system
Program Outcomes A1
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2. Develop cultural sensitivity for appropriate, individualized clinical approach 3. Appreciate human life and values of different cultures as they affect health-illness
9. Course Coverage
:
3
WEEK
TOPIC
Week 1 Orientation to the Course & Leveling of expectations; discussing the course requirements
METHODOLOGY & STRATEGY
EVALUATION TOOLS
Orientation & presentation of course syllabus; discussion of objectives, course requirements & leveling of expectations
Week 2, 3 UNIT I. Transcultural Framework A. B. C. D.
Week 4
Introduction Cultural concepts and terminologies History of Transcultural Nursing Lecture-discussion (Ppt Major assumptions to support presentation) Leininger’s Cultural Care Diversity and Universality Individual and group report Experiential group sharing UNIT II.Cultural Diversity Case Analysis Role Play A. Definition of basic/related concepts Surfing the Internet B. The World in Review C. Population Overview 1. Worldwide 2. In the U.S. 3. Others D. Race 1. Basic/Related concepts 2. Race categories E. The Immigrants 1. Reasons for migration 2. Metropolitan areas with the largest no. of immigrants 3. Leading 10 primary destinations of immigrants (2000) 4. Leading 10 countries of origin of legal immigrants (1990-2000) F. Factors to consider in the nursing care of culturally diverse groups
Class participation Pencil-paper evaluation (will not only apply in this UNIT but throughout the course. This activity will either be announced or not announced and the student is expected to read and prepare for the assigned lesson of the day
UNIT III. Health and Illness
Week 4,5
A. The HEALTH Traditions Paradigm 1. Concepts of health and illness 2. The interrelated aspects of health B. The HEALTH Traditions model 1. Traditional methods of maintaining, practicing, and restoring health 2. Symbolic examples 3. Factors influencing traditional beliefs and practices C. Health Belief Systems 1. Magico-religious 2. Scientific or biomedical 3. Holistic D. Types of Healing Systems 1. Self-care 2. Professional Care 3. Folk Healing System VCD: Ayurveda 4. Complementary/alternative therapies
)
MIDTERM EXAMINATION UNIT IV. Transcultural Nursing Care
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Models A. Leiningers’s Sunrise Cultural Care Diversity and Universality Model B. Purnell’s Model for Cultural Competence C. Giger and Davidhizar’s Transcultural Assessment Model and the organizing phenomena of culture D Cross-Cultural phenomena impacting nursing care F. Selected examples of etiquette related to selected cultural Phenomena G. Transcultural assessment H. Barriers to Health Care Week 6
Week 7
Week 8
Week 9, 10
Unit V. Application of Organizing Cultural Phenomena to People from Different Cultural Heritage: An Interactive Session A. People of Filipino Heritage B. People of Japanese Heritage C. People of Chinese Heritage D. People of Indian (Hindu) Heritage E. People of Anglo-American Heritage F. People of African-American Heritage G. People of Mexican Heritage H. People of Italian Heritage I. People of Jewish Heritage J. People of Middle Eastern Heritage
Interactive session: Group report on Organizing Cultural Phenomena on people with different cultural heritage (mentioned on left)
UNIT VI. Contemporary Challenges in Transcultural Nursing
Lecture/discussion
A. Transcultural aspects of pain 1. Definition of pain 2. Basic/related concepts 3. Measurement of pain 4. Expressions of pain 5. Applying transcultural nursing concepts to clients in pain
Lecture/Discussion
B. Cultural Disparities in Health and Group activity Health Care Delivery 1. Factors that account for cultural disparities: minority groups, vulnerable populations, the poor, the homeless C. Cultural Diversity in the Workforce 1. The aspects of cultural diversity 2. The effects of multicultural healthcare workforce 3. Barriers/conflicts in the workforce 4. Promoting harmony in multicultural workplaces 5. Strategies to promote effective cross-cultural communication in the multi-cultural workplace D. Transcultural Values and Ethics 1. Transcultural Values: Basic /related concepts, transcultural assessment and clarification of values and beliefs 2. Transcultural Ethics: Basic/related concepts, Western and Eastern ethical theories D. Culturally competent model of ethical
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decision-making E. Transcultural Care Principles, Human Rights and Ethical Considerations Bibliography Week 11
FINAL EXAMINATION
Pencil and paper test
10. Course Outcomes and Relationship to Course Objectives/ Program Outcomes
Course Outcomes
Course Objectives
Program Outcomes
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1. Explain aspects and components of cultural diversity in Asia and in different countries
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2. Discuss traditional and transcultural HEALTH belief models and healing systems, including assessment of these paradigms
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3. Know the different transcultural nursing models and apply culturally competent nursing care. 4. Recognize contemporary challenges in transcultural nursing.
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A student completing this course should be able to:
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Contribution of Course to Meeting the Professional Component: HEALTH & NURSING topics – General education component –
90% 10%
11. Textbook: Books in # 12: 13. Course Evaluation: The student is evaluated based on his/her performance in the following areas: LECTURE Quizzes___________________________________15% Midterm__________________________________ 25% Final Examination _______________________
50%
Academic Requirements and other related Activities
______________________ TOTAL
10% 100%
Aside from academic deficiency, other grounds for a failing grade are: • Cheating during examinations • More than 20 % of the total number of meetings in a quartermaster as per CHED ruling • Failure to take the final examination with no valid excuse Note:
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The final grade of the student will be given as reflected in the table below. Average (%) Final Grade
Below 60 5.00
60-64 3.00
65- 69 2.75
70-74 2.50
75-79 2.25
80-84 2.00
85-89 1.75
90-94 1.50
95-97 1.25
98-100 1.00
12. References/Course Materials Made Available: Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing care. (3rd ed.). Lippincott. Philadelphia, New York, Baltimore. Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing ( 2nd ed.). Thomson Asian Edition. Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing concepts, process, and practice. (7th ed.).Pearson Education, Inc. Upper Saddle River, New Jersey. Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd ed.). Delmar Learning. Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a culturally competent approach (2nd ed.). F.A. Davis Co. Philadelphia. Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, N.J: Prentice Hall. Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and health care (6th ed.). Pearson Education South Asia Pte Ltd. Jurong, Singapore. Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and science of nursing care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.
13. Committee Members: Fortuno , Carolina P. Capaque, Dawn Valderrama, Deogracia M.
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VISION Mapúa shall be an international center of excellence in technology education by: • providing instructions that are current in content and state-of-the art in delivery; • • •
engaging in cutting-edge research; and responding to the big local and global technological challenges of the times
MISSION d) The mission of Mapúa Institute of Technology is to disseminate, generate, preserve and apply scientific, engineering, architectural and IT knowledge. e) The Institute shall, using the most effective means, provide its students with professional and advanced scientific foundation in engineering, architectural, information technology and health sciences education through rigorous and up-todate academic programs with ample opportunities for the exercise of creativity and the experience of discovery. f) It shall implement curricula that, while being steeped in technologies, shall also be rich in the humanities, languages and social sciences that will inculcate ethics. e) The Institute shall advance and preserve knowledge by undertaking research and reporting on the results of such inquiries. f) The Institute, singly or in collaboration with others, shall bring to bear the world's vast store of knowledge in health sciences, engineering and other realms on the problems of the industry, and the community in order to make the Philippines and the world a better place
5. To equip the students with a broad foundation on the basic concepts, theories, principles and fundamentals of professional nursing practice 6. To develop the student’s capability to apply these learned concepts, theories, and principles in the practice of professional nursing 7. To inculcate in the students the importance of lifelong learning. 8. To develop in the student an appreciation of human values in the care of individuals, families, population at
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MISSION b c d
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e √
addressed by DLHS
PROGRAM EDUCATIONAL OBJECTIVES
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COURSE CONTENT Unit I. Overview of Transcultural Nursing A. Introduction B. Providing a Comprehensive Approach to Health Care C. Cultural Concepts and Terminologies D. History of Transcultural Nursing E. Major Assumptions to Support Leininger’s Culture Care Diversity and Universality Unit II. Cultural Diversity
V. Definition of Related Concepts VI. The World in Review
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C. Population Overview 1. Worldwide 2. Most populous cities of the world 3. US. population D. Race 1. Basic concepts 2. Race categories E. The Immigrants 1. Reasons for migration 2. Metropolitan areas with the largest number of immigrants 3. Leading 10 primary destinations of immigrants (2000) 4. Leading 10 countries of origin of legal immigrants (1990-2000) F. Factors to Consider in the Nursing Care of Culturally Diverse Groups Unit III. Health and Illness
A. The HEALTH Traditions Paradigm
1. Concepts of health and illness 2. The interrelated aspects of health B. The HEALTH Traditions Model 1. Traditional methods of maintaining, practicing and restoring health 2. Symbolic examples 3. Factors influencing traditional beliefs and practices C. Health Belief Systems 1. Magico-religious 2. Scientific or biomedical 3. Holistic D. Types of Healing Systems 1. Self-care 2. Folk Healing System 3. Professional Care 4. Complementary, alternative and integrative therapies Unit IV. Transcultural Nursing Care Models
A. Leininger’s Sunrise Cultural Care Diversity and Universality Model B. Purnell’s Model for Cultural Competence C. Giger and Davidhizar’sTranscultural Assessment Model and Cultural Heritage Consistency D. The Organizing Phenomena of Culture: Environmental control, Biological variation, Social organization, Space, Time, and Communication E. Selected Examples of Etiquette Related to Selected Cultural Phenomena F. Cross-Cultural Phenomena Impacting Nursing Care G. Transcultural Assessment H. Barriers to health Care Unit V. Application of Organizing Cultural Phenomena to People from Different Cultural Heritage: an Interactive Session People People People People People F. People G. People H. People I. People J. People A. B. C. D. E.
of of of of of of of of of of
Filipino Heritage Japanese Heritage Chinese Heritage Indian (Hindu) Heritage Anglo-American Heritage African-American Heritage Mexican Heritage Italian Heritage Jewish Heritage Middle Eastern Heritage
UNIT VI. Contemporary Challenges in Transcultural Nursing A. Transcultural Aspects of Pain 9
1. Definition of pain 2. Basic/related concepts 3. Measurement of pain 4. Expressions of pain 5. Questions on Cultural Attitude Toward Pain 6. Applying transcultural nursing concepts to clients in pain B. Cultural Disparities in Health and Health Care Delivery 1. Factors that account for culture disparities: minority groups, the poor, vulnerable populations, the homeless C. Cultural Diversity in the Workforce 1. The aspects of cultural diversity in the workforce 2. The effects of multicultural healthcare workforce 3. Barriers/conflicts in the workforce 4. Promoting harmony in multicultural workplaces 5. Strategies to promote effective cross-cultural communication in the multicultural workplace D. Transcultural Values and Ethics 1. Transcultural Values Basic/related concepts Transcultural assessment and clarification of values and beliefs 2. Transcultural Ethics Basic/related Concepts Overview of Western and Eastern Ethical Theories Culturally competent model of ethical decision-making 3. Transcultural Care Principles, Human Rights and Ethical Considerations
CULTURAL HERITAGE BIOBLIOGRAPHY ADDENDUM
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TRANSCULTURAL NURSING UNIT I. OVERVIEW OF TRANSCULTURAL NURSING “…demography is destiny, demographic changes is reality, and demographic sensitivity is imperative.” Giger and Davidhizar, Transcultural Nursing
A. INTRODUCTION The rapidly changing demographic scenario beckons us into viewing the world where people are no longer bound by physical boundaries. Societies everywhere, particularly in the United States, are becoming multicultural, multilingual, and pluralistic. Nursing, therefore, must rapidly adapt itself to a changing heterogeneous society if it is to provide culturally appropriate and culturally competent nursing care in the twenty-first century. Madeleine Leininger, a nurse-anthropologist, saw this trend in the 50’s, and envisioned transcultural nursing as a formal area of study and practice for nurses. Also called cross-cultural, intercultural, multicultural and culture-care nursing by some authorities Leininger defined this new field of study as a “humanistic and scientific area of formal study and practice which is focused upon differences and similarities among cultures with respect to human care, health or well-being), and illness based upon the people’s cultural values, beliefs and practices.” The ultimate goal of transcultural nursing, according to Leininger, is “to use relevant knowledge to provide culturally specific and culturally congruent nursing care to people.” An understanding of culture and related concepts is therefore important. Culture refers to the common lifestyles, knowledge, beliefs, behavior patterns, attitudes, values, habits, customs, languages, symbols, ritual, ceremonies, and practices that are unique to a particular group of people. Some of the characteristics of culture are the following: Culture is learned and taught. Cultural knowledge is transmitted from one generation to another. A person is not born with cultural concepts but instead learns them through socialization. Culture is shared. The sharing of common practices provides a group with part of its cultural identity. Culture is social in nature. Culture develops in and is communicated by groups of people. Culture is dynamic, adaptive, and ever-changing. Adaptation allows cultural groups to adjust to meet environmental changes. Culture change occurs slowly and in response to the needs of the group. This dynamic and adaptable nature allows a culture to survive. Source: Delaune, Sue C. and Patricia K. Landner. Fundamentals of Nursing. 3rd ed. Thomson, Asian ed. 2006. p. 389.
B. PROVIDING A COMPREHENSIVE APPROACH TO HEALTH CARE To provide a comprehensive approach to health care, nurses have to respect common humanistic aspects of people worldwide, be aware of distinguishing characteristics of divergent cultural groups, and be able to deliver health care that is culturally sensitive, culturally appropriate, and culturally competent.
Culturally sensitive has more to do with personal attitudes and not saying things that might be offensive to someone from a cultural or ethnic background different 11
from the health-care provider’s. (Ethnic – “You eat like a pig, use spoon and knife as in our culture,” or saying “You Indians “smell”.
Culturally appropriate implies that the nurse applies the underlying background knowledge that must be possessed to provide a given client with the best possible health care. (End-of-life spiritual care – a nurse will suggest to a Jewish patient and his family the availability of a rabbi, if they wish)
Culturally competent implies that within the delivered care the nurse understands and attends to the total context of the client’s situation and uses a complex combination of knowledge, attitudes, and skills. 1. Basic/Related Concepts
Cultural competence is a process in which “the nurse continuously strives to achieve the ability and availability to effectively work within the cultural context of an individual, family or community. (Campinha-Bacote, 1998, p.6). Culturally competent nursing care treats each person as an individual whether coming from same or divergent cultural system. Nursing care is planned and implemented in a way that is sensitive to the needs of individuals and families, groups from diverse cultural populations within society. The nurse who recognizes and respects cultural diversity has cultural sensitivity and provides nursing care that accepts the significance of cultural factors in health and illness. The nurse must be aware that the healthcare system itself is a culture with customs, rules, values and a language of its own and that cultural imposition and ethnocentrism must be avoided. Interaction between the nurse and patient are affected by the particular set of cultural values they bring to the interaction. The cultural background of each participant The expectation and beliefs of each about health care The cultural context of the encounter (e.g, hospital, clinic, home) The degree of agreement between the two persons’ sets of beliefs and values (Andrew & Boyle, 2000b). Nurses must avoid cultural imposition which is the tendency to impose their beliefs, practices and values on people of other cultures, and ethnocentrism, the belief that one’s own ideas, beliefs and practices are the best and superior, or must be preferred over those of others.
2. The Five Elements of Cultural Competence:
1) Cultural awareness - a cognitive process in which the nurse becomes aware of and sensitive to the clients cultural vales, beliefs, and practices.
You play when interacting with individuals who are different from yourself. (Purnell, op. cit. 3). Identify biases in own life and how they affect your feelings about others, and the nursing care you plan and give to them 2) Cultural knowledge – The nurse seeks a sound educational base about different cultures. Learn as much as possible about the belief system and practices of people in your community and of the patients in the area in which you work. Practice techniques of observation and listening to acquire knowledge of the beliefs and values of your patients. 3).Cultural skill - The nurse’s ability to perform a culturally specific assessment (i.e., physical and psychosocial). Cultural assessment:
Is an important aspect of comprehensive nursing assessment. facilitates better understanding sometimes overlooked factors that influence health behaviors and decisions.
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helps nurses to properly identify and understand the meanings of behaviors that might otherwise be judged negatively or be confusing to the nurse
recognize that each person is culturally unique and that not all persons in a
particular group believe or respond the same way. the nurse can anticipate and assess patient’s values, religion, dietary practices, family lines of authority, life patterns, and beliefs and practices related to health and illness.
4. Cultural encounters – The nurse interacts with clients from diverse cultural backgrounds. A very essential feature of our humanity is the diversity of cultures and the many different ways we find meaning in our lives, and in the lives of other people. The hospital or health care environment is in itself a little world – it typifies the diversity of culture possessed by patients and health care givers, and other individual involved in health care. To be culturally competent the nurse must know how to interact with people from diverse cultural background and learn to adjust and or adapt her assessment and caring skills accordingly. 5. Cultural desire – The nurse’s motivation (“want to”) to become culturally competent. The nurse must have the desire and motivation to develop and apply the elements of cultural competence which are developing awareness, acquiring knowledge, and practicing skills. Source: Data from Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38 (5), 204-205), Quoted in Ethical Issues in Contemporary Nursing, p. 342. Taylor, Lillis and LeMone, op. cit. pp. 53-54.
B. CULTURAL CONCEPTS AND ESSENTIAL TERMINOLOGY Subculture – smaller groups within a culture. Each subculture has its own value system and related expectations of behavior.
Subcultures may be based on: 1. Professional and occupational affiliations (nurses, engineers) 2. Nationality or race (a shared historical and political past) 3. Age groups (adolescents, senior citizens) 4. Gender ( feminists, men’s groups) 5. Socioeconomic factors ( the working class, the middleclass, the upper class) 6. Political viewpoints (Nationalista, Liberal) 7. Sexual orientation (gay, lesbian group)
Bicultural – used to describe a person who crosses two cultural, lifestyles, and sets of values. (Example: a young woman whose mother is Filipino and whose father is American)
Acculturation - occur when people adapt to or borrow traits from another culture. Also defined as the changes of one’s cultural patterns to those of the host society.
Assimilation – the process by which an individual develops a new cultural identity. It means becoming like the members of the dominant culture. The person from a given cultural group loses his or her original cultural identity to acquire the new one. There are 4 forms of assimilation: 1. Cultural – ability to speak excellent American English 2. Marital – intermarriage with members of another group
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3. Primary structural – the relationships between people are warm, personal 4.
interactions between group members in the home, the church, and social groups Secondary structural – there is nondiscriminatory sharing, often of a cold interpersonal nature between different groups in settings such as school and workplaces
C. HISTORY OF TRANSCULTURAL NURSING
"That the culture care needs of people in the world will be met by nurses prepared in transcultural nursing." M. Leininger, Ph.D.
In the 1950’s, Dr. Madeleine M. Leininger noted cultural differences between patients and nurses when working with emotionally disturbed children. This clinical experience led her to study cultural differences in the perceptions of care in 1954, and in 1965 she earned a doctorate in cultural anthropology from the University of Washington. Leininger recognizes that anthropology’s most important contribution to nursing was the realization that health and illness are strongly influenced by culture. In 1991, Leininger already a well-known nurse anthropologist, published her book Cultural Care Diversity and Universality: A Theory of Nursing. Leininger produced the Sunrise model (described in Unit IV) to depict her theory of culture care diversity and universality.
D. MAJOR ASSUMPTIONS TO SUPPORT LEININGER’S CULTURE CARE DIVERSITY AND UNIVERSALITY THEORY 1. Care is the essence of nursing and is a distinct dominant, central, and unifying focus.
2. Care (caring) is essential for well-being, health, healing, growth, survival, and face handicaps or death.
3. Culture care is the broadest holistic means to know, explain, interpret, and predict nursing care phenomena to guide nursing care practices.
4. Nursing is a transcultural humanistic and scientific care discipline and profession with the central purpose to serve human beings worldwide.
5. Care (caring) is essential to curing and healing, or there can be no curing without caring.
6. Culture care concepts, meanings, expressions, patterns, processes, and structural
forms of care are different (diversity) and similar (towards commonalities or universalities) among all cultures of the world. 7. Every human culture has generic (lay, folk or indigenous) care knowledge and practices and usually professional care knowledge and practices, which vary transculturally. 8. Cultural care values, beliefs and practices are influenced by and tend to be embedded in the world view, language, religious (or spiritual), kinship (social), political (or legal) educational, economic, technological, ethnohistorical, and environmental context of a particular culture. 9. Beneficial, healthy, and satisfying culturally based nursing care contributes to the well-being of individuals, families, groups, and communities within their environmental context.
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10. Culturally congruent (in agreement) or beneficial nursing care an occur only when the individual, group, family, community, or culture care values, expressions, or patterns are known and used appropriately and in meaningful ways by the nurse with the people. 11. Culture care differences and similarities between professional caregiver(s) and client (generic) care-receiver(s) exist in any human culture worldwide. 12. Clients who experience nursing care that fails to be reasonably congruent with the client’s beliefs, values, and caring lifeways will show signs of cultural conflicts, noncompliance, stresses, and ethical or moral concerns. 13. The qualitative paradigm provides new ways of knowing and different ways to discover epistemic and ontological dimensions of human care transculturally.” Source: Leininger, Madeleine. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press. 16:44-45.
UNIT II. CULTURAL DIVERSITY The world is a conglomeration of people coming from different cultures. More than ever, because of the great strides made in science and technology, people from all over are now able to travel, live and work in different parts of the world, bringing with them their world view, ethnohistory, racial and social structure features (i.e. family, religion, language, cultural and ethical values, etc), as well as their health behavior and practices. Thus, everyone in a way is different; this fact or state of being different is known as cultural diversity. The nurse has to confront the issue of cultural diversity in the practice of the profession. She/he has to know and understand cultural diversity as it is manifested in the world today. What brings about cultural diversity? What are the reasons for population movement or migration? What racial or ethnic groups comprise the different parts of the world? What life and health ideologies, beliefs and practices are brought by them?
A. DEFINITION OF RELATED CONCEPTS Race – Racial categories are based on specific physical characteristics Ethnicity – The sense of identification with a collective cultural group, largely based on the group’s common heritage. Includes language and dialect. Religious practices, literature, music, folklore, political interests, food preferences, and employment patterns.
Biracial/multiracial – when an individual crosses two or more racial and cultural groups. Multiracial (Tiger Woods – White, Black, Indian, and Asian)
Dominant Group – The group within a country or society that has the most authority to control values and sanctions.
Minority Group – Most often has some physical or cultural characteristics that identifies the people within it as different.
Discrimination - The differential treatment of individuals or groups based on categories such as race, ethnicity, gender, social class, or exceptionality, occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.
Stereotyping – Assuming that all members of a culture, subculture, or ethnic group act alike.
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Cultural Imposition – The belief that everyone should conform to the majority belief system.
Cultural Blindness – The result of ignoring differences and proceeding as though they do not exist.
Culture Conflict – The state that occurs when people become aware of cultural
differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure.
Source: Taylor.p.40; Kozier,208-209.
B. THE WORLD IN REVIEW Divided into units or continents: Africa, Asia, Europe, North America, South America, Oceania. Of these, Asia is the largest continent.
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ASIA
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NORTH AMERICA and CANADA
SOUTH AMERICA
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C. POPULATION OVERVIEW 1. World Population
Year 2000 Projected: Year 2020 Year 2050
– – –
6.1 billion 7.6 billion 9.3 billion
2. Most Populous Cities of the World (Source: TIME Almanac 2006). 1. China 2. India 3. United States 4. Indonesia 5. Brazil 6. Pakistan 7. Bangladesh 8. Russia 9. Nigeria 10. Japan 11. Mexico 12. Philippines
1,306,313,812 1,080,264,388 295,734,134 241,973,879 186,112794 162,419,946 144,319,628 143,420,309 128,771,988 127,417,244 106,202,903 87,857,473
3. In the U. S.
Between 1990 and 2002 – population increased from 248.7 million to 293.02
million Composition of population: • 75.1% White
• • • • • • •
12.5%
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Spanish/Hispanic/Latino (of any race)
12.3%
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Black or African American
0.9%
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American Indian or Alaskan Native
3.6%
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Asian
0.1%
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Native Hawaiian or other Pacific Islander
5.5%
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some other race
2.4%
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are of two or more races
D. RACE 1. Basic Concepts
Race is an emotionally-charged word that often divides or separates people even though the Human Genome Project provides evidence that all human beings share a genetic code that is over 99% identical. Race is genetic in origin and includes all physical characteristics that are similar among members of the group, such as skin color, bone structure, blood type, hair type, and eye color. However, it is this less than 1% difference that is usually significant in determining and providing variants in health care as certain diseases may be racially determined. Ethnicity (group identity) and race may sometimes overlap because the cultural and biological commonalities support one another. The similarities of people in racial and ethnic groups reinforce a sense of commonality and cohesiveness.
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2. Race Categories
White – refers to people having origins in any of the peoples of Europe, the Near
East, and the Middle East, or North Africa. This category includes Irish, German, Italian, Lebanese, Turkish, Arab and Polish Black or African American – refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any person who self-designated this category regardless of origin. American Indian and Alaskan Native refers to people having origins in any of the original peoples of North, South or Central America, and who maintains tribal affiliation or community attachment. Asian – refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This category includes the term Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani and Thai. Native Hawaiian and other Pacific Islander refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands, and Chuuk. “Some other race” was included for people who are unable to identify with the other categories. Additionally the respondent could identify, as a write-in, with two races (http://www.census.gov, 2001.)
E. THE IMMIGRANTS 1. Reasons for migration: Economic – seek better economic opportunities Religious – escape religious oppression Political freedom – escape political persecution 2. Metropolitan Areas with the Largest Numbers of Immigrants
New York, N.Y. Los Angeles-Long Beach, CA Miami, FL Chicago, IL Washington, DC-MD-VA Orange County, CA Houston, TX San Jose, CA Boston-Lawrence-Lowell-Brockton MA Oakland, CA
In 1996 there were 4.6 to 5.4 million of undocumented immigrants. California is the leading state of residence for undocumented people, followed by Texas, New York and Florida.
3. Leading 10 Primary Destination States for Immigrants 2000
California New York Florida Texas New Jersey Illinois Massachusetts Virginia Washington Pennsylvania
4. Leading 10 Countries of Origin for Legal Immigrants Between 1990-2000.
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Mexico Peoples Republic of China Philippines India Vietnam Nicaragua El Salvador Haiti Cuba Dominican Republic
It is predicted that by the year 2020 immigration will be a major source of new people for the United States and will be responsible for whatever growth occurs in the United States after 2030. The United States will continue to attract about 2/3s of the world’s immigrants, and 85 % will be from Central and South America. Source: www.ins.gov.
F. FACTORS TO CONSIDER IN THE NURSING CARE OF CULTURALLY DIVERSE GROUPS Lack of employment opportunities and finances for health care services. Different traditional belief systems as well as different norm and values. 3. The lack of cultural sensitivity on the part of social service and health care workers. 4. Lack of bilingual personnel or staff members or the lack of interpreters to assist clients and providers. 5. Rapid changes in the U.S. health care systems where clients are “lost” in the gaps between agencies and services. 6. Inconvenient locations or hours that preclude clients from accessing care. 7. A lack of understanding, trust, and commitment on the part of health care providers. 1. 2.
Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed Lippincott Wiliams & Wilkins, Philadelphia, p. 338
UNIT IV. CULTURAL HEALTH TRADITIONS, BELIEFS AND PRACTICES Cultural and health belief systems are embraced by people from different cultures. This unit explores the concepts of HEALTH/ILLNESS, health traditions model, belief systems and practices, healing systems as well as the barriers to health care.
A. THE HEALTH TRADITIONS PARADIGM 1. Concept of Health and Wellness Health (according to WHO, 1948) – a state of complete physical, mental, emotional, social well-being and not merely the absence of disease or infirmity. Health and illness defined from a transcultural standpoint
Health – is a complex, interrelated phenomena characterized by a balance of the person, both within one’s being---physical, mental and spiritual---and in the outside world- the environment, the community, and the natural forces surrounding him/her.
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Illness – is the imbalance of one’s being---physical, mental, and spiritual---and in the outside world- the environment, the community and the natural forces surrounding him/her.
The health traditions model is predicated on the concept of holistic HEALTH and describes what people do from a traditional perspective to maintain, protect, and restore HEALTH.
2. Interrelated Aspects:
The body includes all physical aspects such as genetic inheritance, body chemistry, gender, age, nutrition, and physical condition. The mind includes cognitive processes, such as thoughts, memories, and knowledge of such emotional processes feelings, defenses, and self-esteem. The spiritual facet includes both positive and negative learned spiritual practices and teachings, dreams, symbols, stories; protecting forces; and metaphysical or native forces.
These aspects are in constant flux and change over time, yet each is completely related to the others an also related to the context of the person. The context includes the person’s family culture, work, community, history, and environment. Source: Kozier, op. cit. p. 210.
B. THE HEALTH TRADITIONS MODEL 1. The health traditions model for maintaining, practicing, and restoring health
Traditional methods of maintaining health
physical, mental, and spiritual – include following a proper diet and wearing proper clothing, concentrating and using the mind, and practicing one’s religion. Traditional methods of practicing health – physical, mental, and spiritual – include wearing protective object such as amulets, avoiding people who may cause trouble, and placing religious objects in the home.Traditional methods of restoring health – physical, mental, and spiritual – include the use of herbal remedies exorcism, and healing rituals.
The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and Personal Methods of Maintaining Health, Protecting Health and Restoring Health
Maintain Health
Protect Health
Restore Health
PHYSICAL Proper clothing Proper diet Exercise/Rest Special foods and food combination Symbolic clothing
Homeopathic remedies
MENTAL Concentration Social and family support systems Hobbies Avoid certain people who can cause illness Family activities
Relaxation Exorcism
SPIRITUAL Religious worship Prayer Meditation
Religious customs Superstitions Wearing amulets and other symbolic objects to prevent the “Evil Eye” or defray other sources of harm Religious rituals Special prayers
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Lineaments Herbal tests Special foods Massage Acupuncture
Curanderos and
other traditional healers Nerve teas
Meditation Traditional healings Exorcism
Source: Spector, R.E. Cultural Diversity in Health and Illness (2000), 5th ed. Upper Saddle River, N.J: Prentice Hall, p. 100.
2. Symbolic examples Following are related health-related images and symbols that may be used to maintain, protect, or restore physical, mental, or spiritual health by people of different heritages.
Thousand-year old eggs, from China, represent traditional foods that may be eaten daily to maintain physical health. The enjoyment of nature, the nature environment, may be a universal way of maintaining mental health. The Islamic prayer from East Jerusalem, represents a prayer, a way of maintaining spiritual health. Red string, from the Tomb of Rachel in Bethlehem, Israel, may be worn to protect physical health. The eye, from Cuba, represents the plethora of eye-related objects that may be worn or hung in the home to protect the mental health of people by shielding them from the envy and bad wishes of others. The thunderbird, from the hopi nation, may be worn for spiritual protection and good luck. The herbal remedy from Africa represents aromatic plants that may be used by people from all ethnocultural traditional backgrounds as one method of restoring mental health. Tiger balm, from Singapore, represents substances that are used in massage therapy as a way of restoring mental health. Rosary beads, from Italy, symbolize prayer and meditation methods used in the spiritual restoration of health.
Source: Spector, R.E. Cultural Diversity in Health and Illness (2000),, 5th ed. Upper Saddle River, N.J: Prentice Hall, p. 100).
Maintain
Protect
Restore
Symbolic Examples
3. Factors Influencing Traditional Beliefs and Practices
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The length of time in the United States. The size of the ethnic or cultural group with which an individual identifies and interacts. Age of the individual. As a general rule, children acculturated more rapidly than adults or seniors. The ability to speak English and communicate with members of the majority culture. Economic and education status. If a Salvadorean woman works outside the home, she may readily learn to speak English than if she remains inside the home. Health status of family members. If individuals and their families seek health care in the country, they begin to “learn the system”, so to speak. Individuals and groups who have distinguishing ethnic characteristics, such as skin color, may be more isolated because of discrimination and thus may retain traditional values related to health beliefs and behavior.
Source: Andrews and Boyle, 3rd ed. p. 318.
C. HEALTH BELIEF SYSTEMS Generally, theories of health and disease/illness causation are based on the prevailing world view held by a group.
The worldview developed reflects the group’s total configuration of beliefs and practices and permeates every aspect of life within the culture of that group. These worldviews include a group’s health-related attitudes, beliefs and practices and frequently are referred to as health belief systems.
Three Major Health Belief Systems 1. Magico-religious
In this belief system, disease is viewed as the action and result of supernatural forces. Supernatural forces dominate. Characterized by cause-and-effect relationship. Health is seen as a reward or gift for being good; illness the result of “being bad” or opposing God’s will. Getting well is also viewed as dependent on God’s will. Illness is viewed as punishment for sins or committing transgressions. Common in countries like: Latino, African American, Middle Eastern and Asian cultures. Five categories of events that are believed to be responsible for illness as derived from the work of Clements (1932): • Sorcery – believed in by some African and American Blacks
• •
Breach of taboo (breaking of social norm, such as committing adultery) Intrusion of a disease object
•
Intrusion of disease-causing spirit – Example: Mal ojo or the evil eye common in Latino culture. • Loss of soul Magic can cause illness. Ex. A sorcerer or witch may put a spell or hex on the client. Such illnesses may require magical treatments in addition to scientific treatments Some view illness as possession by an evil spirit.
2. Scientific or biomedical health belief model
Disavows the metaphysical. This belief system dominates Western thought and the practice of health care. Based on the belief that life and life processes are controlled by a series of physical and biochemical processes that can be manipulated by humans. The
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client will believe that illness is caused by germs, viruses, bacteria or a breakdown of the body. Disease is viewed metaphorically as the breakdown of the human machine as a result of: • Wear and tear (stress) • External trauma (injury, accident) • External invasion (pathogens)
•
Internal damages (fluid and chemical imbalances or structural damages)
Using the metaphor of the machine, Western medicine uses specialists to take
care of the “parts “fixing” the part, etc. The client will expect a pill, or treatment, or surgery to cure health problems. Biomedical model defines health as the absence of disease or of the signs and symptoms of disease. To be healthy, one must be free of disease.
3. The holistic health belief model
The term holistic was coined in 1926 by Jan Christian Smuts who defined holistic
as “an attitude or mode of perception in which the whole person is viewed in the context of the total environment. In a way it is similar to the magico-religious worldview where the forces of nature must be maintained in balance or harmony; when the balance of nature is disturbed illness results. The different aspects of the individual’s nature: the physical, the mental, the emotional, and the spiritual must also be in balance. Holistic paradigm seeks to maintain a sense of balance between humans and the larger universe. Unlike the scientific model which states that disease is caused by external agents, this paradigm states that disease is caused by imbalance or disharmony between humans and the larger universe. For example: Biomedical model – TB is caused by mycobacterium tuberculosis Holistic model - disease is the result of multiple environmental-host interactions: poverty, malnutrition, overcrowding, and the mycobacterium. Examples of holistic belief: The medicine wheel of the Native Americans (see below) and the yin and yang of the Chinese (see Addendum) THE MEDICINE WHEEL From our ancestors, we are taught that everything in life is circular. We are one within the circle of life. The Medicine Wheel teaches us that the physical, mental, emotional and spiritual aspects must be in balance in order to maintain a healthy mind, spirit and body.
Medicine wheel used by Native Americans of North and South America
D. TYPES OF HEALING SYSTEMS Healing – comes from the Anglo-Saxon word hael, which means to make whole, to move forward, or to become whole. It is not the same thing as curing (ridding one of disease) but is a process that activates the individual’s healing forces from within. Important Concept: “that healing potential exists in all of us.” Healing System – refers to the accumulated sciences, arts, and techniques of restoring and preserving health that are used by a cultural group (Smith, 1983).
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1. Self-Care
For common minor illnesses, an estimated 70-90% of all people resort to self
care with over-the-counter medicines, megavitamins, herbs, exercise, any or foods that they believe have healing power. Many self-care practices have been handed down from generation to generation, frequently by oral tradition. When self-care is ineffective, people are likely to turn to professional and/or folk (indigenous, generic, traditional) healing systems. Self-care is the largest component of the North American healing care system.
2. Folk Healing System
Folk healing system (FHS) is a set of beliefs that has a shared social dimension
and reflects what people actually do when they are ill vs. what society says they ought to do according to a set of social standards. All cultures of the world have had a lay health care system, which is referred to as indigenous or generic. Used interchangeably with complementary, alternative, or naturalistic; the key consideration that defines folk systems is their history of tradition. Many have endured over time and often transmitted from one generation to the next. FHS is a mixture of nonprofessional systems and uses healing practices that are learned informally. The FHS is often divided into secular and sacred components. Most cultures have folk healers: Examples: Hispanic – curandero, espiritualista, yerbero, sabador (manipulates bones and massages) Black – “Old Lady”, Spiritualist, voodoo priest or priestess Chinese – herbalist, acupuncturist Greek – Magissa (magician), bonesetters, priest (Orthodox) Native Americans – shaman (a folk-healer priest who uses natural and Supernatural forces to help others), crystal gazer, hand trembler (Navajo) Philippines – manghihilot
3. Professional Care Systems
Are formally taught, learned, and transmitted professional care, health, illness, wellness and related knowledge and practice skills. Characterized by specialized education and knowledge, responsibility for care, and expectation of remuneration for services rendered. Examples of professional care practitioners: Physicians, nurses, physical therapists, pharmacists etc. Conventional medicine is medicine practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals such as physical therapists, psychologists, and registered nurses. Professional medicine/medical care is also known as biomedicine, conventional allopathic, Western medicine
4. Complementary, Alternative and Integrative Therapies Western biomedicine or allopathic medicine must be differentiated from alternative medicine. Comparison of Allopathic and Alternative Medicine ALLOPATHIC PERSPECTIVE ALTERNATIVE PERSPECTIVE Health is absence of disease. Health is a state of well-being characterized by min/body balance. Focus is on cure of disease Emphasis is on health maintenance and disease prevention through lifestyle choices. Mind and body are treated as separate Mind and body are one; what affects one 27
entities
affects the other.
Disease results from causative agents, usually external.
Disease originates from within and is the result of imbalances that occur in response to unhealthy lifestyle and/or inner disharmonies. The body has a natural ability to heal itself.
Healing depends on outside agents to cure disease. Treatment consists of drugs, surgery, and radiation. Healing is aggressive, quick and seeks to destroy the invading organisms. The doctor plays the central role in healing.
Treatment consists of det, exercise, herbal medicines, social support, and stress management. Healing is a slow, natural process.
The client has the most important role in healing (i.e., lifestyle choices). (Data from: Fontaine, K.L. (2000). Healing practices: Alternative therapies for nursing. Upper Saddle River:Prentice Hall, in DeLaune Fundamentals of Nursing. p. 232.
Alternative medicine – is used instead of or in place of conventional medicine Example: Using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.
Complementary medicine – is used together with conventional medicine.
Example: In addition to Valium which an extremely agitated or nervous patient may receive, one can give tea (chamomile, valerian) that calms down the patient, provide a quiet environment, play soothing music, give therapeutic massage, etc. ; gargling with salt or saline solution in addition to antibiotic for strep throat
Integrative medicine – term introduced by Dr. Andrew Weil to define a hybrid of complementary, alternative and conventional medical therapies for which there is some high-quality scientific evidence of safety and effectiveness.
Components of integrative healing therapies:
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1. Surgery – refers to excision or surgical removal of diseased body parts. 2. Pharmaceutical Drugs – use of medicines 3. Herbal medicine - use of herbs or plants that are valued for their medicinal properties, flavors and scents. Examples: Eucalyptus (antibacterial, decongestant), Saint John’s worth (antidepressant), garlic (lowers cholesterol) 4. Nutritional medicine – includes special diet therapies (e.g., macrobiotic, vegetarian, Atkins, South Beach diet, etc.) Orthomolecular medicine, the use of products used as nutritional and food supplements like vitamins and mineral (and not covered in any other category
5. Lifestyle and behavior – modifying or changing unhealthy lifestyle behavior/s or habits to healthy ones; also emphasizes healthy maintenance and disease prevention. Example: eating healthy instead of junk foods, changing or stopping addictive behaviors like drinking or smoking
6. Mind/body or behavioral medicine – uses a variety of techniques designed to
enhance the mind’s capacity to affect bodily function and symptoms. These include biofeedback; relaxation; meditation; guided imagery; hypnosis; prayer; art; music; dance therapy, and yoga.
7. Energy medicine- involves the use of energy fields. The following are commonly accepted • • • • •
beliefs about energy and healing: All things are manifestations of energy. Energy comes from one universal source Life depends on the movement of energy. People consists of several energy fields that interact with the environment. Interpersonal relationships are influenced by energy exchanges.
Types of energy therapies: Biofield involves systems that use subtle energy fields that purportedly surround and penetrate the human in and around the body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Example: qi gong, Reiki, and Therapeutic Touch,
Bioelectromagnetic-based therapies – involve the unconventional use of electromagnetic fields such as pulsed fields, magnetic fields, or alternatingcurrent or direct current fields or bone repair, wound healing and stimulation of the immune system.
Traditional Chinese Medicine (TCM) is based on the premise that the body’s vital energy qi (pronounced chee) circulates through pathways or meridians and can be accessed and manipulated through specific anatomical points along the surface of the body. Disease is described as an imbalance or interruptions in the flow of qi. Components of TCM include: herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage. 8. Manipulative therapies - are diagnostic and therapeutic mechanisms based on manipulation and /or movement of the body, such as osteopathic manipulation, massage therapy, hydrotherapy, chiropractic Osteopathic medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all
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of the body’s systems work together, and disturbance in one system may affect function elsewhere in the body. 9. Others – Humor, laughter therapy, pet therapy, music, aromatherapy Source: Andrews and Boyle, op. cit, 4th ed. pp. 73-86. Related Therapies: Ayurveda – is a CAM alternative medical system that has been practiced in the Indian subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment. Video showing: Ayurveda Chiropractic – is a CAM alternative medical system. It focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractor use manipulative therapy as an integral treatment tool. Homeopathic medicine is a CAM alternative medical system. In homeopathic medicine, there is a belief tat :like cures like,” meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substance given at higher or more concentrated dose would actually cause those symptoms. Example: Immunization Naturopathic medicine, or naturopathy, is a CAM alternative; it proposes that there is a healing power in the body that establishes maintains, and restores health. It includes supporting treatments as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine. Nursing Implications: Nurses must know and understand the nursing implications of CAM Therapies:
When a nurse enters into a relationship with a client/patient she acts as a healing facilitator by offering to be a guide, counselor, agent of change , or instrument of healing, which is help the clients call forth their inner resources for healing. Nurses are encouraged to think critically and assess CAM Therapies before recommending any one particular method or therapy. As such she must develop the following attributes: Has knowledge base Intentionality – conscious direction of goals that is essential in helping the healer to focus Respect for differences: Demonstrated by honoring clients’ culturally based health beliefs Ability to model wellness: Tending to own needs and attempting to stay as healthy and balanced as possible
UNIT V. TRANSCULTURAL CARE NURSING MODELS Following are transcultural care nursing models that depict theory of cultural care and universality (Leininger’s Sunrise Model), provide a model for cultural competence (Purnell’s), and a framework for assessing transcultural phenomena (Giger and Davidhizar’s).
A. LEININGER’S SUNRISE MODEL TO DEPICT THEORY OF CULTURAL CARE
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DIVERSITY AND UNIVERSALITY Focuses on describing, explaining, and predicting nursing similarities and differences
primarily on human care and caring in human cultures. Leininger uses word view, social structure, ethnohistory, environmental context, and the generic (folk) and professional systems to provide a comprehensive and holistic view of influences in culture care and well-being. This model emphasizes that health and care are influenced by elements of the social structure, such as technology, religious and philosophic factors, kinship and social systems, cultural values, political and legal factors, economic factors, and educational factors. In order for nurses to assist people of diverse cultures, Leininger presents three intervention modes to demonstrate ways to provide culturally congruent nursing care. These modes are assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a designated culture in:
a. Culture care preservation and maintenance –refers to the assistive,
b.
c.
supportive, facilitative, or enabling professional actions to retain and/or reserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death.” Culture care accommodation or negotiation – refers to the assistive, supportive, facilitative, or enabling professional actions to negotiate to /with others for beneficial or satisfying health outcomes with professional care providers.” Culture care restructuring and repatterning – refers to the assistive, supportive, facilitative, or enabling professional actions to help a client reorder, change, or greatly modify his or her lifeways for a new, different, and beneficial health care pattern, and maintenance of respect for the client’s cultural values and beliefs while still providing a beneficial or healthier lifeway than before the changes were co-established with the client.
(Leininger, 1991, pp. 48-49, in Andrews and Boyle, 3rd ed. op. cit. p. 521).
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THE SUNRISE MODEL
C.THE PURNELL MODEL FOR CULTURAL COMPETENCE 1. Macro Aspects of the Model Global society – phenomena
related to global society include world communication and politics; conflicts and warfare; natural disasters and famines; international exchanges in education, advances in health sciences, etc. Community – physical, social, and symbolic characteristics that cause people to connect Family – is two or more people who are emotionally connected. Family structure and roles change according to age, generation, marital status, relocation, etc. Person – is a biopsychocultural being who is constantly adapting to his or her environment.
2. Micro Aspects of the Model
The 12 domains essential for assessing the ethnocultural attributes of an individual, family, or group are as follows: Overview, inhabited localities, Nutrition and topography Pregnancy and child-bearing Communication practices Family roles and organization Death rituals Workforce Issues Spirituality Biocultural ecology Health-care practices High-risk behaviors Health-care practitioners
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C. THE GIGER AND DAVIDHIZAR’S TRANSCULTURAL ASSESSMENT MODEL The metaparadigm for this model includes: 1. 2. 3. 4. 5.
Transcultural nursing and culturally diverse nursing; culturally competent care; culturally unique individuals; culturally sensitive environments; and, health and health status based on culturally specific illness and wellness behavior.
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The Giger and Davidhizar’s Transcultural Assessment Model Model shows:
The client, a unique cultural being, in the center.
It is important to remember that the client is culturally unique and as such is a product of past experiences, cultural beliefs and cultural norms. Cultural expressions vary but it is that which give an individual a unique identity.
Cultural heritage consistency: This theory analyzes the degree to which
people identify with the dominant and traditional cultures . Its essential elements are: culture, ethnicity, and religion
1. Culture – represents non-physical traits, such as values, attitudes, beliefs,
2.
customs shared by a group of people and passed from generation to the next. Culture is also the sum f beliefs, practices, habits, likes dislikes, norms, customs and rituals learned from the family during the ears of socialization. Ethnicity – is a sense of identification associated with a cultural group’s common social and cultural heritage. Ethnicity is indicative of the following characteristics a group may share in some combination: i. Common geographic origin ii. Migratory status iii. Race iv. Language and dialect v. Religious faith or faiths vi. Ties that transcend kinship, neighborhood, and community boundaries vii. Shared traditions, values, and symbols viii. Literature, folklore, and music ix. Food preferences x. Settlement and employment patterns xi. Special interest with regard to politics in the homeland and in the United States xii. Institutions that specifically serve and maintain the group
Filipino ethnicity: The “Filipino blend,” is a considerable mix of cultural and linguistic groups, the result of varied historical and local relationships: • Earliest known settlers were the Negritos, small Negroes, related to the Andaman Islands and Malaya, who entered via land bridges at the height of the last glacier age. They are found in the Bataan peninsula and other marginal areas. • Next wave of settlers came from Southeast Asia by way of the China sea and remained in Luzon and Visayas. • Arab and Indian traders added their blood to the Muslim populations and settled in the southern islands. • Invasion of the Philippines by Spain in 1521, and the U.S. in 1898. Language is one of the most identifying ethnic feature of Filipino groups. There are 76 linguistic groups, the 3 most important are Tagalog, Visayas and Ilokano. Cultural Minorities – 4 million or 12% of total population. ¾ Muslims found in Mindanao, Sulu Archipelago and Palawan. (See addendum) There are at least 106 ethnic groups in North America and more than 170 Native American Indian tribes. (Thernstrom, 1980).
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Filipino Ethnicity: The “Filipino Blend,”
3. Religion – “the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler (s) of the universe; and a system of beliefs, practices and ethical values. It is not possible to isolate the aspects of culture religion, and ethnicity that shape a person’s worldview. Each is a part of the other, and all three are united within the person. Therefore, when religion is discussed, culture and ethnicity must also be included. a. Relationship between religion, culture and ethnicity: Examples
Ethnicity and religion are clearly related, and one’s religion is quite often the determinant of one’s ethnic group. Example: Israeli- Jewish; Japanese – Shintoism; Thai - Buddhism Religion in many cultures plays a vital role in one’s perception of health and illness as well as the way people interpret and respond to the signs and symptoms of illness. Religion, religious beliefs, and rituals are closely interwoven with the cycles and stages of life as birth, marriage, dying and death. Examples: Baptism is a sacrament in the Catholic religion. In Islam, circumcision must be performed on the 7th day after birth, and on the 8 th day in the Jewish faith. In the Hindu religion, the eldest son must perform the rituals for the dead. Personal and cultural values and ethical principles and practices are greatly determined and influenced by religion. Examples: According to Christian Science abortion is incompatible with faith. Family life is valued and birth control is contrary to Mormon belief. Euthanasia is not acceptable in Islam. Healing through prayer, relics or religious objects or through the intercession of saints is a belief common to many religions. Examples: Prayer for the sick. Intercession of saints: St. Joseph – dying, St. Vitus – epilepsy, Our Lady of Lourdes – bodily ills, Use of religious medal, holy water, etc.
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GEOGRAPHICAL DISTRIBUTION
b. Top Ten Organized Religions of the World RELIGION Christianity Islam Hinduism Buddhism Sikhism Judaism Baha’ism Confucianism Jainism Shintoism
PERCENTAGE 3.0% 20.1 13.3 5.9 0.4 0.2 0.1 0.1 0.1 0.0
POPULATION 2.1 billion 1.3 billion 851 million 375 million 25 million 15 million 7.5 million 6.4 million 4.5 million 2.8 million
c.
c. Largest Denominational Families in the United States 2001 DENOMINATION Catholic Baptist Methodist/ Wesleyan Lutheran Presbyterian Pentecostal, Charismatic Episcopalian/ Anglican Latter-Day Saints/ Mormon Church of Christ Congregational United Church of Christ Jehovah’s Witness Assemblies of God
ESTIMATED % OF U.S. POPULATION 24.5% 16.3% 6.8% 4.6% 2.7% 2.1% 1.7% 1.3% 1.2% 0.7% 0.6% 0.5%
ESTIMATED ADULT POPULATION 50,873,000 33,830,000 14,150,000 9,580,000 5,580,000 4,407,000 3,451,000 2,697,000 2,593,000 1,373,000 1,331,000 1,106,000
D. Giger and Davidhizar’s Transcultural Assessment Model: The Six Cultural Organzing Phenomena 36
Culturally diverse nursing must take into account six cultural phenomena that vary but are evident in all cultural groups and affect health care. These have been identified by Giger & Davidhizar, 1999, and Engebertson & Headley(2000), as: (1) environmental control, (2) biological variations, (3) social organization (4) communication, (5) space, and (6) time orientation.
1. ENVIRONMENTAL CONTROL – refers to the ability of members of a particular group to plan activities that control nature or direct environmental factors. • Plays an extremely important role in the way patients respond to health-related experiences, including the ways in which they define health and illness and seek and use health care resources and social supports. •
Examples of environmental control systems: complex traditional health and illness beliefs, the practice of folk medicine, the use of traditional healers, etc.
2. BIOLOGICAL VARIATIONS – The several ways in which people from one cultural group differ biologically (i.e., physically and genetically) from other cultural groups constitute their biological variations. These are: Body built and structure – specific bone structure and structural differences between groups. Example: smaller stature of Asians Skin color, including variations in tone, texture, healing abilities, and hair follicles. Example: African Americans – dark skinned; Europeans – light skinned Enzymatic and genetic variations, including differences in response to drug and dietary therapies Susceptibility to disease which can manifest as a higher morbidity rate of certain diseases within certain groups Nutritional variations. Examples: “hot and cold” preferences among Hispanic Americans, yin and yang among Asian Americans, rules of the kosher diet among Jewish and Islamic Americans, etc. Common nutritional disorder, lactose intolerance, is found among Mexicans. Africa, Asian, and Eastern European Jewish Americans.
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3. SOCIAL ORGANIZATION – refers to the ways in which groups determine rules of acceptable behavior and role of individual members. Family unit (nuclear, single parent, extended, blended) Children learn their cultural responses to life events from the family and its ethnoreligious group through socialization. Gender – gender roles vary according to cultural context: *patriarchal structure – husband/father is the dominant person (Latino, Hispanic and traditional Muslim families *matriarchal structure – the wife is responsible for child care and household maintenance whereas the father’s role is to support and protect the family members. Lifestyle – alternative lifestyles. Example: homosexual couples and communal groups Social organization also prescribes behavior for such significant events as birth, death, child rearing, and illness. Nurses must demonstrate respect for client’s lifestyles even when they differ from theirs by: Being aware of own tendency to be ethnocentric Being sensitive to client’s needs especially those expressed non-verbally Use self-awareness to determine the impact of own beliefs and values
4. SPACE (PROXEMICS) – The area around a person’s body, surrounding environment, and objects within that environment; affects people’s behaviors and attitudes toward the space around themselves. Territoriality refers to the behavior and attitude people exhibit about an area they have claimed and defend or react emotionally when others encroach on it. Both personal space and territoriality are influenced by culture, thus different ethnocultural groups have varying norms related to the use of space. Space and related behaviors have different meanings in the following zones: Intimate zone – extends up to 1 ½ feet. Acceptable only in private places because this distance allows adults to have the most bodily contact for perception of breath and odor, Personal distance – extends from 1 ½ to 4 feet. This is an extension of the self that is like a “bubble” of space surrounding the body. At this distance the voice may be moderate, body odor may not be apparent, and visual distortion may have disappeared. Social distance – extends from 4 to 12 feet. This is reserved for impersonal business transactions. Perceptual information is much less detailed. Public distance – extends 12 feet or more. Individuals interact only impersonally. Communicator’s voices must be projected, and subtle facial expressions may be lost. Use of personal space varies among individuals and ethnic groups. The extreme modesty practiced by members of some cultural groups may prevent members from seeking preventive health care.
5. Time Orientation (Temporal Relationships) – refers to viewing of time in the present,
past or future; varies among different cultural groups. Most cultures include all three time orientation, but one orientation is more likely to dominate the cultural perspective. Examples: American culture – future oriented; time is a highly valuable resource: do not waste time, “time is money” German culture – past-oriented society, where laying a proper foundation by providing historical background information can enhance communication Central American culture – present oriented Asian, Latin countries – punctuality is not taken seriously.
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Time Orientation To Past
Selected Consequences of Time Orientation Possible Consequences
When traditions conflict with a prescribed treatment regimen, The person may have trouble accepting or maintaining the plan of care. In contrast, a strong connection with the past may ground the person with others in the same culture and provide a sense of self that encourages positive health practices. To the present A present-oriented person may have little concern for long-term preventive health practices and may respond better to sort-term goals. In contrast, a present-oriented person may be most able to enjoy the here-and-now and may engage fully in exercise, enjoy nutritious food, and appreciate the company of others – all attributes associated with good health. To the future This person has little difficulties and inconvenience of the present, focusing instead on the future. The present is important only if what is happening now will help the person realize long-term goals. This person may have little trouble following a treatment plan as long as its benefits are clear. However, the person may have difficulty with chronic illnesses for which no complete cure is known. A future-oriented person naturally tends to become more of a presentoriented person with age because, as the future life becomes shorter, the present becomes more important. Source: Harreader, Helen and Mar Ann Hogan. Fubdamentals of Nursing. Saunders, An imprint of lsevier, Inc. reprinted 2005, p. 47.
4. Communication – Language differences possibly play the most important obstacle to providing multicultural health care because clients come from all over the world and they affect all stages of the patient caregiver relationship. to, and evaluate our experience.
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“Language allows us to initially identify, label, attach significance A. Basic/Related Concepts:
Communication occurs when a person (the sender (S) or encoder) sends a message to another person (the receiver (R) or decoder). Communication is most effective when the message received is exactly the same as the message that was sent and both sender and receiver agree on the meaning of the message. Communication fails when (1) the sender’s message is blocked for some reason and the receiver never gets the message; or (2) the message is distorted. Distortion of message occurs when the message has as different meaning for the receiver than the sender intended. Distortion is amplified when both receiver and sender fail to clarify message. Factors that can distort message: anger, fatigue, fear, pain, and anxiety. Communication may be blocked. Factors that foster blockage: different cultural, ethnic, racial, socioeconomic, or educational backgrounds. Example: Asians (Filipinos, Japanese, Chinese, etc) may silently accept a physician’s recommendation even when they do not understand the reasons for the medications or procedures that are ordered. B. Types of Communication: 1. Verbal – includes spoken or written word. Language is the code senders use to carry their message. Language barriers can cause severe communication problems between S and R.
Causes: 1. May arise from use of the language (e.g. S is speaking English and the R is speaking Spanish. 2. Can arise when the S uses technical terms, abbreviation, idioms or regionalisms that are unfamiliar to the receiver (e.g., when a nurse uses medical terms when explaining a procedure to a layperson). Every culture has standards for verbal communication – especially for word choice, the degree of emotion considered appropriate, volume and speed of speech, inflection, directness, and the use of silence.
•
Word Choice: American speech is filled with abbreviated words, slang, and jargon. Americans tend to communicate in an informal way with superiors and subordinates alike. Japanese use of language is distinguished by many levels of formality and directness depending upon the status of the people who are conversing. Distinctions are also made between men’s and women’s speech. Choice of word depends largely on the relationship between the people who are communicating.
•
Emotional Expressiveness, Tone, Pitch, Volume of Voice, and Speed of Speech White American middle-class culture values a controlled tone and some emotional restraint Many black Americans are more verbal and value emotional expressiveness in conversation
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Appalachians – speak very slowly and seem to dwell on each word, giving their speech a hesitant, disjointed quality. Many Asians and Native Americans display great emotional restraint in their speech patterns, speaking slowly and quietly. These cultures value the ability to endure pain and grief with silent stoicism. Southern Europeans are typically warm, expressive; will loudly express their discomfort Hispanics use a lot of endearing words, are warm and expressive.
•
Voice Inflection When emphasis is placed on certain words more than the words themselves. Example: “What do you need now?” “What do you need now?”
•
Directness in Speech Americans – quite direct, they go straight to the point rather than wasting time on lengthy preliminaries or long silences. Japanese – strive to be polite, diplomatic, and tactful. Mexicans –may take time for small talk and then lead into a discussion.
•
Use of Silence Some cultures value silence, whereas others feel that silence is a vacuum that must immediately be filled with word. Among Native Americans – silence is an essential element of showing respect and understanding. In some Arab cultures, silence may indicate concern for personal privacy. In French, Spanish, and Eastern European cultures silence may be a sign of agreement. Silence during a conversation gives each person an opportunity to speak without having to interrupt.
B. Nonverbal Communication It has been estimated that as much as 2/3 of all communication is non-verbal consisting of messages that are conveyed via body language and facial expressions.
•
Gestures and Facial Expressions
•
Common types of nonverbal communication may differ from culture to culture. A smile may imply acceptance and compliance, or may mean respect and social grace, or flirting. In nearly all cultures, people used their mouths and eyebrows to convey anger, surprise, pleasure, fear and hand gestures to convey openness or intimidation.
Eye Movement and Eye Contact “The eyes are the windows of the soul.”
When a person avoids eye contact, many Americans assume that it is a negative sign. It is not unusual for an American to say, “Look at me when I talk to you.” or “She must be lying. Did you notice that she avoided looking at us?” American physician and nurses usually note if a patient avoids eye contact when they perform a psychosocial assessment. Some Asians and Native Americans believe that prolonged eye contact is rude and an invasion of privacy.
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•
Native Americans may direct their eyes to the floor when they are paying attention or thinking. Muslim women may avoid eye contact as a show of modesty.
Touch
Touch patients only when you know touching is acceptable. Conveys many meanings: gentle, sensual, harsh or brutal We use touch to connect with others and to establish a feeling of warmth, approval, emotional support, and intimacy. Touch can also indicate anger, aggression, frustration, and a desire to control others by invading their personal space. Cultures have specific guidelines for times and situations when it is acceptable to touch others.
Handshake – a form of greeting, esp. when introduced; consummate a business deal Native Americans – view a firm handshake as aggressive and even offensive. Many Westerners think nothing of kissing or hugging a friend as a form of greeting when meeting in public places; in traditional Asian cultures, such behavior is reserved for intimate relationship in private settings. In many Asian cultures (Indians, Vietnamese, Japanese, Thai) avoid touching the head because the head has been traditionally considered to be the “the abode of the spirit.” •
Posture
Helps to communicate how one person feels towards another Middle-class Americans may lean in the direction of individuals they like or respect Posture can also communicate a tense or relaxed state Rigid muscles and a flexed body may indicate physical pain.
C. Barriers to Transcultural Communication Lack of knowledge – remember that each culture dictates what is “normal” when sick. Examples: • Japanese patients might react with silent obedience to your request • White middle-class patients might wish to discuss their nursing care with you • Italian patients might dramatically express their discomfort • Inner city youth might loudly demand your attention
Fear and Distrust – some people from diverse culture pass through different stages of adjustment during their initial encounter: • Fear • Dislike • Distrust • Acceptance • Respect • Trust • Like
Racism Bias and Ethnocentrism Stereotyping Ritualistic behavior Language barrier – 3 types of language barriers:
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• •
•
Foreign languages Different dialects and regionalisms *There are 3 major Chinese dialects: Mandarin, Cantonese, and Shanghainese *Aside from the 3 main Filipino languages there are numerous regional dialects: Ilongo. Cebuano, Ibanag, Itawis Idioms, slang, and “street talk”
Differences in perceptions and expectations Source: Munoz, C. and Kuckmann, op. cit. 177. D. The Use of an Interpreter: A way to resolve language barrier. When obtaining the precise meaning of words in a language that is difficult, it is best for health care providers to obtain someone who can interpret the meaning and message, not just translate the individual words. Some guidelines for communicating with non-English speaking clients:
Use interpreters rather than translators. Translators just restate the words from
one language to another. An interpreter decodes the words and provides the meaning behind the message. Use dialect-specific interpreters in the health-care field. Use interpreters trained in the health-care field. Give the interpreter time alone with the client. Provide time for translation and interpretation. Use same-gender interpreters whenever possible. Maintain eye contact with both the client and interpreter to elicit feedback: read nonverbal cues. Speak slowly without exaggerated mouthing, allow time for translation, use the active rather than the passive tense, wait for feedback, and restate the message. Do not rush; do not speak loudly. Use a reference book, a dictionary, etc. Use as many words as possible in the client’s language and nonverbal communication when unable to understand the language. Use phrase charts and picture cards if available. During the assessment, direct your questions to the patient, not to the interpreter. Ask one question at a time and allow interpretation and a response before asking another question. Be aware that interpreters may affect the reporting of symptoms, insert their own ideas, or omit information. Remember that clients can usually understand more than they can express; thus, they need time to think in their own language. They are alert to the health care provider’s body language, and they may forget some or all of their English in time of stress. Avoid the use of relatives who may distort information or not be objective. Avoid using children as interpreters, especially with sensitive topics. Avoid idiomatic expressions and medical jargon. If an interpreter is unavailable, the use of translator may be acceptable. The difficulty with translation is omission of parts of the message, distortion of the message, including transmission of information not given to the speaker, and messages not being fully understood. If available, use an interpreter who is older than the patient. Review responses with the patient and interpreter at the end of a session. Be aware that social class differences between the interpreter and the client may result in the interpreter’s not reporting information that he or she perceives as superstitious or unimportant. Source: Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd ed. 2003. F.A. Davis Co. , p.15.
E. SELECTED EXAMPLES OF ETIQUETTE AS RELATED TO SELECTED CULTURAL PHENOMENA
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TIME
Visiting Being on time Taboo times
Inform person when you are coming Avoid surprises Inform person when you are coming Explain your expectations about time Ask people from other regions and cultures what they expect Be familiar with the times and meanings of person’s ethnic and religious holidays
SPACE
Body language and distances
Know cultural and/or religious customs regarding contact, such as eye and touch, from many perspectives
COMMUNICATION
Greetings
Know the proper forms of address for people from a given culture and the ways by which people welcome another. Know when touch, such as embrace or handshake, is expected and when physical contact is prohibited. Gestures do not have universal meaning; what is acceptable to one cultural group is taboo with another. Smiles may be indicative of friendliness to some, taboo to others. Avoiding eye contact may be a sign of respect
Gestures Smiling Eye contact
SOCIAL ORGANIZATION
Holidays Special events Births Weddings Funerals
BIOLOGICAL VARIATIONS
Food customs
ENVIRONMENTAL CONTROL
HEALTH practices and remedies
Know what days are important and why, whether or not to give gifts, what to wear to special events, what the customs and beliefs are. Know how the event is celebrated, meaning of colors used for gifts, expected rituals at home or religious services. Know what can be eaten for certain events, what foods may be eaten together or are forbidden, what and how utensils are used. Know what the general HEALTH traditions are for a given person and question observations for validity
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Contextual cuingUse of silenceDialects, written
loyaltyFamily: Hierarchical structure,
Present
Non-contact
preference
Lactose intoleranceHypertensionCoccidioidomycosisStomach cancerLiver cancer
Traditional practitioners: Chinese doctors, herbalistsUse of traditional medicinesTraditional health and illness beliefs
characteristicsNational language
Many religions, incl. Taoism, Buddhism, Islam, and ChristianityDevotion to tradition
Nonverbal and
Southeast Asia (Cambodia, Laos, Vietnam)JapanKoreanPhilippinesHawaiiChinaAsian
Source: Adapted from Dresser, N. (1996). Multicultural manners. New York:Wiley. Copyright c 1960 John Wiley & Sons, Inc.
F. CROSS-CULTURAL EXAMPLES OF CULTURAL PHENOMENA IMPACTING NURSING CARE
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OrganizationsCommunity social
Family: many female,
illness beliefsTraditional health and
single parent
Present over Future
SpaceClose Personal
Lactose intoleranceCoccidiomycosisStomach cancerCancer of the esophagusHypertensionSickle cell anemia
Large, extended family
networks
workerTraditional healer: Root Folk medicine tradition
Strong church affiliation
within community
Spanish, and FrenchDialect pidgin, Creole,National languages
West Indian Islands (Dominican Republic, Haiti, Jamaica)Many African countriesWest coast (as slaves)African
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Some remaining folk
medicine traditions
England
GermanyEurope
Future over present
Primary reliance on modern
ThalassemiaDiabetes mellitusHeart diseaseBreast cancer
health care
Judeo-Christian religionsExtended familiesNuclear families
illness beliefsTraditional health and system
Social organizationsCommunity
Italy
Many learn English National languages
Ireland
immediately
Other European
Distant Southern countries: closer contact and touchAloofNon-contact people
Countries
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OrganizationsCommunity social grps.
families
Extremely family oriented
illness beliefsTraditional health and I
Biological and extended
Present
Diabetes mellitusCirrhosis of the liverHeart diseaseAccidents
Use of silence and body Tribal languages
500 American American Indian
Space very important and has no boundaries
language
Indian tribes
medicine manTraditional healer: Folk medicine tradition
Children taught to respect
traditions
Eskimos Aleuts
Lactose intoleranceCoccidioidomycosisParasitesDiabetes mellitus
illness beliefsTraditional health and
VARIATIONSBIOLOGICAL
CONTROLENVIRONMENTAL
SOCIAL ORGANIZATION
TIME ORIENTATION
SPACE
COMMUNICATION
NATIONS OF ORIGIN
partera, senora
esperitista,
Curandero,
Traditional healers:Folk medicine tradition
organizationssocial Community GodparentsCompadrozzo;Extended familiesNuclear family
Present
Value physical presenceEmbracingTouch, HandshakesTactile relationships
Spanish or Portuguese primary language
Central and South American Mexico Cuba SpainHispanic countries
Compiled by Rachel Spector, R.N., Ph.D. In Potter, P.A. and Perry, A.G. (1997). Fundamentals of nursing: concepts, process, and practice (ed. 4). St. Louis: Mosby.
G. TRANSCULTURAL ASSESSMENT: BASIC PRINCIPLES OF CULTURAL ASSESSMENT 1. All cultures must be viewed in the context in which they have developed. Cultural practices develop as a “logical” or understandable response to a particular human problem, and the setting as well as the problem must be considered. 2. Understanding the premises of the behavior must be examined. Example: The Hispanic clients refusal to take a “hot” medication with a “cold” liquid is understandable if the client is aware that many Hispanic patients adhere to hot/cold theories of illness causation.
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3. The meaning and purpose of the behavior must be interpreted within the context of the specific culture. Example: Close relationship often seen in Asian and Hispanic cultures may be viewed as abnormal in European American families. 4.There is such a phenomenon as intracultural variation. Not every member of a cultural group displays all the behaviors that we might associate with that group. Example: Not every Filipino will adhere to the same methods of folk healing. Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed Lippincott Wiliams & Wilkins, Philadelphia, p. 338.
Sample Assessment Questions 1. To what cause(s) do you attribute your illness or disease (e.g., divine imbalance in hot/cold or yin/yang, punishment for moral transgression, loss, pathogenic organisms)?
wrath, hex, soul
Ano ang dahilan ng inyong sakit (halimbawa: galt ng diyos, hindi pantay na lamig o init, yin/yang, kaparushan sa maling Gawain, sumpa kawalan ng kaluluwa, mickrobyo)?
2. What are your cultural beliefs about the ideal body size and shape? What is the patient’s self-image compared to the ideal? Anu-ano ang inyong paniwalang cultural tungkol sa kanaisnais a katawan o hugis?
3. What name do you give to your health related condition? Ano ang taway ninyo sa iyong kalagayan?
4. What do believe promotes health (eating certain foods; wearing amulets to bring good luck; sleep; rest; good nutrition; exercise; prayer; rituals to ancestors saints, or intermediate deities)? Sa palagay ninyo ano po ang pamamaran upang makabuti and inyong kalusugan? Kahgaya ng pagpili ng tamang pagkain, pagsuot ng anting-anting, pagbigayang swerte, pagtulog, pagehersisyo, pagdadasal, agsamba sa mga santo?
5. What is your religious affiliation?)? How actively involved are you in the practice of your religion? Ano po and relihyon ninyo? Gaano kayo kaaktibo sa inat-ibang Gawain ng inyong relihyon?
6. Do you rely on cultural healers? Who determines when you are sick and when you are healthy? Who influences the choice/type of healer and treatment that be sought?
should
Naniniwala ba kayo sa mga hilot o albularyo? Sino and nagsasabi kung may sakit kayo o wala. Sino ang namimili ng uri ng panggagamot/mangagamot?
7. What types of cultural practices do you patient engage or use (use of herbal remedies, potions, massage, wearing of talisman, copper bracelets, or charms to discourage evil spirits; healing rituals, incantations, prayers)? Nong klase ng gawain or paniniwala and inyomg ginagamit o ginagawa (paggamit ng mga gamut, gayuma, masahe, anting-anting, porselas, o mga alahas na nagtataboy ng masamang espiritu, dasal)?
8. How do you perceive biomedical/scientific healthcare providers? How do you and your family perceive nurses? care?
What are your expectations of nurses and nursing
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Ano ang tingin ninyo sa mga nagbibigay ng syentipikong panggagamot? Ano ang tingin ninyo at inyong pamilya sa mga narses? Ano ang inaasahan ninyo sa mga nars at pamamaran ng pagalaga?
9. What comprises appropriate “sick role” behavior? Who determines what symptoms constitute disease/illness? Who decides when you are no longer sick? Who cares for for you at home?
10.
Ano ang bumubuo ng tamang pag-aasal ng may sakit? Sino ang nagsasabi kung ano ang sintomas ng inyong sakit? Sino ang nagdedesisyon kung may sakit ka o wala na? Sino ang nag-aalaga sa iyo sa bahay? How does your cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses? Ano ang tingin ng nyong grupo cultural sa mga taong may sakit sa pag-iisip? Ano ang pagkakaiba ng phisikal ng paguugali sa pag-iisip ba karamdaman?
Source: Andrews, M. & Boyle, J. (2002b). Transcultural concepts in nursing care (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Assessment questions revised and translated in Pilipino.
H. BARRIERS TO HEALTH CARE In order for people to receive adequate health care, a number of considerations need to be addressed. Availability: Is the service available and at a time when needed? For ex.: No services after 6:00 p.m. Accessibility: Transportation services may not be available, or rivers and mountains may make it difficult for people to obtain needed health-care services when no health provider is available in their immediate region? Affordability: The service is available, but the client does not have financial resources. Appropriateness: Maternal and child services are available, but what might be needed are geriatric and psychiatric services. Accountability: Are health-care providers accountable for their own education and do they learn about the cultures of the people they serve? Adaptability: A mother brings her child to the clinic for an immunization. Can she get a mammogram at the same time or must she make an appointment? Acceptability: Are services and client education offered in a language preferred by the client? Awareness: Is the client aware that needed services exist in the community? The service may be available, but if clients are not aware of it, the service will not be used. Attitudes: Adverse subjective beliefs and attitudes from caregivers means that the client will not return for needed services until the condition is more compromised. Do health-care providers have negative attitudes about patients’ home-based traditional practices? Approachability: Do clients feel welcomed? Do health-care providers and receptionists greet patients in the manner in which they prefer? This includes greeting patients with their preferred names.
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Alternative practices and practitioners: Do biomedical providers incorporate clients’ alternative or complementary practices into treatment plans? Additional services: Are child and adult services available if a parent must bring children or an aging parent to the appointment with them? Source: Purnell, Larry D. & Betty J. Paulanka, op. cit. p. 35.
UNIT V. APPLICATION OF ORGANIZING CULTURAL PHENOMENA TO PEOPLE FROM DIFFERENT CULTURAL HERITAGE: AN INTERACTIVE SESSION INTERACTIVE SESSION IS AN OPPORTUNITY FOR THE STUDENT TO PRESENT:
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A. INDIVIDUALLY Present and submit a “Search Paper” on a transcultural subject/phenomenon/issue/topic, or about culturally based health-related beliefs and practices of people from diverse backgrounds. You may search the internet or use any book or magazine as source material. Credit Source.
Search Paper must not be less than 3 pages long on 8 1/2 x 11 bond, double-spaced,
Font 12. Must be submitted on day of Midterm. No late papers will be accepted. You may be requested to provide a diskette of your paper. If time permits, you may be asked to read your “Search Paper” in class.
B. AS A GROUP MEMBER Group report on application of Organizing Cultural Phenomena to Nursing Care in diverse groups from Different Cultural Heritage. A. People of Filipino Heritage B. People of Japanese Heritage C. People of Chinese Heritage VII.People of Indian (Hindu) Heritage VIII.People of Mexican Heritage IX. People of Arabian Heritage X. People of African-American Heritage XI. People of Anglo-American Heritage XII.People of Italian Heritage XIII.People of Jewish Heritage
Group report must contain information given below.
I.
II.
III.
IV.
Social
Organization Family: Gender Roles Religion Others Biological Variation Dietary Practices/Preferences Increased Susceptibility to: Environmental Control Definition of Health Causative Factors of Illness Communication Language(s) Silence
Eye Contact Other V. Space Social Distance Touch VI. Time Orientation Present oriented Past oriented Future oriented Flexible VII. Cultural beliefs and practices across lifespan VIII. Nursing Implication/s of the different cultural phenomena described.
You are encouraged to be as creative as possible. Make report concise. You are NOT TO READ YOUR REPORT in its entirety. Submit hard copy of report before or on the day of reporting.
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UNIT VI. Contemporary Challenges in Transcultural Nursing A. TRANSCULTURAL ASPECTS OF PAIN “Pain is whatever the experiencing person says it is, existing whenever he says it does.” McCafery (1979) WHY IS THE SUBJECT OF PAIN A CHALLENGE IN CONTEMPORARY TRANSCULTURAL NURSING? 1. Definition Pain – an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. U.S. Department of Health and Human Services, 1992 Definitions of pain are diverse because of its complex nature and because of the many different existing perspectives on pain. 2.
Basic/Related Concepts
3.
Pain is a universally recognized phenomenon and the most frequent and compelling reason for seeking health care. Pain is a very private experience and is influenced by cultural heritage. Thus, expectations, manifestations and management of pain are embedded in a cultural context. Therefore, understanding culture is critical when dealing with clients in pain. The experience of pain is determined by the: meaning of painful stimuli for individuals; way individuals define their situation; and, impact of previous personal experiences help determine the experience of pain. Measurement of Pain
In terms of pain measurement, it is generally believed that humans normally experience similar pain thresholds. Research suggests that there are no differences in the amount of stimulation needed to produce a detectable sensation. Measurement of pain would differ in pain threshold, pain tolerance and encouraged pain tolerance. Pain Threshold – refers to the point at which the individual reports that a stimulus is painful. For example, some people required higher intensities before describing the stimuli as painful. Pain Tolerance – is the point at which the individual withdraws or asks to have the stimulus stopped. Cultural background appears to have a strong influence on pain tolerance levels. Examples from studies using radiant heat techniques in South African Americans, Northern European Americans, Russian Jewish Americans, and Italian Americans.
Northern European Americans – had the highest pain and pain reaction threshold Italian Americans – vocalized their pain African Americans – did not verbally express their pain
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Encouraged Pain Tolerance – is the amount of painful stimuli an individual accepts when encouraged to tolerate increasingly higher levels of stimulation. Example: North American Plains Indians – tolerate large amounts of pain as described in Sun Dance “self-torture” ceremonies. Nursing Implication: Because many factors, aside from culture, play a role in pain perception, the nurse should not expect all clients to react in the same way to painful stimuli. 4.
Expressions of Pain
Expressions of pain vary from culture to culture. What are appropriate verbal
behavior and body language in response to pain are dictated by culture. Example: the Japanese culture does not approve of loud verbal expressions of pain. Within each culture, expressions of pain may vary from person to person. How people express their pain is strongly influenced by their level of assimilation and acculturation. In relation to gender – men demonstrate greater stoicism than women. However, stoicism decreases with increasing age. (Zatzick & Dimsdale, 1990)
Categories of responses: a. Stoic – responses to pain are less expressive verbally and nonverbally. Some reasons are: Denial of pain A desire to be the perfect patient Avoiding loss of control Avoiding worrying the family Fear of addiction Fear of overdose and side effects from pain medications Paying a price for past sins and future joys Acceptance of the pain b. Emotive – responses are quite vocal and will express their pain loudly. Some reasons are: Fear of the pain A desire for help and fear of not receiving it Anger Grief over loss of dignity Exorcism of the pain through the act of crying out Experiencing great pain 4. Questions on Cultural Attitude Toward Pain CHARACTERISTIC Experience of pain
QUESTIONS How do we express pain? Is it ok to show pain? Is there a difference in how people in my culture show pain (gender, age, married, poor/rich)?
Causes of pain
What causes physical pain? Does the evil eye cause pain? Is pain a form of punishment? An opportunity For reward in the afterlife? Or atonement?
Treatment of pain
Does every pain justify relief? What traditional and other healing methods are used? 55
What is the impact of religion on treatment of pain? Do you seek medical attention self-medicate? What are the beliefs about using narcotics to treat pain? Values about pain
What types of pain have stigma? Are people avoided/marginalized? Do people use pain to seek attention?
Source: http://tcn.sagepub.com 5.
Applying Transcultural Nursing Concepts to People in Pain Respect clients as individuals Respect the client’s response to pain and their autonomy regarding choices they make about pain control. Never stereotype a person based on culture Communicate openness, acceptance, and a willingness to listen to views of client Seek the support of colleagues and health team members to assist you in exploring culture-specific pain management strategies.
B. CULTURAL DISPARITIES IN HEALTH AND HEALTH CARE DELIVERY 1.
Some factors that account for cultural disparities in the delivery of health care.
a. Minority groups. According to ANA (1998), minorities experience some diseases at a much higher rate than white Americans. Cancer is the leading cause of death for Chinese and Vietnamese individuals. Vietnamese women suffer from cervical cancer at nearly 5x the rate of white American women. Compared with the general population, Hispanics have a higher incidence of cancer of the stomach, esophagus, pancreas, and cervix. African-Americans have a life expectancy that is six times shorter than the life expectancy for white Americans. The Native American population has significant rates of diabetes, sudden infant death syndrome, and congenital malformation. Overall Native Americans and Alaskan Native rates of diabetes, tuberculosis fetal alcohol syndrome, alcohol-related morbidity and mortality, and suicide exceed those of other racial and ethnic groups in the United States. (Kavanagh et al., 1999, p. 10). b. Vulnerable Populations As a result of societal changes more people are at risk for health problems. As a result, many vulnerable populations are underserved because of the high demand for services, lack of services, and limited availability and access to services. Groups that are especially susceptible for health-related problems include the poor, the homeless, migrant workers, abused individuals, the elderly, pregnant adolescents, and people with std’s such as HIV/AIDS. c. The Poor In every race and ethnic group there is a relationship between socioeconomic status and health. Poverty affects health status and accessibility to health care services. Living in poverty means being unable to meet the financial demands of basic living expenses, such as food, shelter, and clothing. “Childhood poverty has long-lasting negative effect on one’s health. Children in low-income families fare less well than children in more affluent families.” (U.S. Bureau of the Census, 2000).
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The poor population has more complex health problems including a higher incidence of chronic illness. (U.S. Bureau of the Census, 2000). The following high risk factors are related to lower income: (CDC, 1998) • Higher prevalence with cigarette smoking • Greater incidence of obesity • Elevated blood pressure • Sedentary lifestyle • Less likely to be covered by health insurance
•
Less likely to receive preventive health care services
Poor Production
Insufficient Salaries Poor intellectual and physical development
Increased Sickness
Poor economic production
Lack of Preventive Care
Subsistence Economy
Lack of Potable Water Poor Nutrition
Important role of high human reproduction
High Cost of HealthCare needs
Poor and Densely Populated Housing
High incidence of illness
The Cycle of Poverty d. The Homeless In the U.S. it is estimated that 350,000 to 6 million people are homeless (Walker, 1998, p. 27). Societal factors that contribute to homelessness are: Lack of affordable housing Increasingly stringent criteria for public assistance Decreased availability of social services Inadequate or lack of employment A history of psychological trauma Deinstitutionalization of clients from mental health facilities community support (such as half-way houses and group homes).
C.
without
CULTURAL DIVERSITY IN THE WORKFORCE 1. The aspects of cultural diversity in the workforce:
Race and ethnicity The racial/ethnic diversity among registered nurses in the United States (1993) RACE BLACK (NON-HISPANIC) HISPANIC ASIAN/PACIFIC ISLANDER AMERICAN INDIAN ALASKAN NATIVE GRADUATES OF FOREIGN PROGRAM
NO. OF REGISTERED NURSES IN THE U.S. 90,600 30,400 76,000 10,000 73,000
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Sex – the net rate of growth between 1986 and 2000 in the U.S. labor force: RACE HISPANIC FEMALES ASIAN FEMALES HISPANIC MALES ASIAN MALES AFRICAN AMERICAN FEMALES AFRICAN AMERICAN MALES WHITE FEMALES WHITE MALES
% GROWTH IN U.S. 85% 83% 68% 61% 83% 24% 22% -9%
Source: Schwartz & Sullivan, 1993
2. The effects of multicultural healthcare workforce a. Positive: Healthcare workers from diverse background bring a variety of experiences and a wide range of knowledge to the health care setting They offer fresh ideas and different solutions to long- term problems. Foreign nurses can help American nurses understand and relate better to patients who are also from diverse cultural backgrounds. b. Negative: Cultural diversity in the workforce may produce serious barriers and conflicts. 3. Barriers/conflicts in the workforce
Different cultural patterns and biases that affect the relationship between
physicians, nurses and ancillary personnel. Example: many male physicians from the Middle East think of women as subservient and feel that they have the right to shout at female nurses.
Racism and prejudice that can undermine professional relationships. Three types of racism:
a. Individual racism – Discrimination based on visible biological characteristics. Example: black skin or the epicanthic fold of the eyelid in Asians.
b. Cultural racism – Occurs when an individual or institution claims that its
c.
d.
cultural heritage is superior to that of other individual institutions. Example: During World War II, the Nazis claimed that their Aryan genetic and cultural heritage was superior to the Jewish heritage. They justified persecution of the Jews by convincing themselves that the Jews were an inferior people. Institutional racism – Institutions (universities, businesses, hospitals, schools of nursing) manipulate or tolerate policies that unfairly restrict the opportunities of certain races, cultures, or groups. Example: At one time, “black” people were not allowed to use the comfort room used by “white” people, sit in the front row of transportation facilities, enroll their children in universities, etc. Bias and ethnocentrism – Whatever their cultural background, people have a tendency to be biased toward their own cultural values and to feel that their values are right and the values of others are wrong or not as good. Example: “White” nurses are biased not only toward their own health care system but also toward their learned values, such as cleanliness. Cleanliness is essential to good health care. A nurse who finds that a child is dirty might translate her observation into a value judgment that the mother is not practicing good health practices.
Clashes in values that arise between foreign nurses and nurses trained in the
United States. In a study of Philippine American nurses, the most important finding was the theme of obligation to care that prevailed in all aspects o their work (Spangler, 1992). This theme was expressed in 3 important ways:
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(1) Expressed seriousness and dedication to work; (2) Attentiveness to the patients’ physical comfort; and, (3) Respect and patience. Example of conflict: The theme of an obligation to care reflected the Philippine American nurses’ strong belief that bedside nursing is truly the core of nursing practice. This value conflicts with the attitude of some American nurses that the physical care of patient is devalued work with low prestige and should therefore be delegated to ancillary personnel.
Different perceptions of nursing responsibilities and patient care that are based on different cultural values. Example: Unlike Western nurses, Asian nurses tend to accept difficult assignments without complaint. They may also be more willing to do what American nurses might consider demeaning (e.g., cleaning cabinets).
Differences in time orientation. Cultural groups are either past, present, or future oriented. American value future over the present, Southern blacks and Puerto Ricans value the present over the future, and Mexican Americans value the present. Example: People who work in the operating room must be both future and present oriented. Surgical cases are scheduled ahead of time (future) and health workers must abide by the calendar and clock, but once surgical procedure begins, nurses must now switch to a present orientation)
Language differences that result in serious miscommunications. Example: A Filipino nurse who was temporarily assigned to an unfamiliar medical unit transcribed a telephone order from a physician. The physician said: “Give Johnson 50 mg. Demerol for pain. If she is still complaining of pain after an hour, call me and I’ll increase the dosage.” When transcribing the order the nurse missed the physician’s reference to the patient as a she, a common error among Filipinos and other Asians. Mr. Johnson, who happened to be on the same ward might have received the medication had another nurse not intervened and questioned the order. Source: Muniz & Luckmann, op. cit.
4. Promoting harmony in multicultural workplaces
Identification of cultural values of the organization, institution, or agency Mission statement and policies about diversity Zero tolerance for discrimination Effective cross-cultural communication Skill with conflict resolution involving diversity Commitment to multiculturism at all levels of management
5. Strategies to promote effective cross-cultural communication in the multicultural workplace. STRATEGIES
1. 2. 3. 4. 5.
6.
Pronounce names correctly. When in doubt, ask the person for the correct pronunciation. Use proper titles of respect: “Doctor,” “Reverend,” “mister.” Be sure to ask for the person’s permission to use his or her first name, or wait until you are given the permission to do so. Be aware of gender sensitivities. If uncertain about the marital stats of a woman or her preferred title, it is best to refer to her as Ms. (pronounced mizz). Be aware of subtle linguistic messages that may convey bias or inequality, for example, referring to a white man as Mister while addressing a Black female by her first name. Refrain from Anglicizing or shortening a person’s given name without his or her permission. For example, calling a Russian American “Mike” instead of Mikhael, or shortening the Italian American Maria Rosa to Maria. The same principle applies to the last name, or surname. Call people by their proper names. Avoid slang such as “girl”, “boy”, “honey”,
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7.
8. 9.
10. 11. 12. 13.
14.
15.
16. 17.
“dear”, “guy”, “fella”, “babe”, “chief”, “mama”, “sweetheart”, or similar terms. Refrain from using slang, pejorative, or derogatory terms when referring to persons ethnic, racial, or religious groups, and convey to all staff that this is a work environment in which there is zero tolerance for the use of such language. Violators should be counseled immediately. Identify people by race, color, gender, and ethnic origin only when necessary and appropriate. Avoid using words and phrases that may be offensive to others. For example, “culturally deprived” or culturally disadvantaged” imply inferiority, and “nonWhite” implies that White is the normative standard. Avoid clichés and platitudes such as “Some of my best friends are Mexicans” or “I went to school with Blacks”. Use language in communication that includes all staff rather than excludes some of them. Do not expect a staff member to know all other employees of his or her background or to speak for them. They share ethnicity, not necessarily the same experience, friendship, or beliefs. Communications describing staff should pertain to their job skills, not their color, age, sex, race, or national origin. Refrain from telling stories or jokes demeaning to certain ethnic, racial, age, or religious groups. Also avoid those pertaining to gender-related issues or persons with physical or mental disabilities. Convey to all staff that there will be zero tolerance for this inappropriate behavior. Violators should be counseled immediately. Avoid remarks that suggest to staff from diverse backgrounds that they should consider themselves fortunate to be in the organization. Do not compare their employment opportunities and conditions with those people in their country of origin. Remember that communication problems multiply in telephone communications because important nonverbal cues are lost and accents may be difficult to interpret. Provide staff with opportunities to explore diversity issues in their workplace, and constructively resolve differences.
Source: Boyle and Andrews, 4th ed. op. cit., pp. 380, 398.
D. TRANSCULTURAL VALUES AND ETHICS “The nurse…promotes an environment in which the values, customs, and spiritual beliefs of the individuals are respected.” International Council of Nurses, 1973. Cultural values – are principles or standards that members of a cultural group share in common.
1. Basic/Related Concepts a. Accepting and respecting the values of patients from other cultures is the first step toward successful transcultural communication.
b. Values have important functions: They provide people with a set of rules by which to govern their lives. They serve as a basis for attitudes, beliefs, and behavior. They help to guide actions and decisions They give direction to people’s lives and help them solve common problems. They influence how individuals perceive and react to other individuals. They help determine basic attitudes regarding personal, social and philosophical issues. They reflect a person’s identity and provide a basis for self-evaluation. c. Values differ from culture to culture. For example: Examples of traditional Asian, Mainstream American, and Hispanic values. ASIAN VALUES Group
AMERICAN VALUES Individuality, independence
HISPANIC VALUES Group
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Submission to authority Extended family Tradition Respect for elders Respect for the past Conformity Fatalism Acceptance /resignation
Resistance to authority Nuclear/blended family Innovation Emphasis on youth Future orientation Competition Self-determination Aggression/assertion
Submission to authority Extended family Tradition Respect for elders Present orientation Conformity Fatalism Acceptance/resignation
d. Culture care values carry cultural care meanings. To provide congruent care the
nurse must understand that cultural values carry care meanings which influence nurse-client interaction, provide useful information about the client’s expectations of care, and influence the client’s sense of appropriate sick role behaviors, choice of healers, views toward technology, and health-related beliefs and practices. Examples of cultural values and culture care meanings and action modes for selected groups. CULTURAL VALUES ANGLO AMERICAN CULTURE (MAINLY U.S. MIDDLE AND UPPER CLASSES) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Individualism- focus on self-reliance Independence and freedom Competition and achievement Materialism (things and money) Technology dependent Instant time and actions Youth and beauty Equal sex rights Leisure time highly valued Reliance on scientific facts and numbers Less respect for authority Generosity in time of crisis
MEXICAN AMERICAN CULTURE 1. Extended family valued 2. Interdependence with kin and social activities
3. 4. 5. 6. 7. 8. 9.
Patriarchal (machismo) Exact time less valued High respect for authority and the elderly Religion valued (many Roman Catholics Native food for well-being Traditional folk-care healers for folk illnesses Belief in hot/cold therapy
HAITIAN AMERICAN CULTURE 1. Extended family as support system 2. Religion – God’s will must prevail 3. Reliance on folk foods and treatments 4. Belief in hot/cold theory 5. Male decision makes and direct caregiver 6. Reliance on native language
AFRICAN AMERICAN CULTURE 1. Extended family networks 2. Religion valued (many are Baptists 3. Interdependence with “Blacks” 4. Daily survival 5. Technology valued, e.g., radio, care 6. Folk (soul) foods
7.
Folk healing modes 8. Music and physical activities NORTH-AMERICAN INDIAN CULTURE 1. Harmony between land, people, and environment 2. Reciprocity with Mother Earth 3. Spiritual inspiration (spirit guidance) 4. Folk healers (shamans; the circle and four directions)
CULTURAL CARE MEANINGS AND ACTION MODES 1. 2. 3.
4.
Stress alleviation by Physical means Emotional means Personalized acts doing special things giving individual attention Self-reliance (individualism) by reliance on self reliance on self (self-care) becoming as independent as possible reliance on technology Health instruction teach us how “to do” this care for self Give us the “medical” facts
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Succorance (direct family aid) Involvement with extended family (“other care”) Filial love/loving Respect for authority Mother as care decision maker Protective (external) male care Acceptance of God’s will Use of folk-care practices Healing with foods Touching
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Involve family for support (other care) Respect Trust Touching (body closeness) Reassurance Succorance Spiritual Healing Use of folk food, care rituals Avoid evil eye and witches Speak the language
1. 2. 3. 4. 5. 6. 7.
Concern for “my brother and sisters” Being involved Giving presence (physical) Family support and get togethers” Touching appropriately Reliance on folk home remedies Rely on “Jesus to save us” with prayers and songs
1. Establishing harmony between people and environment with reciprocity 2. Actively listening 3. Using periods of silence (“Great Spirit” guidance)
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5. 6. 7. 8. 9.
Practice culture rituals and taboos Rhythmicity of life and nature Authority of elder Pride in cultural heritage and “nations” Respect and value for children
4. 5. 6.
Rhythmic timing (nature, land, and people) in harmony Respect for native folk healers, careers, and curers (use of circle) Maintaining reciprocity (replenish what is taken from Mother Earth)
These findings were from the author’s (Leininger) transcultural nurse studies (1970, 1984) and other transcultural nurse studies in the United States during recent two decades. From M. M. Leininger (1991). Culture care diversity and universality: A theory of nursing (pp. 355-357). New York:National League for Nursing Press. Sources: Andrews and Boyle, op. cit. 86-88. Kozier, op. cit. 209. Munoz, Cora and Joan Luckmann, Transcultural Communication in Nursing. 2nd ed. C 2005, Delmar Learning. p. 24, 29. Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd ed. 2003. F.A. Davis Co. 2. Transcultural Assessment and Clarification of Values and Beliefs Assessment of values and beliefs is a starting point in continuing dialogue to foster mutual understanding among health care providers and recipients of care. This assessment, though not exhaustive, encompasses cultural values and ethical issues regarding health care delivery from the patient’s perspective. TO THE CLIENT The health care professionals assigned to care for you want to understand your values and beliefs so they can deliver culturally relevant health care. Please assist them in better understanding you by completing this form. BACKGROUND INFORMATION 1. Where were you born? 2. How long have you lived in the ____________? 3. Did you receive any formal education in the __________? How much?
4.
Where were your family members born?
_____________
RELATIONSHIPS 5. Who are the decision makers in your family? 6. Who do you consider “family?” 7. Who do you want to make health care decisions for you? 8. In the event you cannot make health care decisions fo yourself, who would you appoint to make these decisions for you? COMMUNICATION 9. What language do you consider you “mother” tongue? 10. Do you read and write in your “mother” tongue? 11. In which language do you prefer you receive health information? CULTURAL BONDS 12. What cultural traditions do you observe in your home? RELIGIOUS AFFILIATION 13. Do you have a religious affiliation? If so, what is the affiliation? 14. Do your cultural or religious beliefs influence your attitude toward prevention of illness? If so, how? 15. How would describe your health status? 16. Do you have any symptoms that require “healing?” 17. How long have you had these symptoms? 18. What “healing” strategies do you use to relieve these symptoms? 19. Do these symptoms affect your ability to work or fulfill other obligations? 20. During your course of treatment what cultural/religious beliefs would you like us to consider? OTHER 21. Is there anything else you would like to share with us that would help us care for you in a more sensitive way?
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If clinically related to the diagnosis or chief complaint, it may be useful to collect data about transplantation, organ donation, autopsy, blood transfusions, drugs containing alcohol of caffeine, or foods that are taboo or prohibited.
Developed using data from Spector, R.E. (1996). Cultural Diversity in Health and Illness (4th ed.). Stamford, CT: Appleton and Lange. In Andrews and Boyle, op. cit. 3rd ed. P. 448.
2. TRANSCULTURAL ETHICS
Ethics is a systematic philosophical method of inquiry that assists people in understanding the morality (rightness or wrongness) of human behavior and social policies.
1. Basic/Related Concepts Ethics also refers to the standards of behavior expected of professional groups as
described in their code of professional conduct. It is important for nurses to have a knowledge of ethics in order to develop an ethical framework to guide their professional practice and to cope with unethical uncertainties stemming from work with clients, their families, and colleagues. Ethical knowledge also prepares nurses to fully understand and participate in multidisciplinary committees on bioethical issues. Ethical theories and principles are not universal in theory and application. Thus, ethical conflicts may occur when applied transculturally. Example: Issue surrounding informed consent, disclosure of diagnosis and prognosis, and discussion of termination of treatments are reflections of Western cultural values. In some cultures, particularly in Oriental or Eastern cultures, the approach is different: In Oriental cultures like Japanese, Chinese, Pakistani, etc – the family expects to be informed of bad news first, and then decides whether to inform patient or not. Autonomy does not exist in numerous cultures. Decision/s regarding health care are made in consultation with other family members. Ethical relativism views morality as relative to the community within which an individual lives and the manner in which the individual was raised. When applied transculturally ethical conflicts may arise. Example: Freedom of speech would only be a moral value for cultures that believe in it. Therefore, moral values are only right in sociocutural contexts that think they are right. The nurse and other health care professionals should be aware of existing ethical theories and principles and their implications for care in a client’s lifeway, belief system and health care practices. Two contrasting ethical theories come from the East and West.
2. Overview of Western and Eastern Ethical Theories
Western Ethical Theories – are based on European or American philosophies and are influenced by Judeo-Christian belief systems. Review Western ethical theories – Utilitarianism, consequentialism, character ethics, ethic of care, situation ethics, ethical relativism, natural law ethics, etc. Review ethical principles: autonomy, beneficence, nonmaleficence justice, veracity, fidelity, etc.
Eastern Ethical Theories During the 6th B.C. two philosophical systems developed in China – Confucianism and Taoism. The theories developed in these systems are based on Asian/Indian philosophies and may also be influenced by religious beliefs. The theories serve as ethical guidelines for living. Confucianism All teachings of this theory emphasize human relations. Emphasizes the virtues of: Righteousness (yi) and Benevolence (yen). 63
This virtue combines all virtues and is considered “perfect virtue”. Another aspect of benevolence is Shu, which stresses treating others as
we would want to be treated. This theory views humans as essentially social creatures. Humans are bound together by jen, that is, sympathy, humanheartedness, or loving others. Jen is expressed through five relations: Sovereign and subject Parent and Child Elder/Younger/Brother Husband and Wife Friend and Friend Rituals and etiquette help these relations function smoothly. Correct conduct proceeds through a sense of virtue developed by observing appropriate models of ethical conduct. The standards of conduct come from within a person. If after thoughtful consideration a person finds an action morally acceptable, that person should act without any hesitation.
Taoism - This philosophical system developed in china during the 6th B.C. Taoism is concerned with the origin and meaning of life. This system believes that human happiness is achieved in following the natural order. It emphasizes trusting in one’s intuitive knowledge. Taoism focuses on the observation of nature in order to discover the “characteristic of the Tao”, or the way of life knowledge. Taoism focuses on the observation of nature to discover the way of life, whereas Confucianism focuses on man and values, social conventions and rituals. Source: Andrews and Boyle, 3rd ed. pp. 444-456.
3. Culturally Competent Model of Ethical-Decision Making The model for ethical decision-making, was drawn from Mann’s human right’s model and Leininger’s culturally congruent theory.
It affirms the fundamental rights of individuals, families, groups, and populations to health care that is meaningful, supportive, and beneficial. It is predicated on the basic human right of respect for diversity of values and assumptions about life transitions and events. It is based on the principle that caring preserves human rights and dignity.
SOCIETY PROFESSION ORGANIZATION
HUMAN RIGHTS
HUMAN RIGHTS
PATIENTS FAMILIES
CA
CA
CR
CP
CR CP
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CA – Cultural Accomodation CP – Cultural Preservation CR –Cultural Repatterning
Culturally Competent Model of Ethical Decision Making
GUIDE FOR USING THE CULTURALLY COMPETENT MODEL 1. ASSESSMENT Client/families
Ethnohistory Concepts of the human body and soul Meaning of life, pain, suffering, and death Caring values, patterns, and expressions Social organization Established social hierarchy Roles and obligations of family members and kin Differential acculturation of family/group members Family and community resources Cultural gatekeepers and brokers in the community Communication norms and linguistic patterns Experience with professional health care
Organizational cultural Variables
Staff cultural knowledge and skills Conflicting values between staff and patient/ family/ group Conflicting values among care providers Cultural expertise available Policies and procedures Flexibility in accommodating cultural differences Material resources available
Determination of professional and societal services
Legal mandates Regulatory requirements Impact of decisions on other patients and self Professional code of ethics
2. PLANNING Establish relationship with client/s/families/communities Define problems and priorities that reflect the emic perspectives of client/s Determine material and personnel resources needed Determine aspects of action plans that need to be negotiated with participants 3. INTERVENTION Cultural care preservation or maintenance Cultural care accommodation or negotiation Cultural care repatterning or restructuring 4. EVALUATION Allow clients/families to identify outcomes and indices for achievement Differentiate culturally meaningful from biomedical outcomes Validate outcomes achievement with clients/families Source: Andrews and Boyle, op. cit. p. 525.
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3. TRANSCULTURAL CARE PRINCIPLES, HUMAN RIGHTS AND ETHICAL CONSIDERATIONS 1. Human beings of any culture in the world have a right to have their cultural care values known, respected and appropriately used in nursing and other health care services. 2. Human cultures have diverse and universal modes of caring and healing practices that need to be recognized and used by professional nurses to function effectively and therapeutically with people of different cultures. 3. Care is the essence of nursing and a basic human need for growth, well-being, recovery, and survival. 4. Cultural care is a critical component influencing health, well-being, and recovery from illness or disabilities. 5. Every culture has at least two major types of health care systems namely, the folk (generic, lay or indigenous) care system and the professional care system which influences their health outcomes, and the transcultural nurse is challenged to use this knowledge to guide nursing care decisions and actions. 6. All professional nurses are challenged to respect common humanistic aspects of people worldwide, and also the divergent care expressions, meaning, and practices. 7. Transcultural nurses are expected to respect Western and non-Western cultures who often have different values, beliefs, and norms to assess and understand human beings. 8. Transcultural nursing principles and practices are the arching framework for all nursing care practices which differ from nursing practices that rely on traditional medical symptoms diseases and treatment regimes. 9. Since transcultural nursing focuses upon comparative cultural care values, beliefs and practices of cultures, the nurse is expected to work with individuals, families, groups, cultures, subcultures and institutions that reflect cultural care variables. 10. Nurses with transcultural knowledge are expected to respond appropriately to culture care differences and similarities in order to ease or ameliorate a human condition or lifeway, and to help clients face death. 11. Ethical and moral differences and similarities exist among human cultures which necessitates that nurses recognize, respect, and respond appropriately to such variables. 12. It is essential that transcultural nurses be open-minded and willing to learn from cultural informants about their human values, beliefs, needs and practices in order to make appropriate nursing care plans, judgments and actions. 13. The ability of the nurse to listen, use silence and envision the client’s or family’s human condition or cultural circumstance with its positive or less positive features is important in transcultural nursing. 14. Transcultural nursing often requires that nurses communicate with clients in their native language to know, learn, and understand individuals, families and groups of different cultures. 15. Transcultural nurses are challenged to identify what constitutes ethical or moral principles and norms of cultures and not assume that all cultures are alike. 16. Transcultural nurses are expected to guide other nurses who have not been prepared in transcultural nursing in order to prevent marked ethnocentricism, cultural imposition practices and inappropriate ethical and moral judgments about clients. 17. Transcultural nursing reflects that an individual or group of a designated culture are active participants and decision-makers in culture care practices in order to develop and maintain creative and effective professional care practices. 18. Clients of diverse or similar culture have a right to have their caring life styles and expressions known and used in transcultural nursing in order to promote client health or well-being, 19. Transcultural nursing takes into account the world view, environmental context ethnohistory, social structure features (including the religious, kinship philosophic economic, political, technological and cultural values) language, expressions, gender and age difference of people. 20. Transcultural nursing is concerned with the assessment of caregiver and carereceiver expressions, beliefs and lifeways that often go beyond nurse-client dyadic
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relationship to that of care relationships with families, groups, institutions and communities in order to facilitate congruent care practices and to avoid unfavorable care conflicts stress and negligent care practices. 21. Since ethical, moral and legal systems of human values and rights exist in all cultures, it is the task and responsibility of transcultural nurses to discover these dimensions with key and general informants and in diverse cultural contexts. 22. Human care rights tend to be covert and embedded in social structure, cultural values and world view of clients, and so the transcultural nurse is challenged to discover these dimensions mainly through qualitative research methods. 23. Transcultural nurses recognize that culture is complex, dynamic and change over time and in varying ways. 24. Transcultural nurses recognize that many cultures and subcultures in the world have not been studied and yet nurses are expected to care or all peoples including minorities. 25. Transcultural nursing is a major breakthrough for new nursing knowledge and practices that do not follow the traditional nursing or medical disease, symptom and illness models. Source: Leininger, M. (1991) Journal of Transcultural Nursing, 3, 21-23, as printed in Ethics and Issues in Contemporary Nursing by Margaret A. Burkhardt and Alvita K. Nathaniel. 2nd ed. Thomson Asian Edition. pp. 341-342.
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CULTURAL HERITAGE – A SUMMARY I. FILIPINO HERITAGE A. OVERVIEW Location – in Southeast Asia, surrounded by the South China Sea, Celebes Sea, Philippine Sea, and the Sulu Sea. Composed of 7,107 islands; 3 major islands: Luzon, Visayas, Mindanao Negritos – earliest known settlers. Successive foreign invasions by the Chinese, Arabian, Indian Spanish, American, and Japanese. Filipino culture - “Filipino blend” from mixture of different languages, traditions and religions has resulted in “identity crisis.” Weather – tropical; hot and dry during summer months, Wet and humid during monsoon season July to December Population – 87,857473 (2006) B. BIOLOGICAL VARIATION Body built and structure – short to medium built; small thoracic capacity, eyes set in almond shaped eyelids, mildly flared nostrils, slightly low to flat nose bridges. Skin color – of Malay stock (brown complexion) light to fair complexion – resulting from intermarriage with foreigners Hair – black, very curly or kinky (Negritos); straight Enzymatic and genetic variations o Blood type “B” – 40%; low incidence of Rh-negative factor o As with other Asians, Filipinos have lower tolerance for alcohol but are more sensitive to its adverse effects. o lactose intolerance Nutritional variations o Food more than nourishment for the body; it is a fundamental form of socialization o Rice – staple food; although known to be carnivores, fish and seafood forms bulk of Filipino diet. o Regional cooking variations; in Manila – a variety of food preparations – Pilipino, Chinese, Spanish, Japanese. fast-food catching on o Traditional 3 meals a day with merienda o Milk almost absent in Filipino diet o Malnutrition especially among the poor and less educated; one of the 10 leading cause of infant mortality C. SOCIAL ORGANIZATION Strong family attachment =nuclear +extended family Traditionally patriarchal, but now egalitarian - tendency is for husband and wife to share in decision making, disciplining and finances Filipino women enjoy better status in society than their Asian counterpart, e.g. women working outside the home, decision-making and social and political movers, more women now occupy managerial or administrative positions as CEO’s, COO’s Values orientation is characterized by a deep sense of personal indebtedness (utang na loob) and loyalty to kin which carries an obligation to repay or perform service to another; hospitality, community togetherness (bayanihan). D. RELIGION Predominantly Christians – majority of which are Catholics (83%), 9% Protestant, 5% Muslim, and 3% Buddhist and other religions. Novenas and prayers are often said on behalf of sick persons Rosaries, medals, scapulars and talismans are often worn by the sick
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Source of strength found in religion - intimate relationship with God, The expression Bahala na (it is up to God) points to a higher power to take care of the rest when almost everything fails. E. COMMUNICATION Tagalog – national language; 87 languages and 111 dialects Third largest English speaking country following US and UK. Silence – may imply “yes,” “no” or don’t know May also convey emotional expressions of disgust, anger, resentment. Eye contact – eyes may convey many messages as shown by eye rolling up and down, squinting, eyes popping to show surprise Telecommunication literate especially in Manila. Availability of newspapers, local and foreign publications, TV, landline and mobile phones. Philippines has been dubbed the “Texting capital of the world.” Touch – Filipinos are a warm people, affection usually expressed by touching and embracing. Rural folks are more conservative Though known to be shy and non-aggressive, as nurses they are known to be dedicated, patient, respectful, and attentive to the needs of their patient Use of words to show respect like Manong, Manang, “oho”, “opo” F.
SPACE In poor families, space is limited and family members all live and sleep together. As they are family-oriented, they do not perceive the family as invasive in personal space parameters.
G. TIME ORIENTATION Past oriented – respect for elderly wisdom, familial closeness and honoring dead ancestors Future oriented – parents conscious of sacrificing and saving for the future of their children Poor observers of punctuality H. ENVIRONMENTAL CONTROL Health care beliefs and practices o Many still believe in the magico-religious (witchcraft, soul loss, soul intrusion, evil eye) predominantly in areas far from hospitals, clinics and professionally trained health care givers. o Many health beliefs o Intimate circle of family largely influence decisions about when, where, and from whom to seek help. o The ethical principles of beneficence and nonmaleficence take precedence over patient autonomy. Before a decision is made to inform the patient about his or her terminal condition, a discussion among family members occurs, and they may request the doctor not to divulge the truth to protect the patient. o Major decision maker – doctor more than patient or family members
Health/healing practitioners o
Use of folk practitioners like
• • • • • •
Hilot – in rural areas hilot ambiguously refers to both the midwife (magpapaanak) and the chiropractic practitioner (manghihilot, masahe). mangihihilot-manipulation and massage for the diagnosis and treatment of musculoligamentous and musculoskeletal ailments albularyo-are general practictioners, usually with a history of healer in the family-line and their healing considered a “calling”, a power bestowed by a supernatural being. Their treatment modalities: tapal, lunas, kudlit, pang-kontra, bulon, otasyon manglulop manghihila mantatawas
• spiritista; faith healers o Western medicine familiar and acceptable to most Filipinos o Increase in use of integrative or alternative health practitioners noted Health Census a. Ten leading causes of mortality (2007) 1. Heart diseases 2. Vascular system diseases 3. Accidents 4. Pneumonia 5. Tuberculosis 6. Diabetes 7. CVA/stroke
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8. Chronic lower respiratory diseases 9. Liver cirrhosis 10. Prenatal conditions Source: -http://emeritus.blogspot.com/2007/07/Philippines-top-ten-causes-of-mortalitty.html. b. Ten leading cases of morbidity (2007) 1. Malaria 2. Diarrhea 3. Pneumonia 4. Hypertension 5. Influenza 6. Sepsis 7. Bronchitis 8. Tuberculosis 9. Chickenpox 10. Measles Source: -http://www.nationmaster.com/discussion/country/rp/Health
II.
JAPANESE HERITAGE
A. OVERVIEW Location – lies off the east coast of Asia and entirely within the temperate zone. Land area – 142,727 sq. miles Population – 127,417244 (Time Almanac 2006) Environmental risks –Japan is subject to intense crustal movements and violent earthquakes and volcanic activity. B. BIOLOGICAL VARIATION Body built and structure – short to medium height, rarely tall; medium built. Japanese are rarely obese Skin color – white to fair in complexion Enzymatic and genetic variations o Lactose intolerance - inability to digest lactose from milk attributed to inadequate production of/or defect in the enzyme lactase. Calcium is supplied in tofu small, unboned fish o Rise in obesity, diabetes, heart disease, and premature death associated with increasingly Westernized food tastes that are higher in fat and carbohydrate content than traditional Japanese food. o High rate of CVA attributed to sodium content of traditional soups and sauces. Nutritional variations o All food groups are well-represented o Staple food - rice or gohan. Other foods include miso, nori, fish, pickles, ramen (noodles) vegetables, soybean cake/curd, pork seasoned with mirin (sweet sake) o Holidays and family celebrations are times for ritual use of food o Japanese use chopsticks to eat, meals often eaten on a tatami mat around a low table. o Widely used for their medicinal properties: green tea, Vitamin C, garlic and various herbs o Dietary therapy recommends eating seasonal foods and balancing foods from land, sea and mountain o Proper food combination takes into account the yin/yang properties of food. C. SOCIAL ORGANIZATION Family roles – nuclear family structure Marriage – Love not highly valued as a prerequisite for a successful marriage. Motivation – to fulfill societal expectations than desire for spousal companionship Children’s organization – is family’s paramount concern. Primary relationship is between motherchild, particularly between mother and son. Socialization process – children socialized to study hard, make their best effort, and be good group members. Self-expression is not valued. Girls are taught to take care of boys. Traditional Japanese arts as tea ceremony, ikebana, bonsai, kimono wearing, calligraphy, doll making, etc. diligently studied by women. Small size of women of “the floating world” or entertainment industry (Geisha) live outside constraints of home and gender and enjoy a fair amount to autonomy. D. RELIGION Dominant religions: Shintoism - 110 million Buddhism – 90 million
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Other religions – Confucianism, Christianity No strong religious feelings but rather a strong commitment to ancestral traditions like ancestral worship and ceremonies as births, weddings and funerals. E. COMMUNICATION Illiteracy is nearly zero High school graduates complete 6 years of English Use of language is distinguished by many levels of formality and directness depending upon the status of the people who are conversing Bowing is an expression of respect and courtesy for elders. Different levels of bowing dependent upon socio-political status of person Handshake – an appropriate form of meeting and greeting. Laughter may mean embarrassment or discomfort. Eye contact – Direct eye contact may be avoided. o Prolonged eye contact (staring) is not polite even within families.
Touch – The Japanese don’t like touching. o o
Social touching occurs among group members but not among people who are less closely acquainted. Men do not engage in backslapping or other forms of touching.
Gestures – avoid expansive arm and hand movements, dramatic or unusual facial expressions. Pointing with less than the whole hand is impolite. Moving the open hand with palm facing left in a fanning motion in front of one’s face indicates a negative response Silence - a natural and expected form of non-verbal communication. o Pain is borne in silence. o Considered inappropriate to yell out during labor as this brings shame to family. Grunting is encouraged rather than screaming and yelling. o o
F.
SPACE Body space is respected. Public kissing is criticized. Showing affection such as hugging or shoulder slapping should be avoided in public. Intimate behavior in the presence of others is taboo.
G. TIME ORIENTATION Past - future- present oriented: They cherish their history as they will direct future generations as to how their society evolved so that they will appreciate where they are now. H. ENVIRONMENTAL CONTROL Health care beliefs and practices o Japanese medicine borrowed from Chinese medicine the concepts of yin and yang, and the concept of ki(energy) o Cleanliness and purity are seen as the keys to health alongside correct eating, behavior, respiration, exercise and spiritual devotion. The Japanese also attribute their generally high level of well-being to their traditional daily bath in neck-deep water, at temperature of 105F. o Exposure to the beauty of nature considered important for attaining calmness and serenity. o Energetic healing through massage or shiatsu (reflexology) o Reiki – a Japanese form of therapy based on the belief that when spiritual energy is channeled through a practitioner, the patient’s spirit is healed and this in turn heals the body. o Shiatsu – a form of massage that uses thumb pressure along the energy meridians in the body o Herbal medicine (kanpo) o Macrobiotic diet – a form of vegetarian diet that consists of balancing yin and yang energies of food. Health care practitioners o Traditional health practitioners – diet, herbs, energetics o Allopathic physician Mortality and morbidity o Leading causes of death: cancer, heart disease, stroke, pneumonia, accidents, liver disease, diabetes, hypertension (related to high sodium diet) tuberculosis. o Asthma – related to dust mites in tatami straw mats and air pollution in urban areas
III. CHINESE HERITAGE
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A. OVERVIEW Location - East Asia. One of the world’s oldest civilization dating back more than six millennia. The last Chinese Civil War produced two political entities using the name China: • the People’s Republic of China (PRC)- comprising mainland China, Hong Kong and Macau, and • the Republic of China (ROC) administering Taiwan and its surrounding islands.
Population – 1,306,313,812 (TIME Almanac 2006) B. BIOLOGICAL VARIATION Body built and structure o Generally small in stature but some can get over 6 ft. tall, small slanted eyes, thick and straight hair, and a flat face. Skin color o May vary; many skin colors similar to Westerners with pink undertone, yellow tones, and others very dark o Chinese men do not have facial hair. Hair color is black Enzymatic and genetic variations o Thalassemia –– an inherited disease of the RBC classified as hemoglobinopathy. The genetic defect results in synthesis of an abnormal hemoglobin molecule. The blood cells are vulnerable to mechanical injury and die easily. People with thalassemia need blood transfusion at regular intervals to survive. o Lactose intolerance (90%). Condition gives rise to higher risk of osteoporosis. o Higher prevalence of insulin autoimmune syndrome characterized by spontaneous hypoglycemia o Hantavirus (HVD) characterized by flu-like symptoms, fever, headache, hemorrhagic manifestations, shock and renal failure. Spread via rodent excreta. o Diverticulosis or inflammatory bowel disease (IDS) are uncommon due to high intake of vegetables and high fiber food. o Hypertension leading CV risk factor due too frequent consumption of salty and spicy food o Deficiencies associated with food - rickets, goiter, and anemia o Tobacco consumption – major problem in rural China giving rise to increased incidence of lung disease. o Tuberculosis and Hepatitis B among Chinese immigrants due to overcrowding, malnutrition, and unsanitary conditions Nutritional variations o Food meals have specific orders with focus on the balance for a healthy body. o Traditional Chinese medicine (TCM) uses food and food derivatives to prevent and cure disease. o Foods are also classified as yin (cold) or yang (hot) and a proper balance is required to maintain health. o Chinese daily meal consists of four food groups: grains, vegetables, fruit and meat. o Regional cuisine - food depends upon weather conditions: Szechuan (cold weather), food is hot and spicy; Fujian, a seaport, sea foods are plentiful o Usual desserts – sliced fruit and bean curd C. SOCIAL ORGANIZATION Confucianism – plays a very important role in forming Chinese character and behavior. Its purpose is to achieve harmony, considered the most important social value. Confucianism prescribes well-defined roles and acting in a proper way to achieve harmony. There are 5 cardinal relations: sovereign-subject, fatherson, elder- younger brother, husband-wife, and friend-friend. Family unit is the center and comes before the individual. There is no Chinese equivalent for the word “self.” o Extended family – relatives expected to help each other; filial loyalty very strong. Elderly are viewed as very wise o Father –the undisputed head of the family. o Male dominance fathers, sons and uncles assume very important roles in family and business. With regards to filial piety, sons, especially the eldest son, have specific obligations towards the family and are expected to respect and care for parents. o Son preferred to daughter o Female gender – perpetuated to ensure male dominance in a society, female feticide common Traditional role of women – to maintain a happy and efficient home “Me” generation – new and changing orientation of young, educated Chinese men and women. Quotation by Wang Ning, 27, Advertising Company owner, “We are more self-centered. We live for ourselves, and that’s good. We contribute to the economy. That’s our power.”(TIME magazine, August 6, 2007, pp. 24-27). D. RELIGION
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Primary religions: o Buddhism – a religious movement which originated in India. Religious precepts of the Buddha make up the tenets of this religion. o Taoism (Lao Tsu) – 20 million followers mostly in Taiwan. “Tao” or “The Way” – refers to the ultimate being or ultimate truth, the power which envelopes, surrounds and flows through all things, living and non-living. It regulates the natural processes and nourishes balance in the Universe and embodies the harmony of opposites, no love without hate, no light without dark, no male without female. o Confucianism – named after the great Chinese emperor. Emphasis is on governance and family relations. E. COMMUNICATION Language – Mandarin official language of China spoken by 70% of the population o Other dialects: 10: Cantonese, Fujianese, Shanghainese,Taoishanese, and Hunanese o They speak in a moderate to low voice although many times they sound loud.
Silence – is held in high regard in China. They want to contemplate without interruption. o
They avoid disagreeing or criticizing, especially in public.
Smile – they appreciate smiles when talking with others Touching – Chinese generally not a touching society especially with visitors. Hence, health care workers must know the meaning of touch. o Non-family members should not touch the head of a child, especially an adult, as head is traditionally considered sacred. o By family members, patting gently on the shoulder or cheek shows affection for children o Friendship by the same sex – handholding or walking arm in arm. o Using feet t move objects, such as chairs or doors, are considered disrespectful to others.
Distance – they maintain a formal distance from each other, which is a form of respect Eye contact – uncomfortable with face-to-face communication especially when there is direct eye contact o
Excessive eye contact may indicate impoliteness and rudeness, even threatening
Gestures – More reserved, gestures expressing emotions are comparatively less expressive. o
To show special respect, a slight bow may be given to the elderly or to government officials.
o The whole open palm should be used in pointing rather than the index finger. o Beckoning to people should be done with the palm facing done instead of up. o
Handshake – common greeting when meeting for the first time.
Emotional display – no public display of affection but open and demonstrative among family and friends Addressed by their whole name or by their family name and title. To health care providers ask the person how they wish to be called. F. SPACE Group interaction – facing each other directly, being closer, touching more, eye contact, and speaking more loudly Non-contact – Body position while sitting/standing can be side by side or right angle arrangement because they feel uncomfortable facing each other. G.TIME ORIENTATION Chinese perception of time is different, neither past, present or future oriented. Time is perceived as a dynamic wheel with circular movements and the present as a reflection of the eternal. The wheel continually turns in an unforeseeable direction and individuals are expected to adjust to the present, which surrounds the rotating wheel, and seek harmonious relationship with their surroundings. Time concept is described as polychromic and Westerners as monochromic. Polychronic time orientation adheres less rigidly to time as a distinct and linear entity, focuses on completion of the present, and often implements one activity at a time. Monochronic orientation to time emphasizes schedules, promptness, standardization of activities and synchronization with clocks. I.
ENVIRONMENTAL CONTROL
Philosophical belief - Many Chinese subscribe to fatalism, accepting things as they come. o The body as an energy system – ancient belief that the body is an energy system of opposing o
forces of yin (negative energy, female, inactive cold) and yang ( positive energy, male, active, hot) . Every aspect of the universe is a constant interplay of yin and yang.
HEALTH BELIEFS 73
o Illness results from an imbalance of yin and yang. Proper balance is required to maintain health and treatments are geared to this end.
o Chinese believe in feng shui (meaning wind and water) which refers to art of location, orientation and design of physical structures in an effort to achieve harmony and balance.
o Positive feng shui wards of evil spirits and promotes good health and prosperity. o Belief in colors and numbers. White is considered bad luck, red good luck. 8 is considered a lucky number and 4 extremely unlucky as 4(si) when pronounced the same as the word death in Chinese. HEALING PRACTICES o Belief in Traditional Chinese Medicine (TCM) and its practices remain strong. o Acupuncture – insertion of an ultra-fine needing into meridian points or pathways of energy (chi) to balance energy o Cupping – heated cups to rduce stress, congestion and colds o Herbology – use of herbs and medicinal plants to stimulate chi. o Qi jong – combines body movements, meditation, regulation of breathing to enhance the flow of chi and improve the circulation and enhance the immune system. o Meditation to relieve stress HEALTH CARE PRACTIONERS o Acupuncturist o Herbologist
IV. INDIAN HERITAGE A. OVERVIEW Location – in S Asia, south of the Himalayas, including a large peninsula between te Arabian Sea and the Bay of Bengal 1,177,000 sq.mil. Population - 1,080,264,388 (TIME Almanac 2006) B. BIOLOGICAL VARIATION Body built and structure – varies according to racial strain (6): Mediterranean strain, Broad-headed strain, Nordic strain, Mongoloid strain, Negritos, and Proto-Australoids Skin color – varies according to racial strain; light to dark brown Enzymatic and genetic variations o Thallasemia, G-6-PD, lactose intolerance (2) o Susceptibility to diseases: heat stress, food or waterborne diseases: bacterial diarrhea, hepatitis A and E, typhoid fever, vector borne diseases: dengue fever, malaria, encephalitis, rabies, mental illness Nutritional variations o Indian cuisine has been designed by the medicine men of old, in contrast to Western cuisine, which is designed by creative chefs. o Most Hindus are vegetarians – diet consisting primarily of grains and legumes, vegetables o Non-vegetarian diet includes different kinds of meat except beef as the cow is considered a sacred animal o Rice (in the North), different kinds of bread (in the South) like chapatti, puri,naan, paratha o A healthy and balanced diet which involves a combination of the six main tastes: sweet - ex: sugarcane, breads, pasta sour - acidic: yoghurt, lemon salty - salt and alkalis – rock salt, sea salt pungent -acrid, often aromatic – ginger, chili, hot peppers, bitter - neem, bitter melon, fenugreek astringent - constricting quality – beans, lentils, pomegranate o Eating utensil: use of right hand for eating, never left hand as it is used for hygiene and toileting C. SOCIAL ORGANIZATION Extended - family structure living together as a single family unit, usually composed of grandparents, parents, children, may include families of parental uncles. Respect is highly valued; touching the feet of the elderly Gender roles o Men –dominant and authoritative role because they are the point of contact with society o Women – passive role; manage the home, keeping all finances, family and social issues in order.
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Caste system – is the world’s longest surviving social hierarchy. A person is considered a member of the case into which he or she is born and remains within that caste until death, although the particular ranking of that cate may vary from region to region. The caste categories are: the Brahmins (priests and teachers), the Ksyatriyas (rulers and soldiers), the Vaisyas (merchants and traders), and the Sudras (laborers and artisans). A fifth category consists of the “untouchables” or Dulits, who are often assigned tasks too ritually polluting to merit inclusion within the traditional caste system. D. COMMUNICATION National language – Hindi (40% of population) Second language – English Use of head movements and hand gestures during conversation Silence – to show respect Eye contact – men maintain eye contact with each other while conversing, while women look downward when talking to their husband, grandfather and father to show respect. Touching – Public display of affection and touching among relatives, friends and acquaintances are socially not acceptable in Hindu culture. o Show of affection is private but not in the view of children or elders. E. SPACE In poor families, space is limited and family members all live and sleep together. As they are family-oriented, they do not perceive the family as invasive in personal space parameters. F.
TIME ORIENTATION Past oriented – importance paid to traditions and rituals that are inherent to their culture Present oriented – because they view that individuals are continuously in the process of “becoming.” Future oriented – because life in the present is lived with an emphasis on the hereafter.
G. RELIGION Hinduism – dominant religion; about 83% of total population Religious tenets of Hinduism: o aims for freedom from endless reincarnation and suffering from bad karma o belief in Dharma – a code of conduct that secures human happiness, contentment and saves from suffering and degradation Other religions: Buddhism, Sikhism, Jainism Islam – practiced by approx. 13.4% of all Indians Christianity, Zoroasterianism, Judaism, Baha’I Faith – small number H. ENVIRONMENTAL CONTROL HEALTH BELIEFS o Health reflects living in total harmony with nature o Illness is an external event or misfortune; karmic o Good health and illness – may be karmic in origin o Body consists of 5 elements (earth, water, fire, wind, space). Health is achieved when there is a balance of the elements; illness results from an excess or deficiency of one of the elements. Environmental factors affecting illness: o air pollution o water pollution from raw sewage, agricultural pesticides, untreated water o huge growing population that overstrain natural resources o lifestyle, climatic factors HEALING PRACTICES o Ayurveda (Science of Life) - 30000 BC, said to be the oldest most complete medical system in the world. Its sources are the Atharva Veda and the Samhitas with comprehensive treatises on health-care and medical procedures. o Ayurveda system of natural healing involves the totality of life and the whole human being and its relationship with the environment. o Ayurvedic treatments involves a process of detoxification or cleansing and purification known as Pancharma Treatments through fasting, massage application of oily herbal preparation, ingestion of herbal oils and pills. o Balancing of yin and yang o Yoga – breathing exercises, asanas or physical exercises, meditation
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o
Allopathy
HEALTH PRACTIONERS o Ayurvedic physician o Allopathic doctor
V. MEXICAN A. OVERVIEW Location – Middle America, bordering the Caribbean Sea and the Guild of Mexico between Belize and the US and bordering the North Pacific Ocean, between Guatemala and the United States. Population – 107,449,525 (20006 est. Climate – varies from tropical to desert B. BIOLOGICAL VARIATION Body built and structure – short, medium to tall Skin color – dark skinned as among the indigenous inhabitants, fair to light skin Enzymatic and genetic variations o Vitamin A deficiency and anemia prevalent in lower socio-economic group lactose intolerance High risk behavior o Alcoholism – associated with their colorful lifestyle; a crucial health problem for many Mexicans o Drug addiction: Marijuana – readily available from people who are in farming and ranching occupations; cocaine, heroin, and inhalants . Nutritional variations o Mexican food is rich in color, flavor, texture and spiciness. o Food is a primary form of socialization so much so that prescribed diet for illness such as D.M. and CV diseases may not be adhered to. o *Diet depends upon the individual’s region of origin . o Staple food – rice (arroz), o Popular Mexican foods – taco, beans and tortillas from corn (maiz). eggs, pork, chicken, sausage, chili, peppers, squash, potatoes, leche flan C. SOCIAL ORGANIZATION Family– traditional family is still the foundation of society o Patriarchal slowing moving towards egalitarian pattern in more educated and higher socioeconomic families o Extended family o Blended communal families – the norm in lower socioeconomic groups and migrant worker camps. Single, divorced, and never-married male and female children usually live with their parents and extended families regardless of economics Social status highly valued. A person with an academic degree or position commands great respect and admiration from family, friends and the community. Gender roles – Machismo complex sees men as having strength, valor, self-confidence which is considered a valued trait. Men are seen as wiser, braver, stronger, and more knowledgeable regarding sexual matters. o Women – expected to be devoted wife and mother, responsible for maintaining the home and family’s health. o The mother is the “queen” of the home and kitchen and socialization, family affairs and communication revolve around food D. COMMUNICATION Language – Spanish; 54 indigenous languages and more than 500 different dialects Meaningful conversations important, often loud and seemingly disorganized “Small talk” often indulged in before addressing real issues, also apply to actual health concerns Touch – touching and embracing acceptable. Handshake – initial form of greeting, then smiling, backslapping or nodding of head. Eye-contact – as a rule, sustained eye contact when speaking directly to an older person is considered rude. o Avoiding direct eye-contact with a superior is a sign of respect.
Addressing non-family members more formal; Titles often used as Dona, Don, Senor, Senora
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o Approaching the Mex-Am client with respect and personalismo (being friend-like) and directing questions to the dominant member of the group (usually a man) may help to facilitate more open communication. E. SPACE Intimate zone – with family members and friends as touching and embracing between the sexes acceptable. F.
TIME ORIENTATION Present-oriented – especially those from lower socio-economic group. Trend is to live in the “more important” here and now because tomorrow (manana) cannot be predicted. Unclear meaning of Manana – may or may not really mean tomorrow; it often means “not today” or “later.” More relaxed concept of time – hence punctuality is not generally practiced. Time is perceived as relative than categorically imperative. they may arrive late for appointments. This presents a problem in scheduling appointment.
G. RELIGION – predominantly Roman Catholic (89%). Catholic religious practices are influenced by indigenous Indian practices. H. ENVIRONMENTAL CONTROL Current Issues o scarcity of hazardous waste disposal facilities, o scarce and polluted fresh water resources o raw sewage and industrial effluents polluting rivers and urban areas o deforestation – widespread erosion o deteriorating agricultural lands o serious air and water pollution HEALTH and ILLNESS BELIEFS o Definition of health – to be free of pain, to be able to work, and spend time with family. Good health is a gift from God and from living a good life. o Traditional Illness Theory • The body’s imbalance – “Hot and Cold” Hot and Cold theory – a theory which originated in ancient Greece during the time of Hippocrates, who considered illness to be the result of humoral imbalance causing the body to become too hot or too cold. A state of balance among the body humours (blood, phlegm, lack bile, and yellow bile) manifest itself in a wet, warm body. Illness results from imbalance.
o o o
Hot-cold theory describes intrinsic properties of food, beverage, or medication and its effect on the body. If imbalance occurs, symptoms are treated by eating food from the opposite group to restore body equilibrium. • Dislocation of parts of the body – empacho (caused by a ball of food clinging to the wall of the stomach) and caida de mollera (depressed anterior fontanel in infants and child) due to diarrhea, dehydration. • Magic or supernatural causes outside the body • Strong emotional stress • Envidia (envy) Common health problems: malnutrition, malaria, cancer, alcoholism, drug abuse, obesity, hypertension, diabetes, heart disease, adolescent pregnancy, dental disease, HIV and AIDS. Among Mex-American migrant workers: infectious, communicable and parasitic diseases; tuberculosis Leading cause of death • cardiovascular disease – influenced by behavioral, cultural and social factors
• I.
diabetes mellitus – five times higher in Mexican-Americans than European-American groups
HEALING MODALITIES and PRACTIONERS Folk practitioners o brujas (witches) – to remove evil spirits from the body o curandero –who may claim to have received talent from God or has served as apprentice to another curandero; treats many traditional illnesses; usually a member of extended family, does not accept payment
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o yerbero –uses herbs, teas, and roots for prevention and cure of illness o sobador – similar to a Western chiropractor; treats illnesses affecting joints and musculoskeletal system, with massage and manipulation.
o partera - midwives Professional health care professionals – doctors, nurses, therapist It is suggested that health care providers must always consider clients’ use of FHS practitioners to prevent conflicting treatment regimens.
VI. MIDDLE EASTERN HERITAGE (Arabian) A. OVERVIEW Arab – this term often connotes the Middle East, but the larger (and more populous) part of the Arab World is North Africa. The Arab League defines Arab as “A person whose language is Arabic, who lives in an Arabic speaking country, who is in sympathy with the aspirations of the Arabic speaking peoples.” Saudi Arabia – largest country in the Arab Middle East The Arab World straddles two continents, Africa and Asia. Population – 287 million, 5% of global population B. BIOLOGICAL VARIATION Body built and structure – medium built to tall, medium to heavy in weight Skin color – dark brown or olive skin; some may have blonde or auburn hair, blue eyes and fair complexion Enzymatic and genetic variations o G-6-PD deficiency, sickle cell anemia, thalassemia o Hypertension, diabetes, and coronary heart disease (due to high prevalence of cigarette smoking, high cholesterol diets, obesity, and sedentary lifestyle Nutritional variations o Medicines derived from pork such as insulin are not prescribed or administered o Muslims are prohibited from eating pork and its by-products such as insulin, lard, gelatin such as Jell-O, and marshmallows. o “Kosher” meat – some Muslims will abstain from eating meat if they are uncertain of how it was slaughtered. Animals must have been slaughtered in a humane fashion with the remembrance of God and gratefulness for the sacrifice of the animal’s life. o “Thahiba” – proper way of slaughtering an animal. o “Halal” – animal must be properly slaughtered by a Mudlim or a Person of the Book (Christian or Jew), while remembering the name of Allah. Animal may not be killed by being boiled or electrocuted, and the carcass should be hung upside down long enough to be blood-free. o Consuming alcohol or any intoxicants likes drugs of abuse eating or drinking blood and its byproducts, and eating the meat of a carnivore or omnivore (pig, monkey, dog, cat) and fish without scales are prohibited. *Fasting – during Ramadan, 30-day period, strictly observed. C. SOCIAL ORGANIZATION Family – foundation and basis of society Extended family with 3 to 4 generations • Gender roles are clearly defined. o Men - leadership role, breadwinners, protectors, and decision makers o Women – responsible for care and education of the children and or maintenance of a successful marriage by tending to satisfy their husband’s needs. • Women have to be totally dependent, loyal and obedient to their husband. • Wives are considered the sexual property of their husband. • High status accorded to women as mothers in Islam • 60% - educated Muslim women o Sons – taught to be protectors of their sisters, help father with duties inside and outside the house o Daughters – taught to be the source of love and emotional support in the family, help mother with household chores. Equitability in the role of the sexes. Allah has no bias for or against men and women. Both spouses might need to engage in financial activities Rights and responsibilities within the family are intertwined. Men are obliged to cover themselves from navel to their knees.
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Childbearing Muslim women (except old women) wear the hijab including headscarf; should be fully covered in public, except hands and face. Color of outfit – black except in: o Africa – women wear cloths of different colours depending on their tribe, area or family. o Bangladesh, Pakistan, India – bright orange or red garments o Turkey and Indonesia – majority do not wear veil except when they attend Friday Salat o Iran – younger ones wear transparent Hijabs to protest but keep within the law of the state.
Reason for wearing Hijab: men and women are not to be viewed as sexual objects Most Arab marriages are monogamous; 2-5% are polygamous. o Men can marry up to four women if they can support them currently. o “Talaq” – divorce is practiced. Men can divorce and remarry the same woman many times. o Islamic law forbids a Muslim woman from marrying a non-Muslim unless he converts to Islam. o A woman may propose marriage to a man directly or through an intermediary o When a couple is to be married, the man must pay mahr or dowry to his future bride. D. RELIGION Life centers on worshipping Allah Allah – Almighty God Mohammed – messenger of God Islam – founded between 610 and 632 A.D. by the prophet Muhammad. Islam means “submission to Allah. Moslem, Muslim – follower of Islam Qur’an – Bible, Holy Book Seven components of Islamic Foundation: o Allah, the Only True God o Prophets and Messengers o The Guidance from Allah o The Last Day o The Life Hereafter o Al Qadr (Measure, Destiny, Decree Mosque or Masjid – temple; women and men are completely segregated Women cannot lead (as an imam) men in prayer E.COMMUNICATION Language: Arabic is the universal language of Muslims, as it is the language of the Qu’ran Silence o Arabs behave conservatively o Display of affection between spouses, arguments are kept private o Acting in a manner that attracts attention is looked upon as a sign of imbalance in behavior and character Eye Contact o Maintain steady eye contact when conversing to Arabs o Do not prolong eye contact with a Arab woman. Arab women are conservative and sensitive. Touch o Greeting with a kiss is taboo. o Between members of the same sex, touch hand or shoulder to gain trust o Do not compliment your Arab host/associate on the beauty of wife or sister or daughter. F. SPACE Face-to-face meetings in doing business Gender separation - no mixing of Arab men and women who are not directly blood related, or not married to each other. Dewaiahs or Majlis – for male guest gathering only, separate from rest of the house Only female doctors and health care personnel are permitted to attend to female patients G.
TIME ORIENTATION Predestination – believed by first generation Arabs. This means that God has predetermined the events of one’s life Plans and intentions are qualified with the phrase inshallah, “if God wills.” Punctuality – at prayer 5x a day and in business appointments. Praying and observance of death rituals include turning one’s head and the patient’s bed in the direction of their prophet.
H. ENVIRONMENTAL CONTROL
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HEALTH BELIEFS o Good health is seen as the ability to fulfill one’s roles. o Diseases are attributed to a variety of factors: inadequate diet, hot and cold shifts, emotional or spiritual distress envy or evil eye. o Preventive care not generally sought; Arabs seek care for actual symptoms o Cultural emphasis on modesty – women shy about disrobing for examination. Only female health care providers can attend to an Arab woman. o Muslim concept of death is the return of the soul to its Creator, God, and the inevitability of death and the Hereafter is never far from his consciousness. o Notifying the nearest Islamic Center so that someone could come and pray and read from the Qu’ran to a seriously ill is appreciated. HEALTH CARE PRACTICES o Birth Rites – Baby is bathed immediately after birth. o Circumcision to facilitate cleanliness recommended at anytime but especially during the first 5 days. o Life Interventions – Permissible to use life support to save and lengthen life. o Euthanasia or Physician Assisted Aid in Dying is prohibited o Death Rites – cremation is forbidden. Burial recommended as soon as possible especially during summer. o As soon as death occurs, the body should be completely covered and placed if possible with feet towards Mecca. o Only family member should touch and wash the dead body, usually by the same gender. o Embalming the body is prohibited. A corpse is not left alone between death and burial. HEALTH CARE PRACTIONERS Allopathic doctor
VII. BLACKS or AFRICAN AMERICANS A.
OVERVIEW Refers to people having origins in any of the Black race groups of Africa who were brought as slaves about the 17th century. Today the black population comprise those who migrated voluntarily from African countries, the West Indian islands, the Dominican Republic, Haiti, and Jamaica. The Blacks are the nations largest majority population-12.9% of the US (2000). 54.8% live in the South. Blacks are presented in every socioeconomic group; however 21.1% of the group live in poverty. Over half live in urban areas surrounded by the symptoms of poverty – crowded and inadequate housing, poor schools, and high crime rates. Black population is also young, 54.5% are under 18 (2001). Civil Rights Movemen o 1962- Civil Rights Movement formally organized. o 1962 – Civil Rights Act passed. o 1968 – Dr. Martin Luther King Jr. assassinated o 1995 – Million Man March
B. BIOLOGICAL VARIATION Body built and structure o Differ in bone length o Tend to have shorter trunks than Whites and have longer legs than Whites, Orientals and American Indians. o Have wider shoulders and narrower hips than Orientals, who tend to have narrow shoulders and wide hips o Average height and weight between Black and Whites tend to be the same 18-74 years age group, but White men tend to be taller than black men. o Black women are consistently heavier than White women, although average in height for both races. Skin color o Color - “white” to very dark brown or o Black – lower risk for cancer o The groin, the genitalia and the nipples tend to be darker than the rest of the body. o Hypopigmentation and hyperpigmentation in different parts of the body. Enzymatic and genetic variations
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o
o o o o o o o o
Sickle-cell anemia - genetically inherited trait hypothesized to fight malaria. Results in hemolysis and thrombosis of red blood cells because these cells do not flow properly through the blood vessels.Symptoms: hemolysis, anemia, states of sickle cell crises in which severe pain occurs in the areas of the body where the thrombosed cells are located, i.e spleen, liver Hypertension – attributed to diet; too much red meat and high fatcontent Cancer of the esophagus Stomach cancer Coccidiodomycosis Lactose intolerance Obesity Diabetes AIDS and STD’s – high incidence; rapid increase of infectious primary and secondary syphilis since 1985. Mortality: Heart disease Cancer Stroke Diabetes Pneumonia/influenza Morbidity: Hypertension Coronary artery disease Stroke End stage renal disease Dementia Diabetes Certain cancers
Nutritional variations and Dietary Practices: o Black Muslims observe Jewish kosher diet and halal- no pork or pork products which they believe to be filthy. o Food is used as a way to celebrate special events, holidays, and birthdays. Food is a symbol of health and wealth. o African-American diet is high in fat, cholesterol and sodium. They eat more animal fat, less fiber, and fewer fruits and vegetables than the rest of American society. o Salt pork (fatback or fat meat) – key ingredient in their diet because it is inexpensive. o “Soul food” – a combination of dishes created with ingredients from Africa, the Caribbean, and the Southern United States. comes from the need of African Americans to “express the group feeling of “soul.” Common “soul food” ingredients: black-eyed peas, kidney beans, ham hocks, bacon or pork chops. o Being overweight is considered positive. It is important for them to have meat on their bones to be able to afford to lose weight in times of sickness. o Pica – the eating of non-food substances such as laundry starch (amylophagia) clay or dirt (geophagia), ice, burnt matches, ashes,wall plaster, hair and stones have been frequently reported among African American women of different cultural groups. One theory suggests the body’s need to acquire certain missing nutrients, hunger, cultural tradition, prevention of nausea, attention seeking. C. SOCIAL ORGANIZATION Family o Large, extended family networks o Many single parent households headed by females. 50-60% of women in this culture are single mothers. Adolescent pregnancy is a major concern with the population. o Strong church affiliations within community o Community social organizations D. COMMUNICATION Language and dialects o Black English – not a language but a dialect in which the pronunciation of words may be different. Ex.: th=d; brother-broda; going=goin; going to=gonna o Dialect: Pidgin – occurs when two groups do not have a common language and are forced to develop a third language (pidgin), which is a combination of their respective languages. • Creole – when a pidgin becomes the first language of a group of speakers. • Gullah – spoken by descendants of freed slaves from the Georgia and South Carolina sea islands who developed their own culture. Expression of feelings 81
o Express feelings openly to family or trusted friends o Speech is dynamic, expressive, loud o Body movement are involved when communicating o Facial expression can be demonstrative o Use of humor to release hostility, anger, stress, anxiety Eye contact o Maintaining direct eye contact can be misinterpreted as aggressive behavior. Touch o Used freely between adults and children, or people of the same gender as a way to convey empathy, acceptance and, when dealing with health issues, to infuse hope. E. SPACE – Comfortable with close personal space more than other ethnic groups. F.TIME ORIENTATION Past orientation – due to factors such as the traumatizing racial segregation Future – arose during the time of Martin Luther King Jr. His famous line “I have a dream” gave hope for a brighter future for the African Americans Punctuality – very punctual and normally arrive 15-30 minutes earlier as a sign of respect. G.ENVIRONMENTAL CONTROL HEALTH BELIEFS o Health is viewed as harmony with nature o Illness is a disruption of this harmonic state due to demons, “bad spirits,” or both. o Natural illness - occurs in response to normal forces from which individuals have not protected themselves. o Unnatural illness – harm or sickness can come to individuals via a person or spirit. o Pain – a sign of illness or disease o Traditional health and illness beliefs may continue to be observed by “traditional” people HEALING MODALITIES Traditional o Voodoo – synonyms are “fix”, “hex”, or “spell.” - brought by the slaves about 1724. Involves a lot of rituals and procedures such as drinking blood, use of oils, powders candles. Modern health care o Receiving health care sometimes seen as a degrading and humiliating experience. Ongoing use of home remedies due to poverty. o Some Blacks fear or recent health clinics. Appointments not often kept because they may lose a day’s work, not being understood by health care worker, discrimination HEALTH CARE PRACTIONERS Folk healing practitioners Conventional or allopathic practitioners
VIII. ANGLO-AMERICAN A. OVERVIEW Anglo-American – an American of English birth or ancestry. America - nation of immigrants. o 1820-1920 – people from Germany, Italy, United Kingdom, Ireland, Austria-Hungary, Canada and Russia. o Now considered a “melting pot” of different cultures B. BIOLOGICAL VARIATION Body built and structure – usually tall, medium to heavy built; structure reflective of European descent Skin color - white Enzymatic and genetic variations o Drug variation: Due to liver differences, caffeine is metabolized and excreted faster by people of other cultural groups. Genetic Diseases: o Favism (Hemolytic anemia caused by deficiency of the X-linked enzyme G6PD triggered by eating fava beans(broad beans). o Thalassemia syndrome
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Increased susceptibility to: Cardiovascular diseases, breast cancer (the most common form of cancer in women), diabetes, Leading causes of death: 1. Heart Disease 2. Cancer 3. Stroke 4. Chronic lower respiratory diseases 5. Accidents (unintentional injuries) 6. Diabetes 7. Influenza, Pneumonia 8. Alzheimer’s Disease 9. Nephritis, nephritic syndrome, and nephrosis 10. Septicemia Nutritional variations o Traditional American cuisine – steak and potatoes, hamburger, vegetables, salad, rich deserts o 20th century – consumption of packaged foods – breads and cookies, preserved fruits, pickles soups, frozen vegetables, reserved meats, instant puddings and gelatins, fruit juices o 21st century – Fully prepared meals outside the home reflected changing economic status (wife working outside home). Emphasis on convenience and rapid consumption gave birth to fast foods chain like Burger King, McDonalds, Pizza Hut, etc. – French fries, hamburgers pizza, etc. o
C. SOCIAL ORGANIZATION Nuclear family structure: small family size - parents and children only Decision-making process: made by individual or self, or by either parent or their child Independence: children encouraged to be independent; allows children to disagree with parents which may be considered disrespectful in other cultures Few social services to support family: children encouraged to live outside the home at age 18 o No guarantee that children will support their elderly parents; hence, many elderly live in nursing homes Gender roles: males and females expect to be treated with equal respect, rights and role opportunities at home and in the work place Dominant cultural values: o Individualism and self-reliance o Independence and freedom o Competition, assertiveness and achievement oriented o Highly materialistic and too technologically oriented o Equal gender roles and rights o Instant time and action (doing) o Youth and beauty o Reliance on “scientific facts” and numbers o Generosity and helpfulness in crises D. COMMUNICATION Language – predominantly English (about 97%) o Other languages – speak German, French, Polish, Spanish. Italian, o English spoken with accent in different parts of the US Manner of communication o Direct, informal, use of person’s name often o Will ask a lot of explanations and facts, services available, health instructions regarding health care. o ”Small talk” on sports, weather, jobs, or past experiences. Most people don’t talk about religion, politics or personal feelings with strangers. o Few “ritualistic” exchanges in English like “How are you,” How’s it going” are greetings, not questions about your life. ”See you later,” or “See you soon” are ways of saying good-bye, not appointments. o Conversations are moderate in volume with few gestures. Eye contact o Direct – an important component of direct and honest communication o Direct eye contact – specially between sexes may be interpreted as sexually suggestive o Avoidance of eye contact – suggest withholding information, sometimes a psychiatric symptom to evidence of dissembling direct eye contact Touch – Aggressive, self-seeking, independent, individualistic, competitive, and not touch oriented.
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o o o
Handshaking – acceptable at initial meeting. Touching for casual acquaintances is considered a bit too intimate. Kissing or hugging as a form of greeting even in public places is common between the sexes. Holding hands or touching another of the same sex may indicate homosexuality.
SPACE o Value space and territory, especially with middle-class and upper class Americans. They often seek to increase their space at home and at work. o Require more personal space than in other cultures. Space is an expression of money and materiality (storing material goods and possession). o Often described as “territorial animals.” Because they like to protect and control their space. o Casual conversation – maintain a distance of 36-48 inches, otherwise he/she will feel that you are “in their face” and will try to back away. E. TIME ORIENTATION “Time is gold”. Time is equated with money, Time – a dominant value in American culture. Observe punctuality in keeping and maintaining appointments and schedules. Time closely related to action, doing, efficiency and productivity. Generally goal and future oriented especially when it comes to monetary security. Thus they value personal goals over group goals. Outlook on time may vary with their socio-economic class: Poor – present oriented Middle and upper class –future oriented F. RELIGION Predominantly Christian – Catholicism, Protestantism Minority – Judaism, Islam, Buddhism G. ENVIRONMENTAL CONTROL Believe that Man, and not Fate, can and should be the one who controls the environment. Thus, they are good at planning and executing short-term projects. HEALTH BELIEFS AND PRACTICES o Generally prefer an aggressive approach to treating illness o Believe that germs and microorganisms cause disease, treatment aimed at destroying them. Management of microbes is more important than bolstering resistance to them. Antibiotics often requested. o Expect to leave doctor’s office with a prescription. o Have a high expectation that their disease/s will be cured or at least well managed, through technology and powerful drugs. o Drug culture - a mixture of legal, illegal and prescription drugs. HEALING MODALITIES o Strong preference for biomedicine. o Trend towards complementary and alternative medicine HEALTH/HEALING PRACTIONERS o M.D. trained at different levels of specialization o Trend towards alternative medicine and therapies. o Certified Nurse Specialist – specialization in different areas of health care
IX. ITALIAN HERITAGE A. OVERVIEW Location – country in S Europe mostly on a peninsula extending into the Mediterranean and including the islands of Sicily and Sardinia Land area – 116,304 sq. miles Capital – Rome B. BIOLOGICAL VARIATION Body built and structure – varied physical characteristics because of Italy’s proximity to Switzerland, Austria, and Germany in the north, and to North Africa in the South. Skin color o northern background have lighter skin, lighter hair, and blue eyes
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o from the south of Rome, particularly Sicily – have dark often curly hair, dark eyes, and olivecolored skin. Enzymatic and genetic variations o First generation Italians – suffered from somatic complaints and physical ailments attributed to il mal occhio (evil eye) o Second generation immigrants – tend to develop neurologic and psychotic symptoms attributable to guilt toward the parents whose culture they have broken. o People of Italian ancestry have some notable genetic diseases: familial Mediterraneanfever, G6PD, B-thalassemia o Italian-Americans - high incidence of hypertension and AD related to smoking and Type A behavior Nutritional variations o Nutritional deficiencies are rare because the Italian diet is rich in fruits, vegetables, garlic, pasta and olive oil o Food – is symbolic of life and the principal medium of family life. An Italian mother may demonstrate her affection by feeding her family and anyone else she likes. To the average Italian mom, love is a four letter word: food. o Staples of the Italian-American diet: spaghetti, lasagna, ravioli, pasta, manicotti, vegetables, fruits, lentils, sausages, eggplant parmigiana, etc. C. SOCIAL ORGANIZATION Family – central in Italian’s lives, and “Mama” is queen Father – breadwinner, authority absolute in traditional Italian families; decision maker Women – dominate decision making on childbearing issues and family social events; have more power in economic decisions because the husband turns over paycheck to her. Sons frequently live at home well into their 20’s Parents often live in children’s homes and care for grandchildren D. RELIGION Predominantly Roman Catholic (90%); 30% regularly attend service Religious beliefs have evolved from diverse cultures in Italy through the centuries.Thus ItalianAmericans’ spiritual and religious beliefs have their roots in: -pagan customs -magical beliefs -Mohammedan practices -Christian doctrines -Italian pragmatism Most Italians pray to the Virgin Mary, the Madonna, and a number of saints Italians view God as an all-understanding, compassionate and forgiving being. E. COMMUNICATION Italian – official language Several different dialects spoken in 19 regions of Italy Voice – discussions can become quite passionate, with voice volume raised and many people speaking at the same time Willingness to share thoughts and feelings among family members is a major distinguishing characteristic of the Italian-American family. Emotional people, conflict expressed as periodic outbursts Value close family ties expressed as warmth feeling, emotional bond reaffirmed by frequent kissing on each cheek Touch – frequently touch and embrace family and friends. Touching between men and women, frequently seen during verbal communication. F.
SPACE o Related to close family ties, Italians like contact which makes them feel comforted, secure, and make them feel that they belong.
G. TIME ORIENTATION Past orientation –is evidenced by the pride they take in their home country’s rich Roman heritage Present orientation – occupy themselves with concrete problems and situations, and accept things Future – they give importance to planning ahead and saving financially for the future. H. ENVIRONMENTAL CONTROL HEALTH BELIEFS AND PRACTICES
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In traditional terms, illnesses are attributable to: -wind currents that carry disease -contamination -heredity -supernatural (God’s will) or human causes -psychosomatic interactions o Superstition Evil spirits manifesting in hysteria, nervousness, mental illness o
HEALING MODALITIES o The family is viewed as the most credible source of health-care practices. o Italians take responsibility for their own health care and engage in health promotions. o Majority also have health insurance coverage o From the family perspective, the mother assumes responsibility for the health of the children HEALTH/HEALING PRACTIONERS o Traditional vs. Biomedical Care: Some humans are believed to have potent magical powers: shaman, maghi (male witch); maghe (female witch), lupo mannaro (powerful sorcerer) o *Health Care Providers • Some physicians collaborate with shamans and herbalists to accommodate clients cultural preferences o Success in persuading children of Italian parentage to take medicine depends on the trust the mother has on health care provider.
X. JEWISH HERITAGE A. OVERVIEW Jewish refer to both a people and a religion; it is not a race Jew is derived from Judah, one of Jacob’s son Hebrew – is the official language and is used for religious prayers by all Jews wherever they live. The people are called Jewish, their faith Judaism, their language Hebrew, and their land Israel. Religious persecution – cause of mass migration of Jews from Europe in the 1800’s. o Ashkenazi Jews – from Eastern Europe and Russia o Sephardic – from Spain, Portugal, Mediterranean area, North Africa, South and Central America o Sabra – is a Jew born in Israel Continued learning – most respected value of the Jewish people. Prominent in all fields of endeavor – 39% Nobel prize in the life sciences, 11% in Chemistry, 41% in Physics; business, arts and culture B. BIOLOGICAL VARIATION Body built and structure – varies according to region of country of origin Skin color o Ashkenazi Jews – same as white Americans. White to fair; blonde hair to darker skin and brunette hair o Sephardic Jews – slightly darer skin tone and hair coloring, similar to those from Mediterranean area. Enzymatic and genetic variations o Bloom syndrome – a specific abnormality of chromosome 15 in which the individual suffers from recurrent infection blistering areas of the hand and lips, and poor growth o Breast and ovarian cancer o Cystic fibrosis – a hereditary disease affecting cells of exocrine glands including mucus secreting glands) o Fanconi anemia – disorder characterized by severe aplastic anemia (failure of the bone marrow to produce either red or white blood cell) o Gaucher’s disease a genetically determined disease resulting from deposition of glucocerebrosis in the brain and other tissues (bone) o Pempigus vulgaris – a rare but serious disease marked by successive outbreaks of blisters o Tay-Sachs disease – an inherited disease of lipid metabolism in which abnormal accumulation of lipid in the brain leads to blindness mental retardation, and death in infancy. o Torsion dystonia – Abnormal twisting of a testis within the scrotum or a loop of bowel in the abdomen Nutritional variations
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o
o
o
Food satisfies hunger but also teaches discipline and reverence for life as also an instrument of ethnic identity. Chicken soup is frequently referred to as “Jewish Penicillin.” Kashrut (keeping Jewish dietary laws or keeping Kosher found in Leviticus and Deuteronomy) Strict observance of Kashrut. Some patients will not eat hospital food unless it is certified Kosher and cooked in a Kosher kitchen. The family should identify their level of Kashrut and help the hospital staff with their needs. Meat and milk are not mixed in cooking, serving, or eating.
When working in a Jewish person’s home, the health care provider should not bring food into the house without knowing whether or not the client adheres to kosher standards. Kosher meals are available in most hospitals. C.SOCIAL ORGANIZATION Family – core of Jewish society. Needs of all family members are respected. Gender roles: o Men – breadwinner; father’s legal obligation is to educate children and provides daughter with the means to make them marriageable. • Jewish husband are required to provide their wife with food, clothing, medical care and conjugal return • Jewish men are prohibited from “beating their wives, restricting or forcing them into sex. o Women – raises children, keeps a Jewish home. Are at the forefront of activities to demand and protect all human rights, gain women’s suffrage, reproductive health care rights o Children – most valued treasure. Families are encouraged to have at least 2 children
•
In Judaism, age of majority is 13 years for boy and 12 for a girl. At this age they are deemed capable of differentiating right from wrong. Recognition of adulthood occurs during a ceremony called a bar or bar mitzvah Marriage – an ideal human state for adult. Goal – to propagate the race and companionship. Sexuality is a right of both men and women. Sexual intercourse is viewed as a pure and holy act when performed within marriage. Women must physically separate themselves from all men during their menstrual period and for seven days after. No man may touch a woman nor sit where she sat until she has been to the mikveh for purification.
D. RELIGION Judaism – a monotheistic faith that believes only in one God. o Jews consider only the Old Testament as their Bible. o Torah refers to the first five books of the Bible also known as the five books of Moses, directs Jews on how they should live their lives. o 3 main branches of Judaism: 1. the Orthodox – the most traditional. They observe the Sabbath by attending the synagogue on Friday evening and Saturday morning; abstain from work, spending money and driving on the Sabbath 2. the Conservative and 3. the Reconstructionism. o Hasidic (or Chadsidic) - ultra orthodox fundamentalist, usually live, work and study within a segregated area. They have full beards, uncut hair around the ears, wear black hats or fur streimels, dark clothing and no exposed extremities. Women, especially those who are married, keep their extremities covered and may have shaved heads covered by a wig and hat as well. o Saturday is considered as the 7th day of the week and should be kept very holy. o Visiting the sick (bikkur cholin) is considered as one of their most religious practice; it is one the social obligations of Judaism and assures that Jews look after the physical, emotional, psychological and social well-being of others. E. COMMUNICATION Language: English – primary language; Hebrew – official language o Yiddish – a Judeo-German dialect, spoken by Ashkenazi Jews
Use of Humor – frequently used; the Jews like self-criticism thru humor, but any jokes that refer to the holocaust or concentration camps are considered inappropriate.
Touch – Jewish men are not permitted to touch a woman other than their wives. They often keep their hands in their pocket to avoid touch.
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o They do not shake hands with women, engage in idle talk with them nor look directly at their F.
faces. Non-Hasidic Jews – more informal, may use touch and short spatial distance when communicating.
SPACE Intimate and personal space between husband and wife Maintain distance outside of family home “Distance oneself from a bad neighbor, and do no befriend an evil person.” (Avot 1:7)
G. TIME ORIENTATION They are past, present, and future oriented. o Present – Jews live for today and plan and worry about tomorrow. o Past – they are raised with stories of their past. They are warned to “never forget.” They value time. Punctuality is observed. H. ENVIRONMENTAL CONTROL HEALTH BELIEFS AND PRACTICES o Beliefs are determined by Jewish law. Hasidic husband may not touch his wife during labor, attend delivery, or view her genitals. o Circumcision – both a medical and a religious rite, performed on the 8th day by a mohel, trained in the circumcision procedure, asepsis and the religious ceremony. o Sabbath begins 18 inutes before sunset on Friday and ends 42 minutes after sunset (or when 3 stars can be seen) on Saturday. Day is devoted to prayer. Jews do no work on this day. In Health Care: Doctor appointments are not scheduled on the Sabbath or Holy Days. Surgical procedures, except life-saving procedures, are not done on the Sabbath or holy days, o Death is an expected part of the life cycle. HEALTH/HEALING PRACTIONERS Allopathic doctor
END
BIBLIOGRAPHY
Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing care. (3rd ed.). Lippincott. Philadelphia, New York, Baltimore. Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing ( 2nd ed.). Thomson Asian Edition. Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing concepts, process, and practice. (7th ed.).Pearson Education, Inc. Upper Saddle River, New Jersey. Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd ed.). Delmar Learning. Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a culturally competent approach ( 2nd ed.). F.A. Davis Co. Philadelphia. 88
Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, N.J: Prentice Hall. Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and health care (6th ed.). Pearson Education South Asia Pte Ltd. Jurong, Singapore. Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and science of nursing care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.
ADDENDDUM
Medicine Wheel teachings are among the oldest teachings of First Nations people. The teachings create a holistic foundation for human behaviour and interaction; the teachings are about walking the earth in a peaceful and good way; they assist in helping to seek healthy minds (East), strong inner spirits (South), inner peace (West), strong healthy bodies (North). The term “Medicine” as it is used by First Nations people does not refer to drugs or herbal remedies. It is used within the context of inner spiritual energy and healing or an enlightened experience, in other words, spiritual energy. The Medicine Wheel and its sacred teachings assist individuals along the paths towards physical, mental, emotional and spiritual enlightenment.
There are several teachings, such as the four directions (north, south, east and west), the four colours of races (red, black, yellow and white), the four directions, or the four stages of life (spiritual, mental, physical and emotional). Different tribes have different colours to represent the
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four directions. The Medicine Wheel below is represented in the traditional four colours (red, black, yellow and white). EAST (yellow): from the East, we begin to seek knowledge, the direction where everything is fresh and new. The sacred plant of this direction is tobacco. SOUTH (red): from the South we experience growth, the direction where everything in life is replenished and in full bloom. The sacred plant of this direction is cedar. WEST (black): from the West we encounter reflection and spiritual insight, the direction where dreams and visions allow you to go within and appreciate yourself and your Creator. The sacred plant of this direction is sage. NORTH (white): from the North we experience the purity, the direction where the secret to many cures is found for healing. The sacred plant being the Sweet Grass, to keep you free from evil and make your travels safe. The Aboriginal philosophy is based upon universal principles known as the seven teachings
Sharing 2. Caring 3. Kindness 4. Humility 5. Trust 6. Honesty 7. Love
The seven natural ways of healing are: 1. 2. 3. 4. 5. 6. 7.
Talking Crying Laughing Yelling Dancing Singing Shaking
All exist within the MEDICINE WHEEL and the CIRCLE OF LIFE
Yin and Yang in Chinese Culture Originates in ancient Chinese philosophy and metaphysics, which describes two primal opposing but complementary forces found in all things in the universe. Yin, the darker element, is passive, dark, feminine, downward-seeking, and corresponds to the night; yang, the brighter element, is active, light, masculine, upward-seeking and corresponds to the day; yin is often symbolized by water, while yang is symbolized by fire. The pair probably goes back to ancient agrarian religion; it exists in Confucianism, and it is prominent in Taoism. Though the words yin and yang only appear once in the Tao Te Ching, the book is laden with examples and clarifications of the concept of mutual arising. Yin and yang are descriptions of complementary opposites rather than absolutes. Any yin/yang dichotomy can be seen as its opposite when viewed from another perspective. The categorisation is seen as one of convenience. Most forces in nature can be broken down into their respective yin and yang states, and the two are usually in movement rather than held in absolute stasis. Yin and yang are often used in reference to disease, and many Asian cultures treat the hot/cold or wet/dry diseases with opposite treatments. For example, a yin symptom such as
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coldness would be treated with yang treatments, such as hot foods. A yang symptom such as nervousness would be treated with yin treatments- cold foods such as fruits. Yin and yang can also be seen as a process of transformation which describes the changes between the phases of a cycle. For example, cold water (yin) can be boiled and eventually turn into steam (yang). One way to write the symbols for yin and yang are a solid line (yang) and a broken line (yin) which could be divided into the four stages of yin and yang and further divided into the eight trigrams (these trigrams are used on the South Korea flag). The symbol shown at the top righthand corner of this page, called Taijitu (太極圖), is another way to show yin and yang. The mostly white portion, being brighter, is yang and the mostly dark portion, being dim, is yin. Each, however, contains the seed of its opposite. Yin and yang are equally important, unlike the typical dualism of good and evil. The concept is called yin yang, not yang yin, just because the former has a preferred pronunciation in Chinese (see Standard Mandarin - Tones for detail), and the word order has no cultural or philosophical meaning. Principles Everything can be described as both yin and yang. 1. Yin and yang are opposites. Everything has its opposite—although this is never absolute, only relative. No one thing is completely yin or completely yang. Each contains the seed of its opposite. For example, winter can turn into summer; "what goes up must come down". 2. Yin and yang are interdependent. One cannot exist without the other. For example, day cannot exist without night. Peace cannot exist without chaos. 3. Yin and yang can be further subdivided into yin and yang. Any yin or yang aspect can be further subdivided into yin and yang. For example, temperature can be seen as either hot or cold. However, hot can be further divided into warm or burning; cold into cool or icy. Within each spectrum, there is a smaller spectrum; every beginning is a moment in time, and has a beginning and end, just as every hour has a beginning and end. 4. Yin and yang consume and support each other. Yin and yang are usually held in balance—as one increases, the other decreases. However, imbalances can occur. There are four possible imbalances: Excess yin, excess yang, yin deficiency, and yang deficiency. They can again be seen as a pair: by excess of yin there is yang deficiency and vice versa. The imbalance is also a relative factor: the excess of yang "forces" yin to be more "concentrated". 5. Yin and yang can transform into one another. At a particular stage, yin can transform into yang and vice versa. For example, night changes into day; warmth cools; life changes to death. However this transformation is relative too. Night and day coexist on Earth at the same time when shown from space. 6. Part of yin is in yang and part of yang is in yin. The dots in each serve: 1. as a reminder that there are always traces of one in the other. For example, there is always light within the dark (e.g., the stars at night), these qualities are never completely one or the other. 2. as a reminder that absolute extreme side transforms instantly into the opposite, or that the labels yin and yang are conditioned by an observer's point of view. For example, the hardest stone is easiest to break. This can show that absolute discrimination between the two is artificial. HOT and COLD conditions and their corresponding treatment Hot conditions Hot foods Hot medicines and herbs Fever Chocolate Penicillin Infections Cheese Tobacco Diarrhea Eggs Ginger root Kidney problems Peas Garlic Rashes Onions Cinnamon
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Skin ailments Sore throat Liver problems Ulcers Constipation
Aromatic beverages Hard liquor Oils Meat such as beef Goat’s milk Cereal grains Chili peppers
Cold conditions Cancer Pneumonia Malaria Joint pain Menstrual periods Teething Earache Rheumatism Tuberculosis Colds Headache Paralysis Stomach cramps
Anise Vitamins Castor
Cold foods Fresh vegetables Tropical fruits Dairy products Meat such as goat, chicken Fish, cod Honey Raisins Bottled milk Barley water
Cold medicines and herbs Orange flower water Linden Sage Milk of Magnesia Bicarbonate of soda
PHILIPPINE CULTURAL MINORITIES Cultural Minorities – 4 million or 12% of total population ¾ Muslims found in Mindanao, Sulu Archipelago and Palawan Mindanao A. Negrito 1. Bukidnon 2. Subanon 3. Manggungan 4. Mandaya 5. Ata
6. Manobo 7. Bukidnon 8. Subanon 9. Manggungan 10. Mandava
11. Ata 12. Bagobo 13. Isamal
B. Muslim Group 1. Maranao 92
2. Maguindanao 3. Sangul 4. Yaka 5. Tausug 6. Samal 7. Badjaw Luzon
Visayas
(Negrito)
(Negrito)
1. Isneg 2. Kalinga 3. 4. 5. 6. 7. 8.
Bontoc Ifugao Kankanai Tinguian (Itneg) Gaddang Ilongot
Mindoro 1. 2. 3. 4. 5.
6.
1. Sulod 2. Bukidnon
Iraya Nauhan Buwid Buhid Ratagon Hanunon
Palawan (Pagan Groups) 1. Batak 2. Tagbanua 3. Palawan (Muslim Group) 1. Malbog
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Course Content PREPARED BY
PROF. VALENTINA B. PATACSIL 1
MAPÚA INSTITUTE OF TECHNOLOGY
SCHOOL OF HEALTH SCIENCES VISION Mapúa shall be an international center of excellence in technology education by: • providing instructions that are current in content and state-of-the art in delivery; • • •
b)
c) d) e)
MISSION The mission of Mapúa Institute of Technology is to disseminate, generate, preserve and apply scientific, engineering, architectural and IT knowledge. The Institute shall, using the most effective means, provide its students with professional and advanced scientific foundation in engineering, architectural, information technology and health sciences education through rigorous and up-todate academic programs with ample opportunities for the exercise of creativity and the experience of discovery. It shall implement curricula that, while being steeped in technologies, shall also be rich in the humanities, languages and social sciences that will inculcate ethics. The Institute shall advance and preserve knowledge by undertaking research and reporting on the results of such inquiries. The Institute, singly or in collaboration with others, shall bring to bear the world's vast store of knowledge in health sciences, engineering and other realms on the problems of the industry, and the community in order to make the Philippines and the world a better place
PROGRAM EDUCATIONAL OBJECTIVES 1. To equip the students with a broad foundation on the basic concepts, theories, principles and fundamentals of professional nursing practice 2. To develop the student’s capability to apply these learned concepts, theories, and principles in the practice of professional nursing 3. To inculcate in the students the importance of lifelong learning. 4. To develop in the student an appreciation of human values in the care of individuals, families, population at
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MISSION b c d
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e √
addressed by DLHS
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engaging in cutting-edge research; and responding to the big local and global technological challenges of the times
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COURSE SYLLABUS
1. Course Code
: HUN 023
2. Course Title
: ASIAN CIVILIZATION
3. Pre-requisite
: NONE
4. Co-requisite
:
5.
Credit/ Class Schedule: 3 Units Lec.
Second Year Quarter 3
6. Course Description
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Focuses on health practices of different countries as a basis for the practice of Transcultural Nursing. It examines the transcultural bases of health care based on Giger and Davidhizer’s six cultural organizing phenomena: environmental control, biological variations, social organizayion, communication, space, and time orientation. It also takes into consideration the contemporary challenges in transcultural nursing such as transcultural aspects of pain, cultural disparities in health and health care delivery, cultural diversity in the workforce and transcultural values and ethics. 7.
Program Outcomes and Relationship to Program Educational Objectives
Program Educational Objectives 1 2 3 4
Program Outcomes
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(b) (c) (d)
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A. Utilize the health process in a variety of institutional and community settings to design nursing systems which shall assist clients to attain and maintain an optimum level of self care through: 1. application of principles of goal oriented communication to establish and maintain therapeutic relationship with individuals, families, groups 2. synthesizing knowledge from general education, sciences and nursing courses as basis for health interventions designed to meet the self-care deficits of clients across life span 3. collaboration with health team members to improve the delivery of care to individuals, families, groups and the community 4. utilization of research methods and findings in the provision of nursing care and investigation of client health problems 5.implementation of strategies based on knowledge of teaching-learning principles, leadership-management methodologies and theories in the attainment of goals with clients (individual, family, group, community) B. Demonstrate beginning skills in the application of information technology in the development of skills for nursing practice C.Accept responsibility and accountability for the choice and outcomes of nursing interventions and for their legal and ethical implications
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8. Course Objectives and Relationship to Program Outcomes:
Course Objectives The students should be able to: 1. Examine the interrelationships of socio-cultural, public health and medical events that have produced the crisis in today’s modern health care system
Program Outcomes A1
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2. Develop cultural sensitivity for appropriate, individualized clinical approach 3. Appreciate human life and values of different cultures as they affect health-illness
9. Course Coverage
:
3
WEEK
TOPIC
Week 1 Orientation to the Course & Leveling of expectations; discussing the course requirements
METHODOLOGY & STRATEGY
EVALUATION TOOLS
Orientation & presentation of course syllabus; discussion of objectives, course requirements & leveling of expectations
Week 2, 3 UNIT I. Transcultural Framework A. B. C. D.
Week 4
Introduction Cultural concepts and terminologies History of Transcultural Nursing Lecture-discussion (Ppt Major assumptions to support presentation) Leininger’s Cultural Care Diversity and Universality Individual and group report Experiential group sharing UNIT II.Cultural Diversity Case Analysis Role Play A. Definition of basic/related concepts Surfing the Internet B. The World in Review C. Population Overview 1. Worldwide 2. In the U.S. 3. Others D. Race 1. Basic/Related concepts 2. Race categories E. The Immigrants 1. Reasons for migration 2. Metropolitan areas with the largest no. of immigrants 3. Leading 10 primary destinations of immigrants (2000) 4. Leading 10 countries of origin of legal immigrants (1990-2000) F. Factors to consider in the nursing care of culturally diverse groups
Class participation Pencil-paper evaluation (will not only apply in this UNIT but throughout the course. This activity will either be announced or not announced and the student is expected to read and prepare for the assigned lesson of the day
UNIT III. Health and Illness
Week 4,5
A. The HEALTH Traditions Paradigm 1. Concepts of health and illness 2. The interrelated aspects of health B. The HEALTH Traditions model 1. Traditional methods of maintaining, practicing, and restoring health 2. Symbolic examples 3. Factors influencing traditional beliefs and practices C. Health Belief Systems 1. Magico-religious 2. Scientific or biomedical 3. Holistic D. Types of Healing Systems 1. Self-care 2. Professional Care 3. Folk Healing System VCD: Ayurveda 4. Complementary/alternative therapies
)
MIDTERM EXAMINATION UNIT IV. Transcultural Nursing Care
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Models A. Leiningers’s Sunrise Cultural Care Diversity and Universality Model B. Purnell’s Model for Cultural Competence C. Giger and Davidhizar’s Transcultural Assessment Model and the organizing phenomena of culture D Cross-Cultural phenomena impacting nursing care F. Selected examples of etiquette related to selected cultural Phenomena G. Transcultural assessment H. Barriers to Health Care Week 6
Week 7
Week 8
Week 9, 10
Unit V. Application of Organizing Cultural Phenomena to People from Different Cultural Heritage: An Interactive Session A. People of Filipino Heritage B. People of Japanese Heritage C. People of Chinese Heritage D. People of Indian (Hindu) Heritage E. People of Anglo-American Heritage F. People of African-American Heritage G. People of Mexican Heritage H. People of Italian Heritage I. People of Jewish Heritage J. People of Middle Eastern Heritage
Interactive session: Group report on Organizing Cultural Phenomena on people with different cultural heritage (mentioned on left)
UNIT VI. Contemporary Challenges in Transcultural Nursing
Lecture/discussion
A. Transcultural aspects of pain 1. Definition of pain 2. Basic/related concepts 3. Measurement of pain 4. Expressions of pain 5. Applying transcultural nursing concepts to clients in pain
Lecture/Discussion
B. Cultural Disparities in Health and Group activity Health Care Delivery 1. Factors that account for cultural disparities: minority groups, vulnerable populations, the poor, the homeless C. Cultural Diversity in the Workforce 1. The aspects of cultural diversity 2. The effects of multicultural healthcare workforce 3. Barriers/conflicts in the workforce 4. Promoting harmony in multicultural workplaces 5. Strategies to promote effective cross-cultural communication in the multi-cultural workplace D. Transcultural Values and Ethics 1. Transcultural Values: Basic /related concepts, transcultural assessment and clarification of values and beliefs 2. Transcultural Ethics: Basic/related concepts, Western and Eastern ethical theories D. Culturally competent model of ethical
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decision-making E. Transcultural Care Principles, Human Rights and Ethical Considerations Bibliography Week 11
FINAL EXAMINATION
Pencil and paper test
10. Course Outcomes and Relationship to Course Objectives/ Program Outcomes
Course Outcomes
Course Objectives
Program Outcomes
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1. Explain aspects and components of cultural diversity in Asia and in different countries
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2. Discuss traditional and transcultural HEALTH belief models and healing systems, including assessment of these paradigms
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3. Know the different transcultural nursing models and apply culturally competent nursing care. 4. Recognize contemporary challenges in transcultural nursing.
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A student completing this course should be able to:
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Contribution of Course to Meeting the Professional Component: HEALTH & NURSING topics – General education component –
90% 10%
11. Textbook: Books in # 12: 13. Course Evaluation: The student is evaluated based on his/her performance in the following areas: LECTURE Quizzes___________________________________15% Midterm__________________________________ 25% Final Examination _______________________
50%
Academic Requirements and other related Activities
______________________ TOTAL
10% 100%
Aside from academic deficiency, other grounds for a failing grade are: • Cheating during examinations • More than 20 % of the total number of meetings in a quartermaster as per CHED ruling • Failure to take the final examination with no valid excuse Note:
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The final grade of the student will be given as reflected in the table below. Average (%) Final Grade
Below 60 5.00
60-64 3.00
65- 69 2.75
70-74 2.50
75-79 2.25
80-84 2.00
85-89 1.75
90-94 1.50
95-97 1.25
98-100 1.00
12. References/Course Materials Made Available: Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing care. (3rd ed.). Lippincott. Philadelphia, New York, Baltimore. Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing ( 2nd ed.). Thomson Asian Edition. Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing concepts, process, and practice. (7th ed.).Pearson Education, Inc. Upper Saddle River, New Jersey. Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd ed.). Delmar Learning. Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a culturally competent approach (2nd ed.). F.A. Davis Co. Philadelphia. Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, N.J: Prentice Hall. Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and health care (6th ed.). Pearson Education South Asia Pte Ltd. Jurong, Singapore. Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and science of nursing care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.
13. Committee Members: Fortuno , Carolina P. Capaque, Dawn Valderrama, Deogracia M.
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VISION Mapúa shall be an international center of excellence in technology education by: • providing instructions that are current in content and state-of-the art in delivery; • • •
engaging in cutting-edge research; and responding to the big local and global technological challenges of the times
MISSION d) The mission of Mapúa Institute of Technology is to disseminate, generate, preserve and apply scientific, engineering, architectural and IT knowledge. e) The Institute shall, using the most effective means, provide its students with professional and advanced scientific foundation in engineering, architectural, information technology and health sciences education through rigorous and up-todate academic programs with ample opportunities for the exercise of creativity and the experience of discovery. f) It shall implement curricula that, while being steeped in technologies, shall also be rich in the humanities, languages and social sciences that will inculcate ethics. e) The Institute shall advance and preserve knowledge by undertaking research and reporting on the results of such inquiries. f) The Institute, singly or in collaboration with others, shall bring to bear the world's vast store of knowledge in health sciences, engineering and other realms on the problems of the industry, and the community in order to make the Philippines and the world a better place
5. To equip the students with a broad foundation on the basic concepts, theories, principles and fundamentals of professional nursing practice 6. To develop the student’s capability to apply these learned concepts, theories, and principles in the practice of professional nursing 7. To inculcate in the students the importance of lifelong learning. 8. To develop in the student an appreciation of human values in the care of individuals, families, population at
a
MISSION b c d
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addressed by DLHS
PROGRAM EDUCATIONAL OBJECTIVES
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COURSE CONTENT Unit I. Overview of Transcultural Nursing A. Introduction B. Providing a Comprehensive Approach to Health Care C. Cultural Concepts and Terminologies D. History of Transcultural Nursing E. Major Assumptions to Support Leininger’s Culture Care Diversity and Universality Unit II. Cultural Diversity
V. Definition of Related Concepts VI. The World in Review
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C. Population Overview 1. Worldwide 2. Most populous cities of the world 3. US. population D. Race 1. Basic concepts 2. Race categories E. The Immigrants 1. Reasons for migration 2. Metropolitan areas with the largest number of immigrants 3. Leading 10 primary destinations of immigrants (2000) 4. Leading 10 countries of origin of legal immigrants (1990-2000) F. Factors to Consider in the Nursing Care of Culturally Diverse Groups Unit III. Health and Illness
A. The HEALTH Traditions Paradigm
1. Concepts of health and illness 2. The interrelated aspects of health B. The HEALTH Traditions Model 1. Traditional methods of maintaining, practicing and restoring health 2. Symbolic examples 3. Factors influencing traditional beliefs and practices C. Health Belief Systems 1. Magico-religious 2. Scientific or biomedical 3. Holistic D. Types of Healing Systems 1. Self-care 2. Folk Healing System 3. Professional Care 4. Complementary, alternative and integrative therapies Unit IV. Transcultural Nursing Care Models
A. Leininger’s Sunrise Cultural Care Diversity and Universality Model B. Purnell’s Model for Cultural Competence C. Giger and Davidhizar’sTranscultural Assessment Model and Cultural Heritage Consistency D. The Organizing Phenomena of Culture: Environmental control, Biological variation, Social organization, Space, Time, and Communication E. Selected Examples of Etiquette Related to Selected Cultural Phenomena F. Cross-Cultural Phenomena Impacting Nursing Care G. Transcultural Assessment H. Barriers to health Care Unit V. Application of Organizing Cultural Phenomena to People from Different Cultural Heritage: an Interactive Session People People People People People F. People G. People H. People I. People J. People A. B. C. D. E.
of of of of of of of of of of
Filipino Heritage Japanese Heritage Chinese Heritage Indian (Hindu) Heritage Anglo-American Heritage African-American Heritage Mexican Heritage Italian Heritage Jewish Heritage Middle Eastern Heritage
UNIT VI. Contemporary Challenges in Transcultural Nursing A. Transcultural Aspects of Pain 9
1. Definition of pain 2. Basic/related concepts 3. Measurement of pain 4. Expressions of pain 5. Questions on Cultural Attitude Toward Pain 6. Applying transcultural nursing concepts to clients in pain B. Cultural Disparities in Health and Health Care Delivery 1. Factors that account for culture disparities: minority groups, the poor, vulnerable populations, the homeless C. Cultural Diversity in the Workforce 1. The aspects of cultural diversity in the workforce 2. The effects of multicultural healthcare workforce 3. Barriers/conflicts in the workforce 4. Promoting harmony in multicultural workplaces 5. Strategies to promote effective cross-cultural communication in the multicultural workplace D. Transcultural Values and Ethics 1. Transcultural Values Basic/related concepts Transcultural assessment and clarification of values and beliefs 2. Transcultural Ethics Basic/related Concepts Overview of Western and Eastern Ethical Theories Culturally competent model of ethical decision-making 3. Transcultural Care Principles, Human Rights and Ethical Considerations
CULTURAL HERITAGE BIOBLIOGRAPHY ADDENDUM
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TRANSCULTURAL NURSING UNIT I. OVERVIEW OF TRANSCULTURAL NURSING “…demography is destiny, demographic changes is reality, and demographic sensitivity is imperative.” Giger and Davidhizar, Transcultural Nursing
A. INTRODUCTION The rapidly changing demographic scenario beckons us into viewing the world where people are no longer bound by physical boundaries. Societies everywhere, particularly in the United States, are becoming multicultural, multilingual, and pluralistic. Nursing, therefore, must rapidly adapt itself to a changing heterogeneous society if it is to provide culturally appropriate and culturally competent nursing care in the twenty-first century. Madeleine Leininger, a nurse-anthropologist, saw this trend in the 50’s, and envisioned transcultural nursing as a formal area of study and practice for nurses. Also called cross-cultural, intercultural, multicultural and culture-care nursing by some authorities Leininger defined this new field of study as a “humanistic and scientific area of formal study and practice which is focused upon differences and similarities among cultures with respect to human care, health or well-being), and illness based upon the people’s cultural values, beliefs and practices.” The ultimate goal of transcultural nursing, according to Leininger, is “to use relevant knowledge to provide culturally specific and culturally congruent nursing care to people.” An understanding of culture and related concepts is therefore important. Culture refers to the common lifestyles, knowledge, beliefs, behavior patterns, attitudes, values, habits, customs, languages, symbols, ritual, ceremonies, and practices that are unique to a particular group of people. Some of the characteristics of culture are the following: Culture is learned and taught. Cultural knowledge is transmitted from one generation to another. A person is not born with cultural concepts but instead learns them through socialization. Culture is shared. The sharing of common practices provides a group with part of its cultural identity. Culture is social in nature. Culture develops in and is communicated by groups of people. Culture is dynamic, adaptive, and ever-changing. Adaptation allows cultural groups to adjust to meet environmental changes. Culture change occurs slowly and in response to the needs of the group. This dynamic and adaptable nature allows a culture to survive. Source: Delaune, Sue C. and Patricia K. Landner. Fundamentals of Nursing. 3rd ed. Thomson, Asian ed. 2006. p. 389.
B. PROVIDING A COMPREHENSIVE APPROACH TO HEALTH CARE To provide a comprehensive approach to health care, nurses have to respect common humanistic aspects of people worldwide, be aware of distinguishing characteristics of divergent cultural groups, and be able to deliver health care that is culturally sensitive, culturally appropriate, and culturally competent.
Culturally sensitive has more to do with personal attitudes and not saying things that might be offensive to someone from a cultural or ethnic background different 11
from the health-care provider’s. (Ethnic – “You eat like a pig, use spoon and knife as in our culture,” or saying “You Indians “smell”.
Culturally appropriate implies that the nurse applies the underlying background knowledge that must be possessed to provide a given client with the best possible health care. (End-of-life spiritual care – a nurse will suggest to a Jewish patient and his family the availability of a rabbi, if they wish)
Culturally competent implies that within the delivered care the nurse understands and attends to the total context of the client’s situation and uses a complex combination of knowledge, attitudes, and skills. 1. Basic/Related Concepts
Cultural competence is a process in which “the nurse continuously strives to achieve the ability and availability to effectively work within the cultural context of an individual, family or community. (Campinha-Bacote, 1998, p.6). Culturally competent nursing care treats each person as an individual whether coming from same or divergent cultural system. Nursing care is planned and implemented in a way that is sensitive to the needs of individuals and families, groups from diverse cultural populations within society. The nurse who recognizes and respects cultural diversity has cultural sensitivity and provides nursing care that accepts the significance of cultural factors in health and illness. The nurse must be aware that the healthcare system itself is a culture with customs, rules, values and a language of its own and that cultural imposition and ethnocentrism must be avoided. Interaction between the nurse and patient are affected by the particular set of cultural values they bring to the interaction. The cultural background of each participant The expectation and beliefs of each about health care The cultural context of the encounter (e.g, hospital, clinic, home) The degree of agreement between the two persons’ sets of beliefs and values (Andrew & Boyle, 2000b). Nurses must avoid cultural imposition which is the tendency to impose their beliefs, practices and values on people of other cultures, and ethnocentrism, the belief that one’s own ideas, beliefs and practices are the best and superior, or must be preferred over those of others.
2. The Five Elements of Cultural Competence:
1) Cultural awareness - a cognitive process in which the nurse becomes aware of and sensitive to the clients cultural vales, beliefs, and practices.
You play when interacting with individuals who are different from yourself. (Purnell, op. cit. 3). Identify biases in own life and how they affect your feelings about others, and the nursing care you plan and give to them 2) Cultural knowledge – The nurse seeks a sound educational base about different cultures. Learn as much as possible about the belief system and practices of people in your community and of the patients in the area in which you work. Practice techniques of observation and listening to acquire knowledge of the beliefs and values of your patients. 3).Cultural skill - The nurse’s ability to perform a culturally specific assessment (i.e., physical and psychosocial). Cultural assessment:
Is an important aspect of comprehensive nursing assessment. facilitates better understanding sometimes overlooked factors that influence health behaviors and decisions.
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helps nurses to properly identify and understand the meanings of behaviors that might otherwise be judged negatively or be confusing to the nurse
recognize that each person is culturally unique and that not all persons in a
particular group believe or respond the same way. the nurse can anticipate and assess patient’s values, religion, dietary practices, family lines of authority, life patterns, and beliefs and practices related to health and illness.
4. Cultural encounters – The nurse interacts with clients from diverse cultural backgrounds. A very essential feature of our humanity is the diversity of cultures and the many different ways we find meaning in our lives, and in the lives of other people. The hospital or health care environment is in itself a little world – it typifies the diversity of culture possessed by patients and health care givers, and other individual involved in health care. To be culturally competent the nurse must know how to interact with people from diverse cultural background and learn to adjust and or adapt her assessment and caring skills accordingly. 5. Cultural desire – The nurse’s motivation (“want to”) to become culturally competent. The nurse must have the desire and motivation to develop and apply the elements of cultural competence which are developing awareness, acquiring knowledge, and practicing skills. Source: Data from Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38 (5), 204-205), Quoted in Ethical Issues in Contemporary Nursing, p. 342. Taylor, Lillis and LeMone, op. cit. pp. 53-54.
B. CULTURAL CONCEPTS AND ESSENTIAL TERMINOLOGY Subculture – smaller groups within a culture. Each subculture has its own value system and related expectations of behavior.
Subcultures may be based on: 1. Professional and occupational affiliations (nurses, engineers) 2. Nationality or race (a shared historical and political past) 3. Age groups (adolescents, senior citizens) 4. Gender ( feminists, men’s groups) 5. Socioeconomic factors ( the working class, the middleclass, the upper class) 6. Political viewpoints (Nationalista, Liberal) 7. Sexual orientation (gay, lesbian group)
Bicultural – used to describe a person who crosses two cultural, lifestyles, and sets of values. (Example: a young woman whose mother is Filipino and whose father is American)
Acculturation - occur when people adapt to or borrow traits from another culture. Also defined as the changes of one’s cultural patterns to those of the host society.
Assimilation – the process by which an individual develops a new cultural identity. It means becoming like the members of the dominant culture. The person from a given cultural group loses his or her original cultural identity to acquire the new one. There are 4 forms of assimilation: 1. Cultural – ability to speak excellent American English 2. Marital – intermarriage with members of another group
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3. Primary structural – the relationships between people are warm, personal 4.
interactions between group members in the home, the church, and social groups Secondary structural – there is nondiscriminatory sharing, often of a cold interpersonal nature between different groups in settings such as school and workplaces
C. HISTORY OF TRANSCULTURAL NURSING
"That the culture care needs of people in the world will be met by nurses prepared in transcultural nursing." M. Leininger, Ph.D.
In the 1950’s, Dr. Madeleine M. Leininger noted cultural differences between patients and nurses when working with emotionally disturbed children. This clinical experience led her to study cultural differences in the perceptions of care in 1954, and in 1965 she earned a doctorate in cultural anthropology from the University of Washington. Leininger recognizes that anthropology’s most important contribution to nursing was the realization that health and illness are strongly influenced by culture. In 1991, Leininger already a well-known nurse anthropologist, published her book Cultural Care Diversity and Universality: A Theory of Nursing. Leininger produced the Sunrise model (described in Unit IV) to depict her theory of culture care diversity and universality.
D. MAJOR ASSUMPTIONS TO SUPPORT LEININGER’S CULTURE CARE DIVERSITY AND UNIVERSALITY THEORY 1. Care is the essence of nursing and is a distinct dominant, central, and unifying focus.
2. Care (caring) is essential for well-being, health, healing, growth, survival, and face handicaps or death.
3. Culture care is the broadest holistic means to know, explain, interpret, and predict nursing care phenomena to guide nursing care practices.
4. Nursing is a transcultural humanistic and scientific care discipline and profession with the central purpose to serve human beings worldwide.
5. Care (caring) is essential to curing and healing, or there can be no curing without caring.
6. Culture care concepts, meanings, expressions, patterns, processes, and structural
forms of care are different (diversity) and similar (towards commonalities or universalities) among all cultures of the world. 7. Every human culture has generic (lay, folk or indigenous) care knowledge and practices and usually professional care knowledge and practices, which vary transculturally. 8. Cultural care values, beliefs and practices are influenced by and tend to be embedded in the world view, language, religious (or spiritual), kinship (social), political (or legal) educational, economic, technological, ethnohistorical, and environmental context of a particular culture. 9. Beneficial, healthy, and satisfying culturally based nursing care contributes to the well-being of individuals, families, groups, and communities within their environmental context.
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10. Culturally congruent (in agreement) or beneficial nursing care an occur only when the individual, group, family, community, or culture care values, expressions, or patterns are known and used appropriately and in meaningful ways by the nurse with the people. 11. Culture care differences and similarities between professional caregiver(s) and client (generic) care-receiver(s) exist in any human culture worldwide. 12. Clients who experience nursing care that fails to be reasonably congruent with the client’s beliefs, values, and caring lifeways will show signs of cultural conflicts, noncompliance, stresses, and ethical or moral concerns. 13. The qualitative paradigm provides new ways of knowing and different ways to discover epistemic and ontological dimensions of human care transculturally.” Source: Leininger, Madeleine. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press. 16:44-45.
UNIT II. CULTURAL DIVERSITY The world is a conglomeration of people coming from different cultures. More than ever, because of the great strides made in science and technology, people from all over are now able to travel, live and work in different parts of the world, bringing with them their world view, ethnohistory, racial and social structure features (i.e. family, religion, language, cultural and ethical values, etc), as well as their health behavior and practices. Thus, everyone in a way is different; this fact or state of being different is known as cultural diversity. The nurse has to confront the issue of cultural diversity in the practice of the profession. She/he has to know and understand cultural diversity as it is manifested in the world today. What brings about cultural diversity? What are the reasons for population movement or migration? What racial or ethnic groups comprise the different parts of the world? What life and health ideologies, beliefs and practices are brought by them?
A. DEFINITION OF RELATED CONCEPTS Race – Racial categories are based on specific physical characteristics Ethnicity – The sense of identification with a collective cultural group, largely based on the group’s common heritage. Includes language and dialect. Religious practices, literature, music, folklore, political interests, food preferences, and employment patterns.
Biracial/multiracial – when an individual crosses two or more racial and cultural groups. Multiracial (Tiger Woods – White, Black, Indian, and Asian)
Dominant Group – The group within a country or society that has the most authority to control values and sanctions.
Minority Group – Most often has some physical or cultural characteristics that identifies the people within it as different.
Discrimination - The differential treatment of individuals or groups based on categories such as race, ethnicity, gender, social class, or exceptionality, occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.
Stereotyping – Assuming that all members of a culture, subculture, or ethnic group act alike.
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Cultural Imposition – The belief that everyone should conform to the majority belief system.
Cultural Blindness – The result of ignoring differences and proceeding as though they do not exist.
Culture Conflict – The state that occurs when people become aware of cultural
differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure.
Source: Taylor.p.40; Kozier,208-209.
B. THE WORLD IN REVIEW Divided into units or continents: Africa, Asia, Europe, North America, South America, Oceania. Of these, Asia is the largest continent.
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ASIA
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NORTH AMERICA and CANADA
SOUTH AMERICA
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C. POPULATION OVERVIEW 1. World Population
Year 2000 Projected: Year 2020 Year 2050
– – –
6.1 billion 7.6 billion 9.3 billion
2. Most Populous Cities of the World (Source: TIME Almanac 2006). 1. China 2. India 3. United States 4. Indonesia 5. Brazil 6. Pakistan 7. Bangladesh 8. Russia 9. Nigeria 10. Japan 11. Mexico 12. Philippines
1,306,313,812 1,080,264,388 295,734,134 241,973,879 186,112794 162,419,946 144,319,628 143,420,309 128,771,988 127,417,244 106,202,903 87,857,473
3. In the U. S.
Between 1990 and 2002 – population increased from 248.7 million to 293.02
million Composition of population: • 75.1% White
• • • • • • •
12.5%
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Spanish/Hispanic/Latino (of any race)
12.3%
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Black or African American
0.9%
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American Indian or Alaskan Native
3.6%
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Asian
0.1%
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Native Hawaiian or other Pacific Islander
5.5%
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some other race
2.4%
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are of two or more races
D. RACE 1. Basic Concepts
Race is an emotionally-charged word that often divides or separates people even though the Human Genome Project provides evidence that all human beings share a genetic code that is over 99% identical. Race is genetic in origin and includes all physical characteristics that are similar among members of the group, such as skin color, bone structure, blood type, hair type, and eye color. However, it is this less than 1% difference that is usually significant in determining and providing variants in health care as certain diseases may be racially determined. Ethnicity (group identity) and race may sometimes overlap because the cultural and biological commonalities support one another. The similarities of people in racial and ethnic groups reinforce a sense of commonality and cohesiveness.
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2. Race Categories
White – refers to people having origins in any of the peoples of Europe, the Near
East, and the Middle East, or North Africa. This category includes Irish, German, Italian, Lebanese, Turkish, Arab and Polish Black or African American – refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any person who self-designated this category regardless of origin. American Indian and Alaskan Native refers to people having origins in any of the original peoples of North, South or Central America, and who maintains tribal affiliation or community attachment. Asian – refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This category includes the term Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani and Thai. Native Hawaiian and other Pacific Islander refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, Tahiti, the Mariana Islands, and Chuuk. “Some other race” was included for people who are unable to identify with the other categories. Additionally the respondent could identify, as a write-in, with two races (http://www.census.gov, 2001.)
E. THE IMMIGRANTS 1. Reasons for migration: Economic – seek better economic opportunities Religious – escape religious oppression Political freedom – escape political persecution 2. Metropolitan Areas with the Largest Numbers of Immigrants
New York, N.Y. Los Angeles-Long Beach, CA Miami, FL Chicago, IL Washington, DC-MD-VA Orange County, CA Houston, TX San Jose, CA Boston-Lawrence-Lowell-Brockton MA Oakland, CA
In 1996 there were 4.6 to 5.4 million of undocumented immigrants. California is the leading state of residence for undocumented people, followed by Texas, New York and Florida.
3. Leading 10 Primary Destination States for Immigrants 2000
California New York Florida Texas New Jersey Illinois Massachusetts Virginia Washington Pennsylvania
4. Leading 10 Countries of Origin for Legal Immigrants Between 1990-2000.
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Mexico Peoples Republic of China Philippines India Vietnam Nicaragua El Salvador Haiti Cuba Dominican Republic
It is predicted that by the year 2020 immigration will be a major source of new people for the United States and will be responsible for whatever growth occurs in the United States after 2030. The United States will continue to attract about 2/3s of the world’s immigrants, and 85 % will be from Central and South America. Source: www.ins.gov.
F. FACTORS TO CONSIDER IN THE NURSING CARE OF CULTURALLY DIVERSE GROUPS Lack of employment opportunities and finances for health care services. Different traditional belief systems as well as different norm and values. 3. The lack of cultural sensitivity on the part of social service and health care workers. 4. Lack of bilingual personnel or staff members or the lack of interpreters to assist clients and providers. 5. Rapid changes in the U.S. health care systems where clients are “lost” in the gaps between agencies and services. 6. Inconvenient locations or hours that preclude clients from accessing care. 7. A lack of understanding, trust, and commitment on the part of health care providers. 1. 2.
Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed Lippincott Wiliams & Wilkins, Philadelphia, p. 338
UNIT IV. CULTURAL HEALTH TRADITIONS, BELIEFS AND PRACTICES Cultural and health belief systems are embraced by people from different cultures. This unit explores the concepts of HEALTH/ILLNESS, health traditions model, belief systems and practices, healing systems as well as the barriers to health care.
A. THE HEALTH TRADITIONS PARADIGM 1. Concept of Health and Wellness Health (according to WHO, 1948) – a state of complete physical, mental, emotional, social well-being and not merely the absence of disease or infirmity. Health and illness defined from a transcultural standpoint
Health – is a complex, interrelated phenomena characterized by a balance of the person, both within one’s being---physical, mental and spiritual---and in the outside world- the environment, the community, and the natural forces surrounding him/her.
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Illness – is the imbalance of one’s being---physical, mental, and spiritual---and in the outside world- the environment, the community and the natural forces surrounding him/her.
The health traditions model is predicated on the concept of holistic HEALTH and describes what people do from a traditional perspective to maintain, protect, and restore HEALTH.
2. Interrelated Aspects:
The body includes all physical aspects such as genetic inheritance, body chemistry, gender, age, nutrition, and physical condition. The mind includes cognitive processes, such as thoughts, memories, and knowledge of such emotional processes feelings, defenses, and self-esteem. The spiritual facet includes both positive and negative learned spiritual practices and teachings, dreams, symbols, stories; protecting forces; and metaphysical or native forces.
These aspects are in constant flux and change over time, yet each is completely related to the others an also related to the context of the person. The context includes the person’s family culture, work, community, history, and environment. Source: Kozier, op. cit. p. 210.
B. THE HEALTH TRADITIONS MODEL 1. The health traditions model for maintaining, practicing, and restoring health
Traditional methods of maintaining health
physical, mental, and spiritual – include following a proper diet and wearing proper clothing, concentrating and using the mind, and practicing one’s religion. Traditional methods of practicing health – physical, mental, and spiritual – include wearing protective object such as amulets, avoiding people who may cause trouble, and placing religious objects in the home.Traditional methods of restoring health – physical, mental, and spiritual – include the use of herbal remedies exorcism, and healing rituals.
The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and Personal Methods of Maintaining Health, Protecting Health and Restoring Health
Maintain Health
Protect Health
Restore Health
PHYSICAL Proper clothing Proper diet Exercise/Rest Special foods and food combination Symbolic clothing
Homeopathic remedies
MENTAL Concentration Social and family support systems Hobbies Avoid certain people who can cause illness Family activities
Relaxation Exorcism
SPIRITUAL Religious worship Prayer Meditation
Religious customs Superstitions Wearing amulets and other symbolic objects to prevent the “Evil Eye” or defray other sources of harm Religious rituals Special prayers
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Lineaments Herbal tests Special foods Massage Acupuncture
Curanderos and
other traditional healers Nerve teas
Meditation Traditional healings Exorcism
Source: Spector, R.E. Cultural Diversity in Health and Illness (2000), 5th ed. Upper Saddle River, N.J: Prentice Hall, p. 100.
2. Symbolic examples Following are related health-related images and symbols that may be used to maintain, protect, or restore physical, mental, or spiritual health by people of different heritages.
Thousand-year old eggs, from China, represent traditional foods that may be eaten daily to maintain physical health. The enjoyment of nature, the nature environment, may be a universal way of maintaining mental health. The Islamic prayer from East Jerusalem, represents a prayer, a way of maintaining spiritual health. Red string, from the Tomb of Rachel in Bethlehem, Israel, may be worn to protect physical health. The eye, from Cuba, represents the plethora of eye-related objects that may be worn or hung in the home to protect the mental health of people by shielding them from the envy and bad wishes of others. The thunderbird, from the hopi nation, may be worn for spiritual protection and good luck. The herbal remedy from Africa represents aromatic plants that may be used by people from all ethnocultural traditional backgrounds as one method of restoring mental health. Tiger balm, from Singapore, represents substances that are used in massage therapy as a way of restoring mental health. Rosary beads, from Italy, symbolize prayer and meditation methods used in the spiritual restoration of health.
Source: Spector, R.E. Cultural Diversity in Health and Illness (2000),, 5th ed. Upper Saddle River, N.J: Prentice Hall, p. 100).
Maintain
Protect
Restore
Symbolic Examples
3. Factors Influencing Traditional Beliefs and Practices
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The length of time in the United States. The size of the ethnic or cultural group with which an individual identifies and interacts. Age of the individual. As a general rule, children acculturated more rapidly than adults or seniors. The ability to speak English and communicate with members of the majority culture. Economic and education status. If a Salvadorean woman works outside the home, she may readily learn to speak English than if she remains inside the home. Health status of family members. If individuals and their families seek health care in the country, they begin to “learn the system”, so to speak. Individuals and groups who have distinguishing ethnic characteristics, such as skin color, may be more isolated because of discrimination and thus may retain traditional values related to health beliefs and behavior.
Source: Andrews and Boyle, 3rd ed. p. 318.
C. HEALTH BELIEF SYSTEMS Generally, theories of health and disease/illness causation are based on the prevailing world view held by a group.
The worldview developed reflects the group’s total configuration of beliefs and practices and permeates every aspect of life within the culture of that group. These worldviews include a group’s health-related attitudes, beliefs and practices and frequently are referred to as health belief systems.
Three Major Health Belief Systems 1. Magico-religious
In this belief system, disease is viewed as the action and result of supernatural forces. Supernatural forces dominate. Characterized by cause-and-effect relationship. Health is seen as a reward or gift for being good; illness the result of “being bad” or opposing God’s will. Getting well is also viewed as dependent on God’s will. Illness is viewed as punishment for sins or committing transgressions. Common in countries like: Latino, African American, Middle Eastern and Asian cultures. Five categories of events that are believed to be responsible for illness as derived from the work of Clements (1932): • Sorcery – believed in by some African and American Blacks
• •
Breach of taboo (breaking of social norm, such as committing adultery) Intrusion of a disease object
•
Intrusion of disease-causing spirit – Example: Mal ojo or the evil eye common in Latino culture. • Loss of soul Magic can cause illness. Ex. A sorcerer or witch may put a spell or hex on the client. Such illnesses may require magical treatments in addition to scientific treatments Some view illness as possession by an evil spirit.
2. Scientific or biomedical health belief model
Disavows the metaphysical. This belief system dominates Western thought and the practice of health care. Based on the belief that life and life processes are controlled by a series of physical and biochemical processes that can be manipulated by humans. The
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client will believe that illness is caused by germs, viruses, bacteria or a breakdown of the body. Disease is viewed metaphorically as the breakdown of the human machine as a result of: • Wear and tear (stress) • External trauma (injury, accident) • External invasion (pathogens)
•
Internal damages (fluid and chemical imbalances or structural damages)
Using the metaphor of the machine, Western medicine uses specialists to take
care of the “parts “fixing” the part, etc. The client will expect a pill, or treatment, or surgery to cure health problems. Biomedical model defines health as the absence of disease or of the signs and symptoms of disease. To be healthy, one must be free of disease.
3. The holistic health belief model
The term holistic was coined in 1926 by Jan Christian Smuts who defined holistic
as “an attitude or mode of perception in which the whole person is viewed in the context of the total environment. In a way it is similar to the magico-religious worldview where the forces of nature must be maintained in balance or harmony; when the balance of nature is disturbed illness results. The different aspects of the individual’s nature: the physical, the mental, the emotional, and the spiritual must also be in balance. Holistic paradigm seeks to maintain a sense of balance between humans and the larger universe. Unlike the scientific model which states that disease is caused by external agents, this paradigm states that disease is caused by imbalance or disharmony between humans and the larger universe. For example: Biomedical model – TB is caused by mycobacterium tuberculosis Holistic model - disease is the result of multiple environmental-host interactions: poverty, malnutrition, overcrowding, and the mycobacterium. Examples of holistic belief: The medicine wheel of the Native Americans (see below) and the yin and yang of the Chinese (see Addendum) THE MEDICINE WHEEL From our ancestors, we are taught that everything in life is circular. We are one within the circle of life. The Medicine Wheel teaches us that the physical, mental, emotional and spiritual aspects must be in balance in order to maintain a healthy mind, spirit and body.
Medicine wheel used by Native Americans of North and South America
D. TYPES OF HEALING SYSTEMS Healing – comes from the Anglo-Saxon word hael, which means to make whole, to move forward, or to become whole. It is not the same thing as curing (ridding one of disease) but is a process that activates the individual’s healing forces from within. Important Concept: “that healing potential exists in all of us.” Healing System – refers to the accumulated sciences, arts, and techniques of restoring and preserving health that are used by a cultural group (Smith, 1983).
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1. Self-Care
For common minor illnesses, an estimated 70-90% of all people resort to self
care with over-the-counter medicines, megavitamins, herbs, exercise, any or foods that they believe have healing power. Many self-care practices have been handed down from generation to generation, frequently by oral tradition. When self-care is ineffective, people are likely to turn to professional and/or folk (indigenous, generic, traditional) healing systems. Self-care is the largest component of the North American healing care system.
2. Folk Healing System
Folk healing system (FHS) is a set of beliefs that has a shared social dimension
and reflects what people actually do when they are ill vs. what society says they ought to do according to a set of social standards. All cultures of the world have had a lay health care system, which is referred to as indigenous or generic. Used interchangeably with complementary, alternative, or naturalistic; the key consideration that defines folk systems is their history of tradition. Many have endured over time and often transmitted from one generation to the next. FHS is a mixture of nonprofessional systems and uses healing practices that are learned informally. The FHS is often divided into secular and sacred components. Most cultures have folk healers: Examples: Hispanic – curandero, espiritualista, yerbero, sabador (manipulates bones and massages) Black – “Old Lady”, Spiritualist, voodoo priest or priestess Chinese – herbalist, acupuncturist Greek – Magissa (magician), bonesetters, priest (Orthodox) Native Americans – shaman (a folk-healer priest who uses natural and Supernatural forces to help others), crystal gazer, hand trembler (Navajo) Philippines – manghihilot
3. Professional Care Systems
Are formally taught, learned, and transmitted professional care, health, illness, wellness and related knowledge and practice skills. Characterized by specialized education and knowledge, responsibility for care, and expectation of remuneration for services rendered. Examples of professional care practitioners: Physicians, nurses, physical therapists, pharmacists etc. Conventional medicine is medicine practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals such as physical therapists, psychologists, and registered nurses. Professional medicine/medical care is also known as biomedicine, conventional allopathic, Western medicine
4. Complementary, Alternative and Integrative Therapies Western biomedicine or allopathic medicine must be differentiated from alternative medicine. Comparison of Allopathic and Alternative Medicine ALLOPATHIC PERSPECTIVE ALTERNATIVE PERSPECTIVE Health is absence of disease. Health is a state of well-being characterized by min/body balance. Focus is on cure of disease Emphasis is on health maintenance and disease prevention through lifestyle choices. Mind and body are treated as separate Mind and body are one; what affects one 27
entities
affects the other.
Disease results from causative agents, usually external.
Disease originates from within and is the result of imbalances that occur in response to unhealthy lifestyle and/or inner disharmonies. The body has a natural ability to heal itself.
Healing depends on outside agents to cure disease. Treatment consists of drugs, surgery, and radiation. Healing is aggressive, quick and seeks to destroy the invading organisms. The doctor plays the central role in healing.
Treatment consists of det, exercise, herbal medicines, social support, and stress management. Healing is a slow, natural process.
The client has the most important role in healing (i.e., lifestyle choices). (Data from: Fontaine, K.L. (2000). Healing practices: Alternative therapies for nursing. Upper Saddle River:Prentice Hall, in DeLaune Fundamentals of Nursing. p. 232.
Alternative medicine – is used instead of or in place of conventional medicine Example: Using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.
Complementary medicine – is used together with conventional medicine.
Example: In addition to Valium which an extremely agitated or nervous patient may receive, one can give tea (chamomile, valerian) that calms down the patient, provide a quiet environment, play soothing music, give therapeutic massage, etc. ; gargling with salt or saline solution in addition to antibiotic for strep throat
Integrative medicine – term introduced by Dr. Andrew Weil to define a hybrid of complementary, alternative and conventional medical therapies for which there is some high-quality scientific evidence of safety and effectiveness.
Components of integrative healing therapies:
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1. Surgery – refers to excision or surgical removal of diseased body parts. 2. Pharmaceutical Drugs – use of medicines 3. Herbal medicine - use of herbs or plants that are valued for their medicinal properties, flavors and scents. Examples: Eucalyptus (antibacterial, decongestant), Saint John’s worth (antidepressant), garlic (lowers cholesterol) 4. Nutritional medicine – includes special diet therapies (e.g., macrobiotic, vegetarian, Atkins, South Beach diet, etc.) Orthomolecular medicine, the use of products used as nutritional and food supplements like vitamins and mineral (and not covered in any other category
5. Lifestyle and behavior – modifying or changing unhealthy lifestyle behavior/s or habits to healthy ones; also emphasizes healthy maintenance and disease prevention. Example: eating healthy instead of junk foods, changing or stopping addictive behaviors like drinking or smoking
6. Mind/body or behavioral medicine – uses a variety of techniques designed to
enhance the mind’s capacity to affect bodily function and symptoms. These include biofeedback; relaxation; meditation; guided imagery; hypnosis; prayer; art; music; dance therapy, and yoga.
7. Energy medicine- involves the use of energy fields. The following are commonly accepted • • • • •
beliefs about energy and healing: All things are manifestations of energy. Energy comes from one universal source Life depends on the movement of energy. People consists of several energy fields that interact with the environment. Interpersonal relationships are influenced by energy exchanges.
Types of energy therapies: Biofield involves systems that use subtle energy fields that purportedly surround and penetrate the human in and around the body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Example: qi gong, Reiki, and Therapeutic Touch,
Bioelectromagnetic-based therapies – involve the unconventional use of electromagnetic fields such as pulsed fields, magnetic fields, or alternatingcurrent or direct current fields or bone repair, wound healing and stimulation of the immune system.
Traditional Chinese Medicine (TCM) is based on the premise that the body’s vital energy qi (pronounced chee) circulates through pathways or meridians and can be accessed and manipulated through specific anatomical points along the surface of the body. Disease is described as an imbalance or interruptions in the flow of qi. Components of TCM include: herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage. 8. Manipulative therapies - are diagnostic and therapeutic mechanisms based on manipulation and /or movement of the body, such as osteopathic manipulation, massage therapy, hydrotherapy, chiropractic Osteopathic medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all
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of the body’s systems work together, and disturbance in one system may affect function elsewhere in the body. 9. Others – Humor, laughter therapy, pet therapy, music, aromatherapy Source: Andrews and Boyle, op. cit, 4th ed. pp. 73-86. Related Therapies: Ayurveda – is a CAM alternative medical system that has been practiced in the Indian subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment. Video showing: Ayurveda Chiropractic – is a CAM alternative medical system. It focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractor use manipulative therapy as an integral treatment tool. Homeopathic medicine is a CAM alternative medical system. In homeopathic medicine, there is a belief tat :like cures like,” meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substance given at higher or more concentrated dose would actually cause those symptoms. Example: Immunization Naturopathic medicine, or naturopathy, is a CAM alternative; it proposes that there is a healing power in the body that establishes maintains, and restores health. It includes supporting treatments as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy, and treatments from traditional Chinese medicine. Nursing Implications: Nurses must know and understand the nursing implications of CAM Therapies:
When a nurse enters into a relationship with a client/patient she acts as a healing facilitator by offering to be a guide, counselor, agent of change , or instrument of healing, which is help the clients call forth their inner resources for healing. Nurses are encouraged to think critically and assess CAM Therapies before recommending any one particular method or therapy. As such she must develop the following attributes: Has knowledge base Intentionality – conscious direction of goals that is essential in helping the healer to focus Respect for differences: Demonstrated by honoring clients’ culturally based health beliefs Ability to model wellness: Tending to own needs and attempting to stay as healthy and balanced as possible
UNIT V. TRANSCULTURAL CARE NURSING MODELS Following are transcultural care nursing models that depict theory of cultural care and universality (Leininger’s Sunrise Model), provide a model for cultural competence (Purnell’s), and a framework for assessing transcultural phenomena (Giger and Davidhizar’s).
A. LEININGER’S SUNRISE MODEL TO DEPICT THEORY OF CULTURAL CARE
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DIVERSITY AND UNIVERSALITY Focuses on describing, explaining, and predicting nursing similarities and differences
primarily on human care and caring in human cultures. Leininger uses word view, social structure, ethnohistory, environmental context, and the generic (folk) and professional systems to provide a comprehensive and holistic view of influences in culture care and well-being. This model emphasizes that health and care are influenced by elements of the social structure, such as technology, religious and philosophic factors, kinship and social systems, cultural values, political and legal factors, economic factors, and educational factors. In order for nurses to assist people of diverse cultures, Leininger presents three intervention modes to demonstrate ways to provide culturally congruent nursing care. These modes are assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a designated culture in:
a. Culture care preservation and maintenance –refers to the assistive,
b.
c.
supportive, facilitative, or enabling professional actions to retain and/or reserve relevant care values so that they can maintain their well-being, recover from illness, or face handicaps and/or death.” Culture care accommodation or negotiation – refers to the assistive, supportive, facilitative, or enabling professional actions to negotiate to /with others for beneficial or satisfying health outcomes with professional care providers.” Culture care restructuring and repatterning – refers to the assistive, supportive, facilitative, or enabling professional actions to help a client reorder, change, or greatly modify his or her lifeways for a new, different, and beneficial health care pattern, and maintenance of respect for the client’s cultural values and beliefs while still providing a beneficial or healthier lifeway than before the changes were co-established with the client.
(Leininger, 1991, pp. 48-49, in Andrews and Boyle, 3rd ed. op. cit. p. 521).
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THE SUNRISE MODEL
C.THE PURNELL MODEL FOR CULTURAL COMPETENCE 1. Macro Aspects of the Model Global society – phenomena
related to global society include world communication and politics; conflicts and warfare; natural disasters and famines; international exchanges in education, advances in health sciences, etc. Community – physical, social, and symbolic characteristics that cause people to connect Family – is two or more people who are emotionally connected. Family structure and roles change according to age, generation, marital status, relocation, etc. Person – is a biopsychocultural being who is constantly adapting to his or her environment.
2. Micro Aspects of the Model
The 12 domains essential for assessing the ethnocultural attributes of an individual, family, or group are as follows: Overview, inhabited localities, Nutrition and topography Pregnancy and child-bearing Communication practices Family roles and organization Death rituals Workforce Issues Spirituality Biocultural ecology Health-care practices High-risk behaviors Health-care practitioners
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C. THE GIGER AND DAVIDHIZAR’S TRANSCULTURAL ASSESSMENT MODEL The metaparadigm for this model includes: 1. 2. 3. 4. 5.
Transcultural nursing and culturally diverse nursing; culturally competent care; culturally unique individuals; culturally sensitive environments; and, health and health status based on culturally specific illness and wellness behavior.
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The Giger and Davidhizar’s Transcultural Assessment Model Model shows:
The client, a unique cultural being, in the center.
It is important to remember that the client is culturally unique and as such is a product of past experiences, cultural beliefs and cultural norms. Cultural expressions vary but it is that which give an individual a unique identity.
Cultural heritage consistency: This theory analyzes the degree to which
people identify with the dominant and traditional cultures . Its essential elements are: culture, ethnicity, and religion
1. Culture – represents non-physical traits, such as values, attitudes, beliefs,
2.
customs shared by a group of people and passed from generation to the next. Culture is also the sum f beliefs, practices, habits, likes dislikes, norms, customs and rituals learned from the family during the ears of socialization. Ethnicity – is a sense of identification associated with a cultural group’s common social and cultural heritage. Ethnicity is indicative of the following characteristics a group may share in some combination: i. Common geographic origin ii. Migratory status iii. Race iv. Language and dialect v. Religious faith or faiths vi. Ties that transcend kinship, neighborhood, and community boundaries vii. Shared traditions, values, and symbols viii. Literature, folklore, and music ix. Food preferences x. Settlement and employment patterns xi. Special interest with regard to politics in the homeland and in the United States xii. Institutions that specifically serve and maintain the group
Filipino ethnicity: The “Filipino blend,” is a considerable mix of cultural and linguistic groups, the result of varied historical and local relationships: • Earliest known settlers were the Negritos, small Negroes, related to the Andaman Islands and Malaya, who entered via land bridges at the height of the last glacier age. They are found in the Bataan peninsula and other marginal areas. • Next wave of settlers came from Southeast Asia by way of the China sea and remained in Luzon and Visayas. • Arab and Indian traders added their blood to the Muslim populations and settled in the southern islands. • Invasion of the Philippines by Spain in 1521, and the U.S. in 1898. Language is one of the most identifying ethnic feature of Filipino groups. There are 76 linguistic groups, the 3 most important are Tagalog, Visayas and Ilokano. Cultural Minorities – 4 million or 12% of total population. ¾ Muslims found in Mindanao, Sulu Archipelago and Palawan. (See addendum) There are at least 106 ethnic groups in North America and more than 170 Native American Indian tribes. (Thernstrom, 1980).
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Filipino Ethnicity: The “Filipino Blend,”
3. Religion – “the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler (s) of the universe; and a system of beliefs, practices and ethical values. It is not possible to isolate the aspects of culture religion, and ethnicity that shape a person’s worldview. Each is a part of the other, and all three are united within the person. Therefore, when religion is discussed, culture and ethnicity must also be included. a. Relationship between religion, culture and ethnicity: Examples
Ethnicity and religion are clearly related, and one’s religion is quite often the determinant of one’s ethnic group. Example: Israeli- Jewish; Japanese – Shintoism; Thai - Buddhism Religion in many cultures plays a vital role in one’s perception of health and illness as well as the way people interpret and respond to the signs and symptoms of illness. Religion, religious beliefs, and rituals are closely interwoven with the cycles and stages of life as birth, marriage, dying and death. Examples: Baptism is a sacrament in the Catholic religion. In Islam, circumcision must be performed on the 7th day after birth, and on the 8 th day in the Jewish faith. In the Hindu religion, the eldest son must perform the rituals for the dead. Personal and cultural values and ethical principles and practices are greatly determined and influenced by religion. Examples: According to Christian Science abortion is incompatible with faith. Family life is valued and birth control is contrary to Mormon belief. Euthanasia is not acceptable in Islam. Healing through prayer, relics or religious objects or through the intercession of saints is a belief common to many religions. Examples: Prayer for the sick. Intercession of saints: St. Joseph – dying, St. Vitus – epilepsy, Our Lady of Lourdes – bodily ills, Use of religious medal, holy water, etc.
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GEOGRAPHICAL DISTRIBUTION
b. Top Ten Organized Religions of the World RELIGION Christianity Islam Hinduism Buddhism Sikhism Judaism Baha’ism Confucianism Jainism Shintoism
PERCENTAGE 3.0% 20.1 13.3 5.9 0.4 0.2 0.1 0.1 0.1 0.0
POPULATION 2.1 billion 1.3 billion 851 million 375 million 25 million 15 million 7.5 million 6.4 million 4.5 million 2.8 million
c.
c. Largest Denominational Families in the United States 2001 DENOMINATION Catholic Baptist Methodist/ Wesleyan Lutheran Presbyterian Pentecostal, Charismatic Episcopalian/ Anglican Latter-Day Saints/ Mormon Church of Christ Congregational United Church of Christ Jehovah’s Witness Assemblies of God
ESTIMATED % OF U.S. POPULATION 24.5% 16.3% 6.8% 4.6% 2.7% 2.1% 1.7% 1.3% 1.2% 0.7% 0.6% 0.5%
ESTIMATED ADULT POPULATION 50,873,000 33,830,000 14,150,000 9,580,000 5,580,000 4,407,000 3,451,000 2,697,000 2,593,000 1,373,000 1,331,000 1,106,000
D. Giger and Davidhizar’s Transcultural Assessment Model: The Six Cultural Organzing Phenomena 36
Culturally diverse nursing must take into account six cultural phenomena that vary but are evident in all cultural groups and affect health care. These have been identified by Giger & Davidhizar, 1999, and Engebertson & Headley(2000), as: (1) environmental control, (2) biological variations, (3) social organization (4) communication, (5) space, and (6) time orientation.
1. ENVIRONMENTAL CONTROL – refers to the ability of members of a particular group to plan activities that control nature or direct environmental factors. • Plays an extremely important role in the way patients respond to health-related experiences, including the ways in which they define health and illness and seek and use health care resources and social supports. •
Examples of environmental control systems: complex traditional health and illness beliefs, the practice of folk medicine, the use of traditional healers, etc.
2. BIOLOGICAL VARIATIONS – The several ways in which people from one cultural group differ biologically (i.e., physically and genetically) from other cultural groups constitute their biological variations. These are: Body built and structure – specific bone structure and structural differences between groups. Example: smaller stature of Asians Skin color, including variations in tone, texture, healing abilities, and hair follicles. Example: African Americans – dark skinned; Europeans – light skinned Enzymatic and genetic variations, including differences in response to drug and dietary therapies Susceptibility to disease which can manifest as a higher morbidity rate of certain diseases within certain groups Nutritional variations. Examples: “hot and cold” preferences among Hispanic Americans, yin and yang among Asian Americans, rules of the kosher diet among Jewish and Islamic Americans, etc. Common nutritional disorder, lactose intolerance, is found among Mexicans. Africa, Asian, and Eastern European Jewish Americans.
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3. SOCIAL ORGANIZATION – refers to the ways in which groups determine rules of acceptable behavior and role of individual members. Family unit (nuclear, single parent, extended, blended) Children learn their cultural responses to life events from the family and its ethnoreligious group through socialization. Gender – gender roles vary according to cultural context: *patriarchal structure – husband/father is the dominant person (Latino, Hispanic and traditional Muslim families *matriarchal structure – the wife is responsible for child care and household maintenance whereas the father’s role is to support and protect the family members. Lifestyle – alternative lifestyles. Example: homosexual couples and communal groups Social organization also prescribes behavior for such significant events as birth, death, child rearing, and illness. Nurses must demonstrate respect for client’s lifestyles even when they differ from theirs by: Being aware of own tendency to be ethnocentric Being sensitive to client’s needs especially those expressed non-verbally Use self-awareness to determine the impact of own beliefs and values
4. SPACE (PROXEMICS) – The area around a person’s body, surrounding environment, and objects within that environment; affects people’s behaviors and attitudes toward the space around themselves. Territoriality refers to the behavior and attitude people exhibit about an area they have claimed and defend or react emotionally when others encroach on it. Both personal space and territoriality are influenced by culture, thus different ethnocultural groups have varying norms related to the use of space. Space and related behaviors have different meanings in the following zones: Intimate zone – extends up to 1 ½ feet. Acceptable only in private places because this distance allows adults to have the most bodily contact for perception of breath and odor, Personal distance – extends from 1 ½ to 4 feet. This is an extension of the self that is like a “bubble” of space surrounding the body. At this distance the voice may be moderate, body odor may not be apparent, and visual distortion may have disappeared. Social distance – extends from 4 to 12 feet. This is reserved for impersonal business transactions. Perceptual information is much less detailed. Public distance – extends 12 feet or more. Individuals interact only impersonally. Communicator’s voices must be projected, and subtle facial expressions may be lost. Use of personal space varies among individuals and ethnic groups. The extreme modesty practiced by members of some cultural groups may prevent members from seeking preventive health care.
5. Time Orientation (Temporal Relationships) – refers to viewing of time in the present,
past or future; varies among different cultural groups. Most cultures include all three time orientation, but one orientation is more likely to dominate the cultural perspective. Examples: American culture – future oriented; time is a highly valuable resource: do not waste time, “time is money” German culture – past-oriented society, where laying a proper foundation by providing historical background information can enhance communication Central American culture – present oriented Asian, Latin countries – punctuality is not taken seriously.
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Time Orientation To Past
Selected Consequences of Time Orientation Possible Consequences
When traditions conflict with a prescribed treatment regimen, The person may have trouble accepting or maintaining the plan of care. In contrast, a strong connection with the past may ground the person with others in the same culture and provide a sense of self that encourages positive health practices. To the present A present-oriented person may have little concern for long-term preventive health practices and may respond better to sort-term goals. In contrast, a present-oriented person may be most able to enjoy the here-and-now and may engage fully in exercise, enjoy nutritious food, and appreciate the company of others – all attributes associated with good health. To the future This person has little difficulties and inconvenience of the present, focusing instead on the future. The present is important only if what is happening now will help the person realize long-term goals. This person may have little trouble following a treatment plan as long as its benefits are clear. However, the person may have difficulty with chronic illnesses for which no complete cure is known. A future-oriented person naturally tends to become more of a presentoriented person with age because, as the future life becomes shorter, the present becomes more important. Source: Harreader, Helen and Mar Ann Hogan. Fubdamentals of Nursing. Saunders, An imprint of lsevier, Inc. reprinted 2005, p. 47.
4. Communication – Language differences possibly play the most important obstacle to providing multicultural health care because clients come from all over the world and they affect all stages of the patient caregiver relationship. to, and evaluate our experience.
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“Language allows us to initially identify, label, attach significance A. Basic/Related Concepts:
Communication occurs when a person (the sender (S) or encoder) sends a message to another person (the receiver (R) or decoder). Communication is most effective when the message received is exactly the same as the message that was sent and both sender and receiver agree on the meaning of the message. Communication fails when (1) the sender’s message is blocked for some reason and the receiver never gets the message; or (2) the message is distorted. Distortion of message occurs when the message has as different meaning for the receiver than the sender intended. Distortion is amplified when both receiver and sender fail to clarify message. Factors that can distort message: anger, fatigue, fear, pain, and anxiety. Communication may be blocked. Factors that foster blockage: different cultural, ethnic, racial, socioeconomic, or educational backgrounds. Example: Asians (Filipinos, Japanese, Chinese, etc) may silently accept a physician’s recommendation even when they do not understand the reasons for the medications or procedures that are ordered. B. Types of Communication: 1. Verbal – includes spoken or written word. Language is the code senders use to carry their message. Language barriers can cause severe communication problems between S and R.
Causes: 1. May arise from use of the language (e.g. S is speaking English and the R is speaking Spanish. 2. Can arise when the S uses technical terms, abbreviation, idioms or regionalisms that are unfamiliar to the receiver (e.g., when a nurse uses medical terms when explaining a procedure to a layperson). Every culture has standards for verbal communication – especially for word choice, the degree of emotion considered appropriate, volume and speed of speech, inflection, directness, and the use of silence.
•
Word Choice: American speech is filled with abbreviated words, slang, and jargon. Americans tend to communicate in an informal way with superiors and subordinates alike. Japanese use of language is distinguished by many levels of formality and directness depending upon the status of the people who are conversing. Distinctions are also made between men’s and women’s speech. Choice of word depends largely on the relationship between the people who are communicating.
•
Emotional Expressiveness, Tone, Pitch, Volume of Voice, and Speed of Speech White American middle-class culture values a controlled tone and some emotional restraint Many black Americans are more verbal and value emotional expressiveness in conversation
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Appalachians – speak very slowly and seem to dwell on each word, giving their speech a hesitant, disjointed quality. Many Asians and Native Americans display great emotional restraint in their speech patterns, speaking slowly and quietly. These cultures value the ability to endure pain and grief with silent stoicism. Southern Europeans are typically warm, expressive; will loudly express their discomfort Hispanics use a lot of endearing words, are warm and expressive.
•
Voice Inflection When emphasis is placed on certain words more than the words themselves. Example: “What do you need now?” “What do you need now?”
•
Directness in Speech Americans – quite direct, they go straight to the point rather than wasting time on lengthy preliminaries or long silences. Japanese – strive to be polite, diplomatic, and tactful. Mexicans –may take time for small talk and then lead into a discussion.
•
Use of Silence Some cultures value silence, whereas others feel that silence is a vacuum that must immediately be filled with word. Among Native Americans – silence is an essential element of showing respect and understanding. In some Arab cultures, silence may indicate concern for personal privacy. In French, Spanish, and Eastern European cultures silence may be a sign of agreement. Silence during a conversation gives each person an opportunity to speak without having to interrupt.
B. Nonverbal Communication It has been estimated that as much as 2/3 of all communication is non-verbal consisting of messages that are conveyed via body language and facial expressions.
•
Gestures and Facial Expressions
•
Common types of nonverbal communication may differ from culture to culture. A smile may imply acceptance and compliance, or may mean respect and social grace, or flirting. In nearly all cultures, people used their mouths and eyebrows to convey anger, surprise, pleasure, fear and hand gestures to convey openness or intimidation.
Eye Movement and Eye Contact “The eyes are the windows of the soul.”
When a person avoids eye contact, many Americans assume that it is a negative sign. It is not unusual for an American to say, “Look at me when I talk to you.” or “She must be lying. Did you notice that she avoided looking at us?” American physician and nurses usually note if a patient avoids eye contact when they perform a psychosocial assessment. Some Asians and Native Americans believe that prolonged eye contact is rude and an invasion of privacy.
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•
Native Americans may direct their eyes to the floor when they are paying attention or thinking. Muslim women may avoid eye contact as a show of modesty.
Touch
Touch patients only when you know touching is acceptable. Conveys many meanings: gentle, sensual, harsh or brutal We use touch to connect with others and to establish a feeling of warmth, approval, emotional support, and intimacy. Touch can also indicate anger, aggression, frustration, and a desire to control others by invading their personal space. Cultures have specific guidelines for times and situations when it is acceptable to touch others.
Handshake – a form of greeting, esp. when introduced; consummate a business deal Native Americans – view a firm handshake as aggressive and even offensive. Many Westerners think nothing of kissing or hugging a friend as a form of greeting when meeting in public places; in traditional Asian cultures, such behavior is reserved for intimate relationship in private settings. In many Asian cultures (Indians, Vietnamese, Japanese, Thai) avoid touching the head because the head has been traditionally considered to be the “the abode of the spirit.” •
Posture
Helps to communicate how one person feels towards another Middle-class Americans may lean in the direction of individuals they like or respect Posture can also communicate a tense or relaxed state Rigid muscles and a flexed body may indicate physical pain.
C. Barriers to Transcultural Communication Lack of knowledge – remember that each culture dictates what is “normal” when sick. Examples: • Japanese patients might react with silent obedience to your request • White middle-class patients might wish to discuss their nursing care with you • Italian patients might dramatically express their discomfort • Inner city youth might loudly demand your attention
Fear and Distrust – some people from diverse culture pass through different stages of adjustment during their initial encounter: • Fear • Dislike • Distrust • Acceptance • Respect • Trust • Like
Racism Bias and Ethnocentrism Stereotyping Ritualistic behavior Language barrier – 3 types of language barriers:
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• •
•
Foreign languages Different dialects and regionalisms *There are 3 major Chinese dialects: Mandarin, Cantonese, and Shanghainese *Aside from the 3 main Filipino languages there are numerous regional dialects: Ilongo. Cebuano, Ibanag, Itawis Idioms, slang, and “street talk”
Differences in perceptions and expectations Source: Munoz, C. and Kuckmann, op. cit. 177. D. The Use of an Interpreter: A way to resolve language barrier. When obtaining the precise meaning of words in a language that is difficult, it is best for health care providers to obtain someone who can interpret the meaning and message, not just translate the individual words. Some guidelines for communicating with non-English speaking clients:
Use interpreters rather than translators. Translators just restate the words from
one language to another. An interpreter decodes the words and provides the meaning behind the message. Use dialect-specific interpreters in the health-care field. Use interpreters trained in the health-care field. Give the interpreter time alone with the client. Provide time for translation and interpretation. Use same-gender interpreters whenever possible. Maintain eye contact with both the client and interpreter to elicit feedback: read nonverbal cues. Speak slowly without exaggerated mouthing, allow time for translation, use the active rather than the passive tense, wait for feedback, and restate the message. Do not rush; do not speak loudly. Use a reference book, a dictionary, etc. Use as many words as possible in the client’s language and nonverbal communication when unable to understand the language. Use phrase charts and picture cards if available. During the assessment, direct your questions to the patient, not to the interpreter. Ask one question at a time and allow interpretation and a response before asking another question. Be aware that interpreters may affect the reporting of symptoms, insert their own ideas, or omit information. Remember that clients can usually understand more than they can express; thus, they need time to think in their own language. They are alert to the health care provider’s body language, and they may forget some or all of their English in time of stress. Avoid the use of relatives who may distort information or not be objective. Avoid using children as interpreters, especially with sensitive topics. Avoid idiomatic expressions and medical jargon. If an interpreter is unavailable, the use of translator may be acceptable. The difficulty with translation is omission of parts of the message, distortion of the message, including transmission of information not given to the speaker, and messages not being fully understood. If available, use an interpreter who is older than the patient. Review responses with the patient and interpreter at the end of a session. Be aware that social class differences between the interpreter and the client may result in the interpreter’s not reporting information that he or she perceives as superstitious or unimportant. Source: Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd ed. 2003. F.A. Davis Co. , p.15.
E. SELECTED EXAMPLES OF ETIQUETTE AS RELATED TO SELECTED CULTURAL PHENOMENA
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TIME
Visiting Being on time Taboo times
Inform person when you are coming Avoid surprises Inform person when you are coming Explain your expectations about time Ask people from other regions and cultures what they expect Be familiar with the times and meanings of person’s ethnic and religious holidays
SPACE
Body language and distances
Know cultural and/or religious customs regarding contact, such as eye and touch, from many perspectives
COMMUNICATION
Greetings
Know the proper forms of address for people from a given culture and the ways by which people welcome another. Know when touch, such as embrace or handshake, is expected and when physical contact is prohibited. Gestures do not have universal meaning; what is acceptable to one cultural group is taboo with another. Smiles may be indicative of friendliness to some, taboo to others. Avoiding eye contact may be a sign of respect
Gestures Smiling Eye contact
SOCIAL ORGANIZATION
Holidays Special events Births Weddings Funerals
BIOLOGICAL VARIATIONS
Food customs
ENVIRONMENTAL CONTROL
HEALTH practices and remedies
Know what days are important and why, whether or not to give gifts, what to wear to special events, what the customs and beliefs are. Know how the event is celebrated, meaning of colors used for gifts, expected rituals at home or religious services. Know what can be eaten for certain events, what foods may be eaten together or are forbidden, what and how utensils are used. Know what the general HEALTH traditions are for a given person and question observations for validity
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Contextual cuingUse of silenceDialects, written
loyaltyFamily: Hierarchical structure,
Present
Non-contact
preference
Lactose intoleranceHypertensionCoccidioidomycosisStomach cancerLiver cancer
Traditional practitioners: Chinese doctors, herbalistsUse of traditional medicinesTraditional health and illness beliefs
characteristicsNational language
Many religions, incl. Taoism, Buddhism, Islam, and ChristianityDevotion to tradition
Nonverbal and
Southeast Asia (Cambodia, Laos, Vietnam)JapanKoreanPhilippinesHawaiiChinaAsian
Source: Adapted from Dresser, N. (1996). Multicultural manners. New York:Wiley. Copyright c 1960 John Wiley & Sons, Inc.
F. CROSS-CULTURAL EXAMPLES OF CULTURAL PHENOMENA IMPACTING NURSING CARE
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46
OrganizationsCommunity social
Family: many female,
illness beliefsTraditional health and
single parent
Present over Future
SpaceClose Personal
Lactose intoleranceCoccidiomycosisStomach cancerCancer of the esophagusHypertensionSickle cell anemia
Large, extended family
networks
workerTraditional healer: Root Folk medicine tradition
Strong church affiliation
within community
Spanish, and FrenchDialect pidgin, Creole,National languages
West Indian Islands (Dominican Republic, Haiti, Jamaica)Many African countriesWest coast (as slaves)African
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Some remaining folk
medicine traditions
England
GermanyEurope
Future over present
Primary reliance on modern
ThalassemiaDiabetes mellitusHeart diseaseBreast cancer
health care
Judeo-Christian religionsExtended familiesNuclear families
illness beliefsTraditional health and system
Social organizationsCommunity
Italy
Many learn English National languages
Ireland
immediately
Other European
Distant Southern countries: closer contact and touchAloofNon-contact people
Countries
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OrganizationsCommunity social grps.
families
Extremely family oriented
illness beliefsTraditional health and I
Biological and extended
Present
Diabetes mellitusCirrhosis of the liverHeart diseaseAccidents
Use of silence and body Tribal languages
500 American American Indian
Space very important and has no boundaries
language
Indian tribes
medicine manTraditional healer: Folk medicine tradition
Children taught to respect
traditions
Eskimos Aleuts
Lactose intoleranceCoccidioidomycosisParasitesDiabetes mellitus
illness beliefsTraditional health and
VARIATIONSBIOLOGICAL
CONTROLENVIRONMENTAL
SOCIAL ORGANIZATION
TIME ORIENTATION
SPACE
COMMUNICATION
NATIONS OF ORIGIN
partera, senora
esperitista,
Curandero,
Traditional healers:Folk medicine tradition
organizationssocial Community GodparentsCompadrozzo;Extended familiesNuclear family
Present
Value physical presenceEmbracingTouch, HandshakesTactile relationships
Spanish or Portuguese primary language
Central and South American Mexico Cuba SpainHispanic countries
Compiled by Rachel Spector, R.N., Ph.D. In Potter, P.A. and Perry, A.G. (1997). Fundamentals of nursing: concepts, process, and practice (ed. 4). St. Louis: Mosby.
G. TRANSCULTURAL ASSESSMENT: BASIC PRINCIPLES OF CULTURAL ASSESSMENT 1. All cultures must be viewed in the context in which they have developed. Cultural practices develop as a “logical” or understandable response to a particular human problem, and the setting as well as the problem must be considered. 2. Understanding the premises of the behavior must be examined. Example: The Hispanic clients refusal to take a “hot” medication with a “cold” liquid is understandable if the client is aware that many Hispanic patients adhere to hot/cold theories of illness causation.
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3. The meaning and purpose of the behavior must be interpreted within the context of the specific culture. Example: Close relationship often seen in Asian and Hispanic cultures may be viewed as abnormal in European American families. 4.There is such a phenomenon as intracultural variation. Not every member of a cultural group displays all the behaviors that we might associate with that group. Example: Not every Filipino will adhere to the same methods of folk healing. Source: Andrews and Boyle, Transcultural concepts in nursing care (2003) 4rd ed Lippincott Wiliams & Wilkins, Philadelphia, p. 338.
Sample Assessment Questions 1. To what cause(s) do you attribute your illness or disease (e.g., divine imbalance in hot/cold or yin/yang, punishment for moral transgression, loss, pathogenic organisms)?
wrath, hex, soul
Ano ang dahilan ng inyong sakit (halimbawa: galt ng diyos, hindi pantay na lamig o init, yin/yang, kaparushan sa maling Gawain, sumpa kawalan ng kaluluwa, mickrobyo)?
2. What are your cultural beliefs about the ideal body size and shape? What is the patient’s self-image compared to the ideal? Anu-ano ang inyong paniwalang cultural tungkol sa kanaisnais a katawan o hugis?
3. What name do you give to your health related condition? Ano ang taway ninyo sa iyong kalagayan?
4. What do believe promotes health (eating certain foods; wearing amulets to bring good luck; sleep; rest; good nutrition; exercise; prayer; rituals to ancestors saints, or intermediate deities)? Sa palagay ninyo ano po ang pamamaran upang makabuti and inyong kalusugan? Kahgaya ng pagpili ng tamang pagkain, pagsuot ng anting-anting, pagbigayang swerte, pagtulog, pagehersisyo, pagdadasal, agsamba sa mga santo?
5. What is your religious affiliation?)? How actively involved are you in the practice of your religion? Ano po and relihyon ninyo? Gaano kayo kaaktibo sa inat-ibang Gawain ng inyong relihyon?
6. Do you rely on cultural healers? Who determines when you are sick and when you are healthy? Who influences the choice/type of healer and treatment that be sought?
should
Naniniwala ba kayo sa mga hilot o albularyo? Sino and nagsasabi kung may sakit kayo o wala. Sino ang namimili ng uri ng panggagamot/mangagamot?
7. What types of cultural practices do you patient engage or use (use of herbal remedies, potions, massage, wearing of talisman, copper bracelets, or charms to discourage evil spirits; healing rituals, incantations, prayers)? Nong klase ng gawain or paniniwala and inyomg ginagamit o ginagawa (paggamit ng mga gamut, gayuma, masahe, anting-anting, porselas, o mga alahas na nagtataboy ng masamang espiritu, dasal)?
8. How do you perceive biomedical/scientific healthcare providers? How do you and your family perceive nurses? care?
What are your expectations of nurses and nursing
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Ano ang tingin ninyo sa mga nagbibigay ng syentipikong panggagamot? Ano ang tingin ninyo at inyong pamilya sa mga narses? Ano ang inaasahan ninyo sa mga nars at pamamaran ng pagalaga?
9. What comprises appropriate “sick role” behavior? Who determines what symptoms constitute disease/illness? Who decides when you are no longer sick? Who cares for for you at home?
10.
Ano ang bumubuo ng tamang pag-aasal ng may sakit? Sino ang nagsasabi kung ano ang sintomas ng inyong sakit? Sino ang nagdedesisyon kung may sakit ka o wala na? Sino ang nag-aalaga sa iyo sa bahay? How does your cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses? Ano ang tingin ng nyong grupo cultural sa mga taong may sakit sa pag-iisip? Ano ang pagkakaiba ng phisikal ng paguugali sa pag-iisip ba karamdaman?
Source: Andrews, M. & Boyle, J. (2002b). Transcultural concepts in nursing care (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Assessment questions revised and translated in Pilipino.
H. BARRIERS TO HEALTH CARE In order for people to receive adequate health care, a number of considerations need to be addressed. Availability: Is the service available and at a time when needed? For ex.: No services after 6:00 p.m. Accessibility: Transportation services may not be available, or rivers and mountains may make it difficult for people to obtain needed health-care services when no health provider is available in their immediate region? Affordability: The service is available, but the client does not have financial resources. Appropriateness: Maternal and child services are available, but what might be needed are geriatric and psychiatric services. Accountability: Are health-care providers accountable for their own education and do they learn about the cultures of the people they serve? Adaptability: A mother brings her child to the clinic for an immunization. Can she get a mammogram at the same time or must she make an appointment? Acceptability: Are services and client education offered in a language preferred by the client? Awareness: Is the client aware that needed services exist in the community? The service may be available, but if clients are not aware of it, the service will not be used. Attitudes: Adverse subjective beliefs and attitudes from caregivers means that the client will not return for needed services until the condition is more compromised. Do health-care providers have negative attitudes about patients’ home-based traditional practices? Approachability: Do clients feel welcomed? Do health-care providers and receptionists greet patients in the manner in which they prefer? This includes greeting patients with their preferred names.
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Alternative practices and practitioners: Do biomedical providers incorporate clients’ alternative or complementary practices into treatment plans? Additional services: Are child and adult services available if a parent must bring children or an aging parent to the appointment with them? Source: Purnell, Larry D. & Betty J. Paulanka, op. cit. p. 35.
UNIT V. APPLICATION OF ORGANIZING CULTURAL PHENOMENA TO PEOPLE FROM DIFFERENT CULTURAL HERITAGE: AN INTERACTIVE SESSION INTERACTIVE SESSION IS AN OPPORTUNITY FOR THE STUDENT TO PRESENT:
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A. INDIVIDUALLY Present and submit a “Search Paper” on a transcultural subject/phenomenon/issue/topic, or about culturally based health-related beliefs and practices of people from diverse backgrounds. You may search the internet or use any book or magazine as source material. Credit Source.
Search Paper must not be less than 3 pages long on 8 1/2 x 11 bond, double-spaced,
Font 12. Must be submitted on day of Midterm. No late papers will be accepted. You may be requested to provide a diskette of your paper. If time permits, you may be asked to read your “Search Paper” in class.
B. AS A GROUP MEMBER Group report on application of Organizing Cultural Phenomena to Nursing Care in diverse groups from Different Cultural Heritage. A. People of Filipino Heritage B. People of Japanese Heritage C. People of Chinese Heritage VII.People of Indian (Hindu) Heritage VIII.People of Mexican Heritage IX. People of Arabian Heritage X. People of African-American Heritage XI. People of Anglo-American Heritage XII.People of Italian Heritage XIII.People of Jewish Heritage
Group report must contain information given below.
I.
II.
III.
IV.
Social
Organization Family: Gender Roles Religion Others Biological Variation Dietary Practices/Preferences Increased Susceptibility to: Environmental Control Definition of Health Causative Factors of Illness Communication Language(s) Silence
Eye Contact Other V. Space Social Distance Touch VI. Time Orientation Present oriented Past oriented Future oriented Flexible VII. Cultural beliefs and practices across lifespan VIII. Nursing Implication/s of the different cultural phenomena described.
You are encouraged to be as creative as possible. Make report concise. You are NOT TO READ YOUR REPORT in its entirety. Submit hard copy of report before or on the day of reporting.
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UNIT VI. Contemporary Challenges in Transcultural Nursing A. TRANSCULTURAL ASPECTS OF PAIN “Pain is whatever the experiencing person says it is, existing whenever he says it does.” McCafery (1979) WHY IS THE SUBJECT OF PAIN A CHALLENGE IN CONTEMPORARY TRANSCULTURAL NURSING? 1. Definition Pain – an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. U.S. Department of Health and Human Services, 1992 Definitions of pain are diverse because of its complex nature and because of the many different existing perspectives on pain. 2.
Basic/Related Concepts
3.
Pain is a universally recognized phenomenon and the most frequent and compelling reason for seeking health care. Pain is a very private experience and is influenced by cultural heritage. Thus, expectations, manifestations and management of pain are embedded in a cultural context. Therefore, understanding culture is critical when dealing with clients in pain. The experience of pain is determined by the: meaning of painful stimuli for individuals; way individuals define their situation; and, impact of previous personal experiences help determine the experience of pain. Measurement of Pain
In terms of pain measurement, it is generally believed that humans normally experience similar pain thresholds. Research suggests that there are no differences in the amount of stimulation needed to produce a detectable sensation. Measurement of pain would differ in pain threshold, pain tolerance and encouraged pain tolerance. Pain Threshold – refers to the point at which the individual reports that a stimulus is painful. For example, some people required higher intensities before describing the stimuli as painful. Pain Tolerance – is the point at which the individual withdraws or asks to have the stimulus stopped. Cultural background appears to have a strong influence on pain tolerance levels. Examples from studies using radiant heat techniques in South African Americans, Northern European Americans, Russian Jewish Americans, and Italian Americans.
Northern European Americans – had the highest pain and pain reaction threshold Italian Americans – vocalized their pain African Americans – did not verbally express their pain
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Encouraged Pain Tolerance – is the amount of painful stimuli an individual accepts when encouraged to tolerate increasingly higher levels of stimulation. Example: North American Plains Indians – tolerate large amounts of pain as described in Sun Dance “self-torture” ceremonies. Nursing Implication: Because many factors, aside from culture, play a role in pain perception, the nurse should not expect all clients to react in the same way to painful stimuli. 4.
Expressions of Pain
Expressions of pain vary from culture to culture. What are appropriate verbal
behavior and body language in response to pain are dictated by culture. Example: the Japanese culture does not approve of loud verbal expressions of pain. Within each culture, expressions of pain may vary from person to person. How people express their pain is strongly influenced by their level of assimilation and acculturation. In relation to gender – men demonstrate greater stoicism than women. However, stoicism decreases with increasing age. (Zatzick & Dimsdale, 1990)
Categories of responses: a. Stoic – responses to pain are less expressive verbally and nonverbally. Some reasons are: Denial of pain A desire to be the perfect patient Avoiding loss of control Avoiding worrying the family Fear of addiction Fear of overdose and side effects from pain medications Paying a price for past sins and future joys Acceptance of the pain b. Emotive – responses are quite vocal and will express their pain loudly. Some reasons are: Fear of the pain A desire for help and fear of not receiving it Anger Grief over loss of dignity Exorcism of the pain through the act of crying out Experiencing great pain 4. Questions on Cultural Attitude Toward Pain CHARACTERISTIC Experience of pain
QUESTIONS How do we express pain? Is it ok to show pain? Is there a difference in how people in my culture show pain (gender, age, married, poor/rich)?
Causes of pain
What causes physical pain? Does the evil eye cause pain? Is pain a form of punishment? An opportunity For reward in the afterlife? Or atonement?
Treatment of pain
Does every pain justify relief? What traditional and other healing methods are used? 55
What is the impact of religion on treatment of pain? Do you seek medical attention self-medicate? What are the beliefs about using narcotics to treat pain? Values about pain
What types of pain have stigma? Are people avoided/marginalized? Do people use pain to seek attention?
Source: http://tcn.sagepub.com 5.
Applying Transcultural Nursing Concepts to People in Pain Respect clients as individuals Respect the client’s response to pain and their autonomy regarding choices they make about pain control. Never stereotype a person based on culture Communicate openness, acceptance, and a willingness to listen to views of client Seek the support of colleagues and health team members to assist you in exploring culture-specific pain management strategies.
B. CULTURAL DISPARITIES IN HEALTH AND HEALTH CARE DELIVERY 1.
Some factors that account for cultural disparities in the delivery of health care.
a. Minority groups. According to ANA (1998), minorities experience some diseases at a much higher rate than white Americans. Cancer is the leading cause of death for Chinese and Vietnamese individuals. Vietnamese women suffer from cervical cancer at nearly 5x the rate of white American women. Compared with the general population, Hispanics have a higher incidence of cancer of the stomach, esophagus, pancreas, and cervix. African-Americans have a life expectancy that is six times shorter than the life expectancy for white Americans. The Native American population has significant rates of diabetes, sudden infant death syndrome, and congenital malformation. Overall Native Americans and Alaskan Native rates of diabetes, tuberculosis fetal alcohol syndrome, alcohol-related morbidity and mortality, and suicide exceed those of other racial and ethnic groups in the United States. (Kavanagh et al., 1999, p. 10). b. Vulnerable Populations As a result of societal changes more people are at risk for health problems. As a result, many vulnerable populations are underserved because of the high demand for services, lack of services, and limited availability and access to services. Groups that are especially susceptible for health-related problems include the poor, the homeless, migrant workers, abused individuals, the elderly, pregnant adolescents, and people with std’s such as HIV/AIDS. c. The Poor In every race and ethnic group there is a relationship between socioeconomic status and health. Poverty affects health status and accessibility to health care services. Living in poverty means being unable to meet the financial demands of basic living expenses, such as food, shelter, and clothing. “Childhood poverty has long-lasting negative effect on one’s health. Children in low-income families fare less well than children in more affluent families.” (U.S. Bureau of the Census, 2000).
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The poor population has more complex health problems including a higher incidence of chronic illness. (U.S. Bureau of the Census, 2000). The following high risk factors are related to lower income: (CDC, 1998) • Higher prevalence with cigarette smoking • Greater incidence of obesity • Elevated blood pressure • Sedentary lifestyle • Less likely to be covered by health insurance
•
Less likely to receive preventive health care services
Poor Production
Insufficient Salaries Poor intellectual and physical development
Increased Sickness
Poor economic production
Lack of Preventive Care
Subsistence Economy
Lack of Potable Water Poor Nutrition
Important role of high human reproduction
High Cost of HealthCare needs
Poor and Densely Populated Housing
High incidence of illness
The Cycle of Poverty d. The Homeless In the U.S. it is estimated that 350,000 to 6 million people are homeless (Walker, 1998, p. 27). Societal factors that contribute to homelessness are: Lack of affordable housing Increasingly stringent criteria for public assistance Decreased availability of social services Inadequate or lack of employment A history of psychological trauma Deinstitutionalization of clients from mental health facilities community support (such as half-way houses and group homes).
C.
without
CULTURAL DIVERSITY IN THE WORKFORCE 1. The aspects of cultural diversity in the workforce:
Race and ethnicity The racial/ethnic diversity among registered nurses in the United States (1993) RACE BLACK (NON-HISPANIC) HISPANIC ASIAN/PACIFIC ISLANDER AMERICAN INDIAN ALASKAN NATIVE GRADUATES OF FOREIGN PROGRAM
NO. OF REGISTERED NURSES IN THE U.S. 90,600 30,400 76,000 10,000 73,000
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Sex – the net rate of growth between 1986 and 2000 in the U.S. labor force: RACE HISPANIC FEMALES ASIAN FEMALES HISPANIC MALES ASIAN MALES AFRICAN AMERICAN FEMALES AFRICAN AMERICAN MALES WHITE FEMALES WHITE MALES
% GROWTH IN U.S. 85% 83% 68% 61% 83% 24% 22% -9%
Source: Schwartz & Sullivan, 1993
2. The effects of multicultural healthcare workforce a. Positive: Healthcare workers from diverse background bring a variety of experiences and a wide range of knowledge to the health care setting They offer fresh ideas and different solutions to long- term problems. Foreign nurses can help American nurses understand and relate better to patients who are also from diverse cultural backgrounds. b. Negative: Cultural diversity in the workforce may produce serious barriers and conflicts. 3. Barriers/conflicts in the workforce
Different cultural patterns and biases that affect the relationship between
physicians, nurses and ancillary personnel. Example: many male physicians from the Middle East think of women as subservient and feel that they have the right to shout at female nurses.
Racism and prejudice that can undermine professional relationships. Three types of racism:
a. Individual racism – Discrimination based on visible biological characteristics. Example: black skin or the epicanthic fold of the eyelid in Asians.
b. Cultural racism – Occurs when an individual or institution claims that its
c.
d.
cultural heritage is superior to that of other individual institutions. Example: During World War II, the Nazis claimed that their Aryan genetic and cultural heritage was superior to the Jewish heritage. They justified persecution of the Jews by convincing themselves that the Jews were an inferior people. Institutional racism – Institutions (universities, businesses, hospitals, schools of nursing) manipulate or tolerate policies that unfairly restrict the opportunities of certain races, cultures, or groups. Example: At one time, “black” people were not allowed to use the comfort room used by “white” people, sit in the front row of transportation facilities, enroll their children in universities, etc. Bias and ethnocentrism – Whatever their cultural background, people have a tendency to be biased toward their own cultural values and to feel that their values are right and the values of others are wrong or not as good. Example: “White” nurses are biased not only toward their own health care system but also toward their learned values, such as cleanliness. Cleanliness is essential to good health care. A nurse who finds that a child is dirty might translate her observation into a value judgment that the mother is not practicing good health practices.
Clashes in values that arise between foreign nurses and nurses trained in the
United States. In a study of Philippine American nurses, the most important finding was the theme of obligation to care that prevailed in all aspects o their work (Spangler, 1992). This theme was expressed in 3 important ways:
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(1) Expressed seriousness and dedication to work; (2) Attentiveness to the patients’ physical comfort; and, (3) Respect and patience. Example of conflict: The theme of an obligation to care reflected the Philippine American nurses’ strong belief that bedside nursing is truly the core of nursing practice. This value conflicts with the attitude of some American nurses that the physical care of patient is devalued work with low prestige and should therefore be delegated to ancillary personnel.
Different perceptions of nursing responsibilities and patient care that are based on different cultural values. Example: Unlike Western nurses, Asian nurses tend to accept difficult assignments without complaint. They may also be more willing to do what American nurses might consider demeaning (e.g., cleaning cabinets).
Differences in time orientation. Cultural groups are either past, present, or future oriented. American value future over the present, Southern blacks and Puerto Ricans value the present over the future, and Mexican Americans value the present. Example: People who work in the operating room must be both future and present oriented. Surgical cases are scheduled ahead of time (future) and health workers must abide by the calendar and clock, but once surgical procedure begins, nurses must now switch to a present orientation)
Language differences that result in serious miscommunications. Example: A Filipino nurse who was temporarily assigned to an unfamiliar medical unit transcribed a telephone order from a physician. The physician said: “Give Johnson 50 mg. Demerol for pain. If she is still complaining of pain after an hour, call me and I’ll increase the dosage.” When transcribing the order the nurse missed the physician’s reference to the patient as a she, a common error among Filipinos and other Asians. Mr. Johnson, who happened to be on the same ward might have received the medication had another nurse not intervened and questioned the order. Source: Muniz & Luckmann, op. cit.
4. Promoting harmony in multicultural workplaces
Identification of cultural values of the organization, institution, or agency Mission statement and policies about diversity Zero tolerance for discrimination Effective cross-cultural communication Skill with conflict resolution involving diversity Commitment to multiculturism at all levels of management
5. Strategies to promote effective cross-cultural communication in the multicultural workplace. STRATEGIES
1. 2. 3. 4. 5.
6.
Pronounce names correctly. When in doubt, ask the person for the correct pronunciation. Use proper titles of respect: “Doctor,” “Reverend,” “mister.” Be sure to ask for the person’s permission to use his or her first name, or wait until you are given the permission to do so. Be aware of gender sensitivities. If uncertain about the marital stats of a woman or her preferred title, it is best to refer to her as Ms. (pronounced mizz). Be aware of subtle linguistic messages that may convey bias or inequality, for example, referring to a white man as Mister while addressing a Black female by her first name. Refrain from Anglicizing or shortening a person’s given name without his or her permission. For example, calling a Russian American “Mike” instead of Mikhael, or shortening the Italian American Maria Rosa to Maria. The same principle applies to the last name, or surname. Call people by their proper names. Avoid slang such as “girl”, “boy”, “honey”,
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7.
8. 9.
10. 11. 12. 13.
14.
15.
16. 17.
“dear”, “guy”, “fella”, “babe”, “chief”, “mama”, “sweetheart”, or similar terms. Refrain from using slang, pejorative, or derogatory terms when referring to persons ethnic, racial, or religious groups, and convey to all staff that this is a work environment in which there is zero tolerance for the use of such language. Violators should be counseled immediately. Identify people by race, color, gender, and ethnic origin only when necessary and appropriate. Avoid using words and phrases that may be offensive to others. For example, “culturally deprived” or culturally disadvantaged” imply inferiority, and “nonWhite” implies that White is the normative standard. Avoid clichés and platitudes such as “Some of my best friends are Mexicans” or “I went to school with Blacks”. Use language in communication that includes all staff rather than excludes some of them. Do not expect a staff member to know all other employees of his or her background or to speak for them. They share ethnicity, not necessarily the same experience, friendship, or beliefs. Communications describing staff should pertain to their job skills, not their color, age, sex, race, or national origin. Refrain from telling stories or jokes demeaning to certain ethnic, racial, age, or religious groups. Also avoid those pertaining to gender-related issues or persons with physical or mental disabilities. Convey to all staff that there will be zero tolerance for this inappropriate behavior. Violators should be counseled immediately. Avoid remarks that suggest to staff from diverse backgrounds that they should consider themselves fortunate to be in the organization. Do not compare their employment opportunities and conditions with those people in their country of origin. Remember that communication problems multiply in telephone communications because important nonverbal cues are lost and accents may be difficult to interpret. Provide staff with opportunities to explore diversity issues in their workplace, and constructively resolve differences.
Source: Boyle and Andrews, 4th ed. op. cit., pp. 380, 398.
D. TRANSCULTURAL VALUES AND ETHICS “The nurse…promotes an environment in which the values, customs, and spiritual beliefs of the individuals are respected.” International Council of Nurses, 1973. Cultural values – are principles or standards that members of a cultural group share in common.
1. Basic/Related Concepts a. Accepting and respecting the values of patients from other cultures is the first step toward successful transcultural communication.
b. Values have important functions: They provide people with a set of rules by which to govern their lives. They serve as a basis for attitudes, beliefs, and behavior. They help to guide actions and decisions They give direction to people’s lives and help them solve common problems. They influence how individuals perceive and react to other individuals. They help determine basic attitudes regarding personal, social and philosophical issues. They reflect a person’s identity and provide a basis for self-evaluation. c. Values differ from culture to culture. For example: Examples of traditional Asian, Mainstream American, and Hispanic values. ASIAN VALUES Group
AMERICAN VALUES Individuality, independence
HISPANIC VALUES Group
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Submission to authority Extended family Tradition Respect for elders Respect for the past Conformity Fatalism Acceptance /resignation
Resistance to authority Nuclear/blended family Innovation Emphasis on youth Future orientation Competition Self-determination Aggression/assertion
Submission to authority Extended family Tradition Respect for elders Present orientation Conformity Fatalism Acceptance/resignation
d. Culture care values carry cultural care meanings. To provide congruent care the
nurse must understand that cultural values carry care meanings which influence nurse-client interaction, provide useful information about the client’s expectations of care, and influence the client’s sense of appropriate sick role behaviors, choice of healers, views toward technology, and health-related beliefs and practices. Examples of cultural values and culture care meanings and action modes for selected groups. CULTURAL VALUES ANGLO AMERICAN CULTURE (MAINLY U.S. MIDDLE AND UPPER CLASSES) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Individualism- focus on self-reliance Independence and freedom Competition and achievement Materialism (things and money) Technology dependent Instant time and actions Youth and beauty Equal sex rights Leisure time highly valued Reliance on scientific facts and numbers Less respect for authority Generosity in time of crisis
MEXICAN AMERICAN CULTURE 1. Extended family valued 2. Interdependence with kin and social activities
3. 4. 5. 6. 7. 8. 9.
Patriarchal (machismo) Exact time less valued High respect for authority and the elderly Religion valued (many Roman Catholics Native food for well-being Traditional folk-care healers for folk illnesses Belief in hot/cold therapy
HAITIAN AMERICAN CULTURE 1. Extended family as support system 2. Religion – God’s will must prevail 3. Reliance on folk foods and treatments 4. Belief in hot/cold theory 5. Male decision makes and direct caregiver 6. Reliance on native language
AFRICAN AMERICAN CULTURE 1. Extended family networks 2. Religion valued (many are Baptists 3. Interdependence with “Blacks” 4. Daily survival 5. Technology valued, e.g., radio, care 6. Folk (soul) foods
7.
Folk healing modes 8. Music and physical activities NORTH-AMERICAN INDIAN CULTURE 1. Harmony between land, people, and environment 2. Reciprocity with Mother Earth 3. Spiritual inspiration (spirit guidance) 4. Folk healers (shamans; the circle and four directions)
CULTURAL CARE MEANINGS AND ACTION MODES 1. 2. 3.
4.
Stress alleviation by Physical means Emotional means Personalized acts doing special things giving individual attention Self-reliance (individualism) by reliance on self reliance on self (self-care) becoming as independent as possible reliance on technology Health instruction teach us how “to do” this care for self Give us the “medical” facts
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Succorance (direct family aid) Involvement with extended family (“other care”) Filial love/loving Respect for authority Mother as care decision maker Protective (external) male care Acceptance of God’s will Use of folk-care practices Healing with foods Touching
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Involve family for support (other care) Respect Trust Touching (body closeness) Reassurance Succorance Spiritual Healing Use of folk food, care rituals Avoid evil eye and witches Speak the language
1. 2. 3. 4. 5. 6. 7.
Concern for “my brother and sisters” Being involved Giving presence (physical) Family support and get togethers” Touching appropriately Reliance on folk home remedies Rely on “Jesus to save us” with prayers and songs
1. Establishing harmony between people and environment with reciprocity 2. Actively listening 3. Using periods of silence (“Great Spirit” guidance)
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5. 6. 7. 8. 9.
Practice culture rituals and taboos Rhythmicity of life and nature Authority of elder Pride in cultural heritage and “nations” Respect and value for children
4. 5. 6.
Rhythmic timing (nature, land, and people) in harmony Respect for native folk healers, careers, and curers (use of circle) Maintaining reciprocity (replenish what is taken from Mother Earth)
These findings were from the author’s (Leininger) transcultural nurse studies (1970, 1984) and other transcultural nurse studies in the United States during recent two decades. From M. M. Leininger (1991). Culture care diversity and universality: A theory of nursing (pp. 355-357). New York:National League for Nursing Press. Sources: Andrews and Boyle, op. cit. 86-88. Kozier, op. cit. 209. Munoz, Cora and Joan Luckmann, Transcultural Communication in Nursing. 2nd ed. C 2005, Delmar Learning. p. 24, 29. Purnell, Lary D. and Betty J. Paulanka, Transculural Health Care, 2nd ed. 2003. F.A. Davis Co. 2. Transcultural Assessment and Clarification of Values and Beliefs Assessment of values and beliefs is a starting point in continuing dialogue to foster mutual understanding among health care providers and recipients of care. This assessment, though not exhaustive, encompasses cultural values and ethical issues regarding health care delivery from the patient’s perspective. TO THE CLIENT The health care professionals assigned to care for you want to understand your values and beliefs so they can deliver culturally relevant health care. Please assist them in better understanding you by completing this form. BACKGROUND INFORMATION 1. Where were you born? 2. How long have you lived in the ____________? 3. Did you receive any formal education in the __________? How much?
4.
Where were your family members born?
_____________
RELATIONSHIPS 5. Who are the decision makers in your family? 6. Who do you consider “family?” 7. Who do you want to make health care decisions for you? 8. In the event you cannot make health care decisions fo yourself, who would you appoint to make these decisions for you? COMMUNICATION 9. What language do you consider you “mother” tongue? 10. Do you read and write in your “mother” tongue? 11. In which language do you prefer you receive health information? CULTURAL BONDS 12. What cultural traditions do you observe in your home? RELIGIOUS AFFILIATION 13. Do you have a religious affiliation? If so, what is the affiliation? 14. Do your cultural or religious beliefs influence your attitude toward prevention of illness? If so, how? 15. How would describe your health status? 16. Do you have any symptoms that require “healing?” 17. How long have you had these symptoms? 18. What “healing” strategies do you use to relieve these symptoms? 19. Do these symptoms affect your ability to work or fulfill other obligations? 20. During your course of treatment what cultural/religious beliefs would you like us to consider? OTHER 21. Is there anything else you would like to share with us that would help us care for you in a more sensitive way?
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If clinically related to the diagnosis or chief complaint, it may be useful to collect data about transplantation, organ donation, autopsy, blood transfusions, drugs containing alcohol of caffeine, or foods that are taboo or prohibited.
Developed using data from Spector, R.E. (1996). Cultural Diversity in Health and Illness (4th ed.). Stamford, CT: Appleton and Lange. In Andrews and Boyle, op. cit. 3rd ed. P. 448.
2. TRANSCULTURAL ETHICS
Ethics is a systematic philosophical method of inquiry that assists people in understanding the morality (rightness or wrongness) of human behavior and social policies.
1. Basic/Related Concepts Ethics also refers to the standards of behavior expected of professional groups as
described in their code of professional conduct. It is important for nurses to have a knowledge of ethics in order to develop an ethical framework to guide their professional practice and to cope with unethical uncertainties stemming from work with clients, their families, and colleagues. Ethical knowledge also prepares nurses to fully understand and participate in multidisciplinary committees on bioethical issues. Ethical theories and principles are not universal in theory and application. Thus, ethical conflicts may occur when applied transculturally. Example: Issue surrounding informed consent, disclosure of diagnosis and prognosis, and discussion of termination of treatments are reflections of Western cultural values. In some cultures, particularly in Oriental or Eastern cultures, the approach is different: In Oriental cultures like Japanese, Chinese, Pakistani, etc – the family expects to be informed of bad news first, and then decides whether to inform patient or not. Autonomy does not exist in numerous cultures. Decision/s regarding health care are made in consultation with other family members. Ethical relativism views morality as relative to the community within which an individual lives and the manner in which the individual was raised. When applied transculturally ethical conflicts may arise. Example: Freedom of speech would only be a moral value for cultures that believe in it. Therefore, moral values are only right in sociocutural contexts that think they are right. The nurse and other health care professionals should be aware of existing ethical theories and principles and their implications for care in a client’s lifeway, belief system and health care practices. Two contrasting ethical theories come from the East and West.
2. Overview of Western and Eastern Ethical Theories
Western Ethical Theories – are based on European or American philosophies and are influenced by Judeo-Christian belief systems. Review Western ethical theories – Utilitarianism, consequentialism, character ethics, ethic of care, situation ethics, ethical relativism, natural law ethics, etc. Review ethical principles: autonomy, beneficence, nonmaleficence justice, veracity, fidelity, etc.
Eastern Ethical Theories During the 6th B.C. two philosophical systems developed in China – Confucianism and Taoism. The theories developed in these systems are based on Asian/Indian philosophies and may also be influenced by religious beliefs. The theories serve as ethical guidelines for living. Confucianism All teachings of this theory emphasize human relations. Emphasizes the virtues of: Righteousness (yi) and Benevolence (yen). 63
This virtue combines all virtues and is considered “perfect virtue”. Another aspect of benevolence is Shu, which stresses treating others as
we would want to be treated. This theory views humans as essentially social creatures. Humans are bound together by jen, that is, sympathy, humanheartedness, or loving others. Jen is expressed through five relations: Sovereign and subject Parent and Child Elder/Younger/Brother Husband and Wife Friend and Friend Rituals and etiquette help these relations function smoothly. Correct conduct proceeds through a sense of virtue developed by observing appropriate models of ethical conduct. The standards of conduct come from within a person. If after thoughtful consideration a person finds an action morally acceptable, that person should act without any hesitation.
Taoism - This philosophical system developed in china during the 6th B.C. Taoism is concerned with the origin and meaning of life. This system believes that human happiness is achieved in following the natural order. It emphasizes trusting in one’s intuitive knowledge. Taoism focuses on the observation of nature in order to discover the “characteristic of the Tao”, or the way of life knowledge. Taoism focuses on the observation of nature to discover the way of life, whereas Confucianism focuses on man and values, social conventions and rituals. Source: Andrews and Boyle, 3rd ed. pp. 444-456.
3. Culturally Competent Model of Ethical-Decision Making The model for ethical decision-making, was drawn from Mann’s human right’s model and Leininger’s culturally congruent theory.
It affirms the fundamental rights of individuals, families, groups, and populations to health care that is meaningful, supportive, and beneficial. It is predicated on the basic human right of respect for diversity of values and assumptions about life transitions and events. It is based on the principle that caring preserves human rights and dignity.
SOCIETY PROFESSION ORGANIZATION
HUMAN RIGHTS
HUMAN RIGHTS
PATIENTS FAMILIES
CA
CA
CR
CP
CR CP
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CA – Cultural Accomodation CP – Cultural Preservation CR –Cultural Repatterning
Culturally Competent Model of Ethical Decision Making
GUIDE FOR USING THE CULTURALLY COMPETENT MODEL 1. ASSESSMENT Client/families
Ethnohistory Concepts of the human body and soul Meaning of life, pain, suffering, and death Caring values, patterns, and expressions Social organization Established social hierarchy Roles and obligations of family members and kin Differential acculturation of family/group members Family and community resources Cultural gatekeepers and brokers in the community Communication norms and linguistic patterns Experience with professional health care
Organizational cultural Variables
Staff cultural knowledge and skills Conflicting values between staff and patient/ family/ group Conflicting values among care providers Cultural expertise available Policies and procedures Flexibility in accommodating cultural differences Material resources available
Determination of professional and societal services
Legal mandates Regulatory requirements Impact of decisions on other patients and self Professional code of ethics
2. PLANNING Establish relationship with client/s/families/communities Define problems and priorities that reflect the emic perspectives of client/s Determine material and personnel resources needed Determine aspects of action plans that need to be negotiated with participants 3. INTERVENTION Cultural care preservation or maintenance Cultural care accommodation or negotiation Cultural care repatterning or restructuring 4. EVALUATION Allow clients/families to identify outcomes and indices for achievement Differentiate culturally meaningful from biomedical outcomes Validate outcomes achievement with clients/families Source: Andrews and Boyle, op. cit. p. 525.
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3. TRANSCULTURAL CARE PRINCIPLES, HUMAN RIGHTS AND ETHICAL CONSIDERATIONS 1. Human beings of any culture in the world have a right to have their cultural care values known, respected and appropriately used in nursing and other health care services. 2. Human cultures have diverse and universal modes of caring and healing practices that need to be recognized and used by professional nurses to function effectively and therapeutically with people of different cultures. 3. Care is the essence of nursing and a basic human need for growth, well-being, recovery, and survival. 4. Cultural care is a critical component influencing health, well-being, and recovery from illness or disabilities. 5. Every culture has at least two major types of health care systems namely, the folk (generic, lay or indigenous) care system and the professional care system which influences their health outcomes, and the transcultural nurse is challenged to use this knowledge to guide nursing care decisions and actions. 6. All professional nurses are challenged to respect common humanistic aspects of people worldwide, and also the divergent care expressions, meaning, and practices. 7. Transcultural nurses are expected to respect Western and non-Western cultures who often have different values, beliefs, and norms to assess and understand human beings. 8. Transcultural nursing principles and practices are the arching framework for all nursing care practices which differ from nursing practices that rely on traditional medical symptoms diseases and treatment regimes. 9. Since transcultural nursing focuses upon comparative cultural care values, beliefs and practices of cultures, the nurse is expected to work with individuals, families, groups, cultures, subcultures and institutions that reflect cultural care variables. 10. Nurses with transcultural knowledge are expected to respond appropriately to culture care differences and similarities in order to ease or ameliorate a human condition or lifeway, and to help clients face death. 11. Ethical and moral differences and similarities exist among human cultures which necessitates that nurses recognize, respect, and respond appropriately to such variables. 12. It is essential that transcultural nurses be open-minded and willing to learn from cultural informants about their human values, beliefs, needs and practices in order to make appropriate nursing care plans, judgments and actions. 13. The ability of the nurse to listen, use silence and envision the client’s or family’s human condition or cultural circumstance with its positive or less positive features is important in transcultural nursing. 14. Transcultural nursing often requires that nurses communicate with clients in their native language to know, learn, and understand individuals, families and groups of different cultures. 15. Transcultural nurses are challenged to identify what constitutes ethical or moral principles and norms of cultures and not assume that all cultures are alike. 16. Transcultural nurses are expected to guide other nurses who have not been prepared in transcultural nursing in order to prevent marked ethnocentricism, cultural imposition practices and inappropriate ethical and moral judgments about clients. 17. Transcultural nursing reflects that an individual or group of a designated culture are active participants and decision-makers in culture care practices in order to develop and maintain creative and effective professional care practices. 18. Clients of diverse or similar culture have a right to have their caring life styles and expressions known and used in transcultural nursing in order to promote client health or well-being, 19. Transcultural nursing takes into account the world view, environmental context ethnohistory, social structure features (including the religious, kinship philosophic economic, political, technological and cultural values) language, expressions, gender and age difference of people. 20. Transcultural nursing is concerned with the assessment of caregiver and carereceiver expressions, beliefs and lifeways that often go beyond nurse-client dyadic
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relationship to that of care relationships with families, groups, institutions and communities in order to facilitate congruent care practices and to avoid unfavorable care conflicts stress and negligent care practices. 21. Since ethical, moral and legal systems of human values and rights exist in all cultures, it is the task and responsibility of transcultural nurses to discover these dimensions with key and general informants and in diverse cultural contexts. 22. Human care rights tend to be covert and embedded in social structure, cultural values and world view of clients, and so the transcultural nurse is challenged to discover these dimensions mainly through qualitative research methods. 23. Transcultural nurses recognize that culture is complex, dynamic and change over time and in varying ways. 24. Transcultural nurses recognize that many cultures and subcultures in the world have not been studied and yet nurses are expected to care or all peoples including minorities. 25. Transcultural nursing is a major breakthrough for new nursing knowledge and practices that do not follow the traditional nursing or medical disease, symptom and illness models. Source: Leininger, M. (1991) Journal of Transcultural Nursing, 3, 21-23, as printed in Ethics and Issues in Contemporary Nursing by Margaret A. Burkhardt and Alvita K. Nathaniel. 2nd ed. Thomson Asian Edition. pp. 341-342.
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CULTURAL HERITAGE – A SUMMARY I. FILIPINO HERITAGE A. OVERVIEW Location – in Southeast Asia, surrounded by the South China Sea, Celebes Sea, Philippine Sea, and the Sulu Sea. Composed of 7,107 islands; 3 major islands: Luzon, Visayas, Mindanao Negritos – earliest known settlers. Successive foreign invasions by the Chinese, Arabian, Indian Spanish, American, and Japanese. Filipino culture - “Filipino blend” from mixture of different languages, traditions and religions has resulted in “identity crisis.” Weather – tropical; hot and dry during summer months, Wet and humid during monsoon season July to December Population – 87,857473 (2006) B. BIOLOGICAL VARIATION Body built and structure – short to medium built; small thoracic capacity, eyes set in almond shaped eyelids, mildly flared nostrils, slightly low to flat nose bridges. Skin color – of Malay stock (brown complexion) light to fair complexion – resulting from intermarriage with foreigners Hair – black, very curly or kinky (Negritos); straight Enzymatic and genetic variations o Blood type “B” – 40%; low incidence of Rh-negative factor o As with other Asians, Filipinos have lower tolerance for alcohol but are more sensitive to its adverse effects. o lactose intolerance Nutritional variations o Food more than nourishment for the body; it is a fundamental form of socialization o Rice – staple food; although known to be carnivores, fish and seafood forms bulk of Filipino diet. o Regional cooking variations; in Manila – a variety of food preparations – Pilipino, Chinese, Spanish, Japanese. fast-food catching on o Traditional 3 meals a day with merienda o Milk almost absent in Filipino diet o Malnutrition especially among the poor and less educated; one of the 10 leading cause of infant mortality C. SOCIAL ORGANIZATION Strong family attachment =nuclear +extended family Traditionally patriarchal, but now egalitarian - tendency is for husband and wife to share in decision making, disciplining and finances Filipino women enjoy better status in society than their Asian counterpart, e.g. women working outside the home, decision-making and social and political movers, more women now occupy managerial or administrative positions as CEO’s, COO’s Values orientation is characterized by a deep sense of personal indebtedness (utang na loob) and loyalty to kin which carries an obligation to repay or perform service to another; hospitality, community togetherness (bayanihan). D. RELIGION Predominantly Christians – majority of which are Catholics (83%), 9% Protestant, 5% Muslim, and 3% Buddhist and other religions. Novenas and prayers are often said on behalf of sick persons Rosaries, medals, scapulars and talismans are often worn by the sick
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Source of strength found in religion - intimate relationship with God, The expression Bahala na (it is up to God) points to a higher power to take care of the rest when almost everything fails. E. COMMUNICATION Tagalog – national language; 87 languages and 111 dialects Third largest English speaking country following US and UK. Silence – may imply “yes,” “no” or don’t know May also convey emotional expressions of disgust, anger, resentment. Eye contact – eyes may convey many messages as shown by eye rolling up and down, squinting, eyes popping to show surprise Telecommunication literate especially in Manila. Availability of newspapers, local and foreign publications, TV, landline and mobile phones. Philippines has been dubbed the “Texting capital of the world.” Touch – Filipinos are a warm people, affection usually expressed by touching and embracing. Rural folks are more conservative Though known to be shy and non-aggressive, as nurses they are known to be dedicated, patient, respectful, and attentive to the needs of their patient Use of words to show respect like Manong, Manang, “oho”, “opo” F.
SPACE In poor families, space is limited and family members all live and sleep together. As they are family-oriented, they do not perceive the family as invasive in personal space parameters.
G. TIME ORIENTATION Past oriented – respect for elderly wisdom, familial closeness and honoring dead ancestors Future oriented – parents conscious of sacrificing and saving for the future of their children Poor observers of punctuality H. ENVIRONMENTAL CONTROL Health care beliefs and practices o Many still believe in the magico-religious (witchcraft, soul loss, soul intrusion, evil eye) predominantly in areas far from hospitals, clinics and professionally trained health care givers. o Many health beliefs o Intimate circle of family largely influence decisions about when, where, and from whom to seek help. o The ethical principles of beneficence and nonmaleficence take precedence over patient autonomy. Before a decision is made to inform the patient about his or her terminal condition, a discussion among family members occurs, and they may request the doctor not to divulge the truth to protect the patient. o Major decision maker – doctor more than patient or family members
Health/healing practitioners o
Use of folk practitioners like
• • • • • •
Hilot – in rural areas hilot ambiguously refers to both the midwife (magpapaanak) and the chiropractic practitioner (manghihilot, masahe). mangihihilot-manipulation and massage for the diagnosis and treatment of musculoligamentous and musculoskeletal ailments albularyo-are general practictioners, usually with a history of healer in the family-line and their healing considered a “calling”, a power bestowed by a supernatural being. Their treatment modalities: tapal, lunas, kudlit, pang-kontra, bulon, otasyon manglulop manghihila mantatawas
• spiritista; faith healers o Western medicine familiar and acceptable to most Filipinos o Increase in use of integrative or alternative health practitioners noted Health Census a. Ten leading causes of mortality (2007) 1. Heart diseases 2. Vascular system diseases 3. Accidents 4. Pneumonia 5. Tuberculosis 6. Diabetes 7. CVA/stroke
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8. Chronic lower respiratory diseases 9. Liver cirrhosis 10. Prenatal conditions Source: -http://emeritus.blogspot.com/2007/07/Philippines-top-ten-causes-of-mortalitty.html. b. Ten leading cases of morbidity (2007) 1. Malaria 2. Diarrhea 3. Pneumonia 4. Hypertension 5. Influenza 6. Sepsis 7. Bronchitis 8. Tuberculosis 9. Chickenpox 10. Measles Source: -http://www.nationmaster.com/discussion/country/rp/Health
II.
JAPANESE HERITAGE
A. OVERVIEW Location – lies off the east coast of Asia and entirely within the temperate zone. Land area – 142,727 sq. miles Population – 127,417244 (Time Almanac 2006) Environmental risks –Japan is subject to intense crustal movements and violent earthquakes and volcanic activity. B. BIOLOGICAL VARIATION Body built and structure – short to medium height, rarely tall; medium built. Japanese are rarely obese Skin color – white to fair in complexion Enzymatic and genetic variations o Lactose intolerance - inability to digest lactose from milk attributed to inadequate production of/or defect in the enzyme lactase. Calcium is supplied in tofu small, unboned fish o Rise in obesity, diabetes, heart disease, and premature death associated with increasingly Westernized food tastes that are higher in fat and carbohydrate content than traditional Japanese food. o High rate of CVA attributed to sodium content of traditional soups and sauces. Nutritional variations o All food groups are well-represented o Staple food - rice or gohan. Other foods include miso, nori, fish, pickles, ramen (noodles) vegetables, soybean cake/curd, pork seasoned with mirin (sweet sake) o Holidays and family celebrations are times for ritual use of food o Japanese use chopsticks to eat, meals often eaten on a tatami mat around a low table. o Widely used for their medicinal properties: green tea, Vitamin C, garlic and various herbs o Dietary therapy recommends eating seasonal foods and balancing foods from land, sea and mountain o Proper food combination takes into account the yin/yang properties of food. C. SOCIAL ORGANIZATION Family roles – nuclear family structure Marriage – Love not highly valued as a prerequisite for a successful marriage. Motivation – to fulfill societal expectations than desire for spousal companionship Children’s organization – is family’s paramount concern. Primary relationship is between motherchild, particularly between mother and son. Socialization process – children socialized to study hard, make their best effort, and be good group members. Self-expression is not valued. Girls are taught to take care of boys. Traditional Japanese arts as tea ceremony, ikebana, bonsai, kimono wearing, calligraphy, doll making, etc. diligently studied by women. Small size of women of “the floating world” or entertainment industry (Geisha) live outside constraints of home and gender and enjoy a fair amount to autonomy. D. RELIGION Dominant religions: Shintoism - 110 million Buddhism – 90 million
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Other religions – Confucianism, Christianity No strong religious feelings but rather a strong commitment to ancestral traditions like ancestral worship and ceremonies as births, weddings and funerals. E. COMMUNICATION Illiteracy is nearly zero High school graduates complete 6 years of English Use of language is distinguished by many levels of formality and directness depending upon the status of the people who are conversing Bowing is an expression of respect and courtesy for elders. Different levels of bowing dependent upon socio-political status of person Handshake – an appropriate form of meeting and greeting. Laughter may mean embarrassment or discomfort. Eye contact – Direct eye contact may be avoided. o Prolonged eye contact (staring) is not polite even within families.
Touch – The Japanese don’t like touching. o o
Social touching occurs among group members but not among people who are less closely acquainted. Men do not engage in backslapping or other forms of touching.
Gestures – avoid expansive arm and hand movements, dramatic or unusual facial expressions. Pointing with less than the whole hand is impolite. Moving the open hand with palm facing left in a fanning motion in front of one’s face indicates a negative response Silence - a natural and expected form of non-verbal communication. o Pain is borne in silence. o Considered inappropriate to yell out during labor as this brings shame to family. Grunting is encouraged rather than screaming and yelling. o o
F.
SPACE Body space is respected. Public kissing is criticized. Showing affection such as hugging or shoulder slapping should be avoided in public. Intimate behavior in the presence of others is taboo.
G. TIME ORIENTATION Past - future- present oriented: They cherish their history as they will direct future generations as to how their society evolved so that they will appreciate where they are now. H. ENVIRONMENTAL CONTROL Health care beliefs and practices o Japanese medicine borrowed from Chinese medicine the concepts of yin and yang, and the concept of ki(energy) o Cleanliness and purity are seen as the keys to health alongside correct eating, behavior, respiration, exercise and spiritual devotion. The Japanese also attribute their generally high level of well-being to their traditional daily bath in neck-deep water, at temperature of 105F. o Exposure to the beauty of nature considered important for attaining calmness and serenity. o Energetic healing through massage or shiatsu (reflexology) o Reiki – a Japanese form of therapy based on the belief that when spiritual energy is channeled through a practitioner, the patient’s spirit is healed and this in turn heals the body. o Shiatsu – a form of massage that uses thumb pressure along the energy meridians in the body o Herbal medicine (kanpo) o Macrobiotic diet – a form of vegetarian diet that consists of balancing yin and yang energies of food. Health care practitioners o Traditional health practitioners – diet, herbs, energetics o Allopathic physician Mortality and morbidity o Leading causes of death: cancer, heart disease, stroke, pneumonia, accidents, liver disease, diabetes, hypertension (related to high sodium diet) tuberculosis. o Asthma – related to dust mites in tatami straw mats and air pollution in urban areas
III. CHINESE HERITAGE
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A. OVERVIEW Location - East Asia. One of the world’s oldest civilization dating back more than six millennia. The last Chinese Civil War produced two political entities using the name China: • the People’s Republic of China (PRC)- comprising mainland China, Hong Kong and Macau, and • the Republic of China (ROC) administering Taiwan and its surrounding islands.
Population – 1,306,313,812 (TIME Almanac 2006) B. BIOLOGICAL VARIATION Body built and structure o Generally small in stature but some can get over 6 ft. tall, small slanted eyes, thick and straight hair, and a flat face. Skin color o May vary; many skin colors similar to Westerners with pink undertone, yellow tones, and others very dark o Chinese men do not have facial hair. Hair color is black Enzymatic and genetic variations o Thalassemia –– an inherited disease of the RBC classified as hemoglobinopathy. The genetic defect results in synthesis of an abnormal hemoglobin molecule. The blood cells are vulnerable to mechanical injury and die easily. People with thalassemia need blood transfusion at regular intervals to survive. o Lactose intolerance (90%). Condition gives rise to higher risk of osteoporosis. o Higher prevalence of insulin autoimmune syndrome characterized by spontaneous hypoglycemia o Hantavirus (HVD) characterized by flu-like symptoms, fever, headache, hemorrhagic manifestations, shock and renal failure. Spread via rodent excreta. o Diverticulosis or inflammatory bowel disease (IDS) are uncommon due to high intake of vegetables and high fiber food. o Hypertension leading CV risk factor due too frequent consumption of salty and spicy food o Deficiencies associated with food - rickets, goiter, and anemia o Tobacco consumption – major problem in rural China giving rise to increased incidence of lung disease. o Tuberculosis and Hepatitis B among Chinese immigrants due to overcrowding, malnutrition, and unsanitary conditions Nutritional variations o Food meals have specific orders with focus on the balance for a healthy body. o Traditional Chinese medicine (TCM) uses food and food derivatives to prevent and cure disease. o Foods are also classified as yin (cold) or yang (hot) and a proper balance is required to maintain health. o Chinese daily meal consists of four food groups: grains, vegetables, fruit and meat. o Regional cuisine - food depends upon weather conditions: Szechuan (cold weather), food is hot and spicy; Fujian, a seaport, sea foods are plentiful o Usual desserts – sliced fruit and bean curd C. SOCIAL ORGANIZATION Confucianism – plays a very important role in forming Chinese character and behavior. Its purpose is to achieve harmony, considered the most important social value. Confucianism prescribes well-defined roles and acting in a proper way to achieve harmony. There are 5 cardinal relations: sovereign-subject, fatherson, elder- younger brother, husband-wife, and friend-friend. Family unit is the center and comes before the individual. There is no Chinese equivalent for the word “self.” o Extended family – relatives expected to help each other; filial loyalty very strong. Elderly are viewed as very wise o Father –the undisputed head of the family. o Male dominance fathers, sons and uncles assume very important roles in family and business. With regards to filial piety, sons, especially the eldest son, have specific obligations towards the family and are expected to respect and care for parents. o Son preferred to daughter o Female gender – perpetuated to ensure male dominance in a society, female feticide common Traditional role of women – to maintain a happy and efficient home “Me” generation – new and changing orientation of young, educated Chinese men and women. Quotation by Wang Ning, 27, Advertising Company owner, “We are more self-centered. We live for ourselves, and that’s good. We contribute to the economy. That’s our power.”(TIME magazine, August 6, 2007, pp. 24-27). D. RELIGION
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Primary religions: o Buddhism – a religious movement which originated in India. Religious precepts of the Buddha make up the tenets of this religion. o Taoism (Lao Tsu) – 20 million followers mostly in Taiwan. “Tao” or “The Way” – refers to the ultimate being or ultimate truth, the power which envelopes, surrounds and flows through all things, living and non-living. It regulates the natural processes and nourishes balance in the Universe and embodies the harmony of opposites, no love without hate, no light without dark, no male without female. o Confucianism – named after the great Chinese emperor. Emphasis is on governance and family relations. E. COMMUNICATION Language – Mandarin official language of China spoken by 70% of the population o Other dialects: 10: Cantonese, Fujianese, Shanghainese,Taoishanese, and Hunanese o They speak in a moderate to low voice although many times they sound loud.
Silence – is held in high regard in China. They want to contemplate without interruption. o
They avoid disagreeing or criticizing, especially in public.
Smile – they appreciate smiles when talking with others Touching – Chinese generally not a touching society especially with visitors. Hence, health care workers must know the meaning of touch. o Non-family members should not touch the head of a child, especially an adult, as head is traditionally considered sacred. o By family members, patting gently on the shoulder or cheek shows affection for children o Friendship by the same sex – handholding or walking arm in arm. o Using feet t move objects, such as chairs or doors, are considered disrespectful to others.
Distance – they maintain a formal distance from each other, which is a form of respect Eye contact – uncomfortable with face-to-face communication especially when there is direct eye contact o
Excessive eye contact may indicate impoliteness and rudeness, even threatening
Gestures – More reserved, gestures expressing emotions are comparatively less expressive. o
To show special respect, a slight bow may be given to the elderly or to government officials.
o The whole open palm should be used in pointing rather than the index finger. o Beckoning to people should be done with the palm facing done instead of up. o
Handshake – common greeting when meeting for the first time.
Emotional display – no public display of affection but open and demonstrative among family and friends Addressed by their whole name or by their family name and title. To health care providers ask the person how they wish to be called. F. SPACE Group interaction – facing each other directly, being closer, touching more, eye contact, and speaking more loudly Non-contact – Body position while sitting/standing can be side by side or right angle arrangement because they feel uncomfortable facing each other. G.TIME ORIENTATION Chinese perception of time is different, neither past, present or future oriented. Time is perceived as a dynamic wheel with circular movements and the present as a reflection of the eternal. The wheel continually turns in an unforeseeable direction and individuals are expected to adjust to the present, which surrounds the rotating wheel, and seek harmonious relationship with their surroundings. Time concept is described as polychromic and Westerners as monochromic. Polychronic time orientation adheres less rigidly to time as a distinct and linear entity, focuses on completion of the present, and often implements one activity at a time. Monochronic orientation to time emphasizes schedules, promptness, standardization of activities and synchronization with clocks. I.
ENVIRONMENTAL CONTROL
Philosophical belief - Many Chinese subscribe to fatalism, accepting things as they come. o The body as an energy system – ancient belief that the body is an energy system of opposing o
forces of yin (negative energy, female, inactive cold) and yang ( positive energy, male, active, hot) . Every aspect of the universe is a constant interplay of yin and yang.
HEALTH BELIEFS 73
o Illness results from an imbalance of yin and yang. Proper balance is required to maintain health and treatments are geared to this end.
o Chinese believe in feng shui (meaning wind and water) which refers to art of location, orientation and design of physical structures in an effort to achieve harmony and balance.
o Positive feng shui wards of evil spirits and promotes good health and prosperity. o Belief in colors and numbers. White is considered bad luck, red good luck. 8 is considered a lucky number and 4 extremely unlucky as 4(si) when pronounced the same as the word death in Chinese. HEALING PRACTICES o Belief in Traditional Chinese Medicine (TCM) and its practices remain strong. o Acupuncture – insertion of an ultra-fine needing into meridian points or pathways of energy (chi) to balance energy o Cupping – heated cups to rduce stress, congestion and colds o Herbology – use of herbs and medicinal plants to stimulate chi. o Qi jong – combines body movements, meditation, regulation of breathing to enhance the flow of chi and improve the circulation and enhance the immune system. o Meditation to relieve stress HEALTH CARE PRACTIONERS o Acupuncturist o Herbologist
IV. INDIAN HERITAGE A. OVERVIEW Location – in S Asia, south of the Himalayas, including a large peninsula between te Arabian Sea and the Bay of Bengal 1,177,000 sq.mil. Population - 1,080,264,388 (TIME Almanac 2006) B. BIOLOGICAL VARIATION Body built and structure – varies according to racial strain (6): Mediterranean strain, Broad-headed strain, Nordic strain, Mongoloid strain, Negritos, and Proto-Australoids Skin color – varies according to racial strain; light to dark brown Enzymatic and genetic variations o Thallasemia, G-6-PD, lactose intolerance (2) o Susceptibility to diseases: heat stress, food or waterborne diseases: bacterial diarrhea, hepatitis A and E, typhoid fever, vector borne diseases: dengue fever, malaria, encephalitis, rabies, mental illness Nutritional variations o Indian cuisine has been designed by the medicine men of old, in contrast to Western cuisine, which is designed by creative chefs. o Most Hindus are vegetarians – diet consisting primarily of grains and legumes, vegetables o Non-vegetarian diet includes different kinds of meat except beef as the cow is considered a sacred animal o Rice (in the North), different kinds of bread (in the South) like chapatti, puri,naan, paratha o A healthy and balanced diet which involves a combination of the six main tastes: sweet - ex: sugarcane, breads, pasta sour - acidic: yoghurt, lemon salty - salt and alkalis – rock salt, sea salt pungent -acrid, often aromatic – ginger, chili, hot peppers, bitter - neem, bitter melon, fenugreek astringent - constricting quality – beans, lentils, pomegranate o Eating utensil: use of right hand for eating, never left hand as it is used for hygiene and toileting C. SOCIAL ORGANIZATION Extended - family structure living together as a single family unit, usually composed of grandparents, parents, children, may include families of parental uncles. Respect is highly valued; touching the feet of the elderly Gender roles o Men –dominant and authoritative role because they are the point of contact with society o Women – passive role; manage the home, keeping all finances, family and social issues in order.
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Caste system – is the world’s longest surviving social hierarchy. A person is considered a member of the case into which he or she is born and remains within that caste until death, although the particular ranking of that cate may vary from region to region. The caste categories are: the Brahmins (priests and teachers), the Ksyatriyas (rulers and soldiers), the Vaisyas (merchants and traders), and the Sudras (laborers and artisans). A fifth category consists of the “untouchables” or Dulits, who are often assigned tasks too ritually polluting to merit inclusion within the traditional caste system. D. COMMUNICATION National language – Hindi (40% of population) Second language – English Use of head movements and hand gestures during conversation Silence – to show respect Eye contact – men maintain eye contact with each other while conversing, while women look downward when talking to their husband, grandfather and father to show respect. Touching – Public display of affection and touching among relatives, friends and acquaintances are socially not acceptable in Hindu culture. o Show of affection is private but not in the view of children or elders. E. SPACE In poor families, space is limited and family members all live and sleep together. As they are family-oriented, they do not perceive the family as invasive in personal space parameters. F.
TIME ORIENTATION Past oriented – importance paid to traditions and rituals that are inherent to their culture Present oriented – because they view that individuals are continuously in the process of “becoming.” Future oriented – because life in the present is lived with an emphasis on the hereafter.
G. RELIGION Hinduism – dominant religion; about 83% of total population Religious tenets of Hinduism: o aims for freedom from endless reincarnation and suffering from bad karma o belief in Dharma – a code of conduct that secures human happiness, contentment and saves from suffering and degradation Other religions: Buddhism, Sikhism, Jainism Islam – practiced by approx. 13.4% of all Indians Christianity, Zoroasterianism, Judaism, Baha’I Faith – small number H. ENVIRONMENTAL CONTROL HEALTH BELIEFS o Health reflects living in total harmony with nature o Illness is an external event or misfortune; karmic o Good health and illness – may be karmic in origin o Body consists of 5 elements (earth, water, fire, wind, space). Health is achieved when there is a balance of the elements; illness results from an excess or deficiency of one of the elements. Environmental factors affecting illness: o air pollution o water pollution from raw sewage, agricultural pesticides, untreated water o huge growing population that overstrain natural resources o lifestyle, climatic factors HEALING PRACTICES o Ayurveda (Science of Life) - 30000 BC, said to be the oldest most complete medical system in the world. Its sources are the Atharva Veda and the Samhitas with comprehensive treatises on health-care and medical procedures. o Ayurveda system of natural healing involves the totality of life and the whole human being and its relationship with the environment. o Ayurvedic treatments involves a process of detoxification or cleansing and purification known as Pancharma Treatments through fasting, massage application of oily herbal preparation, ingestion of herbal oils and pills. o Balancing of yin and yang o Yoga – breathing exercises, asanas or physical exercises, meditation
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o
Allopathy
HEALTH PRACTIONERS o Ayurvedic physician o Allopathic doctor
V. MEXICAN A. OVERVIEW Location – Middle America, bordering the Caribbean Sea and the Guild of Mexico between Belize and the US and bordering the North Pacific Ocean, between Guatemala and the United States. Population – 107,449,525 (20006 est. Climate – varies from tropical to desert B. BIOLOGICAL VARIATION Body built and structure – short, medium to tall Skin color – dark skinned as among the indigenous inhabitants, fair to light skin Enzymatic and genetic variations o Vitamin A deficiency and anemia prevalent in lower socio-economic group lactose intolerance High risk behavior o Alcoholism – associated with their colorful lifestyle; a crucial health problem for many Mexicans o Drug addiction: Marijuana – readily available from people who are in farming and ranching occupations; cocaine, heroin, and inhalants . Nutritional variations o Mexican food is rich in color, flavor, texture and spiciness. o Food is a primary form of socialization so much so that prescribed diet for illness such as D.M. and CV diseases may not be adhered to. o *Diet depends upon the individual’s region of origin . o Staple food – rice (arroz), o Popular Mexican foods – taco, beans and tortillas from corn (maiz). eggs, pork, chicken, sausage, chili, peppers, squash, potatoes, leche flan C. SOCIAL ORGANIZATION Family– traditional family is still the foundation of society o Patriarchal slowing moving towards egalitarian pattern in more educated and higher socioeconomic families o Extended family o Blended communal families – the norm in lower socioeconomic groups and migrant worker camps. Single, divorced, and never-married male and female children usually live with their parents and extended families regardless of economics Social status highly valued. A person with an academic degree or position commands great respect and admiration from family, friends and the community. Gender roles – Machismo complex sees men as having strength, valor, self-confidence which is considered a valued trait. Men are seen as wiser, braver, stronger, and more knowledgeable regarding sexual matters. o Women – expected to be devoted wife and mother, responsible for maintaining the home and family’s health. o The mother is the “queen” of the home and kitchen and socialization, family affairs and communication revolve around food D. COMMUNICATION Language – Spanish; 54 indigenous languages and more than 500 different dialects Meaningful conversations important, often loud and seemingly disorganized “Small talk” often indulged in before addressing real issues, also apply to actual health concerns Touch – touching and embracing acceptable. Handshake – initial form of greeting, then smiling, backslapping or nodding of head. Eye-contact – as a rule, sustained eye contact when speaking directly to an older person is considered rude. o Avoiding direct eye-contact with a superior is a sign of respect.
Addressing non-family members more formal; Titles often used as Dona, Don, Senor, Senora
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o Approaching the Mex-Am client with respect and personalismo (being friend-like) and directing questions to the dominant member of the group (usually a man) may help to facilitate more open communication. E. SPACE Intimate zone – with family members and friends as touching and embracing between the sexes acceptable. F.
TIME ORIENTATION Present-oriented – especially those from lower socio-economic group. Trend is to live in the “more important” here and now because tomorrow (manana) cannot be predicted. Unclear meaning of Manana – may or may not really mean tomorrow; it often means “not today” or “later.” More relaxed concept of time – hence punctuality is not generally practiced. Time is perceived as relative than categorically imperative. they may arrive late for appointments. This presents a problem in scheduling appointment.
G. RELIGION – predominantly Roman Catholic (89%). Catholic religious practices are influenced by indigenous Indian practices. H. ENVIRONMENTAL CONTROL Current Issues o scarcity of hazardous waste disposal facilities, o scarce and polluted fresh water resources o raw sewage and industrial effluents polluting rivers and urban areas o deforestation – widespread erosion o deteriorating agricultural lands o serious air and water pollution HEALTH and ILLNESS BELIEFS o Definition of health – to be free of pain, to be able to work, and spend time with family. Good health is a gift from God and from living a good life. o Traditional Illness Theory • The body’s imbalance – “Hot and Cold” Hot and Cold theory – a theory which originated in ancient Greece during the time of Hippocrates, who considered illness to be the result of humoral imbalance causing the body to become too hot or too cold. A state of balance among the body humours (blood, phlegm, lack bile, and yellow bile) manifest itself in a wet, warm body. Illness results from imbalance.
o o o
Hot-cold theory describes intrinsic properties of food, beverage, or medication and its effect on the body. If imbalance occurs, symptoms are treated by eating food from the opposite group to restore body equilibrium. • Dislocation of parts of the body – empacho (caused by a ball of food clinging to the wall of the stomach) and caida de mollera (depressed anterior fontanel in infants and child) due to diarrhea, dehydration. • Magic or supernatural causes outside the body • Strong emotional stress • Envidia (envy) Common health problems: malnutrition, malaria, cancer, alcoholism, drug abuse, obesity, hypertension, diabetes, heart disease, adolescent pregnancy, dental disease, HIV and AIDS. Among Mex-American migrant workers: infectious, communicable and parasitic diseases; tuberculosis Leading cause of death • cardiovascular disease – influenced by behavioral, cultural and social factors
• I.
diabetes mellitus – five times higher in Mexican-Americans than European-American groups
HEALING MODALITIES and PRACTIONERS Folk practitioners o brujas (witches) – to remove evil spirits from the body o curandero –who may claim to have received talent from God or has served as apprentice to another curandero; treats many traditional illnesses; usually a member of extended family, does not accept payment
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o yerbero –uses herbs, teas, and roots for prevention and cure of illness o sobador – similar to a Western chiropractor; treats illnesses affecting joints and musculoskeletal system, with massage and manipulation.
o partera - midwives Professional health care professionals – doctors, nurses, therapist It is suggested that health care providers must always consider clients’ use of FHS practitioners to prevent conflicting treatment regimens.
VI. MIDDLE EASTERN HERITAGE (Arabian) A. OVERVIEW Arab – this term often connotes the Middle East, but the larger (and more populous) part of the Arab World is North Africa. The Arab League defines Arab as “A person whose language is Arabic, who lives in an Arabic speaking country, who is in sympathy with the aspirations of the Arabic speaking peoples.” Saudi Arabia – largest country in the Arab Middle East The Arab World straddles two continents, Africa and Asia. Population – 287 million, 5% of global population B. BIOLOGICAL VARIATION Body built and structure – medium built to tall, medium to heavy in weight Skin color – dark brown or olive skin; some may have blonde or auburn hair, blue eyes and fair complexion Enzymatic and genetic variations o G-6-PD deficiency, sickle cell anemia, thalassemia o Hypertension, diabetes, and coronary heart disease (due to high prevalence of cigarette smoking, high cholesterol diets, obesity, and sedentary lifestyle Nutritional variations o Medicines derived from pork such as insulin are not prescribed or administered o Muslims are prohibited from eating pork and its by-products such as insulin, lard, gelatin such as Jell-O, and marshmallows. o “Kosher” meat – some Muslims will abstain from eating meat if they are uncertain of how it was slaughtered. Animals must have been slaughtered in a humane fashion with the remembrance of God and gratefulness for the sacrifice of the animal’s life. o “Thahiba” – proper way of slaughtering an animal. o “Halal” – animal must be properly slaughtered by a Mudlim or a Person of the Book (Christian or Jew), while remembering the name of Allah. Animal may not be killed by being boiled or electrocuted, and the carcass should be hung upside down long enough to be blood-free. o Consuming alcohol or any intoxicants likes drugs of abuse eating or drinking blood and its byproducts, and eating the meat of a carnivore or omnivore (pig, monkey, dog, cat) and fish without scales are prohibited. *Fasting – during Ramadan, 30-day period, strictly observed. C. SOCIAL ORGANIZATION Family – foundation and basis of society Extended family with 3 to 4 generations • Gender roles are clearly defined. o Men - leadership role, breadwinners, protectors, and decision makers o Women – responsible for care and education of the children and or maintenance of a successful marriage by tending to satisfy their husband’s needs. • Women have to be totally dependent, loyal and obedient to their husband. • Wives are considered the sexual property of their husband. • High status accorded to women as mothers in Islam • 60% - educated Muslim women o Sons – taught to be protectors of their sisters, help father with duties inside and outside the house o Daughters – taught to be the source of love and emotional support in the family, help mother with household chores. Equitability in the role of the sexes. Allah has no bias for or against men and women. Both spouses might need to engage in financial activities Rights and responsibilities within the family are intertwined. Men are obliged to cover themselves from navel to their knees.
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Childbearing Muslim women (except old women) wear the hijab including headscarf; should be fully covered in public, except hands and face. Color of outfit – black except in: o Africa – women wear cloths of different colours depending on their tribe, area or family. o Bangladesh, Pakistan, India – bright orange or red garments o Turkey and Indonesia – majority do not wear veil except when they attend Friday Salat o Iran – younger ones wear transparent Hijabs to protest but keep within the law of the state.
Reason for wearing Hijab: men and women are not to be viewed as sexual objects Most Arab marriages are monogamous; 2-5% are polygamous. o Men can marry up to four women if they can support them currently. o “Talaq” – divorce is practiced. Men can divorce and remarry the same woman many times. o Islamic law forbids a Muslim woman from marrying a non-Muslim unless he converts to Islam. o A woman may propose marriage to a man directly or through an intermediary o When a couple is to be married, the man must pay mahr or dowry to his future bride. D. RELIGION Life centers on worshipping Allah Allah – Almighty God Mohammed – messenger of God Islam – founded between 610 and 632 A.D. by the prophet Muhammad. Islam means “submission to Allah. Moslem, Muslim – follower of Islam Qur’an – Bible, Holy Book Seven components of Islamic Foundation: o Allah, the Only True God o Prophets and Messengers o The Guidance from Allah o The Last Day o The Life Hereafter o Al Qadr (Measure, Destiny, Decree Mosque or Masjid – temple; women and men are completely segregated Women cannot lead (as an imam) men in prayer E.COMMUNICATION Language: Arabic is the universal language of Muslims, as it is the language of the Qu’ran Silence o Arabs behave conservatively o Display of affection between spouses, arguments are kept private o Acting in a manner that attracts attention is looked upon as a sign of imbalance in behavior and character Eye Contact o Maintain steady eye contact when conversing to Arabs o Do not prolong eye contact with a Arab woman. Arab women are conservative and sensitive. Touch o Greeting with a kiss is taboo. o Between members of the same sex, touch hand or shoulder to gain trust o Do not compliment your Arab host/associate on the beauty of wife or sister or daughter. F. SPACE Face-to-face meetings in doing business Gender separation - no mixing of Arab men and women who are not directly blood related, or not married to each other. Dewaiahs or Majlis – for male guest gathering only, separate from rest of the house Only female doctors and health care personnel are permitted to attend to female patients G.
TIME ORIENTATION Predestination – believed by first generation Arabs. This means that God has predetermined the events of one’s life Plans and intentions are qualified with the phrase inshallah, “if God wills.” Punctuality – at prayer 5x a day and in business appointments. Praying and observance of death rituals include turning one’s head and the patient’s bed in the direction of their prophet.
H. ENVIRONMENTAL CONTROL
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HEALTH BELIEFS o Good health is seen as the ability to fulfill one’s roles. o Diseases are attributed to a variety of factors: inadequate diet, hot and cold shifts, emotional or spiritual distress envy or evil eye. o Preventive care not generally sought; Arabs seek care for actual symptoms o Cultural emphasis on modesty – women shy about disrobing for examination. Only female health care providers can attend to an Arab woman. o Muslim concept of death is the return of the soul to its Creator, God, and the inevitability of death and the Hereafter is never far from his consciousness. o Notifying the nearest Islamic Center so that someone could come and pray and read from the Qu’ran to a seriously ill is appreciated. HEALTH CARE PRACTICES o Birth Rites – Baby is bathed immediately after birth. o Circumcision to facilitate cleanliness recommended at anytime but especially during the first 5 days. o Life Interventions – Permissible to use life support to save and lengthen life. o Euthanasia or Physician Assisted Aid in Dying is prohibited o Death Rites – cremation is forbidden. Burial recommended as soon as possible especially during summer. o As soon as death occurs, the body should be completely covered and placed if possible with feet towards Mecca. o Only family member should touch and wash the dead body, usually by the same gender. o Embalming the body is prohibited. A corpse is not left alone between death and burial. HEALTH CARE PRACTIONERS Allopathic doctor
VII. BLACKS or AFRICAN AMERICANS A.
OVERVIEW Refers to people having origins in any of the Black race groups of Africa who were brought as slaves about the 17th century. Today the black population comprise those who migrated voluntarily from African countries, the West Indian islands, the Dominican Republic, Haiti, and Jamaica. The Blacks are the nations largest majority population-12.9% of the US (2000). 54.8% live in the South. Blacks are presented in every socioeconomic group; however 21.1% of the group live in poverty. Over half live in urban areas surrounded by the symptoms of poverty – crowded and inadequate housing, poor schools, and high crime rates. Black population is also young, 54.5% are under 18 (2001). Civil Rights Movemen o 1962- Civil Rights Movement formally organized. o 1962 – Civil Rights Act passed. o 1968 – Dr. Martin Luther King Jr. assassinated o 1995 – Million Man March
B. BIOLOGICAL VARIATION Body built and structure o Differ in bone length o Tend to have shorter trunks than Whites and have longer legs than Whites, Orientals and American Indians. o Have wider shoulders and narrower hips than Orientals, who tend to have narrow shoulders and wide hips o Average height and weight between Black and Whites tend to be the same 18-74 years age group, but White men tend to be taller than black men. o Black women are consistently heavier than White women, although average in height for both races. Skin color o Color - “white” to very dark brown or o Black – lower risk for cancer o The groin, the genitalia and the nipples tend to be darker than the rest of the body. o Hypopigmentation and hyperpigmentation in different parts of the body. Enzymatic and genetic variations
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o
o o o o o o o o
Sickle-cell anemia - genetically inherited trait hypothesized to fight malaria. Results in hemolysis and thrombosis of red blood cells because these cells do not flow properly through the blood vessels.Symptoms: hemolysis, anemia, states of sickle cell crises in which severe pain occurs in the areas of the body where the thrombosed cells are located, i.e spleen, liver Hypertension – attributed to diet; too much red meat and high fatcontent Cancer of the esophagus Stomach cancer Coccidiodomycosis Lactose intolerance Obesity Diabetes AIDS and STD’s – high incidence; rapid increase of infectious primary and secondary syphilis since 1985. Mortality: Heart disease Cancer Stroke Diabetes Pneumonia/influenza Morbidity: Hypertension Coronary artery disease Stroke End stage renal disease Dementia Diabetes Certain cancers
Nutritional variations and Dietary Practices: o Black Muslims observe Jewish kosher diet and halal- no pork or pork products which they believe to be filthy. o Food is used as a way to celebrate special events, holidays, and birthdays. Food is a symbol of health and wealth. o African-American diet is high in fat, cholesterol and sodium. They eat more animal fat, less fiber, and fewer fruits and vegetables than the rest of American society. o Salt pork (fatback or fat meat) – key ingredient in their diet because it is inexpensive. o “Soul food” – a combination of dishes created with ingredients from Africa, the Caribbean, and the Southern United States. comes from the need of African Americans to “express the group feeling of “soul.” Common “soul food” ingredients: black-eyed peas, kidney beans, ham hocks, bacon or pork chops. o Being overweight is considered positive. It is important for them to have meat on their bones to be able to afford to lose weight in times of sickness. o Pica – the eating of non-food substances such as laundry starch (amylophagia) clay or dirt (geophagia), ice, burnt matches, ashes,wall plaster, hair and stones have been frequently reported among African American women of different cultural groups. One theory suggests the body’s need to acquire certain missing nutrients, hunger, cultural tradition, prevention of nausea, attention seeking. C. SOCIAL ORGANIZATION Family o Large, extended family networks o Many single parent households headed by females. 50-60% of women in this culture are single mothers. Adolescent pregnancy is a major concern with the population. o Strong church affiliations within community o Community social organizations D. COMMUNICATION Language and dialects o Black English – not a language but a dialect in which the pronunciation of words may be different. Ex.: th=d; brother-broda; going=goin; going to=gonna o Dialect: Pidgin – occurs when two groups do not have a common language and are forced to develop a third language (pidgin), which is a combination of their respective languages. • Creole – when a pidgin becomes the first language of a group of speakers. • Gullah – spoken by descendants of freed slaves from the Georgia and South Carolina sea islands who developed their own culture. Expression of feelings 81
o Express feelings openly to family or trusted friends o Speech is dynamic, expressive, loud o Body movement are involved when communicating o Facial expression can be demonstrative o Use of humor to release hostility, anger, stress, anxiety Eye contact o Maintaining direct eye contact can be misinterpreted as aggressive behavior. Touch o Used freely between adults and children, or people of the same gender as a way to convey empathy, acceptance and, when dealing with health issues, to infuse hope. E. SPACE – Comfortable with close personal space more than other ethnic groups. F.TIME ORIENTATION Past orientation – due to factors such as the traumatizing racial segregation Future – arose during the time of Martin Luther King Jr. His famous line “I have a dream” gave hope for a brighter future for the African Americans Punctuality – very punctual and normally arrive 15-30 minutes earlier as a sign of respect. G.ENVIRONMENTAL CONTROL HEALTH BELIEFS o Health is viewed as harmony with nature o Illness is a disruption of this harmonic state due to demons, “bad spirits,” or both. o Natural illness - occurs in response to normal forces from which individuals have not protected themselves. o Unnatural illness – harm or sickness can come to individuals via a person or spirit. o Pain – a sign of illness or disease o Traditional health and illness beliefs may continue to be observed by “traditional” people HEALING MODALITIES Traditional o Voodoo – synonyms are “fix”, “hex”, or “spell.” - brought by the slaves about 1724. Involves a lot of rituals and procedures such as drinking blood, use of oils, powders candles. Modern health care o Receiving health care sometimes seen as a degrading and humiliating experience. Ongoing use of home remedies due to poverty. o Some Blacks fear or recent health clinics. Appointments not often kept because they may lose a day’s work, not being understood by health care worker, discrimination HEALTH CARE PRACTIONERS Folk healing practitioners Conventional or allopathic practitioners
VIII. ANGLO-AMERICAN A. OVERVIEW Anglo-American – an American of English birth or ancestry. America - nation of immigrants. o 1820-1920 – people from Germany, Italy, United Kingdom, Ireland, Austria-Hungary, Canada and Russia. o Now considered a “melting pot” of different cultures B. BIOLOGICAL VARIATION Body built and structure – usually tall, medium to heavy built; structure reflective of European descent Skin color - white Enzymatic and genetic variations o Drug variation: Due to liver differences, caffeine is metabolized and excreted faster by people of other cultural groups. Genetic Diseases: o Favism (Hemolytic anemia caused by deficiency of the X-linked enzyme G6PD triggered by eating fava beans(broad beans). o Thalassemia syndrome
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Increased susceptibility to: Cardiovascular diseases, breast cancer (the most common form of cancer in women), diabetes, Leading causes of death: 1. Heart Disease 2. Cancer 3. Stroke 4. Chronic lower respiratory diseases 5. Accidents (unintentional injuries) 6. Diabetes 7. Influenza, Pneumonia 8. Alzheimer’s Disease 9. Nephritis, nephritic syndrome, and nephrosis 10. Septicemia Nutritional variations o Traditional American cuisine – steak and potatoes, hamburger, vegetables, salad, rich deserts o 20th century – consumption of packaged foods – breads and cookies, preserved fruits, pickles soups, frozen vegetables, reserved meats, instant puddings and gelatins, fruit juices o 21st century – Fully prepared meals outside the home reflected changing economic status (wife working outside home). Emphasis on convenience and rapid consumption gave birth to fast foods chain like Burger King, McDonalds, Pizza Hut, etc. – French fries, hamburgers pizza, etc. o
C. SOCIAL ORGANIZATION Nuclear family structure: small family size - parents and children only Decision-making process: made by individual or self, or by either parent or their child Independence: children encouraged to be independent; allows children to disagree with parents which may be considered disrespectful in other cultures Few social services to support family: children encouraged to live outside the home at age 18 o No guarantee that children will support their elderly parents; hence, many elderly live in nursing homes Gender roles: males and females expect to be treated with equal respect, rights and role opportunities at home and in the work place Dominant cultural values: o Individualism and self-reliance o Independence and freedom o Competition, assertiveness and achievement oriented o Highly materialistic and too technologically oriented o Equal gender roles and rights o Instant time and action (doing) o Youth and beauty o Reliance on “scientific facts” and numbers o Generosity and helpfulness in crises D. COMMUNICATION Language – predominantly English (about 97%) o Other languages – speak German, French, Polish, Spanish. Italian, o English spoken with accent in different parts of the US Manner of communication o Direct, informal, use of person’s name often o Will ask a lot of explanations and facts, services available, health instructions regarding health care. o ”Small talk” on sports, weather, jobs, or past experiences. Most people don’t talk about religion, politics or personal feelings with strangers. o Few “ritualistic” exchanges in English like “How are you,” How’s it going” are greetings, not questions about your life. ”See you later,” or “See you soon” are ways of saying good-bye, not appointments. o Conversations are moderate in volume with few gestures. Eye contact o Direct – an important component of direct and honest communication o Direct eye contact – specially between sexes may be interpreted as sexually suggestive o Avoidance of eye contact – suggest withholding information, sometimes a psychiatric symptom to evidence of dissembling direct eye contact Touch – Aggressive, self-seeking, independent, individualistic, competitive, and not touch oriented.
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o o o
Handshaking – acceptable at initial meeting. Touching for casual acquaintances is considered a bit too intimate. Kissing or hugging as a form of greeting even in public places is common between the sexes. Holding hands or touching another of the same sex may indicate homosexuality.
SPACE o Value space and territory, especially with middle-class and upper class Americans. They often seek to increase their space at home and at work. o Require more personal space than in other cultures. Space is an expression of money and materiality (storing material goods and possession). o Often described as “territorial animals.” Because they like to protect and control their space. o Casual conversation – maintain a distance of 36-48 inches, otherwise he/she will feel that you are “in their face” and will try to back away. E. TIME ORIENTATION “Time is gold”. Time is equated with money, Time – a dominant value in American culture. Observe punctuality in keeping and maintaining appointments and schedules. Time closely related to action, doing, efficiency and productivity. Generally goal and future oriented especially when it comes to monetary security. Thus they value personal goals over group goals. Outlook on time may vary with their socio-economic class: Poor – present oriented Middle and upper class –future oriented F. RELIGION Predominantly Christian – Catholicism, Protestantism Minority – Judaism, Islam, Buddhism G. ENVIRONMENTAL CONTROL Believe that Man, and not Fate, can and should be the one who controls the environment. Thus, they are good at planning and executing short-term projects. HEALTH BELIEFS AND PRACTICES o Generally prefer an aggressive approach to treating illness o Believe that germs and microorganisms cause disease, treatment aimed at destroying them. Management of microbes is more important than bolstering resistance to them. Antibiotics often requested. o Expect to leave doctor’s office with a prescription. o Have a high expectation that their disease/s will be cured or at least well managed, through technology and powerful drugs. o Drug culture - a mixture of legal, illegal and prescription drugs. HEALING MODALITIES o Strong preference for biomedicine. o Trend towards complementary and alternative medicine HEALTH/HEALING PRACTIONERS o M.D. trained at different levels of specialization o Trend towards alternative medicine and therapies. o Certified Nurse Specialist – specialization in different areas of health care
IX. ITALIAN HERITAGE A. OVERVIEW Location – country in S Europe mostly on a peninsula extending into the Mediterranean and including the islands of Sicily and Sardinia Land area – 116,304 sq. miles Capital – Rome B. BIOLOGICAL VARIATION Body built and structure – varied physical characteristics because of Italy’s proximity to Switzerland, Austria, and Germany in the north, and to North Africa in the South. Skin color o northern background have lighter skin, lighter hair, and blue eyes
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o from the south of Rome, particularly Sicily – have dark often curly hair, dark eyes, and olivecolored skin. Enzymatic and genetic variations o First generation Italians – suffered from somatic complaints and physical ailments attributed to il mal occhio (evil eye) o Second generation immigrants – tend to develop neurologic and psychotic symptoms attributable to guilt toward the parents whose culture they have broken. o People of Italian ancestry have some notable genetic diseases: familial Mediterraneanfever, G6PD, B-thalassemia o Italian-Americans - high incidence of hypertension and AD related to smoking and Type A behavior Nutritional variations o Nutritional deficiencies are rare because the Italian diet is rich in fruits, vegetables, garlic, pasta and olive oil o Food – is symbolic of life and the principal medium of family life. An Italian mother may demonstrate her affection by feeding her family and anyone else she likes. To the average Italian mom, love is a four letter word: food. o Staples of the Italian-American diet: spaghetti, lasagna, ravioli, pasta, manicotti, vegetables, fruits, lentils, sausages, eggplant parmigiana, etc. C. SOCIAL ORGANIZATION Family – central in Italian’s lives, and “Mama” is queen Father – breadwinner, authority absolute in traditional Italian families; decision maker Women – dominate decision making on childbearing issues and family social events; have more power in economic decisions because the husband turns over paycheck to her. Sons frequently live at home well into their 20’s Parents often live in children’s homes and care for grandchildren D. RELIGION Predominantly Roman Catholic (90%); 30% regularly attend service Religious beliefs have evolved from diverse cultures in Italy through the centuries.Thus ItalianAmericans’ spiritual and religious beliefs have their roots in: -pagan customs -magical beliefs -Mohammedan practices -Christian doctrines -Italian pragmatism Most Italians pray to the Virgin Mary, the Madonna, and a number of saints Italians view God as an all-understanding, compassionate and forgiving being. E. COMMUNICATION Italian – official language Several different dialects spoken in 19 regions of Italy Voice – discussions can become quite passionate, with voice volume raised and many people speaking at the same time Willingness to share thoughts and feelings among family members is a major distinguishing characteristic of the Italian-American family. Emotional people, conflict expressed as periodic outbursts Value close family ties expressed as warmth feeling, emotional bond reaffirmed by frequent kissing on each cheek Touch – frequently touch and embrace family and friends. Touching between men and women, frequently seen during verbal communication. F.
SPACE o Related to close family ties, Italians like contact which makes them feel comforted, secure, and make them feel that they belong.
G. TIME ORIENTATION Past orientation –is evidenced by the pride they take in their home country’s rich Roman heritage Present orientation – occupy themselves with concrete problems and situations, and accept things Future – they give importance to planning ahead and saving financially for the future. H. ENVIRONMENTAL CONTROL HEALTH BELIEFS AND PRACTICES
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In traditional terms, illnesses are attributable to: -wind currents that carry disease -contamination -heredity -supernatural (God’s will) or human causes -psychosomatic interactions o Superstition Evil spirits manifesting in hysteria, nervousness, mental illness o
HEALING MODALITIES o The family is viewed as the most credible source of health-care practices. o Italians take responsibility for their own health care and engage in health promotions. o Majority also have health insurance coverage o From the family perspective, the mother assumes responsibility for the health of the children HEALTH/HEALING PRACTIONERS o Traditional vs. Biomedical Care: Some humans are believed to have potent magical powers: shaman, maghi (male witch); maghe (female witch), lupo mannaro (powerful sorcerer) o *Health Care Providers • Some physicians collaborate with shamans and herbalists to accommodate clients cultural preferences o Success in persuading children of Italian parentage to take medicine depends on the trust the mother has on health care provider.
X. JEWISH HERITAGE A. OVERVIEW Jewish refer to both a people and a religion; it is not a race Jew is derived from Judah, one of Jacob’s son Hebrew – is the official language and is used for religious prayers by all Jews wherever they live. The people are called Jewish, their faith Judaism, their language Hebrew, and their land Israel. Religious persecution – cause of mass migration of Jews from Europe in the 1800’s. o Ashkenazi Jews – from Eastern Europe and Russia o Sephardic – from Spain, Portugal, Mediterranean area, North Africa, South and Central America o Sabra – is a Jew born in Israel Continued learning – most respected value of the Jewish people. Prominent in all fields of endeavor – 39% Nobel prize in the life sciences, 11% in Chemistry, 41% in Physics; business, arts and culture B. BIOLOGICAL VARIATION Body built and structure – varies according to region of country of origin Skin color o Ashkenazi Jews – same as white Americans. White to fair; blonde hair to darker skin and brunette hair o Sephardic Jews – slightly darer skin tone and hair coloring, similar to those from Mediterranean area. Enzymatic and genetic variations o Bloom syndrome – a specific abnormality of chromosome 15 in which the individual suffers from recurrent infection blistering areas of the hand and lips, and poor growth o Breast and ovarian cancer o Cystic fibrosis – a hereditary disease affecting cells of exocrine glands including mucus secreting glands) o Fanconi anemia – disorder characterized by severe aplastic anemia (failure of the bone marrow to produce either red or white blood cell) o Gaucher’s disease a genetically determined disease resulting from deposition of glucocerebrosis in the brain and other tissues (bone) o Pempigus vulgaris – a rare but serious disease marked by successive outbreaks of blisters o Tay-Sachs disease – an inherited disease of lipid metabolism in which abnormal accumulation of lipid in the brain leads to blindness mental retardation, and death in infancy. o Torsion dystonia – Abnormal twisting of a testis within the scrotum or a loop of bowel in the abdomen Nutritional variations
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o
o
o
Food satisfies hunger but also teaches discipline and reverence for life as also an instrument of ethnic identity. Chicken soup is frequently referred to as “Jewish Penicillin.” Kashrut (keeping Jewish dietary laws or keeping Kosher found in Leviticus and Deuteronomy) Strict observance of Kashrut. Some patients will not eat hospital food unless it is certified Kosher and cooked in a Kosher kitchen. The family should identify their level of Kashrut and help the hospital staff with their needs. Meat and milk are not mixed in cooking, serving, or eating.
When working in a Jewish person’s home, the health care provider should not bring food into the house without knowing whether or not the client adheres to kosher standards. Kosher meals are available in most hospitals. C.SOCIAL ORGANIZATION Family – core of Jewish society. Needs of all family members are respected. Gender roles: o Men – breadwinner; father’s legal obligation is to educate children and provides daughter with the means to make them marriageable. • Jewish husband are required to provide their wife with food, clothing, medical care and conjugal return • Jewish men are prohibited from “beating their wives, restricting or forcing them into sex. o Women – raises children, keeps a Jewish home. Are at the forefront of activities to demand and protect all human rights, gain women’s suffrage, reproductive health care rights o Children – most valued treasure. Families are encouraged to have at least 2 children
•
In Judaism, age of majority is 13 years for boy and 12 for a girl. At this age they are deemed capable of differentiating right from wrong. Recognition of adulthood occurs during a ceremony called a bar or bar mitzvah Marriage – an ideal human state for adult. Goal – to propagate the race and companionship. Sexuality is a right of both men and women. Sexual intercourse is viewed as a pure and holy act when performed within marriage. Women must physically separate themselves from all men during their menstrual period and for seven days after. No man may touch a woman nor sit where she sat until she has been to the mikveh for purification.
D. RELIGION Judaism – a monotheistic faith that believes only in one God. o Jews consider only the Old Testament as their Bible. o Torah refers to the first five books of the Bible also known as the five books of Moses, directs Jews on how they should live their lives. o 3 main branches of Judaism: 1. the Orthodox – the most traditional. They observe the Sabbath by attending the synagogue on Friday evening and Saturday morning; abstain from work, spending money and driving on the Sabbath 2. the Conservative and 3. the Reconstructionism. o Hasidic (or Chadsidic) - ultra orthodox fundamentalist, usually live, work and study within a segregated area. They have full beards, uncut hair around the ears, wear black hats or fur streimels, dark clothing and no exposed extremities. Women, especially those who are married, keep their extremities covered and may have shaved heads covered by a wig and hat as well. o Saturday is considered as the 7th day of the week and should be kept very holy. o Visiting the sick (bikkur cholin) is considered as one of their most religious practice; it is one the social obligations of Judaism and assures that Jews look after the physical, emotional, psychological and social well-being of others. E. COMMUNICATION Language: English – primary language; Hebrew – official language o Yiddish – a Judeo-German dialect, spoken by Ashkenazi Jews
Use of Humor – frequently used; the Jews like self-criticism thru humor, but any jokes that refer to the holocaust or concentration camps are considered inappropriate.
Touch – Jewish men are not permitted to touch a woman other than their wives. They often keep their hands in their pocket to avoid touch.
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o They do not shake hands with women, engage in idle talk with them nor look directly at their F.
faces. Non-Hasidic Jews – more informal, may use touch and short spatial distance when communicating.
SPACE Intimate and personal space between husband and wife Maintain distance outside of family home “Distance oneself from a bad neighbor, and do no befriend an evil person.” (Avot 1:7)
G. TIME ORIENTATION They are past, present, and future oriented. o Present – Jews live for today and plan and worry about tomorrow. o Past – they are raised with stories of their past. They are warned to “never forget.” They value time. Punctuality is observed. H. ENVIRONMENTAL CONTROL HEALTH BELIEFS AND PRACTICES o Beliefs are determined by Jewish law. Hasidic husband may not touch his wife during labor, attend delivery, or view her genitals. o Circumcision – both a medical and a religious rite, performed on the 8th day by a mohel, trained in the circumcision procedure, asepsis and the religious ceremony. o Sabbath begins 18 inutes before sunset on Friday and ends 42 minutes after sunset (or when 3 stars can be seen) on Saturday. Day is devoted to prayer. Jews do no work on this day. In Health Care: Doctor appointments are not scheduled on the Sabbath or Holy Days. Surgical procedures, except life-saving procedures, are not done on the Sabbath or holy days, o Death is an expected part of the life cycle. HEALTH/HEALING PRACTIONERS Allopathic doctor
END
BIBLIOGRAPHY
Andrews, Margaret M. and Joyceen S. Boyle. (1999). Transcultural concepts in nursing care. (3rd ed.). Lippincott. Philadelphia, New York, Baltimore. Burkhardt, Margaret A. and Alvita Nathaniel, Ethics and issues in contemporary nursing ( 2nd ed.). Thomson Asian Edition. Kozier, B., Erb, G., Berman, A.J., and Snyder, S.. (c2004). Fundamentals of nursing concepts, process, and practice. (7th ed.).Pearson Education, Inc. Upper Saddle River, New Jersey. Munoz, Cora and Joan Luckmann (c 2005). Transcultural communication in nursing. (2nd ed.). Delmar Learning. Purnell, Larry D. and Betty J. Paulanka (2003). Transcultural health care: a culturally competent approach ( 2nd ed.). F.A. Davis Co. Philadelphia. 88
Spector, R.E. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, N.J: Prentice Hall. Spector, Rachel E. (2004) Transcultural nursing: beliefs and practices in illness and health care (6th ed.). Pearson Education South Asia Pte Ltd. Jurong, Singapore. Taylor, Carol, Lillis and Priscilla LeMone. (2005). Fundamentals of nursing: the art and science of nursing care (5th ed.) .Lippincott Williams and Wilkins, Philippine edition.
ADDENDDUM
Medicine Wheel teachings are among the oldest teachings of First Nations people. The teachings create a holistic foundation for human behaviour and interaction; the teachings are about walking the earth in a peaceful and good way; they assist in helping to seek healthy minds (East), strong inner spirits (South), inner peace (West), strong healthy bodies (North). The term “Medicine” as it is used by First Nations people does not refer to drugs or herbal remedies. It is used within the context of inner spiritual energy and healing or an enlightened experience, in other words, spiritual energy. The Medicine Wheel and its sacred teachings assist individuals along the paths towards physical, mental, emotional and spiritual enlightenment.
There are several teachings, such as the four directions (north, south, east and west), the four colours of races (red, black, yellow and white), the four directions, or the four stages of life (spiritual, mental, physical and emotional). Different tribes have different colours to represent the
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four directions. The Medicine Wheel below is represented in the traditional four colours (red, black, yellow and white). EAST (yellow): from the East, we begin to seek knowledge, the direction where everything is fresh and new. The sacred plant of this direction is tobacco. SOUTH (red): from the South we experience growth, the direction where everything in life is replenished and in full bloom. The sacred plant of this direction is cedar. WEST (black): from the West we encounter reflection and spiritual insight, the direction where dreams and visions allow you to go within and appreciate yourself and your Creator. The sacred plant of this direction is sage. NORTH (white): from the North we experience the purity, the direction where the secret to many cures is found for healing. The sacred plant being the Sweet Grass, to keep you free from evil and make your travels safe. The Aboriginal philosophy is based upon universal principles known as the seven teachings
Sharing 2. Caring 3. Kindness 4. Humility 5. Trust 6. Honesty 7. Love
The seven natural ways of healing are: 1. 2. 3. 4. 5. 6. 7.
Talking Crying Laughing Yelling Dancing Singing Shaking
All exist within the MEDICINE WHEEL and the CIRCLE OF LIFE
Yin and Yang in Chinese Culture Originates in ancient Chinese philosophy and metaphysics, which describes two primal opposing but complementary forces found in all things in the universe. Yin, the darker element, is passive, dark, feminine, downward-seeking, and corresponds to the night; yang, the brighter element, is active, light, masculine, upward-seeking and corresponds to the day; yin is often symbolized by water, while yang is symbolized by fire. The pair probably goes back to ancient agrarian religion; it exists in Confucianism, and it is prominent in Taoism. Though the words yin and yang only appear once in the Tao Te Ching, the book is laden with examples and clarifications of the concept of mutual arising. Yin and yang are descriptions of complementary opposites rather than absolutes. Any yin/yang dichotomy can be seen as its opposite when viewed from another perspective. The categorisation is seen as one of convenience. Most forces in nature can be broken down into their respective yin and yang states, and the two are usually in movement rather than held in absolute stasis. Yin and yang are often used in reference to disease, and many Asian cultures treat the hot/cold or wet/dry diseases with opposite treatments. For example, a yin symptom such as
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coldness would be treated with yang treatments, such as hot foods. A yang symptom such as nervousness would be treated with yin treatments- cold foods such as fruits. Yin and yang can also be seen as a process of transformation which describes the changes between the phases of a cycle. For example, cold water (yin) can be boiled and eventually turn into steam (yang). One way to write the symbols for yin and yang are a solid line (yang) and a broken line (yin) which could be divided into the four stages of yin and yang and further divided into the eight trigrams (these trigrams are used on the South Korea flag). The symbol shown at the top righthand corner of this page, called Taijitu (太極圖), is another way to show yin and yang. The mostly white portion, being brighter, is yang and the mostly dark portion, being dim, is yin. Each, however, contains the seed of its opposite. Yin and yang are equally important, unlike the typical dualism of good and evil. The concept is called yin yang, not yang yin, just because the former has a preferred pronunciation in Chinese (see Standard Mandarin - Tones for detail), and the word order has no cultural or philosophical meaning. Principles Everything can be described as both yin and yang. 1. Yin and yang are opposites. Everything has its opposite—although this is never absolute, only relative. No one thing is completely yin or completely yang. Each contains the seed of its opposite. For example, winter can turn into summer; "what goes up must come down". 2. Yin and yang are interdependent. One cannot exist without the other. For example, day cannot exist without night. Peace cannot exist without chaos. 3. Yin and yang can be further subdivided into yin and yang. Any yin or yang aspect can be further subdivided into yin and yang. For example, temperature can be seen as either hot or cold. However, hot can be further divided into warm or burning; cold into cool or icy. Within each spectrum, there is a smaller spectrum; every beginning is a moment in time, and has a beginning and end, just as every hour has a beginning and end. 4. Yin and yang consume and support each other. Yin and yang are usually held in balance—as one increases, the other decreases. However, imbalances can occur. There are four possible imbalances: Excess yin, excess yang, yin deficiency, and yang deficiency. They can again be seen as a pair: by excess of yin there is yang deficiency and vice versa. The imbalance is also a relative factor: the excess of yang "forces" yin to be more "concentrated". 5. Yin and yang can transform into one another. At a particular stage, yin can transform into yang and vice versa. For example, night changes into day; warmth cools; life changes to death. However this transformation is relative too. Night and day coexist on Earth at the same time when shown from space. 6. Part of yin is in yang and part of yang is in yin. The dots in each serve: 1. as a reminder that there are always traces of one in the other. For example, there is always light within the dark (e.g., the stars at night), these qualities are never completely one or the other. 2. as a reminder that absolute extreme side transforms instantly into the opposite, or that the labels yin and yang are conditioned by an observer's point of view. For example, the hardest stone is easiest to break. This can show that absolute discrimination between the two is artificial. HOT and COLD conditions and their corresponding treatment Hot conditions Hot foods Hot medicines and herbs Fever Chocolate Penicillin Infections Cheese Tobacco Diarrhea Eggs Ginger root Kidney problems Peas Garlic Rashes Onions Cinnamon
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Skin ailments Sore throat Liver problems Ulcers Constipation
Aromatic beverages Hard liquor Oils Meat such as beef Goat’s milk Cereal grains Chili peppers
Cold conditions Cancer Pneumonia Malaria Joint pain Menstrual periods Teething Earache Rheumatism Tuberculosis Colds Headache Paralysis Stomach cramps
Anise Vitamins Castor
Cold foods Fresh vegetables Tropical fruits Dairy products Meat such as goat, chicken Fish, cod Honey Raisins Bottled milk Barley water
Cold medicines and herbs Orange flower water Linden Sage Milk of Magnesia Bicarbonate of soda
PHILIPPINE CULTURAL MINORITIES Cultural Minorities – 4 million or 12% of total population ¾ Muslims found in Mindanao, Sulu Archipelago and Palawan Mindanao A. Negrito 1. Bukidnon 2. Subanon 3. Manggungan 4. Mandaya 5. Ata
6. Manobo 7. Bukidnon 8. Subanon 9. Manggungan 10. Mandava
11. Ata 12. Bagobo 13. Isamal
B. Muslim Group 1. Maranao 92
2. Maguindanao 3. Sangul 4. Yaka 5. Tausug 6. Samal 7. Badjaw Luzon
Visayas
(Negrito)
(Negrito)
1. Isneg 2. Kalinga 3. 4. 5. 6. 7. 8.
Bontoc Ifugao Kankanai Tinguian (Itneg) Gaddang Ilongot
Mindoro 1. 2. 3. 4. 5.
6.
1. Sulod 2. Bukidnon
Iraya Nauhan Buwid Buhid Ratagon Hanunon
Palawan (Pagan Groups) 1. Batak 2. Tagbanua 3. Palawan (Muslim Group) 1. Malbog
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